Uterine fibroids (fibroma, fibromyoma, leiomyoma) - a benign formation that develops from the uterine myometrium (muscular layer). A very common pathology, 10-27% of women turn to gynecologists for it. It is considered a hormone-dependent tumor. It occurs mainly in reproductive age, with a peak incidence at 35-40 years. It not only affects the well-being of the patient, but mainly affects the reproductive function itself. Today, pathology is often found at a younger age, causing infertility.
The size of uterine fibroids is estimated in weeks as it corresponds to the growth of the uterus during pregnancy. Half of the patients receive surgical treatment for myoma as the most effective. Previously, the treatment of any uterine fibroids was reduced to the complete removal of the organ. Today, conservative myomectomy is more often performed, in which reproductive function is fully preserved.
Causes of fibroids
The causes of neoplasms include the following:
- hereditary predisposition;
- defect of myometrial anlage in embryogenesis;
- a large number of abortions;
- menstrual disorders (MC);
- Uterine curettage for diagnostic purposes;
- mother's birth injury;
- some endocrinopathies (diabetes, obesity), thyroid hypofunction;
- no pregnancies under 30;
- early menarche;
- sexual disharmony;
- hypodynamia.
However, hormonal imbalances remain the main cause and trigger.
Types of fibroids
Fibroids can exist as a single formation or be multiple, grow in the form of a node or have a diffuse origin, have a stalk or a wide base, be in the uterus or cervix, be simple, proliferating, presarcoma.
According to the localization of fibroids can be:
- Interstitial or intramural - located in the middle of the myometrium.
- Subserous fibroid - grows under the upper lining of the uterus and is usually directed to the abdominal cavity.
- Submucosal - localized under the mucosa, and its growth is directed to the uterine cavity.
- Intraligamentary uterine fibroids - this localization is rare, the tumor grows outward from the body of the uterus, penetrating between special anatomical formations - ligaments.
Complications
Fibroma is not at all as harmless as it seems, despitefor its goodness. It almost always leads to complications:
- miscarriage, fetal malnutrition and hypoxia;
- infertility;
- after childbirth, decreased uterine tone, bleeding on this basis;
- anemia due to profuse uterine bleeding;
- rebirth into a sarcoma;
- with physical strain and large fibroids, the leg may twist;
- malnutrition;
- accelerated growth in education;
- endometrial hyperplasia;
- development of hydronephrosis or pyelonephritis.
What to do when fibroids appear
Treatment of fibroids depends on the size of the node, the age of the woman and her desire to have offspring in the future. If the tumor is small, does not tend to grow, the woman is not going to give birth, it would be appropriate to treat HRT - hormone replacement therapy. Hormonal preparations, with their correct selection, can not only slow down, but also stop the growth of education. Courses are usually assigned several in a row.
So, indications for hormone treatment:
- Fibroids should not exceed 12 weeks;
- intramural and subserous fibroids;
- no pain or bleeding;
- impossibility of the operation due to contraindications.
Surgical treatment
Surgical treatment with the removal of fibroids is carried out with its large size or complications.
What is it in gynecology - myomectomy of uterine fibroids? This is the excision of myomatous neoplasms from the organ cavity. Today, conservative myomectomy is used, which is considered an organ-preserving operation.
The fibroid nodes are removed with it, but the uterus is not. This is true in the case of pregnancy planning and maintaining menstrual function.
After myomectomy, every second woman can count on pregnancy. Therefore, reviews of conservative myomectomy are always positive. According to some reports, the restoration of reproduction in such women even reaches 69%.
Dependence of myomectomy on the day of the cycle
The operation is most often done from the 6th to the 18th day of the cycle. However, in the absence of gestation, it does not matter on what day of the MC to do myomectomy.
Another thing when it comes to a pregnant woman: the optimal period is 14-19 weeks of pregnancy. By this time, the placenta is already fully functioning, the organs are laid down, and in the peripheral blood of the expectant mother, progesterone doubles. Why is progesterone important? It increases and maintains the obturator function of the internal os of the uterus and reduces the risk of preterm birth. This feature is protective.
Contraindications for surgery
Contraindications include:
- Precancerous or already cancerous lesions in the cervix or endometrium.
- Suspicion of malignancy.
- Diagnosis of fibroids and adenomyosis at the same time.
- Pathologies of the respiratory and cardiac systems.
- Fibroids are larger than 15-20 cm, even after pre-HRT.
- Multiple fibroids with nodes up to 5-6 cm.
Relative contraindications
They can becorrect medically:
- Diabetes mellitus with severe hyperglycemia.
- Obesity.
- Infectious-purulent processes of the uterus and appendages.
- Severe iron deficiency anemia.
Indications in non-pregnant women
It is advisable to perform surgery on patients of childbearing age and nulliparous, as well as:
- growth of a node in the uterine cavity;
- presence of legs in fibroids;
- acyclic bleeding or prolonged and heavy periods leading to anemia;
- infertility;
- when the size of the fibroid is more than 12 weeks, even with no complaints, because it still violates nearby organs;
- signs of compression of adjacent organs;
- atypical location of the node - it can grow in the neck or isthmus, in the ligaments of the uterus;
- myoma necrosis;
- doubling the growth of fibroids in 1 year.
In the case of multiple fibroids, it is advisable to perform UAE first. This leads to the elimination of small nodes, and large ones decrease and become clearly visible during the operation.
Main indications for myomectomy during pregnancy
Surgery during pregnancy is indicated in the following cases:
- Fibroids necrosis due to pedicle torsion.
- Compression of organs due to neoplasm growth.
Preoperative preparation
It is no different from that of other types of operations. A fairly standard set of studies includes:
- blood tests andurine;
- chest x-ray;
- ECG;
- ultrasound;
- vaginal swab;
- rectal examination.
Advantages and disadvantages of conservative myomectomy
Benefits:
- the tumor is removed at once and the uterus is preserved;
- operation technique is well known to most practicing gynecologists.
Cons:
- probability of relapse - according to statistics, this is observed in 70% of cases;
- possibility of complications.
- after laparotomic access there will be a uterine scar, which requires a caesarean section for childbirth in the future;
- technical difficulty in multiple fibroids.
Prices for surgery
They vary a little, but on average the procedure costs between 25 and 120 thousand rubles. The most expensive EMA operation is from 100 to 200 thousand rubles.
The cost depends on the scope of the intervention and the type of access. It includes the cost of operating materials, medicines, dressings. In many clinics, both hospital stay and meals are added here.
The main types are:
- myomectomy;
- embolization;
- radical hysterectomy.
Myomectomy
It is carried out in several ways:
- abdominal (laparotomic myomectomy);
- hysteroscopic;
- laparoscopic.
The important points are the formation of a full-fledged(we althy) scar on the uterus and, if possible, the maximum prevention of adhesions, the choice of the optimal incision site on the uterus, the correct exfoliation of the myoma node after opening its capsule. It is important to stop bleeding without the use of diathermocoagulation (optimally - by squeezing the tissues of the vessels).
If an incision is made in the uterus, its sutures are applied in 3 rows for stitching, using Vicryl threads. They are remarkable in that they are not rejected and resolve themselves over a long time.
They try to cut the capsule along its upper pole, so as not to damage large vessels. In addition, such a cut will allow you to simultaneously remove other nodes if they exist.
To reduce the degree of adhesions, at the end of surgery, the pelvic space is thoroughly dried, and anti-adhesion solutions are introduced into it. At the same time, at least a liter of such a solution may take one operation.
Myomectomy during pregnancy
The technique of the operation is no different, the peculiarities are taking into account the presence of the fetus in the uterus. This is due not only to the presence of the fetus, but also to the enlarged uterus and its abundant blood supply. Therefore, the task becomes to prevent bleeding, trauma to the embryo and sepsis after surgery.
Access is through a median incision in the lower abdominal wall, after which the surgical assistant removes the uterus with the fetus into the wound and holds it. This reduces the risk of major blood loss. In a pregnant uterus, only dominant nodes are husked, which prevent the fetus from growing and squeezeother organs.
Reviews of abdominal myomectomy during pregnancy show the success of the method used, followed by a normal course of pregnancy. Delivery after myomectomy with the same pregnancy is carried out only by caesarean section.
Abdominal myomectomy
The method is also called laparotomy - this is an abdominal operation. Today it is rarely used. Justified only in the case of a severely deformed uterus due to multiple nodes or their large size.
A small incision is made in the suprapubic area of the abdomen, and the neoplasm is carefully exfoliated from the uterine cavity. General anesthesia. The postoperative period in this case is the most difficult and long - 2-3 weeks. Plus manipulations - in controlling the course of the operation directly by the surgeon. Patients in their reviews of the abdominal operation of myomectomy talk about the possible onset of pregnancy 6-18 months after the intervention.
Laparoscopic myomectomy
Laparoscopic myomectomy allows all the necessary manipulations to be performed by small 3-4 punctures in the anterior abdominal wall, after which there are practically no scars. Tiny scars in the form of dots remain at the site of the incisions. The progress of the operation is monitored through the monitor.
Has clear advantages over laparotomy. The postoperative period is shorter than with laparotomy - only 2 weeks. In addition, laparoscopy practically does not give such complications as infection, bleeding, etc., since there is no incision on the uterus, there is no scar, there is a great chance to give birth to a childmost.
Laparoscopic myomectomy reviews are mostly positive. The patient can be discharged home as early as 2-3 days after endoscopic intervention.
Limitations to laparoscopy:
- myoma nodule larger than 9 weeks;
- knot in hard to reach place;
- there should be no pronounced adhesions;
- obesity grade 2;
- multiple fibroids.
Hysteroscopic myomectomy
This is the removal of myomatous nodes from the uterine cavity through its cervix and vagina, i.e. transvaginally, without incisions. Another name is transcervical removal.
Cervical dilation is done with a hysteroscope. Naturally, the method is applicable for small nodes and their submucosal location. There is no scarring on the uterus and skin, which is important for women planning pregnancy and natural childbirth.
Hysteroscopic myomectomy or hysteroresectoscopy is performed on an outpatient basis, often under local anesthesia. Performed mechanically or electrosurgically.
Indications:
- submucosal nodes on the leg less than 10 cm;
- submucosal fibroids subject to prior UAE.
The procedure has positive reviews. Many women like hysteroscopic myomectomy due to its good tolerability and a small amount of time - only 15-20 minutes. Another plus is that in a couple of hours the patient goes home.
Deserves a hysteroscopicmyomectomy reviews of a positive plan also because complications with this method are extremely rare, pregnancy can be planned already in the first six months and hope for its successful course.
FUS ablation of uterine fibroids
A relatively new way to treat uterine fibroids. Its essence lies in the fact that the fibroid cells are exposed to focused ultrasonic waves. Hence the name FUS - focused ultrasound. It is carried out under the control of MRI, without anesthesia. With the help of such ablation, the size of the neoplasm is reduced without surgical intervention. Contraindications: the desire of a woman to become pregnant in the future, more than 5 myoma nodes in the uterus.
Reviews about the operation of myomectomy in this way are positive. Although the procedure itself can take about 6 hours.
Hysterectomy
Total removal of the uterus is the last resort. It is prescribed for large fibroids, multiple, with severe complications. Removal of the uterus is possible by any of the above accesses - laparotomy, laparoscopy, hysteroscopy.
Removing the uterus, the appendages still try to save it. For what? The reproductive function will not work, but the production of estrogens will continue, and the surgical menopause will not occur.
This operation has its advantages:
- getting rid of possible uterine bleeding for various reasons;
- no risk of fibroid recurrence;
- no endometrial cancer;
- don't use protection.
Uterine embolizationarteries (UAE)
Uterine artery embolization is a minimally invasive operation that cuts off the blood supply to fibroids. Its essence is that a catheter is inserted through the puncture of the femoral artery, through which sclerosing special substances are injected into the vessels that feed the tumor.
As a result, the arteries are clogged and blood flow does not occur in them. Myoma cells stop receiving food and gradually die. Connective tissue grows in their place. In the future, it resolves.
Important aspects
Hysteroscopic surgery is an outpatient procedure. Laparoscopy allows the patient to be discharged within 1-3 days. With laparotomy, the patient stays in the department for 7-10 days.
Pain after myomectomy, or rather, discomfort in the lower abdomen occurs during the first 3-4 days in the form of pulling pains in the lower abdomen after surgery. They are easily stopped by conventional analgesics. After hysteroscopic surgery, they are not required at all.
After myomectomy, spotting may occur during the first days. Sometimes they can last up to a month after myomectomy. In the first 2 days they are plentiful. Gradually become scarce, transparent and stop. Otherwise, it will indicate complications.
The menstrual cycle is usually restored without difficulty, in such a way that the operating day is considered the first day of the previous cycle. With myomectomy, menstruation is restored quite quickly: conception is not excluded already in the first month after the operation.
But this is highly undesirable, so the doctorsthe use of contraceptives in the first 4-5 months is recommended. Stitches are removed on days 7-10.
Rehabilitation period
After myomectomy, recovery is determined by the correctness of the chosen treatment, the volume of the operation, the presence of complications, the age of the woman, and comorbidities.
Drugs that help fight anemia, anticoagulants and drugs that improve blood microcirculation in tissues are prescribed. In addition, it is highly recommended to wear elastic compression garments for the lower extremities to prevent thrombosis, which may occur during the rehabilitation period.
All this together will not only restore the myometrium and endometrium, but also help in the formation of a full-fledged scar on the uterus, which is extremely important for a woman of childbearing age.
To prevent secondary infection of the scar and wound, the doctor must prescribe antibiotic therapy with broad-spectrum antibiotics.
Laparoscopic myomectomy reviews in most cases are positive. With this method of intervention, the woman gets up and walks the very next day.
With laparotomic myomectomy, this is possible for 4-5 days. But in any case, it is required: within 3 months after the intervention, you should avoid heavy physical exertion, wear a postoperative bandage and try to prevent constipation.
Treatment after surgery
After myomectomy, treatment is always continued with hormones (HRT). It lasts for several months and includes the use of hormones such as Buserelin,"Mifepristone" and others.
During the rehabilitation period after myomectomy for 5-7 days, and then after 2 months and six months, ultrasound is recommended. It will help assess the condition of the scar on the uterus and the presence of relapse. It must be remembered that until a conclusion is given about a fully formed scar, pregnancy is excluded.
For women who prefer wait-and-see tactics when they have fibroids, hoping that when menopause occurs, the fibroids will resolve themselves (this opinion is very common), it is worth considering that passivity in this matter is dangerous.
Myoma is always a risk factor, and no one can predict its behavior. This tactic often leads later to the need to remove the uterus. If you are going to give birth and have children, myomectomy should be done no later than 3 years after diagnosis.
Possible complications after myomectomy
The following complications are possible:
- Bleeding. To reduce its risk, a course of hormonal therapy, UAE, temporary shutdown of some arteries during surgery is used before surgery.
- Irregular menstruation. The operation is a powerful stress for the body, and hormonal failure is a frequent response of the body. But in the absence of complications, menstruation is restored after a month, maximum - after 3. Otherwise, the cause should be clarified with a doctor.
- Infection - in order to avoid it, the postoperative suture must be looked after very carefully, not to allow the slightest contamination of it.
- The divergence of the seams. The reason may be incorrectits imposition or improper care. To help in such cases, the wound is actively washed with antiseptics and treated with antibiotics. In extreme cases, a second operation may be required.
- Adhesion is a frequent occurrence after abdominal operations. It manifests itself as a pulling pain in the lower abdomen and in its lateral sections. With pronounced adhesions in the fallopian tubes, an ectopic pregnancy may occur with subsequent infertility. Then IVF is shown.
- Fibroids recurrence. Statistics and reviews of myomectomy of uterine fibroids indicate that the operation is not a panacea. With single nodes, recurrence is possible in every fifth patient, with multiple nodes - in every second. They can occur even after 5-10 years. Practitioners therefore advise not to delay conception for years, but to plan a pregnancy 6-12 months after the operation.
Restrictions after myomectomy at home
The following rules should be followed after the operation:
- No sex for 1.5 months.
- Do not lift weights, in extreme cases - no more than 3kg.
- No training or physical work.
- Sports, visits to the solarium, saunas, baths, swimming pools for 2 months are not recommended.
- When menstruating (especially after hysteroscopic myomectomy), do not use tampons.
Important points after surgery
The following activities are recommended:
- Supporting bandage is required within a month.
- Eating without junk food and fermenting foods.
- Wearing onlynatural linen.
- Shower only, no baths.
- Use intimate hygiene products.
When can I plan and give birth after myomectomy?
Plan pregnancy and give birth after any type of myomectomy surgery is possible not earlier than in 4 months, and even better in six months. This is enough time for the scar on the uterus to heal so much that the woman will be able to carry the baby to the end without complications and give birth naturally.
Important to know
Early pregnancy with an incompetent scar can lead to very serious complications during childbirth, up to uterine rupture with massive bleeding. It's not worth counting on. Natural childbirth after myomectomy is possible only after the formation of a we althy scar on the uterus, which will be indicated on ultrasound or as a result of removal of fibroids by transvaginal way.
In other situations, a planned caesarean section is indicated. Women leave different opinions about myomectomy. Practitioners often recommend operative delivery to eliminate the risk. Such tactics are fully justified, because there is always a risk.
Prevention of uterine fibroids
For the purpose of prevention, the following measures should be taken:
- Regular visits to the gynecologist twice a year.
- Ultrasound of the pelvic organs once a year.
- Regular sex life.
- Exclude abortion by any means available.
- Using hormone replacement therapy.
- Therapeutic gymnastics.
- Normalizationweight.
- Prophylactic intake of vitamin-mineral complexes with antioxidant action (vitamins A, E, C, iron, zinc, iodine, selenium).
Reviews
In general, even 2 months after myomectomy, according to reviews, women begin to lead a normal life. Thanks to the operation, many people manage to get pregnant and safely bear the child. Modern surgery gives a woman the full opportunity to give birth on her own, removing fibroids without scarring the uterus.
Very praised by specialists from the Road Clinical Hospital. N. A. Semashko. According to reviews, myomectomy, hysteroscopy and laparoscopy performed in this clinic almost never cause postoperative complications. In addition, rehabilitation in such cases is much faster and easier.
Positive feedback on conservative myomectomy is also left by women who, due to the development of the disease, have experienced secondary infertility. They note that after excision of the pathological node, they gain the opportunity to plan a pregnancy and give birth on their own, even despite the scars on the uterus that remain after the “open” operation. This has to be put up with, often without such intervention, the removal of fibroids is not possible.
The largest institutions where women turn to for myomectomy are the National Medical Research Center named after V. A. Almazov in St. Petersburg and the hospital named after N. A. Semashko - a medical institution in Moscow for railway workers and their families.
Myomectomy reviews inthe center of Almazov is often not so rosy. There are a lot of dissatisfied with this center. Negative reviews of myomectomy at the Almazov Research Institute, apparently, are left by patients who have experienced complications. With regard to the Semashko hospital, there are much fewer negative reviews about myomectomy.
