Myoma of the uterus
- Prevalence of uterine fibroids
- Types and stages of uterine fibroids
- Classification of myomatous neoplasms
- Symptoms of uterine fibroids
- Diagnosis of uterine fibroids
- Treatment of uterine fibroids
- Prevention of uterine fibroids
Myoma is one of the most common gynecological pathologies of non-inflammatory nature, which, according to many modern specialists, does not apply to true tumors. This is a benign, hormone-controlled hyperplasia of the muscular layer of the uterine wall of the mesenchymal origin, which develops as a result of somatic mutation of cells that occurs under the influence of various damaging factors. It is presented in the form of a tumor consisting of intertwined muscle and connective tissue fibers. In clinical practice, there is a myoma of the uterus and myoma of the cervix.
Prevalence of fibroids
This disease, as a rule, is revealed during the next preventive examination in women who have reached the age of 35 (20-40% of the total). It is characteristic that city residents are more prone to this pathology than women living in rural areas. At a young age, myoma is very rare, and it never occurs in adolescents, before puberty, that is, the period of puberty. With a decrease in the level of sex hormones in the blood, which leads to the onset of menopause, myoma, as a rule, begins to decrease in size and gradually resolves.
Myoma is a multifactorial disease. Until now, the true cause of its development is not known to science. The risk factors that contribute to the formation of myomatous nodes include:
- Later, the formation of menstrual function, that is, the late arrival of the first menstruation;
- Abundant menstrual bleeding;
- Frequent medical abortions in history;
- The presence of gynecological diseases;
- Addiction to meat food;
- Change of climatic zones;
- Reduced activity of cellular immunity;
- Addiction to meat products;
- Ethnic factor (in Afro-American women, the risk of developing myomas is twice as high as in women of the Caucasian race).
However, the risk factors for the development of fibroids include such ectrarital disorders as overweight and obesity, cardiovascular and digestive disorders, neuroses and pseudo-neurotic conditions, hormonal disorders (diabetes mellitus), hypertension and frequent stress. Some experts argue that the genetic predisposition is also a risk factor for the development of this disease. The cause of myoma at a young age (in girls under 25), according to doctors, is the damage of uterine cells that occurred in the antenatal period of fetal development.
Types and stages of uterine fibroids
In the course of numerous studies it was found that the rudiments of myomatous nodes appear even in the embryonic period of development of the female body. In the antenatal period, the fetal uterus develops from two mullerian ducts. In this case smooth muscle cells form up to 30 weeks from the mesoderm. However, smooth muscle cells of the uterus can proliferate and undifferentiated cells. They are the prerequisites of myomatous neoplasms when they develop intrauterine, under the influence of various endogenous and exogenous factors. These progenitor cells, remaining in the muscular layer of the uterus, after menarche (arrival of the first menstruation) begin to grow. This growth is a consequence of the expressed secretory activity of hormones produced by the ovaries (estrogens and progesterone).
At the same time, the anlage of the myomatous node can be formed from the muscular membrane of the vessels feeding the uterus, that is, from the pericyte.
According to experts, under the influence of local growth factors, sex hormones and somatic mutations, myometrium can be transformed into myoma.
The myomatous node begins its development from the growth zone located around the thin-walled blood vessel.
There are three stages of morphogenesis of myoma:
- Formation in the myometrium of the rudiment (active growth zone).
- Growth of undifferentiated tumor.
- Growth and maturation of a tumor with differentiated elements.
Some authors argue that the development of a pathological process can be disturbed in the myomatous nodes of neuromuscular regulation, and therefore they are considered to be formations devoid of neural connections with the central nervous system.
To date, uterine fibroids are divided into simple and proliferating
In simple myomas, the growth zones do not reach large sizes and are located in the circulatory space. For proliferating fibroids, the perivascular position is also characteristic, but at the same time, due to its increased "cellularity", it reaches considerable dimensions. However, the principal difference between simple myomatous nodes and proliferating ones is the accumulation of the extracellular matrix in the first and almost complete absence of it in the second. It should be noted that with a change in the balance of growth factors, a simple myoma can transform into proliferating, and vice versa.
In patients with fast-growing tumors proliferating fibroids are most often detected, and simple ones in patients with a slow or moderate tumor growth rate.
Like any neoplasm, myoma is able to grow and increase, reaching sometimes very large. The mass of the tumor can often reach 3-5 kg, rarely 15-20 kg.
Due to the fact that the myoma is a tumor not only of mesenchymal origin, since it can be formed from coelomic epithelium), a large morphological diversity of the types of these tumors occurs in clinical practice.
Classification of myomatous neoplasms
Most often (in 95% of cases) fibroids are localized in the uterus body, and only 5% in the cervix. They can be single and multiple (multiple fibroids in clinical practice occur much more often).
Classification of myomas by the location of the direction of growth in the uterus
1. Myomatous neoplasms with typical localization:
Subferrous (subperitoneal) myoma is a tumor on the pedicle or on a wide base, located in the peritoneum on the surface of the uterus body and growing towards the abdominal cavity. In this case, the myomatous nodes located on the stalk are able to attach to nearby structures (intestine, epiploon or mesentery), developing a secondary blood supply. If the tumor loses its primary blood supply, the parasitizing leiomyoma is diagnosed, and in the case where the myomatous nodes are located between the broad ligaments, it is an intraligamentary myoma.
Submucous (submucosal) myoma is a neoplasm localized under the mucous membrane of the endometrium, the growth of the nodes of which is directed towards the uterine cavity. It can also have a foot or a wide base. Myoma on the leg is sometimes able to "fall out" of the cervical canal, subject to twisting and infection.
Interstitial (intermuscular) myoma - a tumor, the nodes of which are in the thickness of the wall of the uterus.
2. Myomatous neoplasms with atypical localization:
Inter-connective (located behind the peritoneum subserous myoma).
Classification of myomas by localization in relation to the uterine axis
- Corporal myoma is the most common tumor (90.2%), which is located in the body of the uterus.
- Isthmic, or perechechnaya myoma - a neoplasm that causes pain in the bladder.
- Cervical (cervical) myoma is a tumor that grows in the vagina and provokes the development of various infectious complications.
a). Ordinary leiomyoma is a mature hormone-dependent tumor, which is a knot of dense consistency, clearly delineated from healthy tissue. This new formation, consisting only of smooth muscle cells of myometrium, is surrounded by a hyalineized connective tissue layer resembling a capsule. Tumor growth occurs towards the soft tissues, while the integrity of the endothelium is not disturbed.
b). Cell leiomyoma is a tumor of a soft consistency with distinct boundaries, usually located inside the uterine wall. This neoplasm can actively grow during pregnancy. On histological sections examined under a microscope, cells with enlarged, slightly elongated nuclei and low mitotic activity are found.
at). A whimsical leiomyoma is a neoplasm consisting not only of muscle cells of a rounded shape. It also includes multinucleated giant polygonal cells, due to which sometimes this tumor is confused with leiomyosarcoma. However, the confirmation of its benign nature is a small number (or complete absence of mitosis), as well as the lack of infiltrative growth.
g). Epithelial leiomyoma, or leiomyoblastoma, is a tumor that is rare in clinical practice. It consists of a smooth muscle tissue and elements of the vascular walls.
e). Metastatic leiomyoma is also a very rare variant of the tumor. In the course of a histological study, the neoplasm of this tumor is confirmed, but at the same time it is able to metastasize into vascular cracks, and grow into the lumen of the vessel. In the event that the tumor cells come off, they, together with the blood stream, can enter the stomach or into the lungs, where a new myomatous node begins to develop.
f). Proliferating, or growing leiomyoma is a neoplasm, characterized by slow growth and the presence of proliferative zones located in the thickness or along the periphery of the tumor. Initially, the cellular elements in them are presented in the form of couplings, and then they are gradually transformed into the smooth muscle tissues that grow and merge with the surrounding tissues.
g). Myoma with presarcoma phenomena (malignant leiomyoma) is a neoplasm in which atypical cells and cell nuclei are detected.
2. Fibromioma. Depending on the age of the myoma, its microstructure changes. With the passage of time, the neoplasm becomes a clearly bounded site, acquiring the character of fibromyoma (a tumor consisting of connective tissue and muscle elements).
с «возрастом» миомы соединительная ткань становится более грубой и гиалинизированной, а её количество увеличивается. Note: with the "age" of myoma, connective tissue becomes more coarse and hyalineized, and its amount increases.
3. Rhabdomyoma - a neoplasm of benign nature, consisting of striated muscle tissue.
Symptoms of uterine fibroids
The most characteristic symptom of this disease is the development of severe menstrual bleeding. The abdomen increases in size, almost all patients complain of discomfort and the occurrence of pains of varying intensity. There are also painful sensations in the lower back, constipation develops, urination becomes frequent. In the case when there is a twisting of the legs of myoma, symptoms of an acute abdomen are observed.
Clinical manifestations of the disease depend on the site of localization, the direction of growth of myomatous nodes, the size of the tumor, the age of the patient, and also the presence of concomitant gynecological pathologies.
In 25-30% of cases, the development of myoma occurs very slowly, and at first it is not accompanied by a marked symptomatology. Most often for the first time the tumor is detected during pregnancy (since dense myomatous nodes are easily probed on softened myometrium). At the same time, fibroids can be detected during preventive examination, installation of an intrauterine device, ultrasound of the pelvic organs and other diagnostic procedures.
In the case when the patient develops a corporeal myoma of the subperitoneal localization, which has a pedicle or a wide base, due to which her nutrition takes place, the functional activity of the uterus remains unchanged, and therefore all the above symptoms are usually absent.
With the development of a subperitoneal myoma located in the cervical region (or in the isthmus region), the patients complain of bladder problems and pain of varying intensity developing in this area. In this case, urination is difficult, there is discomfort in the vagina, cystitis develops, bladder emptying does not happen until the end. This form of pathology causes deformity of the cervix, infertility or spontaneous abortion. If pregnancy does occur, the symptoms of compression of nearby organs often develop. However, the tumor, due to a violation of blood supply in the pelvic region, can provoke venous congestion and vein thrombosis.
Clinical signs of an acute abdomen are observed in the case when the subperitoneal myoma is twisted legs.
при возникновении резких болей и признаков раздражения брюшины, повышении температуры тела, тошноте и рвоте следует в обязательном порядке провести дифференциальную диагностику с острым аппендицитом, внематочной беременностью, острым воспалением придатков, перекрутом кисты яичника. Note: In case of acute pain and signs of irritation of the peritoneum, an increase in body temperature, nausea and vomiting, differential diagnostics with acute appendicitis, ectopic pregnancy, acute inflammation of the appendages, and torsion of the ovarian cyst should be carried out without fail.
Aching pain in the sacrum and in the lower back are one of the most characteristic signs of the onset of the myomatous node on the posterior wall of the uterus. Retrotservikalnaya myoma moves the uterus forward, filling a small pelvis and squeezing the rectum. As a consequence, patients develop hemorrhoids or chronic colitis, there are frequent desires for defecation, and there is a constant feeling of incomplete emptying of the rectum.
In the case when the tumor grows upwards, it begins to squeeze the ureters, because of which the outflow of urine is disturbed, pyelonephritis can also join the pathological process, and in severe cases - hydronephrosis.
Secondary changes in the myomatous node that result from the torsion of the tumor stem or due to the large size of the neoplasm cause edema and subsequent necrosis (in the presence of a clinical picture of the acute abdomen).
пациентке требуется срочное хирургическое вмешательство, так как в противном случае может развиться гнойный перитонит. Note: the patient needs urgent surgical intervention, as otherwise purulent peritonitis may develop.
Diagnosis of uterine fibroids
The presence of uterine fibroids can show a palpation examination of the pelvic organs. However, in order to confirm this diagnosis, you need ultrasound. As a rule, a diagnostic examination begins with an examination of an anamnesis and a thorough gynecological examination of the patient. The specialist must pay attention to the presence of factors characteristic of this pathology: the absence of labor in the late reproductive age (after 30-35 years), heavy blood loss in menstruation, late onset of menstruation and early menopause, abortion, prolonged intrauterine contraception, irregular sexual life, inflammatory gynecological diseases, etc. At the same time, one should pay attention to the fact that myoma can be hereditary. As a rule, hereditary fibroids are diagnosed in young women (under 25 years of age), who are prone to frequent stresses, as well as those who often were ill during adolescence.
The uterus in patients suffering from fibroids is enlarged and has a dense, bumpy surface. In the presence of a large myomatous node, as a rule, it is inactive and deformed, and sometimes it can reach very large sizes.
Ultrasound (echography) of the uterus is one of the most accessible, safe and informative methods of diagnostic research. As a rule, at the present stage most often ultrasound-diagnosis of pelvic organs provides for simultaneous transvaginal and transabdominal examination. Due to this technique, localization, size and structure of myoma nodes are determined. The sensitivity of this method is 80-100%.
With the development of proliferating fibroids, the uterus is the same size as the 14-17 week gestation. In the case when a specialist suspects malignant transformation (malignization) of the endometrium or myomatous node, color Doppler mapping is performed. With its help, the blood flow is evaluated and the presence of newly formed pathological vessels is revealed.
Diagnostic hysteroscopy is a technique that involves the use of a hysteroscope. With its help, the examination of the walls of the uterus is carried out with suspicion of the development of submucous fibroids (it looks in the form of pale pink formations of oval or round shape).
Retnenovestvizionnaya hysterosalpingography is a diagnostic method that helps visualize the deformation of the inner surface of the uterus, submucous myomatous nodes, intramuscular adhesions, etc.
данная методика, позволяющая получить избирательные снимки, назначается не всем пациенткам, а только по показаниям. Note: this technique, which allows to obtain selective pictures, is not assigned to all patients, but only according to indications.
If there is a suspicion of a malignant process in the endometrium or in the cervical canal, a cytological examination of the material is carried out.
It is very well recommended in gynecological practice diagnostic curettage, conducted under the control of hysteroscopy followed by histological examination of scrapings. Thus, the diagnosis of the state of the endometrium. As a rule, diagnostic scraping is prescribed with the rapid growth of fibroids, before performing an organ-preserving or radical operation, and before prescribing conservative treatment.
It should be noted that prior to the appointment of a surgical operation, the specialist is required to conduct a thorough examination of the patient in order to identify concomitant pathologies. Mandatory evaluation of the urinary tract should be performed ultrasound of the kidneys, as well as other additional methods of research.
при постановке диагноза миому следует дифференцировать с лейомиосаркомой и узловатой формой аденомиоза. Note: when making a diagnosis, myomas should be differentiated with leiomyosarcoma and a knotty form of adenomyosis.
Treatment of uterine fibroids
It is most expedient to begin treatment of fibroids immediately after diagnosis, since subsequent passive observation can lead to progression of the disease and further growth of myomatous nodes. As a consequence, pathological uterine bleeding is intensified, chronic iron deficiency anemia develops, hyperplastic disorders in the endometrium and systemic disorders in the whole organism (decrease in immunological activity, hypovolemia (decrease in the volume of circulating blood), hyperplastic processes and vascular disorders).
Currently, for medical reasons, conservative and operative treatment of fibroids is carried out. As a rule, the tactics of treatment are chosen depending on the size, localization and clinical and morphological variant of the tumor, the hormonal status of the patient, the condition of her reproductive systems, etc. Some experts believe that it is not worth hurrying with the operation, but it is more reasonable to observe the state of the woman's health before the onset menopause. This is due to the fact that during the menopause the tumor ceases to grow. Therefore, competent professionals urge before removing the genital organ, to clearly define the indications for the operation.
1. Many patients suffering from infertility or repeated miscarriage are recommended to perform a conservative myoectomy (of course, if there is no more likely cause of infertility or repeated miscarriage in a history). If the operation is successful, the woman retains the uterus and reproductive function.
When carrying out myoectomy, only the myomatous nodes are removed, and the uterus body is retained. This operation is carried out in 4 stages with the help of a laparoscope. Initially, the myomatous nodes are cut off and removed, then the defects of the myometrium are restored, the cut off nodes are removed, and finally the abdominal cavity is sanitized (removal of blood clots and endoscopic hemostasis of all available bleeding sites). This prevents the development of adhesions.
по статистике, у четверти женщин, перенесших миоэктомию, наблюдается повторный рост опухоли, а также развиваются рубцовые изменения в матке и в других органах малого таза, которые способны спровоцировать бесплодие. Note: According to statistics, a quarter of women who have had a myoectomy experience repeated growth of the tumor, as well as cicatricial changes in the uterus and in other pelvic organs that can provoke infertility.
2. If the myomatous nodes can not be removed and a fairly common pathological process is detected, the patient is shown hysterectomy (a radical operation involving amputation of the uterus). However, indications for the complete removal of the uterus are abundant prolonged menstruation with the release of blood clots, anemia that has arisen due to blood loss, severe pain, constant pressure in the lower abdomen or in the lumbar region, frequent urge to urinate.
In this case, gynecologists do not recommend spending time and money on conservative treatment, as it can only give temporary relief (or not at all).
3. In the case when the patient does not need surgical intervention for medical reasons, she is prescribed conservative therapy, which will help to slow down the growth of the tumor. Such treatment takes place with asymptomatic or low-symptomatic myoma, which does not cause profuse bleeding, which provokes the development of iron deficiency anemia. It is prescribed for women suffering from severe extragenital pathologies and chronic inflammatory processes of the internal genital organs and small pelvic fibrosis, and also when the myoma is combined with adenomyosis or endometriosis of the cervix.
4. The most basic pathogenetic conservative method of treatment is hormonal therapy, which involves the use of androgens and COCs (combined estrogen-progestogen drugs). Thanks to such treatment, menstrual blood loss is reduced, the general condition of the patient improves, the tumor stops growing and even its size can decrease, and water-salt metabolism is normalized.
Conducting conservative treatment includes the appointment of iron preparations, small antipsychotics and sedatives. Adaptogens, immunocorrectors, prostaglandin synthetase inhibitors, combined multivitamins with microelements and iodine preparations were not bad at all. During the exacerbation of the inflammatory process, according to medical indications, antibiotic therapy is performed. At the same time, patients are shown a special diet, apparatus physiotherapy, exercise therapy, mineral water treatment, etc.
It should be noted that in some cases, conservative treatment avoids amputation of the uterus. It can be quite effective at any age, up to the onset of menopause. However, at all stages of treatment of fibroids should observe the maximum oncological alertness.
Prevention of uterine fibroids
First of all, a woman should lead a healthy lifestyle, eat rationally, avoid accumulation of body weight and abandon bad habits. It is also very important physical activity and a normal, full-fledged sleep.
Harmony in matrimonial relations plays an important role in the prevention of myoma development (normalization of sexual life).
Every woman who has reached adulthood, or has started sexual activity, must undergo an annual gynecological examination. This will make it possible to identify the existing pathology as early as possible and to prescribe a timely treatment.
According to many experts, it is very important, in order to avoid the premature aging of myocytes (muscle cells), to give birth to the first child up to 27-30 years.
Every woman should know that most often the uterine myoma begins to develop in 30-35 years. Then for another five years it grows to a macroscopically determined site. Therefore, in this period, adverse external and internal impacts should be avoided whenever possible.
It is very important at this age to protect yourself from unwanted pregnancy, well, and if pregnancy has occurred, then, given contraindications, it should, if possible, be maintained. This is due to the fact that abortion provokes an increased growth of even barely formed tumor.
After 30 years, it is recommended to avoid exposure to high temperatures and excessive solar insolation.
Hereditary fibroid is a disease that develops much earlier (after 20 years). Therefore, experts urge to save the first pregnancy. At the same time, breastfeeding of a child can prevent the further development of an already existing tumor.
As a prophylaxis for the development of hyperplastic processes in the endometrium, patients with large fibroids are shown to have a timely excision of myomatous nodes.