- Prevalence of uterine fibroids
- Types and stages of uterine fibroids
- Classification of myoma tumors
- 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 a non-inflammatory nature, which, according to many modern specialists, does not apply to true tumors. This is a benign, hormonally controlled hyperplasia of the muscular layer of the uterine wall of mesenchymal origin, which develops as a result of the 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, uterine body fibroids and cervical fibroids are found.
Prevalence of fibroids
This disease is usually detected in the course of the next routine examination of women over 35 years of age (20-40% of the total). Characteristically, urban women are more susceptible to this pathology than women living in rural areas. At a young age, fibroids are very rare, and it never occurs in adolescents, before the onset of puberty, that is, puberty. With a decrease in the level of sex hormones in the blood, which entails the onset of menopause, fibroids, as a rule, begin to decrease in size and gradually dissolve.
Myoma is a disease of multifactorial nature. So far, the true reason for its development is not known to science. Risk factors contributing to the appearance of myomatous nodes include:
- The late formation of menstrual function, that is, the late arrival of the first menstruation;
- Profuse menstrual bleeding;
- Frequent medical abortions in history;
- The presence of gynecological diseases;
- Addicted to meat food;
- Change of climatic zones;
- Decrease in the activity of cellular immunity;
- Addiction to meat products;
- Ethnic factor (African American women have a twice higher risk of developing fibroids than women of the European race).
At the same time, clinicians include risk factors for developing fibroids such extragenital pathologies, such as overweight and obesity, disorders of the cardiovascular system and the digestive tract, neuroses and pseudo-neurotic states, hormonal disorders (diabetes mellitus), hypertension, and frequent stress. Some experts argue that genetic predisposition is also a risk factor for the development of this disease. The cause of fibroids at a young age (in girls under 25 years of age), according to doctors, is uterine cell damage 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 beginnings 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. At the same time, smooth muscle cells form up to 30 weeks from the mesoderm. However, in the smooth muscle cells of the uterus, undifferentiated cells can proliferate. It is they who, during fetal development, under the influence of various endogenous and exogenous factors, become the precursor of myomatous tumors. These precursor cells, remaining in the uterine muscle layer, after menarche (the arrival of the first menstruation) begin to grow. This growth is a consequence of a pronounced secretory activity of hormones produced by the ovaries (estrogen and progesterone).
However, the germ of myoma node can be formed from the muscular membrane of the vessels that feed the uterus, that is, from the pericytes.
According to experts, under the influence of local growth factors, sex hormones and somatic mutations, myometrium can be transformed into myoma.
Myomatous node begins its development from the growth zone, located around the thin-walled blood vessel.
There are three stages of fibroid morphogenesis:
- Formation in the myometrium of the rudiment (active growth zone).
- Undifferentiated tumor growth.
- Growth and maturation of the tumor with differentiated elements.
Some authors argue that a disorder in the myomatous nodes of the neuromuscular regulation can provoke the development of the pathological process, and therefore, they are considered to be formations lacking neural connections to the central nervous system.
Today, uterine fibroids can be divided into simple and proliferating
In simple myoma, growth zones do not reach large sizes and are located around the vascular space. Perivascular location is also characteristic of proliferating fibroids, but at the same time, due to its increased “cellularity”, it reaches a considerable size. However, the principal difference between simple myomatous and proliferative nodes is the accumulation of the extracellular matrix in the first and its almost complete absence in the second. It should be noted that by changing the balance of growth factors, a simple myoma can be transformed into a proliferating one, 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, fibroids can grow and grow, sometimes reaching very significant sizes. The mass of the tumor can often reach 3-5 kg, less often - 15-20 kg.
Due to the fact that myoma is a tumor not only of mesenchymal origin, as it can be formed from coelomic epithelium), in clinical practice there is a large morphological diversity of these types of tumors.
Classification of myoma tumors
Most often (in 95% of cases) fibroids are localized in the body of the uterus, and only in 5% - in the cervix. They can be single and multiple (multiple fibroids in clinical practice are much more common).
Myoma classification by uterine growth direction
1. Myomatous neoplasms with typical localization:
Subserous (subperitoneal) fibroid is a tumor on the pedicle or on a wide base, located in the peritoneum on the surface of the uterus and growing towards the abdominal cavity. In this case, myomatous nodes located on the pedicle are able to attach to nearby structures (intestine, omentum or mesentery), developing a secondary blood supply. If at the same time the tumor loses the primary blood supply, a parasitic leiomyoma is diagnosed, and in the case when myomatous nodes are located between the wide ligaments, we are talking about an intraligamentary myoma.
Submucous (submucosa) myoma is a neoplasm localized under the mucosa of the endometrium, the growth of the nodes of which is directed to the uterine cavity. It may also have a foot or a wide base. The fibroids on the leg are sometimes able to “fall out” from the cervical canal, being twisted and infected.
Interstitial (intermuscular) myoma is a tumor, the nodes of which are in the thickness of the uterus wall.
2. Myomatous neoplasms with atypical localization:
Ligamentous (subserous fibroids located behind the peritoneum).
Myoma classification by location in relation to the uterine axis
- Corporal myoma is the most common tumor (90.2%), which is localized in the body of the uterus.
- Isthmic, or perennial myoma is a neoplasm that causes pain in the bladder area.
- Cervical (cervical) myoma is a tumor that grows in the vagina and provokes the development of various infectious complications.
but). Normal leiomyoma is a mature, hormone-dependent tumor, which is a knot of dense consistency, clearly demarcated from healthy tissue. This tumor, consisting only of smooth muscle cells of the myometrium, is surrounded by a hyalinized connective tissue layer, resembling a capsule. Tumor growth occurs towards the soft tissues, while the integrity of the endothelium is not disturbed.
b). Cellular leiomyoma is a soft consistency tumor with clear boundaries, usually located inside the uterine wall. This neoplasm is able to 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 bizarre leiomyoma is a neoplasm consisting of not only round-shaped muscle cells. It also includes multinuclear giant polygonal cells, which sometimes confuse this tumor with leiomyosarcoma. However, confirmation of its benign nature is a small amount (or the complete absence of mitoses), as well as the absence of infiltrative growth.
d). Epithelial leiomyoma, or leiomyoblastoma, is a tumor that is quite rare in clinical practice. It consists of smooth muscle tissue and elements of the vascular walls.
d). Metastatic leiomyoma is also a very rare variant of a tumor. In the course of histological examination confirmed the good quality of this tumor, but at the same time, it is able to metastasize into the vascular gaps, and grow into the lumen of the vessel. In the case when the tumor cells break off, they, along with the bloodstream, can enter the stomach or lungs, where a new myoma node begins to develop.
e). A proliferating, or growing leiomyoma is a neoplasm characterized by slow growth and the presence of proliferation zones located in the thickness or periphery of the tumor. Initially, the cellular elements in them are presented in the form of couplings, and then they gradually transform into smooth muscle strands that grow and merge with nearby tissues.
g) Myoma with pre-sarcoma (malignant leiomyoma) is a neoplasm that identifies atypical cells and cell nuclei.
2. Fibromyoma. Depending on the age of the fibroids, its microstructure changes. Over time, the neoplasm turns into a clearly limited node, acquiring the nature of fibroids (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 fibroids, the connective tissue becomes coarser and more hyalinized, and its amount increases.
3. A rhabdomyoma is 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 strong menstrual bleeding. The abdomen increases in size, almost all patients complain of discomfort and the occurrence of different intensity of pain. There is also pain in the lower back, constipation develops, urination becomes frequent. In the case when torsion of the myoma occurs, symptoms of an acute abdomen are observed.
The clinical manifestations of the disease depend on the site of localization, the direction of growth of myoma nodes, the size of the tumor, the age of the patient, as well as the presence of concomitant gynecological pathologies.
In 25-30% of cases the development of fibroids occurs very slowly, and at first is not accompanied by severe symptoms. Most often, for the first time, a tumor is detected during pregnancy (since dense myoma nodes are rather easily felt on the softened myometrium). However, fibroids can be detected during a routine examination, installation of an intrauterine device, ultrasound of the pelvic organs and other diagnostic procedures.
In the case when the patient develops corporal myoma of the subperitoneal localization, which has a pedicle or a broad base, due to which it is nourished, the functional activity of the uterus remains unchanged, and therefore all of the above symptoms are usually absent.
With the development of subperitoneal fibroids, localized in the cervical area (or in the area of the isthmus), patients complain of bladder problems and pains of varying intensity developing in this area. In this case, urination is difficult, discomfort is observed in the vagina, cystitis develops, and the bladder does not empty completely. This form of pathology causes cervical deformity, infertility, or spontaneous abortion. If the pregnancy has nevertheless occurred, symptoms of squeezing of nearby organs often develop. At the same time, a tumor, due to a disruption of blood supply in the pelvic area, can provoke venous congestion and venous thrombosis.
Clinical signs of acute abdomen are observed in the case when the subperitoneal fibroids torsion of the legs occurs.
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 the event of acute pain and signs of irritation of the peritoneum, fever, nausea and vomiting, a differential diagnosis with acute appendicitis, ectopic pregnancy, acute inflammation of the appendages, torsion of the ovarian cyst should be carried out without fail.
The aching pains in the sacrum and in the lower back are one of the most characteristic signs of the appearance of a myoma node at the back of the uterus. Retrocervical fibroids displaces the uterus anteriorly, filling the pelvis and squeezing the rectum. As a result, patients develop hemorrhoids or chronic colitis, there is a frequent urge to have a bowel movement, and there is a constant feeling of incomplete emptying of the rectum.
In the case when the tumor grows up, 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 myoma node, resulting from torsion of the pedicles of the tumor or due to the large size of the neoplasm, cause edema and subsequent necrosis (in the presence of a clinical picture of an acute abdomen).
пациентке требуется срочное хирургическое вмешательство, так как в противном случае может развиться гнойный перитонит. Note: The patient requires urgent surgical intervention, as otherwise purulent peritonitis may develop.
Diagnosis of uterine fibroids
The presence of uterine fibroids can show palpatory examination of the pelvic organs. However, in order to confirm this diagnosis, you will need an ultrasound. As a rule, a diagnostic examination begins with a study of the history and a thorough gynecological examination of the patient. Without fail, a specialist is obliged to pay attention to the presence of factors characteristic of this pathology: lack of childbirth in late reproductive age (after 30-35 years), abundant blood loss during menstruation, late onset of menstruation and early menopause, abortion, long-term intrauterine contraception, irregular sexual life, inflammatory gynecological diseases, etc. However, you should pay attention to the fact that fibroids can be hereditary. As a rule, hereditary fibroids are diagnosed in young women (up to 25 years old), subject to frequent stresses, as well as in those who are often ill in adolescence.
The uterus in patients with myoma is enlarged and has a dense, hilly surface. In the presence of a large myoma node, it is usually 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 examination. As a rule, at the present stage, most often ultrasound diagnostics of the pelvic organs provides for simultaneous transvaginal and transabdominal studies. Thanks to this technique, localization, size and structure of myomatous nodes are determined. The sensitivity of this method is 80-100%.
With the development of proliferating fibroids, the uterus is about the same size as at 14-17 weeks gestation. In the case when a specialist has a suspicion of a malignant transformation (malignancy) of the endometrium or myoma node, color Doppler mapping is carried out. With its help, blood flow is evaluated and the presence of newly formed pathological vessels is detected.
Diagnostic hysteroscopy is a technique that involves the use of a hysteroscope. It can be used to inspect the walls of the uterus in case of suspected development of submucous fibroids (it appears as pale pink oval or rounded formations).
Retinal hysterosalpingography is a diagnostic method that helps to visualize the deformation of the inner surface of the uterus, submucosal myomatous nodes, intramuscular adhesions, etc.
Примечание: данная методика, позволяющая получить избирательные снимки, назначается не всем пациенткам, а только по показаниям.
При возникновении подозрения на развитие в эндометрии или в цервикальном канале злокачественного процесса, проводится цитологическое исследование материала.
Очень хорошо себя зарекомендовало в гинекологической практике диагностическое выскабливание, проводимое под контролем гистероскопии с последующим гистологическим исследованием соскоба. Таким образом, проводится диагностика состояния эндометрия. Как правило, диагностическое выскабливание назначается при быстром росте миомы, перед проведением органосохраняющей или радикальной операции, а также перед назначением консервативного лечения.
Следует отметить, что перед назначением хирургической операции специалист обязан провести тщательное обследование пациентки в целях выявления сопутствующих патологий. В обязательном порядке для оценки состояние мочевыводящих путей должно быть проведено УЗИ почек, а также другие дополнительные методы исследования.
Лечение миомы матки
Целесообразнее всего начинать лечение миомы сразу после постановки диагноза, так как последующее пассивное наблюдение может привести к прогрессированию болезни и дальнейшему росту миоматозных узлов. Как следствие, усиливаются патологические маточные кровотечения, развивается хроническая железодефицитная анемия, гиперпластические нарушения в эндометрии и системные нарушения во всем организме в целом (снижение иммунологической активности, гиповолемия (уменьшение объема циркулирующей крови) гиперпластические процессы и сосудистые нарушения).
В настоящее время по врачебным показаниям проводится консервативное и оперативное лечение миомы. Как правило, тактика лечения выбирается в зависимости от размеров, локализации и клинико-морфологического варианта опухоли, гормонального статуса пациентки, состояния её репродуктивной систем и пр. Некоторые специалисты считают, что не стоит спешить с операцией, а разумнее наблюдать за состоянием здоровья женщины до наступления менопаузы. Это объясняется тем, что в период менопаузы опухоль перестает расти. Поэтому грамотные профессионалы призывают прежде, чем удалять детородный орган, четко определить показания к проведению операции.
1. Многим пациенткам, страдающим бесплодием или повторным невынашиванием беременности, рекомендовано проведение консервативной миоэктомии (разумеется, если в анамнезе нет более вероятных причин бесплодия или повторного невынашивания беременности). При успешном проведении операции женщине сохраняют матку и репродуктивную функцию.
При проведении миоэктомии удаляются только миоматозные узлы, а тело матки сохраняется. Данная операция проводится в 4 этапа при помощи лапароскопа. Вначале миоматозные узлы отсекаются и вылущиваются, затем восстанавливаются дефекты миометрия, извлекаются отсеченные узлы, и наконец, выполняется санация брюшной полости (удаление кровяных сгустков и эндоскопический гемостаз всех имеющихся кровоточащих участков). Это позволяет предотвратить развитие спаечного процесса.
Примечание: 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.
2. Если же миоматозные узлы удалить невозможно и выявляется достаточно распространенный патологический процесс, пациентке показана гистерэктомия (радикальная операция, предусматривающая ампутацию матки). Вместе с тем показанием к полному удалению матки являются обильные затяжные менструации с выделением кровяных сгустков, анемия, возникшая вследствие кровопотери, сильные боли, постоянное давление внизу живота или в поясничном отделе, частые позывы к мочеиспусканию.
В таком случае гинекологи не рекомендуют тратить время и деньги на консервативное лечение, так как оно может дать только временное улучшение (или совсем не поможет).
3. In the case when the patient, according to medical indications, does not need surgery, she is prescribed conservative therapy, which will help slow the growth of the tumor. Such treatment takes place with asymptomatic or asymptomatic myoma, which does not cause heavy bleeding, provoking the development of iron deficiency anemia. It is assigned to women suffering from severe extragenital pathologies and chronic inflammatory processes of the internal genital organs and tissue of the pelvis, as well as in the case when fibroids are combined with adenomyosis or endometriosis of the cervix.
4. The most basic pathogenetic conservative treatment method is hormone therapy, involving the use of androgens and COCs (combined estrogen-progestin preparations). Due to this treatment, the menstrual blood loss decreases, the patient's general condition improves, the tumor stops growing and even its size can decrease, and the water-salt metabolism normalizes.
Conducting conservative treatment includes prescribing iron supplements, minor antipsychotics, and sedatives. Adaptogens, immunocorrectors, prostaglandins synthetase inhibitors, combined multivitamins with microelements and iodine preparations have proven themselves well. In the period of exacerbation of the inflammatory process, according to medical indications, antibacterial therapy is carried out. However, patients are shown a special diet, physiotherapy, physical therapy, treatment with mineral waters, etc.
It should be noted that in some cases, conservative treatment avoids uterine amputation. It can be quite effective at any age, until menopause. However, at all stages of the treatment of fibroids, maximum oncological vigilance should be observed.
Prevention of uterine fibroids
First of all, a woman should lead a healthy lifestyle, eat rationally, avoiding the accumulation of body weight and give up bad habits. Also very important is physical activity and normal, complete sleep.
Harmony in marital relations (normalization of sex life) plays an important role in preventing the development of fibroids.
Every woman who has reached the age of majority or has begun a sexual life should undergo an annual gynecological examination. This will allow as early as possible to identify the existing pathology and prescribe timely treatment.
According to many experts, it is very important in order to avoid premature aging of myocytes (muscle cells) to have a first child up to 27-30 years.
Every woman should know that most often uterine fibroids begin to develop in 30-35 years. Then, for another five years, it grows to a macroscopically determined node. Therefore, in this period it is necessary to avoid adverse external and internal influences.
It is very important at this age to protect against unwanted pregnancy, well, and if the pregnancy has occurred, then, given the contraindications, it should, if possible, be preserved. This results from the fact that abortion provokes the strengthened growth even of the hardly formed tumor.
After 30 years, it is recommended to avoid exposure to high temperatures and excessive solar insolation.
Hereditary fibroids - a disease that develops much earlier (after 20 years). Therefore, experts urge to keep the first pregnancy. However, to prevent the further development of an existing tumor can breastfeeding a child.
As a preventive measure for the development of hyperplastic processes in the endometrium, patients who have large fibroids are found to have timely excision of myomatous nodes.