Uterine fibroids (leiomyoma): treatment, surgery, symptoms
Uterine fibroids (leiomyoma, fibroid) is a benign tumor that grows from muscle layers of the body. This tumor is the most common disease in women, and by menopause it is found almost one-third of the fair sex. However, having heard such a diagnosis, many women panic, considering him a sentence that requires surgery and removal of the whole organ. In many ways, the fears due to the fact that the treatment approaches most often radical, and the uterus is perceived as something «unnecessary», spent its function, if the woman already has children. At the same time, in recent years there has been a significant rejuvenation of the tumor and are not uncommon when it is diagnosed at the age of 30. This forces doctors to seek new treatments that not only preserve the uterus but to give the patient a chance to become a mother.
To date, scientists have not come to accurate opinion, why is there this tumor. Most likely a hormone factor.
Fibroids often appears in various violations of hormonal levels, when elevated concentrations of estrogen and progesterone causes increased proliferation of smooth muscle cells and the growth of fibroids.
In addition, the cells of the tumors have receptors for female hormones. A specific value is given to heredity, therefore if the mother or grandmother suffered from leiomyoma, the woman should be very alert to their health.
Fibroids are benign in nature, but if a lot of nodes and marked by their rapid growth, there is a high probability that some of them would be a sarcoma (a malignant tumor). The quality of the process explains the frequent wait-and-see tactics in regard to the fibroids, although modern methods of treatment can save a woman from even small tumors.
In the literature, you can still come across the term «fibroids» of the uterus or fibroids, which reflected a significant amount of connective tissue, giving a higher density, but as the tumor grows still of smooth muscle, such names decided to abandon in favor of leiomyomas, more accurately defines the essence of this process.
Causes and types of uterine fibroids
The uterus is a hollow body the wall of which consists of three layers. The middle, muscular layer, and becomes a source of neoplastic growth.
Among the reasons that most likely lead to the growth of uterine fibroids include:
- Hormonal imbalance;
- Genetic predisposition;
- Pathology of the immune system;
- The absence of childbirth and lactation to thirty years;
- Defective sexuality and venous stasis in the pelvis;
- Frequent intrauterine interventions (abortion, curettage, repeated hysteroscopy);
- Overreliance on oral contraceptives;
- Chronic inflammatory processes of small pelvis organs;
- Prolonged stress, neurasthenia, vegetative-vascular dystonia;
- The presence of comorbidity, such as obesity, diabetes mellitus, disorders of thyroid function etc.
It is believed that the rudiment of the tumor occurs at the age of about 30 years, and the time to achieve a size that allows it to detect, is about 5 years. Quite a long time, fibroids may exist without a clear progression, without causing the woman significant discomfort, but under unfavorable circumstances (intrauterine manipulation, epididymitis, or endometritis) the tumor is growing rapidly. Typically, the node sizes in the range of a few centimeters, but often you can detect and advanced forms when the tumor diameter can reach 10 cm and more.
The basis of the tumors are smooth muscle cells, which are surrounded by different amounts of connective tissue. If the latter prevails, then the tumor can called a fibroid.
Fibroids are often accompanied by changes of the endometrium – hyperplasia, growth of polyps, and perhaps a combination of tumors with endometriosis, which is not surprising, because all these States have a common cause – hormonal imbalance.
It happens that in one and the same patient is formed by multiple foci of neoplastic transformation, then the nodes will have multiple – multiple uterine fibroids. Such nodes are located in different parts of the body may be of various sizes, deform the uterus and compress adjacent organs.
Depending on the location of myoma nodes relative to the muscle layer of the uterus that provide:
Subserous fibroids, when a node is under the outer serosal layer, and if it has a thin stem, that is actually located in the abdominal cavity;
If there was a tumor in the cervix are called cervical. This localization is considered unfavorable, because even with a small size of the tumor leads to compression of adjacent organs, flows with pain and reproductive dysfunction.
In most cases revealed nodular growth form, it can also be plural when there are multiple nodes, but is found and diffuse the option of thickening the entire wall of the uterus. Diffuse fibroids particularly difficult in the treatment.
Intensive growth of the tumor occurs in women eligibility age, which is characterized by jumps of level of sex hormones. At menopause, by contrast, is the growth of fibroids slows or stops completely, due to the gradual extinction of hormonal activity of the ovaries. The state of pregnancy frequently has a beneficial effect on small foci of tumor growth, and after birth they may disappear completely.
The behavior of tumors, and prognosis depends on its microscopic structure. Decided to allocate a simple leiomyoma, consisting of Mature smooth muscle cells and a relatively large amount of connective tissue and proliferating (cell), which is characterized by intense multiplication of tumor cells, which explains its rapid growth.
Manifestations and diagnosis of uterine fibroids
Signs of uterine fibroids depends on the age of the woman, the number, size and location of tumor sites, the presence of other diseases of the reproductive system. Small nodes may be asymptomatic, causing no anxiety, and menstrual disorders, and during menopause is a gradual regression of the tumor is accompanied by a decrease of pain, if they were before.
Often the tumor is detected incidentally, but if symptoms are evident, but do not differ significantly by severity, they can be «charged» to another pathology, because of breaking the cycle and heavy menstrual period does not always scare a woman, especially leading an active lifestyle, working and experiencing constant stress. Pain during menstruation and is no surprise, therefore, such non-specific signs and disorders are perceived as rather functional, not associated with the presence of tumors.
Symptoms of uterine leiomyoma reduced to:
- Uterine bleeding, sometimes profuse and prolonged, causing the development of anemia due to chronic blood loss;
- Pain syndrome, with pain often localized in the lower abdomen, may radiate to the lower back. Increased pain during menstruation characterizes submucosal tumor growth, and a sharp acute pain can be a symptom of a node necrosis, torsion of the pedicle and malnutrition education;
- When compression of adjacent organs is possible dysuric disorders (frequent, painful urination, incomplete emptying of the bladder) and constipation.
The progression of the disease and chronic blood loss sooner or later, result in anemia, and the patient begins to feel weakness, reduced working capacity, women often want to relax, there is a tendency to dizziness and fainting.
Meanwhile, without looking at a relatively long latent period and often slow tumor growth, fibroids still threat not only by the development of anemia and chronic disorders, as described above. It is also possible acute conditions requiring urgent surgical care. So node necrosis due to impaired blood flow, accompanied by intense pain, fever and signs of intoxication, and torsion legs tumors located subserous, calls the clinic «acute abdomen». Another danger posed by uterine fibroids, consider the possibility of malignancy of the tumor. Malignancy existing nodes is very unlikely, but the appearance initially of sarcoma in predisposed women, it’s possible.
For correct diagnosis in case of uterine leiomyoma is usually enough of gynecological examination and ultrasound examination. If necessary, it is supplemented by hysteroscopy, colposcopy, laparoscopy, if there is a suspicion subserous variant of the tumor. The doctor evaluates and overall hormonal balance and ovarian function, specify the presence or absence of infections of the genital tract, congenital anomalies of the uterus, etc. Given the growing number of «young» forms of the tumor for the timely diagnosis should have an annual ultrasound examination for all women beginning at 30 years of age and younger persons at risk. Early detection of small tumor foci in young women will allow in future to use conservative treatment, which is especially important if the patient plans to acquire offspring.
The treatment of uterine fibroids
The treatment of uterine fibroids – a difficult task. She required surgery on the pelvic organs brings the woman to psychological discomfort and experiences and if we are talking about removing the whole body, the decision should be well weighed by the attending physician. In difficult cases it is better to consult with several specialists, each of whom can offer the most optimum and the least traumatic for the patient the method of treatment.
Many professionals with uterine fibroids prefer radical methods of treatment, i.e., removing nodes or entire body, but when the patient is young and is planning pregnancy, this approach may be unacceptable, so it is possible we should try to preserve the uterus and fertility. In the case of older women who already have children, radical operation can create a psychological problem because the lack of the uterus are often difficult is experienced by the patient.
Modern approaches to treatment of uterine fibroids involve the use of conservative therapy, minimally invasive interventions and surgeries to remove nodes or the entire affected organ. In each case, the choice of method is carried out individually, taking into account the nature of tumor growth, size, and localization of nodes, their number, must take into account the patient’s age and plans for childbearing.
Today, medicine has leaped forward in the use of sparing methods of treatment of tumors, and often it is possible to do without surgery, so wait and see tactic, which has been more recently applied and individual professionals now, not entirely justified. If the diagnosis is fibroids no doubt, it is best to start treatment, waiting until the tumor reaches a large size, and the ability to solve the question «a little blood» will be gone. The patient should immediately ask, what hospitals you can get treatment where there is appropriate equipment and highly qualified specialists.
Bezoperatsionnye methods of treatment of uterine fibroids do not lead to the complete disappearance of the tumor, but they are able to significantly slow the growth nodes, so this approach is applicable to women in the eligibility period, when the onset of menopause nodes slowly regress themselves and reached a point where health risks will be gone. If a woman is young, conservative treatment will help reduce the amount of surgery that you may need in the future.
The indications for conservative therapy can serve as a young age and a woman’s desire to preserve childbearing function, the small size of the site, oligosymptomatic the course of the tumor, high risk surgery, as well as preparation for the subsequent surgical treatment.
As uterine fibroids grow under the influence of female hormones, it is quite clear the use of different groups of hormonal preparations for treatment without operation:
Combined oral contraceptives are not only able to reduce the growth nodes, but also to normalize the menstrual cycle, to relieve the patient from painful and heavy bleeding and related anemia. These drugs protect against unwanted pregnancy during treatment, but the disadvantage of them are contraindications restricting the use in women with diseases of the cardiovascular system, liver and kidneys, varicose veins, migraine. After 35-40 years of their appointment may also be undesirable.
Intrauterine system releasing local hormones, lack many of the side effects common tableted drugs, and can be used until menopause. The conditions of their application are the small size of the tumor node (up to 6-7 weeks of pregnancy), the absence of inflammatory changes in the uterus and distort.
The appointment of agonists GTRG aims at developing a drug pseudomenopause, when the natural level of sex hormones drops, and comes as close to the climax. In addition to the fibroids, they have a therapeutic effect with endometrial hyperplasia, and endometriosis, often associated tumor. When such treatment may reduce nodes by one third and even half, but the side effects make you not only limit treatment to six months, but in some cases, to abandon it altogether. Most adverse effects of the drugs in this group are considered to be hot flashes, feeling of heat, pressure fluctuations, sleep disorders and emotional disorders.
Lately, as a conservative treatment have been used antagonists of progesterone, which help to reduce the size of the nodes, but do not cause severe symptoms of menopause, giving them an advantage in comparison with the previous group of drugs. They are most often prescribed as a preparatory phase before the surgery, but is studied and the possibility of long-term self-application.
Qualitatively new approaches to the treatment of uterine fibroids are the possibility of application of preparations inhibiting the activity of various growth factors, tumors, and angiogenesis (development of blood vessels of the tumor). We have already proved the positive effect of interferon in uterine fibroids. Many drugs pass clinical trials, but search tools that would allow to refuse completely operation continues.
Hormone therapy still may not be the only method of treatment, especially in young women, when the withdrawal of drugs leads to the resumption of growth nodes in 2-3 months, and the size of the uterus come to its original state. Hormone therapy, usually assigned before the planned surgical intervention to reduce tumor size, and within one to two months after treatment should be performed operation.
Thus, in each case selected an individual treatment plan depending on the nature of tumor growth, age of the woman and presence of contraindications to specific drugs. It is worth mentioning that alone to treat fibroids in this way without advice and monitoring by the gynecologist is unacceptable and even dangerous.
Surgical treatment of fibroids
More recently, surgical treatment of fibroids meant the removal of the entire organ. The operation allows to get rid of the tumor, but the risk of complications and long-term adverse effects remains high to this day. The need for General anesthesia, manipulation inside the abdominal cavity, the possibility of bleeding and adhesions, high risk for pregnancy in the subsequent forced doctors to seek new, more gentle methods of treatment of the tumor. So, if possible, a woman trying to embolize the uterine arteries, FUZZ-MRI ablation, selective removal of nodes while preserving the uterus.
If the possibility of conservative treatment and minimally invasive techniques have been exhausted, there is a progression of the disease, there is a high risk of malignant transformation and the age of the woman no longer young, then resort to the removal of the entire affected uterus with or without cervix.
Among non-invasive methods removing fibroids isolated uterine artery embolization (UAE) and ultrasound ablation (FUZZ-MRI ablation), which, although relates to surgical treatment, nevertheless are not surgery in the conventional sense of the term.
FUZZ-MRI ablation involves the effect on the myoma node of a focused ultrasonic beam, which leads to heating of the tumor tissues and their irreversible destruction. Furthermore, with this exposure disrupted the blood flow in the tumor and no recurrence occurs. The procedure is performed under the control of MRI, which gives a chance aiming to influence the neoplasia, without damaging the surrounding tissue. Selective necrosis of the tumor reduces its size, thus the woman gets rid of the pain, profuse uterine bleeding, compression of nodes adjacent organs.
The undoubted advantages of the method are:
- Duration 3-4 hours;
- Targeted effects on the tumor;
- The possibility of outpatient conduct ablation without General anesthesia;
- Preservation of the uterus and the absence of blood loss, as in the case of surgery;
- Rehabilitation the next day.
Testimony to the FUZZ-MRI ablation are the presence of pain, uterine bleeding, node sizes of between 2 and 15 cm, signs of compression of neighbouring organs and tissues. Usually, treatment is given immediately, if the diameter of the tumor is not more than 9 cm, if the tumor is more, it is advisable to prescribe hormone therapy for several months to reduce tumor size.
Method is very good, but it has contraindications, which are also linked to the need for MRI: claustrophobia (fear of closed spaces), degree of obesity, presence of pacemakers or implants of metallic materials. In addition, certain complications can occur when the scarring of the abdominal wall, adhesive process. It is impossible to conduct FUZZ-ablation and inflammatory processes in the pelvis, pathology of the ovaries, infertility, and unrealized fertility, severe deformation of the uterus, subserous nodes on the stem. Among the most frequent complications of treatment – local first degree burns and small inflammatory reaction.
Uterine artery embolization (UAE) is a quite promising method of treatment which in many cases allows to do without surgery. At high operational risk EMA is an alternative to conventional surgical treatment.
The essence of EMA is the cessation of blood flow through the vessels that feed fibroids. Through a puncture in the femoral artery introduced a special conduit through which the branches of the uterine artery will flow of embolic material (polyvinyl alcohol). The power nodes are terminated, and in healthy myometrium restored by collaterals (workarounds).
The advantages of the method – a selective effect on the fibroids, no bleeding and other postoperative complications, preservation of uterus and fertility. The procedure does not require General anesthesia and a long stay in the hospital. EMA can be conducted in all cases, with the exception of the presence of subserous fibroids on a stalk, the inflammatory process in the pelvis, tumor pathology ovarian and cervical cancer, infertility in the absence of children, renal failure and Allergy to contrast material. At comorbidity, complicating the operation (diabetes, hypertension, obesity), EMA preferred.
Among the complications of the method include the so-called postembolization syndrome associated with damage to the tumor tissue when possible fever, nausea and vomiting, abdominal pain, blood – leukocytosis. These symptoms pass within two days after embolization, provided symptomatic treatment.
Surgery of uterine fibroids
When possible gentle methods have been exhausted or are impossible because of the multiplicity of nodes, their large size, risk of malignancy, the doctor is forced to resort to radical methods of tumor removal. Surgical treatment remains the main, and it is exposed to 80% of women suffering from fibroids.
Indications for surgical treatment of uterine fibroids are:
In each case also takes into account the woman’s age, presence of comorbidity, the nature of the growth and location of the tumor. Radical surgery involves the removal of the entire uterus. If the patient has a background of pathological changes in the cervical (epithelial dysplasia, leukoplakia, etc.), the uterus is removed together with the cervix, although, of course, the doctors are trying to save it.
Sparing method of surgical treatment of fibroids myomectomy consider selective removal of nodes with preservation of the uterus. This organ-preserving approach is very justified in young women under 40 years, wishing to preserve the uterus and menstrual function, and when the patient wishes to become pregnant in the future. The sizes of nodes for such operations range from 20 to 50 mm, then delete them optimally.
Access during the operation can be laparotomies, laparoscopic and hysteroscopic. When laparotomies the access incision of the anterior abdominal wall through which the doctor can view the affected organ, to remove the nodes or the entire uterus and efficiently suturing blood vessels and tumor bed. Laparotomy is preferred in the case of myomectomy, if a woman is planning a pregnancy, because of the quality of stitches it can depend on her for the outcome. To prevent rupture of the uterus in the area of scars remaining after myomectomy, delivery is accomplished by cesarean section.
Laparoscopic access allows you to avoid large incisions and scars, and also has a good cosmetic effect. Such access can be removed not only individual nodes but also the entire organ (hysterectomy), but this will require appropriate equipment and high professionalism of the surgeon.
Hysteroscopic access is justified for small submucosal nodes when their removal is sufficient to penetrate into the cavity of the uterus. These operations performed on young women who need to preserve fertility.
To solve the issue of efficacy of treatment of fibroids needs experienced and highly skilled surgeon that is configured to preserve a woman’s uterus, and only the ineffectiveness of more benign methods, multiple large nodes or a risk of malignancy of the tumor process preference will be given to complete removal of the organ. The treatment option that will offer the surgeon depends not only on its professionalism but also on the technical capabilities of medical institutions, the availability of endoscopic equipment, etc. Many women are willing to drive hundreds of kilometres in order to make it most comfortable and least traumatic.
Along with the described treatments, the importance of a woman’s life, which should avoid stress and strenuous exercise, to get rid of bad habits, if any, to take vitamin complexes and iron supplements in case of anemia. Treatment of folk remedies, which often are addicted to the patient instead of going to the doctor is unacceptable. The tumor did not resolve, but the risk of other complications is very high. So douching with different infusions can cause damage to the mucous membrane of the genital tract and the development of inflammation, and the herbs inside will only lead to loss of time.
In General, priority in the treatment of uterine fibroids in recent years is the use of minimally invasive and bezoperatsionnye methods to preserve the uterus and fertility. The studies in the field of genetics will help to find not only new treatments, but also to develop preventive measures that will eliminate the need for treatment.
Given the increasing frequency of tumor pathology of the uterus, particular importance is attached to preventive measures. Every woman not only should, but must visit the gynecologist at least once a year, if she is responsible for their health. Also recommended to undergo ultrasound of the pelvic organs are examined for STDs and promptly treat them. You should avoid intrauterine manipulation, such as abortion and frequent scraping, and if the woman considers it necessary to postpone for some time the pregnancy then you should think about receiving contraceptive drugs, because they not only will help prevent abortion, but will contribute to the normalization of hormonal background. A healthy lifestyle and taking care of your health can help women to preserve reproductive function and give birth to healthy children and to avoid the appearance of a tumor.