Uterine fibroids are hormone–dependent, benign, tumor-like formation of the uterus, originating from its smooth muscle and connective (fibromyoma) tissue. Disease can be single, but more often – in the form of multiple myomatous nodes with different localization. Uterine fibroids can range in size from a small nodule to a tumor weighing about a kilogram, when it is easily detected by palpation of the abdomen. The size of fibroids is usually compared with the size of the uterus at a particular stage of pregnancy. Pathology of small size can develop without clinical manifestations and are accidentally detected during a gynecological examination.
D25 Uterine leiomyoma
Uterine fibroids are hormone–dependent, benign, tumor-like formation of the uterus, originating from its smooth muscle and connective (fibromyoma) tissue. Disease can be single, but more often – in the form of multiple myomatous nodes with different localization. Uterine fibroids can range in size from a small nodule to a tumor weighing about a kilogram, when it is easily detected by palpation of the abdomen. The size of fibroids is usually compared with the size of the uterus at a particular stage of pregnancy.
This pathology are most often found in women in the reproductive period. In postmenopause, the growth of the tumor usually stops and its reverse development occurs. In general, uterine fibroids are diagnosed in more than 20% of women when contacting a gynecologist with certain complaints or accidentally.
What causes uterine fibroids
Currently, gynecology cannot give an unambiguous answer to the question of the cause of disease. The main cause of the development is considered to be a violation of the hormonal function of the ovaries, producing excess estrogen. This is confirmed by the fact that taking hormonal contraceptives with high doses of estrogens contributes to the increased growth of uterine fibroids, and, on the contrary, the cessation of estrogen production in postmenopause leads to its regression and disappearance. However, there are cases with normal hormonal background.
Other risk factors in the development are surgical termination of pregnancy, complicated pregnancy and childbirth, uterine adenomyosis (endometriosis), inflammatory diseases of the fallopian tubes and ovaries, ovarian cysts, absence of pregnancy and childbirth in a woman over 30 years of age, obesity, hereditary factor, immune and endocrine disorders, prolonged insolation.
In the vast majority of uterine fibroids are located in the body of the uterus (95%), in other cases – in the cervix (5%). Based on the direction of growth of myomatous nodes, the following types are distinguished:
- Subserous. With subserous uterine fibroids, the node develops on a wide base or a long leg. Subserous fibroids are localized peritoneal, on the surface of the uterus under the serous membrane.
- Submucous. Submucous uterine fibroids grow into the uterine cavity.
- Interstitial. In interstitial uterine fibroids, the tumor node is located in the thickness of the muscular wall of the uterus.
Symptoms of uterine fibroids
Uterine fibroids of small size can develop without clinical manifestations and are accidentally detected during a gynecological examination. Cases of degeneration of uterine fibroids (fibromyomas) into a malignant tumor are rare, but still occur in clinical practice.
The growth is accompanied by the appearance of symptoms, the most frequent of which are an increase and prolongation of menstrual bleeding (menorrhagia) with the release of blood clots, the occurrence of acyclic uterine bleeding (metrorrhagia) and anemia developing against their background.
This pathology are characterized by pain syndrome, depending on the location and size of the tumor. Pain most often occurs in the lower abdomen or in the lower back. With the slow growth, the pain can be constant, aching. Submucous form manifest themselves with sudden cramping pains. Pain syndrome develops with an increase in size, at the initial stage they are almost always painless.
During the development of this disease, compression of nearby organs occurs – the bladder and rectum, which is manifested by a disorder of their functions: frequent, difficult urination and chronic constipation. Large uterine fibroids (more than 20 weeks of pregnancy) can cause compression syndrome of the inferior vena cava, manifested by palpitations and pronounced shortness of breath, especially in the supine position.
Pregnancy and uterine fibroids
Uncomplicated and small-sized uterine fibroids are usually not an obstacle to the occurrence and normal course of pregnancy. In cases when uterine fibroids grow into its cavity (submucous fibroids), it hinders the growth of the fetus and often causes miscarriage at 11 weeks of pregnancy. The location of the myomatous node in the area of the cervical canal is an obstacle to natural childbirth. In these cases, cesarean section is used for delivery. Pregnancy and the hormonal background associated with it often cause rapid growth of uterine fibroids, and therefore, a pregnant woman should be under the constant supervision of an obstetrician-gynecologist who conducts pregnancy.
Uterine fibroids are insidious and dangerous with their numerous complications. Most often there is a violation of the blood supply to the myomatous node with the development of necrosis, twisting of the tumor leg, bleeding, anemia. Submucous form can cause uterine contractions and the birth of a myomatous node through an open neck, accompanied by pain and bleeding. Miscarriage and infertility can also accompany the development of uterine fibroids. Malignant degeneration (malignancy) of uterine fibroids into a cancerous tumor is up to 2% of cases.
The diagnosis of “uterine fibroids” can be established already at the initial gynecological examination. With a two-handed vaginal examination, a dense, enlarged uterus with a lumpy, knobby surface is palpated. Ultrasound examination of the pelvic organs allows to more reliably determine the size of uterine fibroids, its localization and classification.
An informative method of diagnosing uterine fibroids is hysteroscopy – examination of the cavity and walls of the uterus using an optical device-a hysteroscope. Hysteroscopy is performed both for diagnostic and therapeutic purposes: detection and removal of uterine fibroids of some localizations. Additionally, hysterosalpingoscopy (ultrasound examination of the uterus and fallopian tubes), probing of the uterine cavity, diagnosis of sexual infections and oncopathology can be performed.
The choice of tactics for the treatment is determined by the size of the tumor, the severity of its clinical manifestations and the age of the patient. Depending on this, treatment can be conservative (therapeutic) or surgical. All patients with uterine fibroids are subject to dynamic observation by a gynecologist (1 time every 3 months).
Asymptomatic uterine fibroids of small size are usually treated conservatively. The therapy is based on the use of hormonal drugs – progesterone derivatives that normalize the function of the ovaries and prevent the development of a tumor. For therapeutic purposes, injections of so-called gonadoliberin agonists of prolonged action, suppressing the secretion of gonadotropins and causing pseudomenopause, are prescribed for uterine fibroids. Injections are administered once a month for six months and can cause a decrease in the size of fibroids by 55%. However, in young women, these drugs with prolonged use can cause the development of osteoporosis.
Conservative therapy can only restrain the development for a certain time, but not completely eliminate it. Therefore, therapeutic methods are more justified in the treatment of older women of childbearing age, inhibiting the development of uterine fibroids before menopause, when it resolves on its own.
The transition to surgical tactics is indicated in the following cases:
- with large sizes of myomatous nodes (over 12 weeks of pregnancy)
- with a rapid rate of increase in size (more than 4 weeks per year)
- with severe pain syndrome
- with a combination with ovarian tumor or endometriosis
- with twisting of the leg of the myomatous node and its necrosis
- with a violation of the function of adjacent organs – the bladder or rectum
- with infertility (if no other causes have been identified)
- with submucous growth of uterine fibroids
- in case of suspected malignant degeneration of uterine fibroids
When deciding on the nature of the surgical intervention and its scope, the age of the patient, the state of general and reproductive health, and the degree of perceived risk are taken into account. Depending on the objective data obtained, surgical intervention can be conservative, with preservation of the uterus, or radical, with complete removal of the uterus. In relation to young, unborn women with uterine fibroids, conservative surgical treatment tactics are chosen, if possible, to preserve reproductive function.
- Myomectomy. Organ–preserving operations include myomectomy – the exfoliation of uterine fibroids. In the future, pregnancy may occur for a woman, but there is a risk of recurrence of the disease. In the postoperative period, the use of hormonal treatment and constant monitoring by a gynecologist for timely relief of the incipient recurrence of uterine fibroids is indicated. The least traumatic is myomectomy by hysteroscopy. Uterine fibroids are excised with a laser under the visual supervision of a doctor, the manipulation is usually performed under local anesthesia.
- Myometroectomy. Another variant of organ-preserving surgery for uterine fibroids is myometroectomy with reconstructive restoration of the uterus. The essence of the operation is reduced to excision of overgrown myomatous nodes in the uterine wall with the preservation of healthy submucosal muscle-serous tissue of the organ. This ensures the preservation of menstrual and reproductive function in the future.
- Radical operations. They assume complete removal of the organ together with myomatous nodes and exclude the possibility of having children in the future. Such operations include: hysterectomy (complete removal of the uterus), supravaginal amputation (removal of the uterus body without the cervix), supravaginal amputation of the uterus with excision of the cervical mucosa. When fibroids are combined with an ovarian tumor or with confirmation of fibroids malignancy, a pangisterectomy is indicated – removal of the uterus with appendages.
Conservative myomectomy or supravaginal amputation of the uterus is possible with the use of laparoscopic techniques (usually with the size up to 10-15 weeks of pregnancy). This significantly reduces the surgical trauma of tissues, the severity of the adhesive process in the future and the period of postoperative recovery.
High-tech methods of treatment
An alternative to surgical treatment is the procedure of uterine artery embolization (UAE), which has been used relatively recently. The essence of the UAE technique is to stop blood flow through the arteries feeding the myomatous node. The UAE procedure is performed under X-ray surgery under local anesthesia and is completely painless. Through a puncture of the femoral artery, a catheter is inserted into the uterine arteries, through which an embolization drug is supplied, blocking the vessels that feed the uterine fibroids.
In the future, due to the cessation of blood supply, myomatous nodes significantly decrease in size or disappear completely. At the same time, all the symptoms of disease that bother the patient subside. The method of uterine artery embolization has already shown its effectiveness: the risk of recurrence of the disease after UAE is completely absent, and in the future patients do not need additional treatment for uterine fibroids.
Prognosis and prevention
With timely detection and proper treatment, the further prognosis is favorable. After organ-preserving operations in women in the reproductive period, pregnancy is likely to occur. However, the rapid growth of uterine fibroids may require radical surgery with the exclusion of childbearing function, even in young women. Sometimes even a small uterine fibroid can cause infertility.
To prevent recurrence in the postoperative period, adequate hormone therapy is necessary. In rare cases, malignancy of uterine fibroids is possible. The main method of prevention is regular observation by a gynecologist and ultrasound diagnostics for timely detection of the disease. Other measures to prevent the development of uterine fibroids are the correct selection of hormonal contraception, prevention of abortions, treatment of chronic infections and endocrine disorders. Women over 40 should limit themselves to prolonged exposure to the sun.