Myoma, or leiomyoma, is a benign tumor of the muscular membrane of the uterus, which appears by the degeneration of smooth muscle cells into connective tissue. Despite the latest methods of early diagnosis, surgical removal of the neoplasm remains one of the most common methods of therapy at the moment.
Prevalence of pathology
In the structure of gynecological diseases, intramural fibroids and other types of benign neoplasms in the uterine cavity take second place. In the reproductive age, the incidence of pathology averages 15-20% of cases, and in the premenopausal period it reaches 30-35%. Due to the recent increase in the number of "aggressive" gynecological and obstetric therapies, as well as the improvement in the quality of diagnostic measures, there has been an increase in the number of patients under 30 years old with this pathology.
Heighteducation usually occurs slowly, usually over five years. In some cases, there is a rapid increase in the tumor, and within one year or even faster, it increases by an amount corresponding to five weeks of normal pregnancy. Doctors determine the size of the tumor in weeks of pregnancy.
Intramural uterine fibroids can cause infertility, miscarriage, malposition of the fetus, heavy uterine bleeding, premature delivery, menstrual irregularities and various complications in childbirth and the postpartum period.
Surgery is indicated for the size of the neoplasm, corresponding to fourteen weeks of pregnancy, in other cases, radical treatment tactics are not justified. This technique is based on the traditional view that the organ performs only a reproductive function, and then can be removed without negative consequences for the body.
This opinion is erroneous, since the risk of fibroid transformation into a malignant tumor is practically absent. After removal of the uterus, a woman loses reproductive and menstrual functions, while many patients experience psychoemotional and vegetovascular disorders.
Conservative treatment, as well as the use of minimally invasive and non-invasive methods of therapy in the early stages of the development of pathology, can stop tumor growth, cause regression and prevent reproductive dysfunction. True, the question of the use of conservative methods of treatment of intramural uterine fibroids still causesdiscussions in the medical community.
Main types of uterine fibroids
There are several types of neoplasm depending on localization:
- Subserous fibroids form in the outer part of the organ and progress into the pelvic cavity. As a rule, this type of tumor does not lead to changes in the menstrual cycle or does not manifest itself at all, but it can cause some inconvenience, since the tumor presses on the surrounding organs and tissues.
- Intramural uterine fibroids (intramuscular) is localized in the muscle layer and leads to an excessive increase in the size of the organ. This is one of the most common types of pathology. With intramural fibroids, the menstrual cycle is disturbed, pain and pressure appear in the pelvic region.
- Interstitial, or intermuscular, is located inside the walls of the uterus. The organ increases evenly, some patients complain of heavy menstrual bleeding. Pain occurs only with a rapid increase in the size of the neoplasm, swelling or necrosis. Intermuscular fibroids have a negative effect on neighboring organs, namely the rectum and bladder.
- Submucosal fibroids (submucosal) grow under the layer of mucous membrane that envelops the organ cavity. Leads to an exacerbation of severe symptoms of pathology.
- Cervical fibroids are formed in the muscle layer of the corresponding part of the organ. This type of pathology is diagnosed in only 5% of patients.
Fibroids can be single or multiple. Often several nodesare located in different parts of the organ, which leads to the diagnosis, for example, of submucosal intramural fibroids or other mixed types of pathology. In this case, treatment is often complicated by the ambiguity of the clinical picture. For example, with subserous-intramural uterine myoma, the menstrual cycle is disrupted, which is typical for intramural, but rarely happens with subserous pathology, but at the same time, pressure is exerted on the surrounding organs and tissues.
Causes of leiomyoma
There are many opinions about the causes of intramural nodes of uterine fibroids. Some scientists believe that the neoplasm is not a tumor, but the result of a focal growth of the myometrium. So, fibroids can occur only in those areas where there is a complex interlacing of muscle fibers - it is these areas that are called areas of risk for the development of dystrophic disorders. Under the influence of various unfavorable factors, hypoxia can occur in these zones, which causes the tendency of muscle cells to divide and grow against the background of normal secretion of sex hormones.
In addition, overgrowth can occur under the influence of mutation of normal muscle fibers due to exposure to growth factors and sex steroids. This is possible under favorable conditions. Modern medicine has not yet established molecular disorders that contribute to such a transformation.
Smooth muscle fibers may retain a tendency to grow from the embryonic period. They go through a longdevelopmental period - from fourteen to thirty weeks of gestation. The fibers at this time are easily mutated under the influence of various external causes or maternal factors (for example, sex steroids, tropic hormones and growth factors). Mutated cells begin to develop after the first menstruation under the influence of estrogens. Currently, this theory of fibroids is the most substantiated.
Provoking factors
The main risk factors that trigger the development of intramural nodes of uterine fibroids and benign neoplasms of a different nature:
- Unfavorable heredity. The probability of pathology in women whose closest relatives suffered from the same disease is higher.
- Early puberty and menses.
- No children. An increase in the number of full-term pregnancies significantly reduces the risk. In women with three full-term pregnancies - by 50-90%.
- Overweight and low physical activity. At the same time, obesity after puberty is a significant risk.
- Presence of hypertension before the age of 35 and taking antihypertensive drugs for five years.
- Frequent stress and chronic psycho-emotional stress.
- Abortion of pregnancy, especially by surgery. Frequent diagnostic and therapeutic curettage of the uterine cavity.
Mechanism of development of pathology
Uterine fibroids develop against the background of localdecrease in the elasticity of the vascular walls, which leads to overflow with blood and the accumulation of potassium ions. According to another version, the neoplasm occurs as a result of the influence of estrogens on the mechanisms of cell death. In recent years, other interrelated mechanisms have been established:
- Increasing the sensitivity of tissues affected by the hormones of the reproductive system.
- Changes in hormones that affect smooth muscle.
- Change in the processes of formation of new vessels in the tumor area.
Stages of development of uterine fibroids
In the development of intramural fibroids and other gynecological pathologies of a similar nature, but of a different localization, there are three stages:
- Formation of a growth zone at the site of concentration of small vessels. Such risk zones are characterized by a high rate of metabolic processes, the permeability of the walls of blood vessels and tissues.
- The tumor differs in the form of a small nodule. The neoplasm consists of fibers that are clearly indistinguishable from neighboring tissues.
- Education is defined as a dense knot with clear boundaries. The capsule is formed by the surrounding tissues. The node differs from normal fibers in its large size, density of nuclei, content of individual muscle fibers in the cytoplasm.
Clinical symptoms
In almost 50% of women, the disease develops without manifestations and is diagnosed by chance during a pelvic ultrasound or routine examination by a gynecologist. However, clinical signs maybe varied:
- Pain of varying intensity and nature in the lower abdomen. In a third of patients, pain is aching or pulling, which is associated with pressure on the plexus of nerve fibers and stretching of the peritoneum. If the tumor grows rapidly, the sensations become more intense. With the development of necrosis, pain may be accompanied by fever, vomiting and general weakness.
- Bleeding outside the cycle, long or too heavy periods. Blood loss leads to headaches, weakness, degenerative changes in the heart muscle, anemia, fatigue.
- Pelvic dysfunction. The symptom is manifested by frequent urge to urinate, constipation.
- Having a dense mass in the lower abdomen.
- Infertility (occurs in 30% of women with uterine fibroids) or miscarriage.
Methods of treating the disease
Treatment of intramural fibroids is reduced to three main tactics: expectant, conservative therapy, surgery. Despite the widespread prevalence of the disease, the algorithm for managing patients has not yet been developed, so much depends on the individual doctor.
Expectant tactics
This method is suitable for a small number of patients. This group includes women who have no symptoms of pathology, and the size of the tumor corresponds to 10-12 weeks of pregnancy, the family already has children, and pregnancy is no longer planned in the future. Patients should be undermonitoring using ultrasound and monitoring of blood levels of tumor markers.
Doctors recommend that patients refrain from lifting weights of more than 3 kg, heavy physical exertion, thermal baths, abdominal massage, body wraps, prolonged sun exposure and visits to the solarium, self-selection of birth control pills, the use of cosmetic techniques on the abdomen and any physiotherapy procedures on the pelvic area.
Conservative treatment
Conservative therapy involves taking hormonal drugs, the most effective of which are analogues of GnRH and hypothalamic hormone. As a result of their use, the synthesis of estrogen and progesterone decreases, and the volume of the tumor can decrease by up to 55%, in addition, pain and bleeding stop. But such drugs, even with a short use, have side effects: pronounced vascular reactions, a feeling of hot flashes, nausea, and a decrease in bone density.
Active Fibroids Therapy
Active tactics involves minimally invasive and surgical procedures. Selective arterial embolization is used, the effectiveness of which is about 98.5%. According to reviews, intramural myoma after such a diagnosis recurs in 40% of cases. Surgery is the main method of therapy for 80% of patients. Surgical excision is especially often used in complex cases, for example, with subserous-intramural myoma.
Indications for surgery
Absolutecontraindications for intervention are:
- The size of the tumor is more than 14 weeks pregnant.
- Any postmenopausal progress or rapid growth into reproductive years.
- Localization on the cervix.
- Long menses with profuse blood loss.
- Node necrosis.
- Infertility if it is caused by fibroids.
- Negative effect of neoplasm on the pelvic organs.
The choice of the method and volume of the operation is made depending on the age of the woman, the presence of concomitant diseases, planning for pregnancy in the future.
