Myoma of the uterus

Myoma uterus is a benign hormone-dependent tumor that develops from the muscular layer of the uterus.

The tumor consists of smooth muscle fibers with connective tissue. Muscle tissue is the parenchyma of the tumor, and the connective tissue is the stroma. The development of tumors of this type is accompanied by absolute or relative hyperestrogenia.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Epidemiology

This is one of the most common tumors of female genital organs. It is detected in 10-27% of gynecological patients, and for preventive examinations, for the first time it is found in 1-5% of the examined.

After 50 years, myoma develops in 20% - 80% of women.

[12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]

Causes of the uterine fibroids

The exact cause of the development of uterine fibroids is unclear. Nevertheless, the role of hormonal imbalance, obesity and genetic predisposition in the development of the disease is assumed.

[23], [24], [25], [26]

Symptoms of the uterine fibroids

Myoma of the uterus has very polymorphic symptoms and depends on the patient's age, duration of the disease, localization and tumor size, its morphogenetic type, and also accompanying genital and extragenital diseases. In 42% of cases, tumors develop asymptomatically for a long time.

The risk of malignant transformation of uterine fibroids is quite low - in the range of 0.25-0.75% (in postmenopause - 2.6-3.7%). At the same time, these neoplasms are often combined with endometrial cancer (4-37%), mammary glands (1.3-5.7%), pancreas (up to 16.5%).

Symptoms have a close relationship with the location of the myomatous node, its magnitude and tumor growth rates. The first symptoms of uterine fibroids in most cases make themselves felt in thirty-five to forty years, since it is during this period that the production of sex hormones in the body begins to decrease. In the early stages, some forms of the disease can be asymptomatic.

Main features:

• uterine bleeding;
• abundant and prolonged periods;
• pulling and pressing pain in the lower abdomen;
• irradiation of pain in the lumbar region, lower limbs;
• frequent urination;
• constipation;
• hot flushes;
• anemia.
• pain,
• bleeding,
• violation of the function of neighboring organs,
• tumor growth.

Frequent urges to urinate occur if the growth of the tumor occurs toward the bladder, compressing it. Constipation is associated with the growth of the tumor in the direction of the rectum, because of which its lumen is squeezed and the stool retention occurs. It should also pay attention to what symptoms of uterine myoma are secondary. These include dizziness, headache and general deterioration of health, often associated with anemia, resulting from lowering the level of hemoglobin and red blood cells, can disturb heart pain, and discomfort and pain can occur during sexual contact.

Pain

As a rule, the pain is localized in the lower abdomen and lower back. Constant aching pain accompanies the subperitoneal myoma and is caused by the dilatation of the peritoneum and / or compression of the pelvic plexus of the pelvis. Frequently expressed long-term pains are associated with rapid growth of the tumor. Acute pains arise, mainly, in the violation of blood supply to the tumor, the progression of which can lead to the development of a clinical picture of the acute abdomen. Cramping pains during menstruation accompany submucosal localization of the tumor and indicate the prescription of the pathological process. At the same time, pain in patients with uterine myoma can be caused by diseases of other organs or systems: cystitis, colitis, endometriosis, inflammation of the uterine appendages, neuritis of various origin, etc.

Bleeding

Bleeding is the most common sign of uterine fibroids. Abundant and prolonged menstruation (menorrhagia) are characteristic for the submucous localization of the tumor. Their origin is caused by a decrease in the uterine tone, an increase in the menstruating surface, and also by the peculiarities of the structure of the blood vessels supplying the submucous myomatous nodes (in these vessels the adventitious membrane is lost, which increases their permeability and at the same time reduces the contractile activity when the vascular integrity is violated). Acyclic uterine bleeding (metrorrhagia) is more typical for intermuscular and subperitoneal localization of the neoplasm, but the most common cause is associated pathological changes in the endometrium.

[27], [28], [29], [30], [31], [32]

Violation of the function of neighboring organs

The change in the function of neighboring organs is observed, as a rule, in the case of the subperitoneal, cervical and intermuscular localization of the nodes and / or the comparatively large size of the tumor. Nodes located anterior to the uterus, exert pressure on the urinary tract and contribute to urinary dysfunction, followed by the formation of hydroureter, hydronephrosis and pyelonephritis; Back-bone tumors complicate the act of defecation. However, in some cases, the cause of the violation of the function of adjacent organs may be a small uterine myoma; This fact is explained by the common mechanisms of innervation, blood and lymph circulation of the sexual and urinary systems in women, as well as by anatomical and embryonic interrelationships between the organs of these systems.

Tumor growth

The growth of uterine fibroids often determines the clinical course of the disease. In general, the growth of the tumor is slow, but at the same time there is a rapid increase in the size of the tumor. Under the rapid growth of the neoplasm is meant an increase in its parameters over a year or less a short period by an amount corresponding to a 5-week pregnancy. The reasons for the rapid growth of the tumor can be accelerated processes of proliferation in the tumor tissue, malignant transformation. The increase in the size of the uterus is possible with the development of the edema of the node due to a violation of its blood supply.

Submucous uterine myoma

One of the most common signs of the formation of submucous fibroids are uterine bleeding. They can be observed in the process of menstruation, and in the period between them. During menstruation there may be pains of a cramping character. And only in very rare cases can he not show himself. The amount of blood allocated has no connection with the size of the nodal formation. Also, the anemic state of the patient, characterized by general weakness, pallor of the skin, is associated with the signs of submucous myoma, associated with heavy blood loss, both during menstruation and between them.

Forms

Myoma of the uterus can be classified by histological structure, morphogenetic type, as well as by the number and location of myomatous nodes.

According to the histological structure of the tumor, a tumor, developing primarily from muscle tissue, is secreted: the myoma itself; fibromioma - a tumor of connective tissue; fibradenomyoma - a tumor mainly of glandular tissue.

According to the morphogenetic type, depending on the functional state of the muscular elements, one distinguishes:

• simple (benign muscular hyperplasia, mitosis absent);
• proliferating (tumor cells retain their normal structure, but in comparison with the simple myoma of the uterus, the number of them per unit area is much higher, the number of mitoses does not exceed 25%);
• pre-sarcomas (tumors with the presence of multiple foci of proliferation of myogenic elements with phenomena of atypia, the number of mitoses reaches 75%).

By localization of myomatous nodes, the following types are distinguished:

• subserous - the foci are located mainly under the peritoneum on the surface of the uterus;
• intramural - with the arrangement of nodes in the thickness of the myometrium;
• submucous or submucosal - with myomatous nodes localized under the endometrium and disrupting the shape of the uterine cavity;
• intrapigamentary - foci located in the thickness of a wide ligament of the uterus, change the topography of uterine vessels and ureters;
• Cervical are characterized by a low location of the neoplasm in the neck and uterine isthmus.

Myomatous nodes are not adequately provided with blood vessels, most of which pass in a connective tissue capsule.

The degree of development of the vessels depends on the location of the nodes. Intramural nodes have a pronounced vascular pedicle; subserosal nodes poorly provided with blood vessels; submucous nodes of the vascular pedicle do not. Directly in the myomatous nodes vessels are rectilinear, weakly branching, and in them there is no adventitia. All this predisposes to necrobiotic processes in the tumor, stasis, varicose vasodilation, thrombosis, hemorrhagic infarcts.

[33], [34], [35], [36], [37], [38]

Complications and consequences

Complications associated with impaired blood circulation in the tumor area are accompanied in most cases by the clinic of acute inflammatory process up to the development of the acute abdominal picture.

1. Edema. The nodes are soft, on the cut - pale, wet with a "flattering homogeneous surface. The connective tissue and muscle elements move apart by sweating the fluid and undergo degenerative changes. The same processes occur in the walls of the vessels. Most often, edema is subjected to interstitial fibroids. When the edema progresses, cavities filled with fluid develop. Muscle fibers undergo hyaline regeneration. With swelling of the node, it is hyalinized and further violations of its nutrition occur. Such neoplasms are called cystic.
2. Necrosis of nodes. It is noted in 6.8-16% of cases. It is more often observed in subserous and submucous nodes, especially during pregnancy and in the postpartum period. There is dry, wet and red necrosis. With dry (coagulative) necrosis, the tissue is wrinkled, cavities are formed in the areas of necrosis. These changes occur, mainly, in the menopausal period. With wet necrosis, softening and moist necrosis are noted with the formation of racemose cavities filled with necrotic tissue. Red necrosis (hemorrhagic infarction) often develops during pregnancy and intramural myomas. The knot becomes red or brownish-red, of a soft consistency with the smell of rotten fish. Microscopically - the enlargement and thrombosis of veins with the phenomena of hemolysis of the blood. Clinical manifestations of node necrosis - severe pain in the lower abdomen, sometimes cramping, raising of body temperature, chills.
3. Infection of the nodes, suppuration and abscess. These changes often occur on the basis of necrosis of submucous nodes due to an ascending infection. There are similar changes in the subserous and intramural nodes - the hematogenous pathway. The most common causes are strepto-, staphylococci and E. Coli. Symptoms with suppuration of the node are manifested by fever, chills, changes in general condition, lower abdominal pain.
4. The deposition of salts in the nodes. They are noted in the foci that underwent secondary changes. Impregnated phosphoric acid, carbonate and sulphate salts. These deposits are often observed on the surface of the tumor, forming a stony density of the framework. It is possible and total calcification of the tumor.
5. Mucous transformation. Myxomatous changes are revealed. The tumor has a jelly-like appearance with massive translucent yellowish inclusions.
6. Atrophy of the nodes. Gradual wrinkling and reduction of the tumor is determined. Most often, such changes occur in the menopausal period. Atrophy is also possible with castration or with androgen treatment.
7. Often there is hyperplasia of the endometrium of various kinds. Cerebro-cystic endometrial hyperplasia is noted in 4% of cases, basal hyperplasia - in 3,6%, atypical and focal adenomatosis - in 1,8% and polyps of endometrium - in 10% of cases. According to Ya. V. Bokhman (1985), atypical hyperplasia is noted in 5.5%, adenocarcinoma in 1.6% of cases.

[39], [40], [41]

Diagnostics of the uterine fibroids

Anamnesis. Characteristic is the age of the patients, since the uterine myoma occurs more often in the active reproductive age, premenopause; violation of menstrual function, pain syndrome, signs of compression of adjacent organs.

Gynecological status. When examining the cervix, it is necessary to exclude the presence of cervical nodes, cervicitis, cervical disease, and colposcopy.

In cervical myoma, the displacement of the external pharynx, the increase in the size of the cervix, the compaction and deformation of it are determined.

When vaginal examination should pay attention to the mobility and size of the neck, the size, consistency and features of the uterine surface. To clarify the localization of nodes, it is necessary to pay attention to the condition of the ligamentous apparatus, the location of the appendages.

Ultrasound diagnosis helps to accurately identify the tumor, its location, size, as well as the differentiation of myoma nodes from ovarian tumors and other processes in the small pelvis. Modern principles of the diagnosis of uterine fibroids provide for the determination of the volume of the uterus during ultrasound examination, since this indicator most objectively reflects the true dimensions of the tumor.

Uterine size for objective and ultrasound examination

Menstruation (ned)	Term of conception (weeks)	Length (mm)	Width (mm)	Anteroposterior size (mm)	Volume (mm 2 )
5	3	71	50	40	74,000
6th	4	80	57	45	94 000
7th	5	91	68	49	119,000
8	6th	99	74	52	152,000
9	7th	106	78	55	1 S3,000
10	8	112	83	58	229 000
Eleven	9	118	39	62	287 000
12	10	122	95	66	342 000
13	Eleven	135	102	70	365000

Magnetic resonance imaging in patients with uterine myoma and endometriosis contributes to determining the localization of nodes, including cervical, and the establishment of degenerative changes. With subserosal nodes, it is possible to determine the "leg" of the node, its centripetal growth. In addition, a clear picture of the relationship to the cavity and walls of the uterus, contiguous capsule foci.

An important role among diagnostic methods belongs to invasive methods of examination, such as: uterine sounding, hysteroscopy and diagnostic curettage of the uterine cavity.

Sounding. With intramural and submucous nodes, the uterine cavity is enlarged and the protrusion of the uterine walls is revealed in the presence of submucous nodes.

Diagnostic curettage. It is carried out for diagnosis of changes in the state of the endometrium: the phase of the menstrual cycle, polyposis and cancer. In practice, to exclude cancer of the cervical canal, a separate diagnostic curettage of the uterine mucosa and cervical canal is performed.

Probing and especially scraping of the uterus with myoma are dangerous because of the possibility of infection in the nodes and disruption of the integrity of the submucosal nodes. In view of the foregoing, it is advisable to make more extensive use of hysteroscopy.

Hysteroscopy. Used to diagnose submucous nodes and determine the state of the endometrium.

[42], [43], [44], [45], [46], [47], [48], [49]

Treatment of the uterine fibroids

Tactics of passive medical supervision of patients should be excluded.

Treatment of uterine fibroids depends on the symptoms, size, number and location of myomatous nodes, the patient's desire to maintain reproductive function, age, the presence of concomitant pathology, the features of patho- and morphogenesis of the tumor, and localization of the foci.

Pathogenetically substantiated concept of treatment is a combined effect - surgical and medicamentous. Therefore, despite the emergence of new operational technologies (the use of endoscopic techniques, lasers, electro- and cryosurgery), hormone therapy has not lost its significance. The goal of conservative treatment is to reduce the severity of clinical symptoms and / or the size of the lesion. For this purpose, gestagens, androgens, antiandrogens, gonadotropin-releasing hormone agonists (a-HH-RG) are now widely used.

The agonists of Gn-RG (zoladex) are prescribed to patients as preoperative preparations in order to:

• reduction of tumor volume and creation of favorable conditions for surgical intervention;
• decrease in the estimated intraoperative blood loss.

Indications for surgical treatment of patients are:

• large tumor sizes (over 14 weeks of gestation);
• submucosal neoplasm, accompanied by prolonged and profuse menstruation, anemia;
• rapid growth of the tumor;
• subperitoneal fibroids on a thin base (on a "pedicle"); these tumors are associated with a high risk of torsion of the base of the node and subsequent development of its necrosis;
• necrosis of the myomatous node;
• violation of the function of neighboring organs;
• Cervical uterine myoma, localized in the vagina;
• combination of neoplasm with other genital diseases requiring surgical intervention;
• infertility (in those cases when it is conclusively proven that the cause of infertility is the uterine myoma).

Surgical treatment is divided into radical, semi-radical and conservative. According to the nature of access to the pelvic organs, operations are divided into abdominal and vaginal. The scope of surgical intervention depends on the age of the patient, concomitant gynecological diseases (condition of the endometrium, cervix, ovaries, fallopian tubes), reproductive function.

The radical operations include:

• extirpation of the uterus;
• supravaginal amputation of the uterus.

By semi-radical operations, after which the menstrual period is retained, but there is no reproductive function of the woman, the following can be classified:

• defundation of the uterus;
• high amputation of the uterus.

To the conservative:

• enucleation of nodes (conservative myomectomy);
• removal of submucous nodes.

Young women interested in preserving the reproductive function are given conservative myomectomy. Conservative myomectomy with a subserous tumor arrangement is performed both in laparoscopic and quadroretically. With submucosal tumor localization, myomectomy can be performed with hysteroresectoscopy.

Radiation therapy of uterine fibroids has, in the main, historical significance.

Indications for the appointment of radiation therapy is the impossibility of using surgical and hormonal treatment.

The effectiveness of radiation therapy is due to the ovarian function being turned off and is manifested by a decrease in the size of the tumor, the cessation of bleeding.