Uterine fibroids are a true benign tumor of the uterus. It develops from muscle tissue.
Depending on the ratio of muscle and connective tissue in its composition, this tumor previously had various names: myoma, fibroma, fibromyoma. However, taking into account that fibromyoma nodes more often develop from the muscle cell, most authors consider the term leuofibromyoma (fibroid) to be more correct.
Uterine fibroids has its own characteristics:
- This is the most common tumor of the uterus in women aged 35–55 years.
- It is capable of growing, diminishing and even completely disappearing during menopause. However, in 10–15% of patients in the first 10 years of the postmenopausal period, the tumor may grow.
- Small uterine fibroids (up to 10 weeks of pregnancy) can maintain a stable condition for a long time, but when exposed to provoking factors (inflammation of the uterus and appendages, curettage of the uterus, prolonged venous plethora of the pelvic organs) increase rapidly and very quickly (the so-called “growth spurt” ).
- The tumor is characterized by a variety of clinical options, depending on the location, size, location and nature of growth.
- Uterine fibroids have autonomous growth, due to the influence of growth factors and the formation of hormone-sensitive and growth receptors.
- As with any tumor, the process of growth and development of fibroids is accompanied by the formation of new vessels, but in this case the vessels are different from normal, because have a sinusoidal character.
The onset of uterus fibromyoma nodes occurs in 30 years, when women have somatic, gynecological diseases and neuroendocrine disorders.
For the subsequent growth of nodes requires further accumulation of adverse factors causing tumor progression:
- lack of childbirth and lactation by the age of 30
- prolonged inadequate contraception
- chronic, subacute and acute inflammation of the uterus and appendages
- ultraviolet irradiation
- education cysts and ovarian cysts.
At the age of 44-45 years old accounted for the highest rate of surgical interventions (most often it is the removal of the uterus), which is an indication for the rapid growth of fibroids Mukti, its large size, the combination of tumor pathology of the endometrium and ovaries.
The growth of fibromyoma increases at the age of 35–45 years, when the functional activity of the ovaries and their sensitivity to hormones decrease, chronic functional tension of the regulation systems (neuroendocrine, hormonal, immune) occurs and homeostasis is most often disturbed (internal balance of the body).
Negative role is played by long-existing neuroendocrine disorders, pathological menopause, action factors such as obesity, violation of carbohydrate and lipid metabolism, endometriosis, adenomyosis.
Uterine fibroids are characterized by a large variety of clinical course. Patient complaints depend on many factors: the location and size of the tumor, the duration of the disease, the presence of concomitant gynecological pathology, etc. The predominance of certain factors is reflected in the symptoms of the disease.
Often, the main and earliest symptom of uterine fibroids is menstrual dysfunction – uterine bleeding or prolonged prolonged spotting . Along with uterine bleeding is often noted pain, usually localized in the lower abdomen, in the lumbosacral region, sometimes with spread to the lower limbs.
Treatment of uterine fibroids is a very difficult problem, because despite hormonal dependence, this tumor is very heterogeneous.
Initially, unconditional indications for surgical treatment should be identified:
- submucous localization of fibroids
- large size of the node (the total value corresponds to the uterus of 14 weeks gestation)
- uterine bleeding with chronic anemia
- rapid tumor growth
- acute malnutrition of myoma ( torsion of the legs of the subserous node, death of the tumor)
- combination of uterine fibroids with endometrial hyperplasia , ovarian tumor
- compression of the ureter, bladder, rectum
- the presence of a node in the tube angle of the uterus, which is the cause of infertility
- cervical and cervical – fusiform localization
- non-regressive and growing uterine myoma in postmenopausal age.
The volume of surgical intervention is largely determined by the patient’s age.
Up to 40 years, if there are indications for surgical treatment, if technical capabilities permit, they produce conservative myomectomy . It is especially advisable to remove myoma nodules of medium size (in diameter from 2 to 5 cm), until their intensive increase in size has occurred. The preferred technique is laparoscopic. Relapses with conservative myomectomy in uterine myoma occur in 15–37% of cases.
After 40 years and postmenopausal age, in the presence of surgical indications, surgery is necessary to remove a myomatous uterus, since if the myoma has not regressed in the first 2 years of postmenopause, its further existence is accompanied by the risk of oncology (adenocarcinoma, sarcoma).
According to Corr. RAMS, Professor I.S. Sidorov, uterine fibroid growth risk factors include: the presence of cysts and cyst ovarian, endometrial proliferative processes, untimely termination of ovarian hormonal activity (delayed menopause) and severe obesity, disorders of carbohydrate metabolism or liver disease.
Conservative treatment of uterine fibroids:
Conservative treatment, carried out immediately after the detection of myomatous nodes of small and medium size, allows in some cases to slow down the further growth of the tumor, to prevent surgery to remove the uterus, to keep the opportunity to have a baby.
Indications for conservative treatment:
- young age of the patient
- small size of myomatous uterus (up to 10–12 weeks of pregnancy)
- intermuscular arrangement of myoma nodes
- relatively slow growth of fibroids
- no deformation of the uterus.
Conservative treatment is the normalization of systemic disorders characteristic of patients with uterine fibroids, among them:
- chronic anemia,
- inflammation of the uterus and appendages,
- violation of the blood supply of the pelvic organs with a predominance of venous congestion and a decrease in the arterial blood supply,
- violation of the functional state of the nervous system and autonomic balance.
The methods of correction of systemic disorders include the following:
- adherence to a healthy lifestyle (normalization of sleep, a balanced diet, physical activity, rejection of bad habits, weight control);
- normalization of sexual life;
- periodic intake of vitamins and minerals in the winter- spring period;
- treatment of anemia;
- neurotropic effects if the patient exhibits disharmonious personality traits.
If a pregnancy has occurred, even if not planned, it is necessary to preserve it, because postpartum uterine reduction, breastfeeding of a child for at least 4–6 months contributes to a change in the composition of fibroids, its transition to a simple one and in some cases to the cessation of its further development.
For the prevention of the inevitable removal of the uterus during tumor growth, the preservation and maintenance of reproductive function up to 40 years is of great importance.
The effectiveness of hormone therapy varies greatly depending on the nature of hormonal disorders, the presence and density of receptors in myomatous nodes and myometrium . In fibromas, where connective tissue prevails, and also in large nodules, hormonal receptors, as a rule, are absent. Therefore, hormone therapy in these patients is not very effective.
However, it is used in the correction of a disturbed menstrual cycle. For this purpose, progesterone and its derivatives ( didrogesterone , cyproterone acetate), and also androgen derivatives, 19– norsteroids ( levonorgestrel , norethisterone acetate) are used. The latter are undesirable at a young age, with obesity, sugar diabetes , cardiovascular diseases.
The most promising drugs in the treatment of patients with uterine fibroid are antigonadotropiny (gestrinone, danazol), which have anti-estrogenic and anti-progesterone effect, causing temporary amenorrhea (cessation of menstruation) and gonadotropin releasing hormone agonist (triptorelin, goserelin, buserelin),inducing a state of reversible hypogonadism .
The following antigonadotropins have been registered in Russia :
- Depot– goserelin 3.6 mg sc; Triptorelin 3.75 mg / m and s / c; Leuprorelin 3.75 mg IM The preparation is a ready-made kit with various routes of administration. Treatment starts at 2–4 days of the menstrual cycle: 1 injection every 28 days.
- Endonasal spray – 0.2% solution of buserelin acetate 0.9 mg per day. Treatment begins with 1-2 days of the menstrual cycle: 0.15 mg per each nasal course 3 times a day at equal intervals of time.
Preparation for surgery using antigonadotropins in the presence of uterine fibroids allows for sparing organ-preserving operations using endoscopic techniques.
To date, several strategies for long-term antigonadotropin therapy have been described , which allow to avoid pronounced side effects while maintaining high clinical efficacy:
- Add – back regimen – a combination of antigonadotropins with small doses of estradiol.
- On – off regimen – antigonadotropic therapy with intermittent courses (three-month therapy with a three-month break up to 2 years).
- Drow – back – use of high doses of antigonadotropins for 8 weeks with the transition to lower doses of the drug for 18 weeks.
The likely response to treatment can be predicted in most cases 4 weeks after the first injection.
The drugs are well tolerated, do not have antigenic properties, do not accumulate, do not affect the blood lipid spectrum. Side effects: hot flashes, sweating, vaginal dryness, headache, depression, nervousness, changes in libido, seborrhea, peripheral edema, deterioration of the prospective memory, decrease in bone density.
Termination of therapy leads to the restoration of normal menstrual cycle and estrogenic status approximately 60–100 days after discontinuation of the drug and rapid re-growth of uterine fibroids to its original size (during the first 3-4 menstrual cycles) with all clinical symptoms (although some authors note that these symptoms are less pronounced).
In addition to general recommendations on the observance of a rational mode of life, the prevention of common diseases in children and adults, the role of excluding abortions, timely correction of hormonal disorders, adequate treatment of gynecological diseases play a role.
There is a specific prevention of uterine fibroids. This is a timely implementation of the reproductive function. The first birth is recommended at 22 years old, the second at 25 years old, subsequent planned births up to 35 years old. Late first childbirth leads to premature aging of myocytes, reduced adaptive ability to stretch and shrink. Abortions and injuries damage the structure of the myometrium .
It should be taken into account that the most frequent detection period of uterine fibroids is 30–35 years, when the actions of damaging factors are summed up.
It is necessary to maintain the first pregnancy, especially in young women with the so-called hereditary myoma. Abortion causes the growth of myoma nodes and growing fibroids are intensively formed from microscopic nodes.
Excessive ultraviolet irradiation, increased temperature effects, especially after 30 years, should be avoided. If there is a hereditary risk (uterine fibroids in the mother and close relatives), the tumor develops 5–10 years earlier, i.e. in 20-25 years. Continued breastfeeding for 4–6 months after delivery normalizes the content prolactin, which affects the change in fibromyoma growth.