Uterine myoma

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

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

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Epidemiology

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

After 50 years, fibroids develop in 20% - 80% of women.

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Causes uterine myomas

The exact cause of uterine fibroids is unclear. However, hormonal imbalance, obesity, and genetic predisposition are thought to play a role in the development of the disease.

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Symptoms uterine myomas

Uterine myoma has very polymorphic symptoms and they depend on the patient's age, duration of the disease, localization and size of the tumor, its morphogenetic type, as well as concomitant 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 - within 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 are closely related to the location of the myomatous node, its size and the rate of tumor growth. The first symptoms of uterine myoma in most cases make themselves known at thirty-five to forty years of age, 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 may be asymptomatic.

Main features:

• uterine bleeding;
• heavy and prolonged periods;
• pulling and pressing pain in the lower abdomen;
• irradiation of pain to the lumbar region, lower limbs;
• frequent urination;
• constipation;
• hot flashes;
• anemia.
• pain,
• bleeding,
• dysfunction of adjacent organs,
• tumor growth.

Frequent urge to urinate occurs if the tumor grows toward the bladder, putting pressure on it. Constipation is associated with the growth of the tumor toward the rectum, which compresses its lumen and causes stool retention. It is also important to pay attention to what symptoms of uterine fibroids are secondary. These include dizziness, headache, and general deterioration in health, often associated with anemia resulting from a decrease in hemoglobin and red blood cell levels, heart pain may be a concern, and discomfort and pain may also occur during sexual intercourse.

Pain

As a rule, the pain is localized in the lower abdomen and lower back. Constant aching pain accompanies subperitoneal myoma and is caused by stretching of the peritoneum and/or compression of the pelvic nerve plexuses. Often severe prolonged pain is associated with rapid tumor growth. Acute pain occurs mainly when blood supply to the tumor is disrupted, the progression of which can lead to the development of a clinical picture of acute abdomen. Cramping pain during menstruation accompanies submucosal localization of the tumor and indicates the long history 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 origins, etc.

Bleeding

Bleeding is the most common symptom of uterine myoma. Heavy and prolonged menstruation (menorrhagia) is typical for submucosal localization of the tumor. Their origin is due to a decrease in uterine tone, an increase in the menstrual surface, as well as the structural features of the vessels supplying the submucosal myomatous nodes (the adventitia is lost in these vessels, which increases their permeability and simultaneously reduces contractile activity when the integrity of the vessels is compromised). Acyclic uterine bleeding (metrorrhagia) is more typical for intermuscular and subperitoneal localization of the neoplasm, but their most common cause is concomitant pathological changes in the endometrium.

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Dysfunction of adjacent organs

Changes in the function of adjacent organs are usually observed with subperitoneal, cervical and interligamentous localization of nodes and/or relatively large tumor sizes. Nodes located in front of the uterus put pressure on the urinary tract and contribute to impaired urination with subsequent formation of hydroureter, hydronephrosis and pyelonephritis; retrocervical tumors complicate the act of defecation. However, in some cases, the cause of dysfunction 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 reproductive and urinary systems in women, as well as the anatomical and embryonic relationships between the organs of these systems.

Tumor growth

The growth of uterine myoma often determines the clinical course of the disease. In general, the tumor grows slowly, but there is also a rapid increase in the tumor size. Rapid growth of a neoplasm means an increase in its parameters over a year or a shorter period by an amount corresponding to a 5-week pregnancy. The causes of rapid growth of a neoplasm may be accelerated proliferation processes in the tumor tissue, its malignant transformation. An increase in the size of the uterus is possible with the development of edema of the node due to a disruption of its blood supply.

Submucous uterine myoma

One of the most common signs of submucous myoma formation is uterine bleeding. It can be observed both during menstruation and in the period between them. During menstruation, there may be cramping pain. And only in very rare cases may it not manifest itself in any way. The amount of blood released has no connection with the size of the nodular formation. Also, the signs of submucous myoma include the anemic state of the patient, characterized by general weakness, paleness of the skin, associated with heavy blood loss, both during menstruation and between them.

Forms

Uterine fibroids can be classified by histological structure, morphogenetic type, as well as by the number and location of fibroid nodes.

According to the histological structure of the tumor, the following are distinguished: myoma proper - a tumor that develops primarily from muscle tissue; fibromyoma - a tumor from connective tissue; fibradenomyoma - a tumor primarily from glandular tissue.

According to the morphogenetic type, depending on the functional state of the muscle elements, the following are distinguished:

• simple (benign muscular hyperplasia, no mitoses);
• proliferating (tumor cells retain a normal structure, however, in comparison with simple uterine myoma, their number per unit area is significantly higher, the number of mitoses does not exceed 25%);
• presarcomas (tumors with the presence of multiple foci of proliferation of myogenic elements with atypia, the number of mitoses reaches 75%).

According to the localization of myomatous nodes, the following types are distinguished:

• subserous - foci are located mainly under the peritoneum on the surface of the uterus;
• intramural - with nodes located in the thickness of the myometrium;
• submucous or submucous - with myomatous nodes localized under the endometrium and disrupting the shape of the uterine cavity;
• intrapigmentary - foci are located in the thickness of the broad ligament of the uterus, changing the topography of the uterine vessels and ureters;
• Cervical tumors are characterized by a low location of the neoplasm in the area of the cervix and isthmus of the uterus.

Myomatous nodes are not sufficiently supplied with blood vessels, the majority of which pass through the connective tissue capsule.

The degree of development of vessels depends on the location of the nodes. Intramural nodes have a pronounced vascular pedicle; subserous nodes are poorly supplied with vessels; submucous nodes do not have a vascular pedicle. Directly in the myomatous nodes, the vessels are straight, weakly branching, and there is no adventitia in them. All this predisposes to necrobiotic processes in the tumor, congestion, varicose veins, thrombosis, hemorrhagic infarctions.

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Complications and consequences

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

1. Edema. The nodes are soft, pale in color on section, moist with a "flattened homogeneous surface. Connective tissue and muscle elements are pushed apart by fluid oozing and undergo degenerative changes. The same processes occur in the walls of blood vessels. Interstitial myomas are most often subject to edema. As the edema progresses, cavities filled with fluid are formed. Muscle fibers undergo hyaline degeneration. When a node swells, it becomes hyalinized and various disturbances in its nutrition occur. Such neoplasms are called cystic.
2. Necrosis of nodes. It is observed in 6.8-16% of cases. It is most often observed in subserous and submucous nodes, especially during pregnancy and in the postpartum period. Dry, wet and red necrosis occur. Dry (coagulation) necrosis is characterized by tissue shrinkage, and cavities are formed in the areas subject to necrosis. These changes occur mainly during the menopausal period. Wet necrosis is characterized by softening and wet necrosis with the formation of cyst-like cavities filled with necrotic tissue. Red necrosis (hemorrhagic infarction) most often develops during pregnancy and in intramural myomas. The node becomes red or brownish-red, soft in consistency and smells like rotten fish. Microscopically - dilation and thrombosis of veins with hemolysis of the blood. Clinical manifestations of node necrosis are severe pain in the lower abdomen, sometimes cramping, increased body temperature, and chills.
3. Infection of nodes, suppuration and abscess. These changes often occur due to necrosis of submucous nodes due to ascending infection. Similar changes are possible in subserous and intramural nodes - by hematogenous route. Most often, the causes are streptococci, staphylococci and E. coli. Symptoms of suppuration of the node are manifested by fever, chills, changes in general condition, pain in the lower abdomen.
4. Salt deposits in nodes. They are observed in foci that have undergone secondary changes. Phosphoric, carbonic and sulphate salts are impregnated. These deposits are often observed on the surface of the tumor, forming a stony-density framework. Total calcification of the tumor is also possible.
5. Mucous transformation. Myxomatous changes are revealed. The tumor has a jelly-like appearance with massive translucent yellowish inclusions.
6. Atrophy of nodes. Gradual shrinkage and reduction of the tumor is determined. Most often, such changes occur during the menopausal period. Atrophy is also possible with castration or androgen treatment.
7. Endometrial hyperplasia of various types often occurs. Glandular-cystic endometrial hyperplasia is observed in 4% of cases, basal hyperplasia - in 3.6%, atypical and focal adenomatosis - in 1.8%, and endometrial polyps - in 10% of observations. According to Ya. V. Bohman (1985), atypical hyperplasia is observed in 5.5%, adenocarcinoma - in 1.6% of cases.

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Diagnostics uterine myomas

Anamnesis. The age of the patients is characteristic, since uterine myoma occurs more often in active reproductive age, premenopause; menstrual dysfunction, 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 diseases, and perform a colposcopy.

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

During vaginal examination, it is necessary to pay attention to the mobility and size of the cervix, the size, consistency and features of the surface of the uterus. To determine the localization of nodes, it is necessary to pay attention to the condition of the ligamentous apparatus, the location of the appendages.

Ultrasound diagnostics helps to accurately identify the tumor, its location, size, and differentiate myomatous nodes from ovarian tumors and other processes in the small pelvis. Modern principles of uterine myoma diagnostics include determining the volume of the uterus during ultrasound examination, since this indicator most objectively reflects the true size of the tumor.

Uterine size during objective and ultrasound examination

Menstruation (weeks)	Period of conception (weeks)	Length (mm)	Width (mm)	Front-rear dimension (mm)	Volume ( mm2 )
5	3	71	50	40	74000
6	4	80	57	45	94,000
7	5	91	68	49	119000
8	6	99	74	52	152000
9	7	106	78	55	1 S3 000
10	8	112	83	58	229,000
11	9	118	39	62	287,000
12	10	122	95	66	342,000
13	11	135	102	70	365000

Magnetic resonance imaging in patients with uterine myoma and endometriosis helps to determine the localization of nodes, including cervical ones, and to establish degenerative changes. In the case of subserous nodes, it is possible to determine the "pedicle" of the node, its centripetal growth. In addition, a clear picture of the relationship to the cavity and walls of the uterus is revealed, the capsule of the foci is contoured.

A major role among diagnostic methods belongs to invasive examination methods, such as: uterine probing, hysteroscopy and diagnostic curettage of the uterine cavity.

Probing. In case of intramural and submucous nodes, the uterine cavity increases and protrusion of the uterine walls is revealed in the presence of submucous nodes.

Diagnostic curettage. It is performed to diagnose changes in the condition of the endometrium: phases of the menstrual cycle, polyposis and cancer. In practice, to exclude cancer of the cervical canal, separate diagnostic curettage of the mucous membrane of the uterus and cervical canal is performed.

Probing and especially curettage of the uterus in case of myoma are dangerous due to the possibility of introducing infection into the nodes and disruption of the integrity of the submucous nodes. Taking into account the above, it is advisable to use hysteroscopy more widely.

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

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Treatment uterine myomas

The tactics of passive medical observation of patients should be excluded.

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

The pathogenetically substantiated concept of treatment is a combined effect - surgical and medicinal. Therefore, despite the emergence of new surgical technologies (the use of endoscopic equipment, lasers, electro- and cryosurgery), hormonal 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 neoplasm. For this purpose, gestagens, androgens, antiandrogens, gonadotropin-releasing hormone agonists (a-Gn-RH) are currently widely used.

GnRH agonists (zoladex) are prescribed to patients as preoperative preparation for the purpose of:

• reducing the tumor volume and creating favorable conditions for surgical intervention;
• reducing the expected intraoperative blood loss.

Indications for surgical treatment of patients are:

• large tumor size (over 14 weeks of pregnancy);
• submucosal location of the neoplasm, accompanied by prolonged and heavy menstruation, anemia;
• rapid tumor growth;
• subperitoneal myoma on a thin base (on a “pedicle”); these tumors are associated with a high risk of torsion of the base of the node and the subsequent development of its necrosis;
• necrosis of myomatous node;
• dysfunction of adjacent organs;
• cervical uterine myoma localized in the vagina;
• combination of neoplasm with other diseases of the genital organs requiring surgical intervention;
• infertility (in those cases where it has been convincingly proven that the cause of infertility is uterine fibroids).

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 patient's age, concomitant gynecological diseases (condition of the endometrium, cervix, ovaries, fallopian tubes), reproductive function.

Radical operations include:

• hysterectomy;
• supravaginal amputation of the uterus.

Semi-radical operations, after which menstrual function is preserved but the woman's reproductive function is absent, may include:

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

To the conservative:

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

Conservative myomectomy is performed on young women interested in preserving their reproductive function. Conservative myomectomy for subserous tumors is performed both by laparotomy and laparoscopy. For submucosal tumors, myomectomy can be performed using hysteroresectoscopy.

Radiation therapy for uterine fibroids is primarily of historical significance.

Indications for the use of radiation therapy are the impossibility of using surgical and hormonal treatment.

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