Uterine leiomyoma are a tumor–like nodular formation of a benign nature that develops from the myometrium against the background of its increased sensitivity to the imbalance of sex steroids. Manifestations of uterine leiomyoma can be severity and pain in the lower abdomen, meno- and metrorrhagia, anemia, dysuria, constipation, infertility, complications of pregnancy and childbirth. Disease are diagnosed using ultrasound, CT (MRI) of the pelvic organs, dopplerography, hysteroscopy, laparoscopy. Hormone therapy, FUZ-ablation, EMA, laser vaporization, myomectomy and hysterectomy are offered for the treatment of uterine leiomyoma.
Uterine leiomyoma (leiomyoma, fibromyoma) is a hormone-dependent benign tumor of the body or cervix located in the thickness of the muscle layer. It is considered the most common form of fibroids (50-61% of cases). In 95% of cases, the uterine body is affected, in 5% cervical fibroids are diagnosed. Disease can be localized within the boundaries of the myometrium (intramural form), grow inside the uterine cavity (interstitial-submucous) or towards the abdominal cavity, protruding outward (interstitial-subserous). Interstitial fibroids are most often found in patients of childbearing age (30-45 years) – at this age, it accounts for about a third of all gynecological pathology.
The main role in the morphological restructuring of the myometrium (hyperplasia and hypertrophy of smooth muscle cells) belongs to the violation of the excretion and metabolism of estrogens and the balance between its fractions (estrone, estradiol and estriol) in different phases of the cycle. Myoma tissue is rich in estradiol and progesterone receptors compared to normal myometrium. Sex steroids regulate the growth of fibroids through a complex of growth factors and inducers (IPFR I and II, TFR-beta, EFR, SAFR-A, angiogenin, FF-2) that control proliferation, apoptosis and angiogenesis in tumor tissue. The determining factor in the development of myomatous nodes is the excessive level of estrogens, which contributes to the acceleration of mitotic activity and hypertrophy of cells of the altered myometrium, an increase in the volume of the intercellular matrix.
The development of uterine fibroids (including interstitial fibroids) can be provoked by endocrine disorders, organ injuries (frequent “aggressive” surgical interventions – abortions, RDV) and obesity. An important point is the hereditary predisposition – the presence of fibroids in the mother or sister. The beginnings of fibroids can form even in embryogenesis due to multiple somatic aberrations in normal cells of the myometrium and after menarche begin their growth against the background of high activity of the ovaries. Risk factors for fibroids are early menarche, childlessness, pituitary and thyroid dysfunction, ethnicity (the highest incidence of fibroids in African-American women), stressful situations.
Interstitial fibroids are represented by a clearly delimited, dense rounded node of altered smooth muscle cells, connective tissue fibers and vessels located in the thickness of the muscular wall of the uterus; more often it is multiple. Myomatous nodes have different growth rates (simple and proliferating) and, therefore, different sizes. The size of myomatous nodes in gynecology is correlated with the size of the uterus at a certain period of pregnancy. With large volumes of fibroids, there is a strong deformation of the uterine body (asymmetry, globularity), a violation of its contractility. Fibroids localized on the anterior and posterior walls of the uterus are considered more favorable in terms of the onset and course of pregnancy than those located on the cervix, isthmus of the uterus and near the mouths of the fallopian tubes.
Manifestations of uterine leiomyoma correlate with the number, volume and location of nodes, the degree of inflammatory and degenerative changes that have developed in them. Interstitial-subserous uterine fibroids have a low risk of malnutrition and destruction, with small sizes (up to 2-4 cm), they are not clinically detected for a long time. With multiple fibroids and large node sizes (10-25 cm), the uterus significantly increases in volume, causing compression of the intestine, bladder and nerve plexuses in the pelvis. Patients are concerned about discomfort and a feeling of heaviness in the lower abdomen, periodic or constant pain in the pelvic region, pain during menstruation (menstrual cramps). Acute pain and fever appear when there is a violation of blood circulation in large nodes.
Uterine leiomyoma can be accompanied by profuse uterine bleeding, usually during menstruation (menorrhagia), less often – acyclic (metrorrhagia). It is possible to deposit some volume of blood in the uterus enlarged due to myomatous nodes. Prolonged and frequent menstrual and intermenstrual blood loss is complicated by iron deficiency anemia, the appearance of weakness, fatigue, headache, dizziness, frequent fainting.
Compression of the inferior vena cava by volumetric interstitial myomatous nodes (>20 weeks) is manifested by shortness of breath and tachycardia in a horizontal position. Fibroids located on the anterior wall of the uterus cause dysuria – difficult or frequent urination, incomplete emptying of the bladder, compulsive urge to urinate, sometimes acute urinary retention. Cervical uterine fibroids with growth towards the rectum complicates defecation, leading to constipation, hemorrhoids.
Small interstitial fibroids do not interfere with reproductive function, large, severely deforming uterine nodes can cause uterine infertility or spontaneous termination of pregnancy at different terms. The location of fibroids in the area of the mouth of the fallopian tube with compression of the latter complicates the process of conception. The growth of interstitial fibroids in the uterine cavity can disrupt the normal development of the fetus, lead to spontaneous miscarriage and premature birth. Attachment of the placenta in the node area increases the risk of premature detachment and profuse bleeding. Pathology can cause complications in childbirth – weak labor and bleeding.
The diagnosis of uterine leiomyoma is established using ultrasound, CT (MRI) of the pelvic organs, hysteroscopy, if necessary, RVV, diagnostic laparoscopy. With interstitial fibroids during gynecological examination, it is possible to determine the increase in size and deformation (tuberosity of the surface, increased density) of the uterus.
Ultrasound of the pelvis allows you to visualize even minor interstitial myomatous nodes up to 0.8-1 cm, to assess the histological structure of fibroids, the direction of growth (centrifuge, centripetal). The homogeneity, hyperechogenicity of myomatous nodes indicates the predominance of fibrous tissue, the presence of intranodular hypoechoic inclusions – cystic cavities or necrosis, hyperechoic elements with acoustic absorption effect – the calcination process. Dopplerography is used to examine the peri- and intranodular blood flow in the vascular network of the myomatous node and determine the morphotype of the tumor. With simple fibroids, a single peripheral blood flow is fixed, with proliferating – enhanced central and peripheral. Low blood flow rate indicates necrosis or hyalinosis of the node.
Hysteroscopy helps to identify interstitial fibroids with centripetal growth due to deformation of the inner surface of the uterus, the presence of secondary changes in myomatous nodes. Also, the determination of cancer markers in the blood, RDV with morphological analysis of endometrial tissue is carried out. Uterine leiomyoma must be differentiated from other types of fibroids, tumors of the uterus, pelvis and abdominal cavity (primarily malignant), pathological processes of the endometrium.
A radical method of treatment of interstitial fibroids – removal of the uterus (hysterectomy, supravaginal amputation of the uterus without appendages) – is indicated for multiple, large sizes (13-14 weeks) and rapid growth of myomatous nodes, especially in postmenopause, necrosis or cervical location of fibroids, severe bleeding, combined pathology. In young patients of reproductive age, minimally invasive, organ-preserving methods of treatment are preferred.
Functional surgery of the uterus with the removal of myomatous nodes (myomectomy) makes it possible to preserve menstrual and reproductive functions, prevent omission and disruption of the pelvic organs. Laparotomic access is indicated for multiple volumetric (>7-10 cm) interstitial fibroids, cervical and isthmian nodes, especially posterior and lateral localization. Small interstitial nodes are removed only in preparation for pregnancy, before ovarian stimulation in infertility in women. Laparoscopic access is used less often and is often not recommended due to the risk of uterine ruptures during pregnancy and childbirth. Pregnancy can be planned 6 months after myomectomy, delivery is preferably by Caesarean section.
With small uterine leiomyoma without noticeable symptoms, dynamic monitoring with annual ultrasound control is possible, with the exception of thermal and sun baths, massage, physiotherapy. As a conservative therapy, COCs, progestogens, and sometimes androgens are used. It is possible to use the intrauterine hormonal system “Mirena”. In order to create a medical menopause, antigestogens (mifepristone), gonadoliberin analogues are used, GnRH agonists are effective during perimenopause. Innovative drugs for the treatment of fibroids are antifibrotic and antiangiogenic agents, somatostatin analogues. An alternative to surgical treatment of uterine leiomyoma are EMA (uterine artery embolization), noninvasive FUZ-MRI ablation, laser vaporization (laparoscopic myolysis).
Uterine leiomyoma are considered a prognostically favorable formation: the tumor is benign, the risk of malignancy is minimal. However, in some cases, primary and secondary infertility may develop against the background of fibroids, with radical surgical treatment, loss of menstrual and reproductive function in young patients is possible.