Dysfunction of the uterine myoma

This condition is due more often to mechanical factors: compression, torsion, etc., as well as the peculiarities of the blood supply to the fibromatous node.

Myoma is the most common tumor of the internal genital organs of women.

[1], [2], [3], [4], [5], [6]

Epidemiology

The disease occurs in 15-17 % of women over the age of 30.

[7], [8], [9], [10], [11],

Causes of the disturbances in nutrition of the uterine myoma

According to modern ideas, uterine myoma is a dyshormonal tumor that is formed in connection with a hypothalamic-pituitary-adrenal cortex disorder in the system-the ovaries. Dyshormonal nature of the tumor causes metabolic disorders, functional liver failure, as well as violations of fat metabolism.

The tumor first appears intermuscularly, then depending on the direction of growth, interstitial (in the thickness of the uterus wall), subserous (growing toward the abdominal cavity) and submucous (growing toward the mucous membrane of the uterus) develop tumor nodes. Around the myomatous node a capsule is formed from the muscle and connective tissue elements of the myometrium. In the presence of subserosus in the formation of the capsule of the tumor, the peritoneal cover of the uterus also participates; in the submucosal nodes the capsule consists of the muscular layer and the mucous membrane of the uterus.

Most often (80%) there are multiple fibroids of different sizes, shapes and with different numbers of nodes. Seldom subserous or interstitial nodes are much less common. Superserous nodes are usually associated with the body of the uterus with a wide base, but sometimes grow directly under the peritoneum, connecting with the uterus with a thin pedicle. Such nodes are very mobile and easily subject to twisting. Submucosal nodes are found in about 10% of women with uterine myoma.

The incidence of necrotic myoma of the uterus, according to summary statistics, is about 7%. Nodules of a tumor are especially necrotic in pregnancy, in the postpartum period or after the abortion period.

[12], [13], [14]

Pathogenesis

Infringement of blood supply in myomatous nodes is explained mainly by mechanical factors (torsion, inflection, compression of the tumor). However, it is impossible not to take into account the peculiarities of hemodynamics during pregnancy. In patients with uterine myoma during pregnancy, there is a significant decrease in blood flow in the uterus, especially pronounced in the region of the intermuscular myomatous node, an increase in vascular tone, predominantly in small-caliber vessels, severe venous outflow, reduced blood flow of the arterial and venous bed. Clinical manifestations of changes in the hemodynamics of the uterus are symptoms of an increase in the tone of the myometrium, mild uterine excitability, the presence of pains (pulling, aching, spastic nature).

Many authors describe various dystrophic processes in the myomatous nodes (edema, foci of necrosis, hemorrhage, hyaline degeneration, degeneration) that develop not only due to the torsion of the abdominal knee but also as a result of ischemia, venous stasis, multiple thrombus formation in the intermuscular nodes of the tumor. A predisposing factor in this case is an increase in the size of the myomatous nodes during the process of uterine enlargement during pregnancy.

There are dry and wet types of uterine fibroids necrosis. The so-called red necrosis of myoma is described. With dry necrosis, there is a gradual wrinkling of areas of necrotic tissue, while creating a peculiar cavernous cavity with the remains of dead tissue. With wet necrosis, softening and moist necrosis of the tissue are observed, followed by the formation of racemose cavities. Red necrosis is often affected by fibroids located intramural. Usually this form of necrosis occurs during pregnancy and in the postpartum period. Macroscopically the nodes of the tumor are colored red or brownish-red, have a soft consistency, microscopically reveal a pronounced expansion of the veins and their thrombosis.

The cause of the appearance of red necrosis, some researchers see in increasing the tone of the surrounding myometrium, followed by the development of circulatory disorders in the tumor capsule and on the periphery. Necrotic changes are usually due to impaired circulation in the tumor. Aseptic necrosis is almost always associated with an infection that penetrates the site with hematogenous or lymphogenous pathways. Infectious agents usually belong to the septic group of microbes (staphylococcus, streptococcus, E. Coli). Infection of necrotically altered nodes of uterine myoma presents a great danger due to the real possibility of diffuse peritonitis and generalized infection (sepsis).

[15], [16], [17], [18], [19]

Symptoms of the disturbances in nutrition of the uterine myoma

Leading symptom - pain in the lower abdomen of varying intensity, depending on the type of eating disorder and the time of development of the process. It is also possible the appearance of symptoms of general intoxication, due to necrosis and infection of the tumor, the tension of the anterior abdominal wall, possible increase in body temperature and leukocytosis.

[20], [21]

Diagnostics of the disturbances in nutrition of the uterine myoma

Diagnosis is based on complaints of a patient who has an anamnesis indicating the presence of uterine fibroids. Possible primary treatment of patients with malnutrition of the myomatous node.

With vaginal examination, the presence of myoma nodes in the uterus is determined, one of which is sharply painful on palpation.

Ultrasound scanning makes it easier to identify difficult-to-probe nodes, and to assess their condition.

A special role belongs to the diagnosis of degenerative changes in the nodes of myoma in pregnant women, which often do not give obvious clinical manifestations.

From instrumental methods, ultrasound of the uterus is of great importance in the diagnostic process, which makes it possible to identify signs of malnutrition of the tumor, as well as diagnostic laparoscopy, which makes it possible to visualize the node.

[22], [23], [24]

Treatment of the disturbances in nutrition of the uterine myoma

Patients with diagnosed necrosis of fibroids need urgent surgical treatment. Amputation or extirpation of the uterus (most often simultaneously remove the fallopian tubes, which can serve as a source of infection). Conservative myomectomy is performed as an exception in young childless women in conditions of intensive antibiotic therapy in the postoperative period

In some cases, conservative management of the patient and its preparation for a planned operation are permissible. Such tactics are possible only with the treatment of young women who do not have children. In order to improve the blood supply of the uterus, rheologically active agents (reopolyglucin, trental) and antispasmodics (papaverine hydrochloride, no-shpa) are prescribed. In the absence of a rapid effect of conservative therapy should resort to surgery.

Treatment of blood supply disorders of hysteromyoma cells in pregnant women begins with conservative measures: prescribe antispasmodics, rheologically active drugs, tocolytics in combination with antibacterial and desensitizing agents. In the absence of the effect of conservative therapy, conducted within 2-3 days, surgical treatment is indicated. Myomectomy is subject only to subperitoneal nodes. Violation of the blood supply of intramural myomatous nodes requires removal of the uterus. In the postoperative period after enucleation of the nodes, it is necessary to carry out treatment aimed at preserving pregnancy and preventing infectious complications.

Operative (the volume of the operation is decided individually). With multiple uterine fibroids in the perimenopausal period - amputation or extirpation of the uterus.

With secondary peritoneal phenomena and intoxication, removal of the uterus is also advisable. In young women, an organ-preserving operation is possible (myomectomy).