The author - Sozinova AV practicing obstetrician-gynecologist. Experience in the specialty for over 14 years. (2015).
Uterine fibroma called benign hormone-dependent tumors, which grow from the muscle layer uterus, while its composition is dominated by connective elements (another name - fibroid uterus).
Kinds
Depending on the nature of the formation and growth emit diffuse nodal fibroma.
In diffuse lesions of uterine fibroids do not have clear boundaries, can fuse together.
In turn, nodal fibroma in accordance with the localization of the nodes is divided into:
- interstitial fibroma, when the node / nodes are arranged in the thickness of the muscle layer;
- submucous submucosa or at which the node increases in the uterine cavity;
- subzeroznuyu podbryushinnye or if the node grows under the peritoneum covering the uterus (serosa), and has a leg.
According to the type of activity of proliferation (proliferation) can be fibroma:
- plain. Characterized by slow growth, proliferation processes are not pronounced;
- proliferating. Activity increased cell division, rapid growth, but no atypia cells;
- predsarkoma. There are multiple foci of atypia.
The causes of uterine fibroids
The mechanism of development of fibroids is still not exactly understood. Many researchers believe that tumors arise from a single progenitor cell which has undergone a mutation and the process Tumor growth is a consequence of tissue homeostasis disorders (disturbed balance between cell proliferation and apoptosis).
It is known that the formation of cells divide more intensively as compared to normal cells of the muscular layer regardless of the phase of the menstrual cycle.
Tumor growth process takes three steps:
- first formed the active zone of growth in the muscle layer;
- It begins on tumor growth, but differentiation (difference between homogeneous cells and tissues) absent;
- continued tumor growth, but with differentiation, maturation and fibrosis.
Sex hormones (estrogen, and progesterone) regulate cell proliferation. Progesterone in the formation of host germ stimulates its growth, but at the same time, in the tissues of the tumor develops relative hyperestrogenia, increased content estradiol and progesterone receptors, the latter increase in secretory phase, and decrease in the proliferative phase, whereas estrogen receptors elevated in both phase of the cycle.
Predisposing factors of uterine fibroids include:
- hormonal ovarian function;
- inflammatory diseases of the uterus and / or appendages;
- disorders of the blood supply to the pelvic;
- long-term abstinence from sexual intercourse;
- hypoplasia of the genitals;
- metabolic disorders (obesity, thyroid pathology, diabetes);
- heredity;
- oncological diseases of genitals in the family;
- childhood infections;
- lack of exercise;
- stress;
- intrauterine interventions (abortion, obstructed labor, uterine curettage);
- chronic diseases (hypertension, etc.).
Symptoms of uterine fibroids
The clinical picture depends on the size of the nodes, their location and quantity. Often, fibroids has no symptoms and is found by chance during a routine checkup.
All signs of uterine fibroids can be divided into several groups:
Menstrual disorders;
- can be observed both abundant and long menstruation (often submucosal fibroids) and acyclic bleeding;
- heavy menstrual flow are due to violation of uterine activity and often lead to patient anemizatsii (weakness, malaise, fatigue, pressure reduction and etc.).
Pain syndrome;
- characterized by pain pulling or aching, which are located in the lower abdomen or in the lumbar region;
- moderate persistent pain arise due to the growth and extension nodes serosa;
- strong contractions on the type of pain observed at birth submucosal node during each menstrual period, which is associated with increased uterine tone;
- sharp intense pain to the clinic "acute abdomen" suggest site necrosis (loss of blood supply to it).
Disorders functions neighboring organs;
- the large size of the tumor leads to compression of adjacent organs;
- at a pressure on the bladder and ureters develops frequent urination, urinary incontinence is possible;
- with compression of the rectum problems with defecation, constipation, pain.
Impact on reproductive function.
- fibroma may be (but not necessarily) the cause of infertility;
- also there are complications during pregnancy and childbirth.
Diagnostics
Diagnosis of fibroids begins with anamnesis and complaints.
During the examination of the patient on the couch trying to find out:
- tumor size;
- its diffuse or focal nature;
- if possible - to the growth direction and location nodes.
Estimated uterine fibroid growth and mobility (dynamics) for the year. For comparison gestation. About rapid growth indicates an increase in fibroid during the year by 4 or more weeks.
The mandatory minimum clinical diagnostic examinations include:
- swabs for microflora and cytology (detection of pathogens and atypical cervical cells);
- vein blood from HIV, syphilis and hepatitis;
- BAC (bilirubin, creatinine, liver enzymes, total protein) to detect liver function disorders;
- KLA (draws attention to the hemoglobin level for diagnosis of anemia);
- OAM.
In addition, determined the blood group, Rh factor, is analyzed coagulogram.
In addition, it held colposcopy to exclude / identify concomitant cervical pathology.
Of additional methods of examination used Pelvic ultrasound with transabdominal and vaginal probes. Ultrasound to determine the size of the nodes, their location, the deformation of the uterus.
Less commonly assigned computed tomography and magnetic resonance imaging.
then, a hysteroscopyWhich, in addition to the diagnostic functions, it allows you to make a biopsy of the endometrium to identify concomitant endometrial hyperplasia.
Metrosalpingography to assess the condition of the endometrium, reveal submucosal unit, its size and location.
If in doubt, resort to the diagnostic laparoscopy (When it is impossible to distinguish other methods subserous fibroma and ovarian tumors).
Differential diagnosis of fibroids, as its symptoms are similar to symptoms of chorionepithelioma (available high values of hCG) and uterine sarcoma (rapid growth, persistent bleeding, histological examination endometrium).
Treatment of uterine fibroids
Treatment of the disease begins with a normalization of the daily routine and rest, a special diet with a high content of fresh fruits and vegetables, iron-containing preparations for the appointment of eliminating anemia.
fibroid treatment can be conservative and surgical.
Drug therapy is conducted in a small package fibroids. If the tumor is less than 12 weeks of pregnancy *, the assigned 2-step therapy:
- on the first stage of a course of gonadotropin-releasing hormone (Zoladex, leuprolide, diferilin, buserilin) intramuscularly for 6 months with breaks for 4 weeks;
- the second stage (if the nodes are not reduced) involves taking an oral contraceptive (regulon, Janine, Novinet) and IUD insertion "Mirena" for a period of 6 months.
Further treatment is adjusted depending on the results.
A new and very effective drug in the treatment of fibroids is antiprogestin - mifepristone, which is assigned to 1 tablet per day continuously for 3 months or more. Mifepristone reduces the size of components and stops the bleeding.
By resorting to surgical treatment when indicated:
- large tumor size (over 12 weeks);
- rapidly growing tumor;
- severe pain;
- combination fibroids or endometriosis ovary tumor;
- node necrosis;
- submucosal node.
For surgical treatments include:
- hysterectomy (removal of the uterus), laparotomy, laparoscopy or vaginal infections;
- conservative surgery (conservative myomectomy). Nodes "husks", and the uterus is preserved; submucous node when it is removed hysteroscopic;
- minimally invasive surgery:
- embolization of uterine vessels. Due to blockage of blood supply to the uterine artery branches nodes stops, their dimensions are reduced;
- FUS-MRI ablation - consistent heating node using ultrasound, evaporation node creation therein of blood disorders and nutrition, which leads to its necrosis (necrosis).
Advantages of MRgFUS-ablation:
- lightweight portability procedure (outpatient);
- Organ preservation;
- there is no need for an intravenous anesthetic;
- no blood loss during the procedure and post-operative complications.
Consequences and outlook
uterine fibroid risk of developing these complications:
- node necrosis;
- torsion legs node;
- birth submucosal node;
- persistent bleeding.
During pregnancy increases the risk of miscarriage, intrauterine hypoxia and malnutrition of the fetus, as well as post-natal complications.
Weather favorable, and the risk of developing uterine sarcoma is not higher than in healthy women.
