Obstetrics and gynecology. Uterine fibroids (lecture notes)

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Obstetrics and gynecology. Uterine fibroids (lecture notes)

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Lecture number 25. Uterine fibroids

A benign tumor formed from the muscular and connective tissue of the uterus. The disease is quite common. 15-17% of women over 30 suffer from uterine fibroids. To date, there is no unified theory of the development of uterine fibroids. Most researchers associate its occurrence with hormonal disorders. Others adhere to the infectious theory of development. According to this theory, the formation of fibroids is associated with the IUD, abortion, inflammatory and infectious processes, and sexual transmission. A certain importance is attached to violations of immunological protection. Undoubtedly, the role of genetic predisposition to the occurrence of fibroids.

Classification. Based on location, they distinguish between uterine fibroids (occurs in 95% of cases) and cervical fibroids (cervical fibroids - in 5% of cases). In relation to the myometrium, there are three variants of growth of fibroid nodes: intermuscular, or interstitial (the tumor is located in the thickness of the uterine wall), submucosal, or submucosal (fibroids grow towards the uterine cavity), subperitoneal, or subserous (fibroids grow towards abdominal cavity). If the submucosal tumor is located predominantly in the muscular layer, the term “intermuscular uterine fibroid with centripetal growth” is used. A special form of submucosal fibroids are tumors that produce tumors when they grow in the uterine cavity towards the internal os. Long-term growing myomatous nodes lead to smoothing and opening of the uterine pharynx, as a result of which the tumor extends beyond the external opening of the uterus.

The clinical picture of uterine myoma depends on the age of the patient, the duration of the disease, localization, size of the tumor and the presence of concomitant extragenital pathology. Often, small uterine fibroids are asymptomatic, while there are no complaints and menstrual dysfunction. The main symptoms of the disease are pain of varying intensity, bleeding (meno- and metrorrhagia), dysfunction of neighboring organs. The most common pain is in the lower abdomen and lower back. Severe prolonged pain most often indicates the rapid growth of the tumor. Acute pain occurs mainly when blood supply to the tumor is disturbed, which can lead to the development of necrosis with a clinical picture of an acute abdomen. Cramping pains during menstruation, as a rule, indicate a submucosal location of the node. Bleeding with uterine myoma are in the nature of hyperpolymenorrhea.

With multiple uterine myoma with interstitial arrangement of nodes, the uterine cavity is stretched and its surface is enlarged. This increases the amount of blood lost during menstruation. Particularly severe bleeding occurs with fibroids with centripetal growth and submucosal arrangement of nodes. Such localization is characterized not only by prolonged bleeding, but also by the presence of intermenstrual bleeding with the development of anemia. Fibroids tend to grow slowly. Rapid growth of fibroids refers to an increase in the size of the uterus, approaching the size of a 5-week pregnancy in a year or less. A rapid increase in neoplasm in some cases may indicate the malignancy of the process. Violation of the function of neighboring organs is observed with large tumor sizes, as well as with subperitoneal, cervical and interligamentous arrangement of nodes.

The most common complication of uterine fibroids is necrosis of the myomatous node, torsion of the node located on the leg. Necrosis of the myomatous node is accompanied by acute pain, fever, the development of a picture of an acute abdomen. Subserous nodes are most often exposed to necrosis. Torsion of the legs of the myomatous node is a common complication of fibroids. In this case, the nutrition of the tumor is disturbed, dystrophic and degenerative changes, edema occur. It gives the impression of rapid tumor growth. There are acute pains accompanied by peritoneal phenomena. Anemia is another complication.

Diagnosis of uterine fibroids. In the early stages of tumor formation, it is not always possible to make a clinical diagnosis of uterine fibroids. Typically, the diagnosis of uterine fibroids is made at an outpatient appointment, taking into account characteristic complaints and data from a bimanual examination, during which an enlarged, dense, tuberous uterus with an uneven, nodular surface is palpated. Reliable results can be obtained by ultrasound scanning of the uterus. This is the most informative method for diagnosing uterine fibroids, allowing you to dynamically monitor the development of the tumor. If the presence of submucosal uterine fibroids or deformation of the uterine cavity due to the centripental growth of the intermuscular node is suspected, hysteroscopy or metrosalpingography is performed. When diagnosing and assessing the effect of therapy, it is necessary to take into account the phase and day of the menstrual cycle, and conduct dynamic examinations and ultrasound scans on the same days of the cycle.

Ultrasound scanning data allow you to accurately determine the location, size, condition of myomatous nodes, determine the tactics of managing patients and the extent of surgical intervention.

Treatment of uterine fibroids. Indications for surgical treatment of uterine fibroids are:

1) rapid tumor growth;

2) profuse prolonged bleeding leading to anemia;

3) large sizes of fibroids (more than 15 weeks of pregnancy);

4) a tumor of 12-13 weeks of gestation and symptoms of compression of adjacent organs;

5) severe pain syndrome;

6) submucosal uterine fibroids;

7) cervical fibroids;

8) necrosis of the myomatous node;

9) torsion of the legs of the myomatous node;

10) intraligamentary tumor;

11) combination of uterine fibroids with ovarian tumor, endometriosis;

12) infertility due to atypical arrangement of nodes;

13) suspicion of malignant degeneration of fibroids;

14) centripental growth of the myomatous node;

15) a combination of uterine fibroids with a precancerous condition of the cervix.

Surgery. Surgical treatment can be conservative or radical. Conservative methods of surgical treatment include laparoscopic myomectomy; hysteroscopic myomectomy, laparotomy with myomectomy. Conservative myomectomy is performed in young women, as a rule, regardless of the size, location and number of nodes.

Laparoscopic myomectomy. Removal of nodes while preserving the uterus. Indications: subserous and intramural myomatous nodes with a diameter of more than 2 cm, pedunculated nodes, lack of effect from conservative therapy. Contraindications: all conditions in which an increase in pressure in the abdominal cavity is unacceptable, the presence of three or more myomatous nodes with a diameter of more than 5 cm, the size of the uterus is more than 16 weeks of pregnancy, a myomatous node with a diameter of more than 15 cm.

Hysteroscopic myomectomy. Removal of nodes through the vaginal route. Indications: submucosal myomatous node. Contraindications: suspicion of endometrial hyperplasia or adenocarcinoma, infection of the upper and lower genital tract.

Laparotomy with myomectomy. It is used when laparoscopic methods are not possible or there are contraindications for their implementation. After conservative surgery, recurrence of new myomatous nodes is possible.

Hysterectomy (removal of the uterus). It is a radical surgical treatment method. This type of surgical intervention is indicated in cases where all of the above methods are contraindicated or have proven ineffective. Conservative treatment of uterine fibroids consists of prescribing drugs that inhibit tumor growth and symptomatic drugs to treat complications. To inhibit tumor growth, norcoltoid gestagens (norkolut) are used. It is prescribed in a cyclic regimen of 5 mg per day from the 16th to the 25th day of the cycle for 3-6 months annually. Potassium iodide electrophoresis is periodically prescribed to the suprapubic area. In the prevention of uterine fibroids, measures to prevent damage to the myometrium as a result of abortion and diagnostic curettage play an important role. Reliable methods of contraception can eliminate or reduce medical abortions and, consequently, damage to the myometrium. Good results in the prevention of infectious complications after uterine curettage are achieved by prescribing antibacterial drugs in the pre- and postoperative periods. The basis for the prevention and timely detection of uterine fibroids is regular visits to a gynecologist for examination.

Author: Ilyin A.A.

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