Uterine fibroids are benign tumors in women of reproductive age (mainly women from 30 to 45 years old suffer from this disease). The tumor appears to be randomly enlarged uterine muscle fibers, forming a knot that is thickly braided by altered vessels (their diameter is several times larger than normal vessels) that feed it. A specific feature of a tumor is that its growth and development depends on the level of sex hormones in a woman’s body (a hormone-dependent tumor).
The disease takes about 30% of all gynecological diseases and is found in 80% of women who may not experience any changes in their own health.
Uterine fibroids can manifest in unborn young women, in elderly women, after undergoing gynecological operations, after childbirth, during menopause and even during pregnancy.
In the case of hemorrhagic syndrome in uterine myoma, as a rule, emergency surgical intervention is necessary, despite the fact that the patient’s condition is sometimes extremely serious and often exacerbates existing disorders of homeostasis due to possible blood loss in the intraoperative period.
Uterine fibroid size
Particular attention should be paid to the fact that the size of uterine fibroids have almost no decisive effect on the symptoms of the disease itself (previously, uterine fibroids were determined by an increase in the uterus, like during pregnancy, hence the “fibroid for 18 or 20 weeks”). However, with the development of diagnostics, primarily the availability of ultrasound and MRI, this has gone down in history.
Currently, it is not the size of the tumor that plays a big role, but its type and location (for example, on the back wall). A large fibroid may not be felt at all by a woman (the pain in the lower abdomen in a woman may also not manifest) and not affect her well-being. At the same time, small fibroids in the submucosal layer of the uterus cause pain in the lumbar region, can disrupt the menstrual cycle, provoke abundant menstruation even when carrying a child during pregnancy.
There are several classifications of this disease, depending on the location of uterine fibroids, its cellular composition, topographic location:
- Subserous uterine myoma (myoma node is located in the uterus directly under the peritoneum covering the uterus). Myoma node grows toward the abdominal cavity.
- Submucous myoma (the node is, on the contrary, directly under the mucous membrane of the uterus). The node grows in the uterine cavity.
- Intermuscular uterine myoma (the node develops in the thickness of the uterus).
- Intraligamentary (interlinker), when the nodular uterine myoma develops between the wide ligaments of the uterus.
Currently, doctors often use clinical classification, which combines several others and has the greatest value in the diagnosis and the choice of further treatment tactics.
Within this classification, there are:
- clinically insignificant myomas or uterine myomas of small size;
- small multiple myomas;
- myoma of the body of the uterus is medium in size;
- multiple uterine myoma with a medium-sized host;
- submucous myoma of the uterus;
- large uterine myoma;
- myoma of the uterus on the leg;
- complex uterine myoma.
It is worth noting that 90% of all myomatous nodes are uterine fibroids. And the tumor itself has a tendency to develop multiple foci (according to scientists, the presence of only one uterine fibroid node indicates only the initial stage of the development of the disease).
Causes of uterine fibroids
Currently, the causes of uterine fibroids are not fully understood. All scientists agree that there is a precursor cell for education. However, on the issue of the mechanism of its appearance, the opinions of scientists differ.
One theory of the development of uterine fibroids implies the appearance of a genetic defect in a smooth muscle cell during embryonic and subsequent uterine development due to a long and unstable period of embryonic rearrangements. The second theory is the possibility of damage to the cell of an already mature uterus under the influence of various factors, which is confirmed by numerous studies (microscopic examination of uterus muscle tissue preparations (myometrium) myomatous nodes were found in 80% of cases).
According to modern concepts, uterine fibroids develop as follows. During multiple cycles of hyperplasia (an increase in mass and volume of the body without an increase in cellular elements) of the myometrium during the menstrual cycle, smooth muscle cells with impaired apoptosis (programmed death) accumulate and are affected by various damaging factors: ischemia (insufficient blood circulation) due to spasm arteries during menstruation, inflammatory processes, traumatic exposure, or a focus of endometriosis.
With each menstrual cycle, the number of damaged cells accumulates. Some of the cells from the myometrium are removed, while others form myomatous nodes with different potential for growth. An active germ of growth in the early stages develops due to physiological fluctuations in the concentration of hormones during the menstrual cycle. In the future, the resulting cell complex activates local stimuli (growth factors) and supportive mechanisms (local synthesis of estrogens from androgens), and the value of the concentration of sex hormones in a woman’s body for the formation of myomatous node ceases to be decisive.
In addition, uterine fibroids are caused by the disruption of certain genes (HMGIC and HMGIY) involved in the rapid growth of embryonic tissues and located on chromosomes 12 and 6, respectively. Complete disruption of the synthesis of proteins from these genes causes rapid cell division with the development of a malignant formation, while at the same time, its partial disruption is characteristic of various benign growths.
Thus, the complex of cells of the myoma node due to the dysregulation of genes and the development of local mechanisms to activate and maintain growth is constantly increasing in size, while the cells of unchanged myometrium are in a state of relative rest. Subsequently, the myoma node increases the amount of connective tissue in its composition and intensifies the synthesis of estrogens from androgens, which leads to a slight decrease in the size of the formation, provided that it is deprived of hormonal stimuli.
Complications of uterine fibroids
The most frequent complication of uterine fibroids is a malnutrition of the subserous node, followed by necrosis of the node, less often – torsion of the legs of the subperitoneal node, acute bleeding, which leads to persistent anemia of the patient. Such a complication as uterine reversal at the nascent submucous node is extremely rare. Malignant degeneration is observed, according to some authors, up to 2%.
Diagnosis of uterine fibroids
In 50% percent of cases, uterine fibroids may be asymptomatic. But, if you have a suspicion of uterine fibroids (see the symptoms of uterine fibroids), you should immediately consult a doctor.
Diagnosis of uterine fibroids begins with a detailed collection of information from the patient about his state of health (both past and present) and the factors that could influence him. Particular attention is paid to the number of births and their complications, the presence of past abortions and their complications. Separately find out about the presence of intrauterine large and small interventions (therapeutic and diagnostic curettage, setting and removing intrauterine devices), the amount of menstrual bleeding.
Methods for diagnosing uterine fibroids
The first method of examination is bimanual (two-handed) vaginal examination. When it is performed, the doctor by touch determines the size and position of the uterus, and may also suspect the presence of uterine fibroids (with its increase, unevenness and roughness of the surface, inhomogeneous density of the uterus).
Ultrasound examination of the pelvic organs in uterine myoma is the second stage if this disease is suspected. This is a routine and widespread method for both the detection of uterine fibroids and its dynamic observation. With the help of ultrasound is determined by the location of nodes, their number and structure. Such an ultrasound can be performed in two ways: abdominal (the sensor is located on the anterior abdominal wall) and transvaginal (the sensor is inserted into the vagina).
In some cases, when a more precise determination of the location of uterine fibroids or a refinement of its structure is necessary, magnetic resonance tomography may be required.
Retained their diagnostic value and hysteroscopy (examination of the uterine cavity using special tools) and hysterosalpingography (determination of patency of the uterus and fallopian tubes using special solutions for ultrasound or fluoroscopic studies).
Determining the hormonal background in a woman (FSH, LH, prolactin, estrogen, progesterone, adrenal hormones and thyroid hormones) are also important diagnostic methods. Endometrial biopsy (the inner layer of the uterus) to exclude its diseases, smear for the detection of pathogens that are sexually transmitted, the state of the blood coagulation system and hemoglobin level is the necessary diagnostic minimum for suspected uterine fibroids.
With great difficulty in diagnosing the disease, laparoscopy may be indicated for some women.
If uterus myoma is suspected, the doctor consistently excludes the following diseases that can cause similar symptoms: benign and malignant ovarian disease, endometrium, uterine malignancy (leiomyosarcoma), metastasis of other tumors – and pregnancy itself.
It is possible to open the abdominal cavity with a median incision or transverse suprapubic according to Pfannenstiel. The surgical wound should be well diluted with a retractor, and the guts are delimited with napkins.
Removal of myoma node on the “leg” is not difficult and comes down to excision of the “leg” at its base. You should not make deep incisions in the direction of the body of the uterus, delving into the myometrium. It is enough to incise the peritoneum and a thin layer of muscle fibers that pass from the body of the uterus to the knot, so that the ends of the scissors stupidly separate the tumor. The excision of the “legs” is stitched with knotted catgut sutures so that the edges of the incisions are well matched and the bleeding is completely stopped.
The interstitial (intramural or intraparietal) located node (or nodes) is removed somewhat differently.
Above the myoma node, along the most convex surface (figure a), the peritoneum and uterine muscular membrane are cut longitudinally with a scalpel to the node, whose tissue differs sharply from muscle tissue in white and a different structure. Sometimes a cross section should be made. Due to the retraction of the uterine muscle fibers, the wound edges diverge widely. Capturing the knot with the Muso or Doyena forceps and vigorously pulling it off, pushing the edges of the incision with forceps or clamps. Stretched tufts of tissue between the tumor and the uterine wall are dissected with scissors (Figure B), and loose connective tissue is separated by blunt stupor or the ends of scissors.
So gradually, one by one, sometimes they peel up to 10-15 or more nodes.
Bleeding vessels are immediately clamped with clips and tied up with catgut. Husking myoma nodes is usually accompanied by significant bleeding, which stops easily and quickly. Sometimes, it is not possible to stop the bleeding only by bandaging the bleeding vessels, since the entire wound surface is bleeding. In such cases, the entire wound surface of the tumor bed is stitched with immersion knotted sutures. If this does not help, and there is reason to assume that intermuscular hematomas can form during the postoperative period, after the restoration of the integrity of the uterus is completed, hemostatic catgut sutures are applied across the body of the uterus (figure c). At the same time, a needle is punctured at the edge of the uterus medial to the vascular bundle so that the needle does not penetrate the uterus and, therefore, the thread does not pass through the endometrium. Tying seams is usually most convenient on the cystic surface of the uterus (Figure D). Two or three hemostatic sutures are sufficient to reliably stop bleeding and prevent the formation of intermuscular postoperative hematomas in the uterus.
If the uterus cavity was opened during the node dissection, it is necessary to apply muscular-muscular immersion knotted sutures after joining the edges of the basal layer of the endometrium (Figure d). When screwing the endometrium between the edges of the wound durable fusion will not occur. In addition, this creates favorable conditions for the development of internal endometriosis. When applying surface seams, the edges of the incision should be correctly mapped (figure e).
At the end of the operation, a thorough abdominal toilet is performed. The surgical wound is sutured in layers tightly. A huge uterus deformed by multiple myomatous nodes after their removal and restoration of the integrity of the tissues surprisingly quickly acquires a normal form, and often a magnitude.
Note the main points of myomectomy surgery:
- opening the abdominal cavity, moving the wound edges apart with a spreader;
- removal of a tumor or uterus in the operative wound and intestinal fencing with napkins;
- exfoliation of the tumor or excision of its “legs”;
- layer-by-layer stitching of the uterus incision (tumor bed);
- the imposition of hemostatic sutures, removal of instruments and wipes, toilet abdominal;
- stitching the wound.
Miommiometry and reconstructive uterine repair
The purpose of this operation, in accordance with its name, is not only to excise myomatous nodes that have grown in the walls of the uterus, but also to reconstruct and model the uterus from saved submucosal-muscular-serous uterine flaps that can perform the menstrual function, and often ensure the preservation of childbearing function.
Myomatous nodes can be located under the peritoneum, sometimes on an elongated “leg”, intramuscularly and directly under the endometrium. These latter, so-called submucosa, nodes may have a “leg”. They also have the ability to move towards the internal throat, as the uterus develops contraction, and after opening and smoothing the cervix, it can infiltrate the cervical canal and “be born”, that is, the uterus can push them into the vagina. This is accompanied by cramping pain and bleeding. Infringement of a “nascent” myoma node may be complicated by its necrosis and suppuration, therefore, its removal by laparotomy is absolutely contraindicated. Such a node must be removed only through the vagina.
The number of myomatous nodes in one patient can be different: from 1-2 to 40 and more. They can be located in groups of several nodes in the form of conglomerates, mainly in the body of the uterus, or at its edges, at one or another angle. The body of the uterus at the same time can reach enormous size and deform. The inner surface of the uterus is also deformed. The uterus can be bizarre in shape and significantly elongated on a large submucosal site. In the lumen of the uterus may be several myomatous nodes of various sizes. Endometrium is often hyperplastic. In some cases, the shape and size of the uterine cavity may not change significantly, despite the significant external dimensions of the uterus.
Laparotomy can be done using one of the known methods, but it is more rational than the middle lower incision or according to Cherni, since these methods create the best access to large tumors.
The surgeon must study the location of myoma nodes and their conglomerates, their topography in order to choose the right incision sites and economically excise the nodes and excess myometrium. When excision of the flaps to be removed, every effort should be made to preserve the integrity of the uterine horns, to prevent damage to the intramural part of the fallopian tubes. This is particularly important for infertility in women of childbearing age. The outlining incision is made to bypass the conglomerate of myomatous nodes through the entire thickness of the uterus, inspect the endometrium, exfoliate the submucosal nodes, remove the hyperplastic endometrium, and then restore its integrity with continuous or knotty catgut sutures. The basal layer should be stitched with thin catgut No. 0. After this, the dissection of myomatous nodes along with the myometrium and the exfoliating of single located nodes continue.
If almost all the nodes are located in one of the walls of the uterus, then this wall should be excised along with all the nodes, and from the remaining front or back wall of the uterus to model its new body, which allows you to save menstrual function. Unfortunately, a woman cannot perform the childbearing function after such an operation.
Therefore, the main points of the operation mommiometrectomy and reconstructive recovery of the uterus after opening the abdominal cavity are the following:
- removal of the uterus from the abdominal cavity, and if this is not possible, then into the surgical wound;
- studying the topography of myomatous nodes;
- making contour cuts;
- Peeling of individual, largest nodes;
- excision of conglomerates of nodes;
- careful hemostasis;
- examination of the uterus, removal of submucosal nodes and scraping of the hyperplastic endometrium;
- layer-by-layer restoration of the integrity of the uterus from preserved mucous-musculo-serous flaps;
- examination of the ovaries and fallopian tubes;
- toilet of the abdominal cavity;
- layer wound surgical incision
Supravaginal amputation of the uterus without appendages
The abdominal cavity is opened with a median layer-by-layer incision between the pubis and the navel or a Pfannenstiel incision, through which you can create optimal access to the uterus; if necessary, the patient is transferred to the Trendelenburg position.
The uterus is fixed with a reliable forceps or a corkscrew and removed from the abdominal cavity, the wound is moved apart by a retractor, the intestine is carefully protected with napkins. Such training greatly facilitates the operation.
If the uterus cannot be removed from the abdominal cavity due to shortening of the ligaments or due to adhesions to the walls of the pelvis, it is brought to the surgical wound and proceeds to perform the actual operation.
Usually, having retracted the uterus up and to the left or right, a circular ligament of the uterus and its own ligament of the ovary with the fallopian tube are dissected between the two clamps (Figure a). In the same manner, the uterus is released from the other side.
Cut through the front piece of the wide ligament of the uterus and the peritoneum of the vesicle-uterine cavity (picture b), push it downwards together with the bladder, so as not to injure or manipulate it when manipulating.
Stupidly exfoliate the anterior and posterior sheets of the broad ligament of the uterus to the internal osma of the uterus, looking for the uterine artery in the depth of the wound; having seized it with two clips, dissect between them and bandage it (figure c, d). In the same way they pinch, cut and tie up the uterine artery on the other side.
After this, slightly below the internal os, the cervix is fixed with forceps and the uterus is cut with a wedge-shaped incision with the tip downwards.
On the stump of the cervix impose 3-4 knotted, usually catgut, suture (Figure d).
The stump is peritonized in the following way: by putting a purse stitch on the leaves of the wide ligament of the uterus, it is gradually tightened by immersing the stump of the severed, for example, right, appendages and round ligament of the uterus, the front and back sheets of the wide ligament of the uterus are connected with a continuous suture (Figure e); the stumps of the left appendages and the round ligament of the uterus are also immersed in a purse-string.
At the end of peritonization, wipes are removed from the abdominal cavity and a careful toilet is made.
Sew the surgical wound usually.
So, the main stages of the operation of supravaginal amputation of the uterus without appendages after opening the abdominal cavity are the following:
- removal of the uterus from the abdominal cavity and intestinal obstruction with napkins;
- clamping the two uterine tube, the ligament of the ovary and the round ligament of the uterus with two clips;
- cutting these formations between the two clips;
- stratification of leaves of the wide ligament of the uterus to the level of the internal os of the uterus;
- doing the same on the other side;
- dissection of the peritoneum of the vesical-uterine cavity and, if necessary, the separation of the bladder downwards;
- clamping, cutting and bandaging the uterine artery, first on one side and then on the other side at the level of the internal os;
- wedge-shaped cutting off of the uterus;
- Closure of the uterus stump with knotted catgut sutures;
- revision of the cavity of the removed uterus;
- translation of the operating table in a horizontal position, toilet of the abdominal cavity after removing wipes and instruments from it;
- layer wound surgical incision
You can also read an article about cervical colposcopy on our website.
This operation is first performed in the same way as >supravaginal amputation of the uterus without fallopian tubes and ovaries, but the bladder is completely detached from the uterus – to the front of the vaginal fornix. As soon as the peritoneum of the vesicle-uterine cavity is dissected, the bladder is pushed away with tupfer downward, while the perineal cellulose is stretched at the same time with scissors closer to the bladder neck (figure a), its further detachment is produced with tupfer. You can make sure that the bladder is already otseparovan, you can use palpation. The surgeon palpates the vesicle with his thumb, and with the index and middle fingers – the intestinal surface of the cervix, gradually sinking down, where the fingers slide off the dense cervix onto the adjacent walls of the vagina.
The uterine artery during the extirpation of the uterus should be clearly visible; below the internal os, it is clamped with two Kocher clamps, between which it is cut first with one, then with the other side and tied.
If the vaginal artery does not enter the clips, it is pinched separately, cut and ligated. After that, the uterus is pulled toward the pubic symphysis. The rectum-uterine fold of the peritoneum is dissected between the rectal-uterine ligaments and separated from top to bottom. Under eye control, each rectangular-uterine ligament is strictly perpendicular to the place of discharge from the uterus, clamped with clamps, between which the ligaments are cut and tied. In order to avoid injury to the ureters, these clips should not capture the circulatory tissue near the side portions of the vaginal fornix. After this, the uterus becomes mobile. Now it is taken away towards the head end of the operating table, the bladder is pushed away by tupfer, and the front wall of the vagina is captured with a bullet forceps or Kocher clamp, a sterile napkin is placed under the uterus and upper part of the vagina so that the contents of the vagina are not opened into the abdominal cavity when it is opened.
Remove the tampon from the vagina. The front part of the vaginal fornix is opened through the opening of the vagina. Treat its mucous membrane with a 1% solution of iodine alcohol and tampon with a long bandage. Next, the hole in the vagina is enlarged in both directions, and the cervix is grasped from the external pharynx with reliable forceps. Vigorously retracted the cervix, scissors cut through the vaginal fornix near its walls around the entire circumference, fixing the edges of the wound with Kocher clips (Figure b).
Produce a revision of the cavity of the uterus removed. The wound of the vagina is sutured with knotty catgut sutures or left open if there is a need for drainage of the abdominal cavity or the circulatory tissue (figure c). After that, the tissue that was brought under the cervix before dissection of the vaginal fornix is removed, and all participants in the operation are replaced by gloves or wash their hands.
The operating sister removes all the tools and material used in the work and replaces it with another sterile kit. The wound is additionally covered with sterile wipes.
Peritonization is performed with a continuous catgut suture connecting the posterior leaflets of the wide ligament of the uterus with the anterior margin of the peritoneum of the bladder-uterine cavity, as a result all the stumps should be immersed in the retroperitoneal space; several seams connect the leaves of the wide ligaments of the uterus with the edges of the vaginal wound.
After the toilet of the abdominal cavity and removal of instruments and napkins from it, the surgical wound is sutured in layers.
The main stages of this operation after opening the abdominal cavity are the following:
- disclosure of the surgical wound by the retractor and the intestinal barrier with napkins;
- the study of the pathological relationships of the pelvic organs;
- separation of the uterus and its appendages from adhesions (if any);
- cutting on both sides between the two Kocher clamps, separately, the round ligament of the uterus and the own ligament of the ovary with the fallopian tube and their immediate ligation;
- dissection of the wide ligament of the uterus along the edge of the uterus to the level of the internal os;
- dissection across the peritoneal clips of the vesicle-uterine cavity and the separation of the bladder down to the front of the vaginal fornix;
- exposing the uterine artery, cutting it between two Kocher clamps and bandaging, cutting and bandaging the vaginal artery, if it does not accidentally hit the Kocher clamp;
- Kocher grasping, cutting and ligation of rectal uterine ligaments;
- opening the vagina after removing a tampon from it;
- additional disinfection and vaginal tamponade;
- cutting off the uterus from the vaginal fornix;
- revision of the cavity of the removed uterus;
- stitching of the vaginal wound (or leaving it open);
- change of gloves, linen, tools and napkins;
- toilet of the abdominal cavity and removing tools and napkins from it;
- stitching the wound;
- extraction of a tampon from a vagina
Treatment of uterine fibroids
Currently, the treatment of fibroids has two main areas: conservative (treatment of uterine fibroids without surgery) and surgical treatment.
The goals of treatment of women with uterine myoma: elimination of the consequences of the disease (anemia, heavy menstruation, damage to neighboring organs and
Treatment of uterine fibroids folk remedies
It should be noted that the official medicine rather cautiously looks at the popular methods of treating uterine fibroids (they are used for small sizes of fibroids with slow or extremely slow growth).
Uterine fibroids is a benign growth that rarely turns into a malignant tumor. However, the treatment of uterine fibroids folk remedies produced by plants with antitumor properties. In folk medicine, the recipe of all kinds of alcohol extracts from the wrestler of Dzungarian and Baikal, speckled hemlock, marshmallow, white mistletoe are widely represented. Plants are poisonous, extracts from them are taken drop by drop, short courses, requires extreme caution in the preparation and adherence to treatment.
The second group of plants used in folk medicine is represented by non-poisonous common shandra, boron uterus, European zyuznik. Tinctures and extracts from them are quite suitable for self-treatment and are taken for a long time. In addition, substances secreted from these plants act exclusively on myomatous nodes.
Separately presented propolis, various dosage forms of which have not only an immunomodulating, immunostimulating property, but not a pronounced antitumor property. It is used not only in the form of various tinctures and extracts, but also as an ointment or suppositories.
Knotweed, Medunitsa officinalis, horsetail are herbs that have the ability to regulate the formation of connective tissue and are also used to treat uterine fibroids. They inhibit the formation of adhesions and scars, and if they already exist, they make them softer and more elastic.
The official drug treatment of fibroids is aimed at inhibiting or reversing the development of the tumor, treating anemia (anemia), which develops against the background of heavy menstrual bleeding in women with this disease. In the treatment used drugs of various groups.
Firstly, these are derivatives of 19-norsteroids (norcolute, etc.), under the action of which the uterus is reduced, blood loss is reduced and the level of hemoglobin in the blood is normalized. But their use is limited to the size of fibroids (you can treat fibroids up to 8 weeks). The second group is represented by drugs that inhibit the production of sex hormones in women – antigonadotropins (gestrinone, etc.) and gonodotropin agonists – releasing hormone (zoladexi, etc.). These drugs affect the growth of fibroids, reducing their size by up to 55%, and impair blood flow within the myoma node. But their use is limited by the obek effect: rapid loss of calcium from the bones of the body of a woman with the development of osteoporosis. In addition, after the cessation of taking the pills, uterine fibroids return to their previous size. The use of these drugs is aimed at achieving 2 main goals: to prepare a woman for further surgical treatment or to speed up her release into menopause.
Surgical treatment of uterine fibroids.
Currently, all operations for the removal of uterine fibroids are divided into radical (hysterectomy) and organ-preserving (removal of myomatous node, uterine artery embolization and some experimental treatment methods). Each of the operations has its advantages and disadvantages.
Complete removal of the uterus with myoma (hysterectomy) is the most common treatment.
Intervention can be carried out in two ways: open (the surgeon has access to the uterus through an incision of the anterior abdominal wall) and laparoscopic (the operation is performed with a special laparoscopic instrument through several small punctures of the abdominal wall).
For all its merits (the method is radical, eliminates uterine myoma and its consequences forever, there are no relapses of the disease), hysterectomy has a number of important shortcomings:
the operation requires general anesthesia with a certain risk of developing complications after the operation, especially in the presence of concomitant diseases (coronary heart disease, anemia, endocrine disorders, etc.);
long periods of treatment and rehabilitation (up to 6 weeks for uncomplicated after the operation);
for patients who do not have children and are planning a pregnancy, surgery is not desirable to an extreme degree;
after this operation increases the risk of posthistectomy syndrome (LNG or PGS) – a complex of disorders in the hormonal, vascular and psychological areas of women, in which the probability of developing breast cancer and coronary heart disease significantly increases.
Removal of the uterus proper myoma (myomectomy) is an organ-preserving operation and consists in removing only myomatous nodes. Intervention can be done as an open method, as well as laparoscopy.
Having a number of advantages over the complete removal of the uterus (the period of full recovery reaches 2-3 weeks, the possibility of further pregnancy, a lesser probability of developing ASG), the treatment of uterine fibroids by this method is not the “gold standard”.
The possibility of an operation depends not only on the size, number and location of myomatous nodes, but also on the experience of the surgeon. The operation requires general anesthesia. And finally, during surgery, uterine bleeding may develop, which is a direct indication for a radical operation. Treatment of uterine fibroids in this way has a fairly high risk of recurrence of fibroids (complete removal of all nodes during surgery is not possible, and the mechanical effect on the uterus during surgery is itself a risk factor for the development of fibroids).
The next method – embolization of the uterine artery – is to disrupt the blood flow until it stops completely by various methods in the choroid plexus, which entangles and nourishes the myomatous node. The diameter of the vessels of such a plexus is several times larger than the diameter of the normal artery of the uterus, which allows selectively during the operation to introduce the drug into these vessels, blocking the blood flow. As a result, wrinkling of the myoma node, replacement with connective tissue or its complete disappearance occurs.
The operation takes about 2 hours, is performed under local anesthesia, and the woman can be discharged from the hospital already on the second day. The probability of recurrence of myoma node is extremely small. However, the treatment of uterine fibroids with this method has a rather high cost, which limits its use.
Thus, the development of the ideal “gold standard” treatment of uterine fibroids, which would guarantee a 100% cure, while maintaining the possibility of further pregnancy, continues to this day.
Symptoms of uterine fibroids
Uterine fibroids – one of the most insidious diseases of the female reproductive system, which in 50-60% of patients can be completely asymptomatic.
Currently, the main symptoms of uterine fibroids are isolated: abundant menstrual bleeding, infertility, compression of adjacent organs (bladder, ureter, rectum), chronic pelvic pain, acute pain at torsion of myoma or malnutrition in the node, iron deficiency anemia. During pregnancy in 10-40% of cases – its interruption, damage to the fetus and premature birth, heavy bleeding in the postpartum period.
Depending on the location of the node and, to a lesser extent, on its size, certain signs of uterine fibroids may prevail.
Symptoms of uterine fibroids with submucous (submucosal) node location prevail in the form of menstrual disorders: prolonged, heavy menstruation – and uterine bleeding, which in the end can lead to the development of iron deficiency anemia (anemia). Pains for such fibroids are not so characteristic, however, during the prolapse of the myoma node in the uterus from the submucosal layer (“birth of the node”) there can be very severe pains of a cramping character. Often, submucous fibroids cause infertility or miscarriage.
Signs of uterine fibroids
However, the symptoms are not clearly defined for all forms of uterine fibroids. In such cases, the doctor conducts his search through secondary symptoms, signs of uterine fibroids. For example, uterine fibroids with subserous nodes may not appear for a long time. But with an increase in size – constant pulling, unexpressed pain and discomfort in the lower abdomen become the leading symptoms of the development of the disease. In extreme cases, when the nutrition of a large subserous node is disturbed, the pain can provoke the clinic of “acute abdomen” and be mistaken for the symptoms of the disease of the abdominal cavity and cause hospitalization in a surgical hospital. Bleeding for such nodes is not typical.
Mixed (interstitial-subserous) myomatous nodes are difficult to diagnose and are not recognized by the doctor for a long time. They can reach a large size (10-30 cm in diameter), manifesting only a slight discomfort in the lower abdomen. With the increase in the size of the tumor, its pressure increases, and the signs of uterine fibroids as damage to neighboring organs come to the fore. Constant pressure on the rectum provokes a violation of bowel processes. Crushing of the bladder and ureter can lead not only to impaired urination, but also damage to the ureter (hydroureter) and kidney (hydronephrosis and pyelonephritis) on the affected side, the development of compression syndrome of the inferior vena cava (the appearance of shortness of breath and abdominal pain when lying down).
Uterine fibroids and pregnancy
Maintaining pregnant women with uterine myoma creates certain difficulties for the doctor and patient. Absolute contraindications for preserving pregnancy in uterine myoma: suspected malignant degeneration of a tumor; rapid growth of myoma nodes; cervical-ischemic localization of myoma node; pinching myoma node, necrosis, torsion of the node on the leg; pelvic venous thrombophlebitis; late pregnancy (age over 40 years) and poor health. And their number with the development of medicine is steadily decreasing.
However, even if a woman suffering from uterine myoma does not have these contraindications, complications – spontaneous abortion, the need for large sizes of fibroids to perform a cesarean section with further removal of the node or uterus is likely to a large extent.
Conducting pregnancy with uterine myoma
From a clinical point of view, all pregnant women with uterine myoma are divided into pregnant women with low and high risk of complications, which have some differences in the future tactics of pregnancy management. However, every pregnant woman suffering from uterine myoma requires increased attention from the doctor and needs early medical support, which is aimed at reducing the tone of the uterus, prolonging pregnancy and giving birth to a healthy child.
From early periods (week 16–18), antispasmodics (no-shpa, etc.), drugs that reduce blood clotting (small doses of aspirin, pentoxifylline, etc.) and reduce the tone of the uterus (hexoprenaline, etc.) are prescribed. The ultrasound frequency for pregnant women with uterine myoma is increased: by 6–10th, 14–16th, 22–24th, 32–34th and 38–39th week of pregnancy. Conduct constant monitoring of the size and localization of myoma nodes, the condition of the fetus.
With insufficient effectiveness of the therapy, doctors are forced to go for surgical treatment – removal of the myoma node with preservation of pregnancy. And with certain indications (the gigantic size of uterine fibroids, the violation of its nutrition, the suffering of the fetus as a result of circulatory failure or compression with a myomatous node, etc.), it is possible to completely remove the uterus after cesarean section.
It is worth noting that with small sizes and a certain arrangement of myomatous nodes (most often it is intramural-subserous), pregnancy can often proceed without complications for the mother and child.