Uterine fibroids remain the most common tumor of the reproductive system in women. According to statistics, more than 50% of all patients in operative gynecology departments are women with uterine myoma. The choice of treatment method should be individual for each patient and is largely determined by the clinical manifestations of the disease.
The incidence of uterine fibroids ranges from 25 to 35% in women of reproductive age, increasing to 43-52% in women of perimenopausal age. Currently, it is not uncommon to identify myomatous nodes in women in their 20s and 30s.
Causes of uterine fibroids
Myoma (leiomyoma) refers to a monoclonal benign smooth muscle tumor, the growth of which is caused by a complex of factors that affect the processes of proliferation, apoptosis and angiogenesis. Numerous studies on the pathogenesis of tumor growth show that sex steroids – estrogen, progesterone and their receptors – in modeling the growth, differentiation and function of the myometrium.
Some experts consider uterine leiomyoma as a local manifestation of complex changes occurring in a woman's body, as a disease of maladaptation, manifested in a violation of the relationship in the hypothalamus-pituitary gland-ovaries-uterus system with a kind of myometrial hyperplasia against the background of disturbed hormonal relationships and / or altered receptor sensitivity of the effector organ.
A certain role in the occurrence of uterine leiomyoma is played by a violation of hemodynamics, innervation and water-electrolyte balance, in which the elasticity of the walls of myometrial blood vessels decreases, stasis occurs, blood and lymph outflow and the Na / K coefficient decrease, and tissue hypoxia occurs. This leads to impaired differentiation of myometrial cells, which acquire the ability for proliferative growth, which, in turn, contributes to the formation of uterine leiomyoma even in conditions of preserved hormonal status.
According to some experts, there is no asymptomatic uterine fibroids. Indeed, if women in the initial stages do not have bleeding, pain, dysfunction of adjacent organs, this does not mean that there will be no tumor growth in the near future. It is believed that fibroids – a tumor of benign origin, but one should not forget that its malignant degeneration can occur at any age.
Currently, gynecologists are inclined to believe that in reproductive age, the risk of developing an oncological process in a tumor is most real in those women who, in addition to uterine leiomyoma, have 2–3 more risk factors, especially in the presence of metabolic disorders. During perimenopause and menopause, uterine fibroids are an independent risk factor, especially if there are other signs of hyperestrogenism or endocrine-metabolic disorders. I'M IN. Bohman unequivocally defined the role of uterine fibroids as a marker of malignant neoplasms. It is not for nothing that in many classifications, fibroids are distinguished as a borderline tumor capable of malignancy.
Management of patients with uterine fibroids
The variety of variants of the clinical course of uterine fibroids, the age range from early reproductive to postmenopausal, frequent combination with other gynecological diseases dictate the need for an individual choice of treatment for these women.
The management of women with uterine fibroids of childbearing age is different, because it largely depends on the need to preserve reproductive function.
Uterine fibroids are not an absolute indication for surgical treatment. Patients of young reproductive age with fibroids up to 4 cm in size without clinical manifestations can be treated conservatively using low-dose oral contraceptives.
However, long-term inactivity and the use of hormonal drugs in the treatment of uterine fibroids in women planning pregnancy can worsen the state of reproductive function and increase the risk of organ loss due to denervation, myometrial hyperplasia and destruction of the myocyte receptor apparatus. Therefore, conservative management can last no more than 3 years with mandatory dispensary observation.
Uterine fibroids and pregnancy
Although pregnancy and its favorable outcome with uterine fibroids are quite possible, in 20% of women, fibroids are the cause of infertility. Pregnancy with uterine myoma, childbirth and the postpartum period often have a complicated course and in some cases end in the loss of the fetus and uterus. The most common gestational complications at present are: threatened miscarriage at various times, fetoplacental insufficiency and fetal growth retardation syndrome, malposition and fetal presentation, placental abruption, especially in cases where it is partially located in the area of the myomatous node, rapid tumor growth which can develop at any gestational age. A frequent complication of pregnancy with uterine myoma is necrosis of the node, which, in laboratory, clinical and ultrasound confirmation is an absolute indication for surgical treatment. The most common complications of childbirth and the postpartum period are: untimely rupture of amniotic fluid, anomalies of uterine contractile activity, tight attachment of the placenta, hypotonic bleeding, subinvolution of the uterus, node necrosis.
In connection with the foregoing, the task of an obstetrician-gynecologist at the outpatient stage is to predict possible complications of pregnancy with uterine myoma in each particular patient and create conditions for favorable pregnancy, childbirth and the postpartum period.
Many years of experience show that reproductive outcomes in women with uterine fibroids planning pregnancy directly depend on timely and high-quality preconception preparation, which should include: topical diagnosis of fibroids with a forecast of its growth during pregnancy; preoperative preparation with sanitation of infectious foci and treatment of anemia; timely myomectomy with nodes larger than 4-5 cm in compliance with surgical technology that provides favorable conditions for the formation of a full-fledged scar (scars) on the uterus; comprehensive postoperative rehabilitation.
Diagnosis of uterine fibroids
Currently, a fairly large number of additional research methods have been proposed that allow diagnosing uterine myoma, assessing the features of its development, conducting differential diagnostics, determining patient management and determining the most rational method of treatment.
Ultrasound is of key importance for the timely diagnosis of fibroids, which has become routine in our time and has become part of the practice of medical institutions. The use of ultrasound scanning allows to identify uterine myoma with an accuracy of up to 97%, correctly determine the number of fibroid nodes, their size, localization, the ratio of nodes to the vascular bundles of the uterus, the presence of dystrophic and necrotic changes in them. The study of blood flow in the vessels of neoplasms, which have their own characteristics, allows us to consider color Doppler mapping (CDC) as an important method in the differential diagnosis of benign and malignant tumors of the uterus. The level of vascularization registered with the help of color doppler allows predicting the rate of growth of the detected formation.
Surgical treatment of uterine fibroids
The question of choosing a surgical approach for myomectomy is still one of the most controversial. We believe that open abdominal and laparoscopic approaches are not competing, and each of them has its own indications and advantages. Large intraligamentary and atypically located fibroids, the possibility of a more thorough layer-by-layer comparison of the wound edges during abdominal dissection, and the absence of coagulative tissue necrosis with this method make laparotomy the method of choice for myomectomy in patients who plan and do not exclude pregnancy in the future.
Indications for myomectomy at the stage of pregnancy planning are:
- volume of nodes (node) exceeding half the volume of a normal uterus (greater than 4 cm);
- uterine bleeding leading to anemia and due to uterine myoma;
- large and giant size of the tumor (exceeding 12 weeks of pregnancy) even in the absence of complaints;
- tumors of any size in the presence of symptoms of compression of neighboring organs (frequent or difficult urination, violation of the act of defecation);
- atypical location of nodes (cervical, isthmus and intraligamentary localization of nodes of uterine fibroids);
- rapid tumor growth;
- impaired blood circulation in the node;
- presence of subserous myoma nodes larger than 4–5 cm;
- infertility in the presence of uterine fibroids.
Features of the surgical technique are: intracapsular exfoliation of the fibroid node; thorough hemostasis due to compression of blood vessels by tissues; exclusion for hemostasis of energy effects; suturing the wound with separate sutures with synthetic long-absorbable suture material; carrying out anti-adhesion measures.
Removal of myomatous nodes can be considered only one of the stages of complex treatment of uterine fibroids, since relapses most often occur in patients with multiple myomatous nodes, combined gynecological pathology, in the absence of hormonal therapy in the postoperative period.
Postoperative rehabilitation is the most important step in the preconception preparation of patients after myomectomy. It is advisable to include hormonal, immunomodulating, anti-inflammatory, antianemic therapy and drugs that improve reparative processes in the uterus in the complex of postoperative rehabilitation measures.
The following groups of drugs are used as a hormonal component: gonadotropin-releasing hormone (a-GnRH) agonists and combined oral contraceptives. Indications for the appointment of hormonal therapy in the postoperative period are: the presence of multiple uterine fibroids, atypical location of the nodes, the combination of fibroids with adenomyosis or external-internal endometriosis, infertility, in cases where surgery was accompanied by opening the uterine cavity, as well as the presence of proliferative-active leiomyoma without concomitant gynecological diseases.
Rehabilitation after complex therapy of uterine fibroids
In order to eliminate hypoestrogenic conditions and better tolerability of a-GnRH at the stage of rehabilitation after organ-preserving operations, it is advisable to prescribe red clover isoflavones.
Dynamic ultrasound in combination with Doppler ultrasound (3 and 6 months after surgery) allows you to control the effectiveness of the operation and conservative therapy, taking into account the assessment of the course of reparative processes and the viability of the scar on the operated uterus.
After the end of complex therapy, menstrual function is restored in the first 1–3 months.
Planning pregnancy is allowed after an average of 6 months. after surgery, taking into account the fact that reproductive function increases immediately after the end of hormone therapy. For women of the age group over 35, in the absence of spontaneous pregnancy within six months after organ-preserving surgery and hormonal rehabilitation, it is advisable to recommend the use of assisted reproductive technologies.
Thus, preconception preparation of patients with uterine myoma and reproductive problems, including timely and thorough examination at the stage of pregnancy planning, substantiation of clear indications for myomectomy, comprehensive postoperative rehabilitation, improves the quality of life of patients, increases the frequency of pregnancy and reduces the frequency recurrence of the disease.
For patients who have realized their childbearing function, but wish to maintain their menstrual function, myomectomy is performed, followed by the use of combined oral contraceptives or the Mirena intrauterine hormonal system.
Even in a rather technically complex surgical situation, we are supporters of organ-sparing operations with subsequent rehabilitation in all patients of childbearing age, and only in the case of a categorical refusal of patients with children, we expand the scope to hysterectomy.
Drug therapy for uterine fibroids
A.L. Tikhomirov et al. offer a two-stage treatment regimen for women with symptomatic uterine fibroids measuring from 2 to 4 cm. At the first stage, patients are prescribed a course of therapy with a-GnRH or antiprogestogens (mifepristone).
Mifepristone is a progesterone receptor blocker, therefore it has a depressing effect on the growth of myomatous nodes and leads to their regression. In the patient's blood serum while taking mifepristone, the levels of estrogens and progesterone do not change, i.e. the drug acts at the local level. Mifepristone does not cause pseudomenopause, which allows it to be used for a long time without supplementing estrogen replacement therapy. According to A.L. Tikhomirova et al., the use of mifepristone at a dose of 50 mg/day for 3 months. allowed to reduce the size of myomatous nodes by an average of 50-60%.
If we limit ourselves to only the first stage of treatment, then the effect obtained may be insufficient due to the high probability of subsequent growth of the nodes. In this regard, the researchers recommend that at the second stage of treatment, patients should be prescribed stabilizing therapy in the form of combined oral contraceptives or the Mirena intrauterine hormonal system. The recommended two-stage treatment regimen is pathogenetically justified. It is clear that with uterine fibroids for more than 12 weeks. pregnancy and uterine bleeding, hormone therapy is ineffective.
Uterine fibroids during menopause
The perimenopausal period is characterized by a deep age-related restructuring of the entire female body, including the neuroendocrine system, against the background of a progressive decline in ovarian function. The age-related decrease in the level of secretion of estrogen and progesterone in postmenopause does not indicate a complete cessation of ovarian function – hormones in the female body undergo qualitative changes.
With the onset of menopause, uterine leiomyoma in 85-90% of cases can regress, especially with small sizes and interstitial-subserous localization of the nodes.
Non-regressing postmenopausal uterine fibroids can serve as a kind of tumor marker for the occurrence of cancer in the reproductive system: in the endometrium, myometrium and ovaries.
It is believed that uterine leiomyoma should be considered a risk factor for the development of atypical endometrial hyperplasia and cancer of the uterine body, and the likelihood of the latter increases with the duration of the existence of the tumor and the age of patients.
After 45 years, uterine fibroids often coexist with other gynecological diseases, and due to the high oncological risk, it is necessary to conduct an examination for tumor markers, extended colposcopy, cytological examination of smears from the cervical canal and the vaginal part of the cervix for the presence of atypical cells, separate diagnostic curettage or aspiration biopsy of the endometrium with subsequent histological examination. Due to the frequent occurrence of atresia of the cervical canal in postmenopausal women, it is difficult to perform a separate diagnostic curettage, the undeniable priority belongs to ultrasound scanning.
The determination of the anteroposterior size of the M-echo is of great importance, given the greatest prognostic value of this criterion in pathological conditions of the endometrium. The ultrasound image of myomatous nodes in the postmenopausal period depends on the type of morphological processes occurring in it: fibrosis – proliferation of connective tissue and obliteration of blood vessels; or necrosis – malnutrition in the node and, accordingly, disorders of blood and lymph circulation; or proliferation processes.
With CDI, vessels located along the periphery of the myomatous node are more often visible. In the outer third of the thickness of the myomatous node, dilated veins are visualized, and the vessels localized along the outer contour of the node are more often represented by arteries. In the central part of the nodes, the vessels are visualized much less frequently. Detection of intense intratumoral blood flow of the myomatous node in the postmenopausal period makes it possible to identify a group of patients with signs of proliferation in the myomatous nodes, malignant degeneration of the node.
If a woman enters postmenopause with a large tumor, high estrogen saturation, and pathology of the cervix, then, without a doubt, she needs surgery in the amount of panhysterectomy. In perimenopause, the issue of removing the appendages is decided individually, depending on the condition of the ovaries.
Indications for surgery are:
- large uterine fibroids with bleeding symptoms;
- endometrial adenocarcinoma;
- multiple uterine fibroids with pain symptom;
- uterine fibroids with a symptom of compression of adjacent organs and a violation of their function;
- atypical location of myoma nodes;
- combination of uterine fibroids with adnexal tumors, endometrial hyperplasia, external-internal endometriosis;
- re-development of disease symptoms after conservative treatment and frequent separate diagnostic curettage.
For women who have premenopausal menstrual disorders, i.e., those who are on the verge of menopause, in this clinical situation, long-term administration of a-GnRH or mifepristone is possible in order to transfer these patients from artificial to natural menopause. In the absence of concomitant gynecological diseases, small tumor sizes (up to 4 cm) and the absence of symptoms of fibroids, patients do not need treatment and may be under dynamic observation.
Thus, there is no single management strategy for patients with uterine myoma, the choice of treatment method should be individual and largely determined by age, premorbid background, clinical manifestations of the disease, the risk of developing an oncological process and the characteristics of tumor morphogenesis.
According to www.rmj.ru
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