Myoma, or leiomyoma, is a benign tumor of the muscular membrane of the uterus, which appears by the transformation of smooth muscle cells into connective tissue. Despite the latest methods of early diagnosis, surgical removal of the neoplasm is currently one of the most common methods of therapy.
Pathology prevalence
In the structure of gynecological diseases, intramural fibroids and other types of neoplasms of a benign nature in the uterine cavity occupy second place. In reproductive age, the incidence of pathology averages 15-20% of cases, and in the premenopausal period reaches 30-35%. In connection with the increase in the number of “aggressive” gynecological and obstetric methods of therapy recently, as well as with an increase in the quality of diagnostic measures, there has been an increase in the number of patients younger than 30 years with this pathology.
Education growth 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 be the cause of infertility, spontaneous abortion, abnormal fetal position, heavy uterine bleeding, premature delivery, irregular menstruation and various complications in childbirth and the postpartum period.
The operation is indicated for the size of the neoplasm corresponding to fourteen weeks of pregnancy, in other cases, the radical treatment tactics are not justified. This technique is based on the traditional belief that an organ performs only a childbearing function, and then can be removed without negative consequences for the body.
This opinion is erroneous, since the risk of transformation of fibroids into a malignant tumor is practically absent. After removal of the uterus, a woman loses her reproductive and menstrual functions, and 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 reverse development and prevent reproductive dysfunction. True, the question of the use of conservative methods of treatment of intramural uterine fibroids still causes debate in the medical community.
The main types of uterine fibroids
There are several types of neoplasms depending on localization:
- Subserous myoma forms in the external part of the organ and progresses to the pelvic cavity. As a rule, this type of tumor does not lead to changes in the menstrual cycle or does not appear at all, but it can cause some inconvenience, since the neoplasm puts pressure on the surrounding organs and tissues.
- Intramural uterine myoma (intramuscular) is localized in the muscle layer and leads to an excessive increase in organ size. This is one of the most common types of pathology. With intramural myoma, the menstrual cycle is disrupted, pain and pressure in the pelvic region appear.
- 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, edema or necrosis. Intramuscular fibroids have a negative effect on neighboring organs, namely the rectum and bladder.
- Submucous myoma (submucosal) grows under the layer of the mucous membrane enveloping the organ cavity. It 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 only in 5% of patients.
Myomas can be single or multiple. Often, several nodes are located in different parts of the body, which leads to the diagnosis of, for example, submucous intramural fibroids or other mixed types of pathology. In this case, the treatment is often complicated by the ambiguity of the clinical picture. For example, with subserous-intramural uterine myoma, the menstrual cycle is violated, which is typical for intramural, but rarely happens with subserous pathology, but at the same time pressure is exerted on surrounding organs and tissues.
Causes of Leiomyoma
There is a lot of opinion about the causes of the intramural nodes of uterine fibroids. Some scientists believe that the tumor is not a tumor, but the result of focal growth of the myometrium. So, fibroids can occur only in those areas where there is a complex interweaving of muscle fibers - these zones are called risk areas for the development of dystrophic disorders. Under the influence of various adverse 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, proliferation can occur under the influence of mutations in 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 disturbances that contribute to such a transformation.
Smooth muscle fibers may remain prone to proliferation from the embryonic period. They pass a long period of development - from fourteen to thirty weeks of gestation. Fibers at this time easily undergo mutations 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 estrogen. Currently, this theory of the occurrence of fibroids is most justified.
Provocative factors
The main risk factors that trigger the development of intramural nodes of uterine fibroids and other benign neoplasms:
- Adverse heredity. The likelihood of pathology in women whose immediate family members suffered from the same disease is higher.
- Early puberty and the onset of menstruation.
- Lack of children. An increase in the number of full-term pregnancies significantly reduces the degree of risk. In women with three full-term pregnancies - by 50-90%.
- Excess weight and low physical activity. At the same time, obesity after puberty is a significant risk.
- The presence of hypertension up to 35 years and taking antihypertensive drugs for five years.
- Frequent stresses and chronic psycho-emotional stress.
- Termination of pregnancy, especially by surgery. Frequent diagnostic and therapeutic curettage of the uterine cavity.
The mechanism of development of pathology
Uterine fibroids develop against the background of a local decrease in the elasticity of the vascular walls, which leads to overflow of blood and the accumulation of potassium ions. According to another version, the neoplasm arises as a result of the influence of estrogen on the mechanisms of cell death. In recent years, other interconnected mechanisms have been established:
- Increased sensitivity of tissues affected by hormones of the reproductive system.
- Change in hormones that affect smooth muscle.
- Changes in the formation of new vessels in the tumor area.
Stage of development of uterine fibroids
In the development of intramural fibroids and other gynecological pathologies of a similar nature, but of a different localization, three stages are distinguished:
- The formation of a growth zone in the place 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 varies in the form of a small nodule. The neoplasm consists of fibers that are clearly not different from neighboring tissues.
- Education is defined as a dense node with clear boundaries. The capsule is formed by surrounding tissues. The node differs from normal fibers in large sizes, density of nuclei, and content of individual muscle fibers in the cytoplasm.
Clinical symptoms
In almost 50% of women, the disease develops without manifestations and is diagnosed accidentally during pelvic ultrasound or a routine examination by a gynecologist. In this case, clinical signs can be varied:
- Pain of varying intensity and character in the lower abdomen. A third of patients have aching or pulling pain, which is associated with pressure on the plexus of nerve fibers and distension of the peritoneum. If the tumor grows rapidly, the sensations become more intense. With the development of necrosis, pain can be accompanied by fever, vomiting, and general weakness.
- Out of cycle bleeding, prolonged or too heavy periods. Blood loss leads to headaches, weakness, dystrophic changes in the heart muscle, anemia, and fatigue.
- Violations of the functions of the pelvis. The symptom is manifested by frequent urges to urinate, constipation.
- The presence of a dense formation in the lower abdomen.
- Infertility (found in 30% of women with uterine fibroids) or miscarriage.
Methods for treating the disease
Treatment of intramural fibroids boils down to three main tactics: expectant, conservative therapy, surgical intervention. Despite the widespread prevalence of the disease, an algorithm for managing patients has not yet been developed, so much depends on the particular 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 monitored using ultrasound and monitoring blood markers.
Doctors recommend that patients refrain from lifting weights of more than 3 kg, heavy physical exertion, thermal baths, massage of the abdomen, body wraps, prolonged sun exposure and visits to the solarium, self-selection of birth control pills, the use of cosmetic methods on the abdomen and any physiotherapeutic procedures on the pelvic area .
Conservative treatment
Conservative therapy involves the use of hormonal drugs, the most effective of which are analogues of gonadoliberin and the hormone hypothalamus. As a result of their use, the synthesis of estrogen and progesterone is reduced, and the tumor volume can decrease to 55%, in addition, pain and bleeding stop. But such drugs, even with short-term use, have side effects: pronounced vascular reactions, a feeling of hot flashes, nausea, decreased bone density.
Active treatment of fibroids
Active tactics involve minimally invasive and surgical procedures. Applied selective embolization of arteries, the effectiveness of which is about 98.5%. According to reviews, intramural fibroids after such a diagnosis recurs in 40% of cases. Surgery is the main treatment method for 80% of patients. Surgical excision is especially often used in complex cases, for example, with subserous-intramural myoma.
Indications for surgery
Absolute contraindications for intervention are:
- Correspondence of tumor size to a period of more than 14 weeks of pregnancy.
- Any progress in postmenopausal women or rapid growth in reproductive age.
- Localization on the cervix.
- Long periods with heavy blood loss.
- Necrosis of the node.
- Infertility, if myoma is the cause of it.
- The negative effect of the neoplasm on the pelvic organs.
The choice of method and volume of operation is made depending on the age of the woman, the presence of concomitant diseases, future pregnancy planning.