Fibromyoma of the uterus

uterus

Uterine fibromyoma (FM) is a limited benign tumor consisting of smooth muscle and fibrous connective tissue elements. The tumor can be single, but more often, multiple nodes (sometimes up to 10 or more) are detected. Frequency. They are detected in 4-11% of all women, in 20% of women over 30 years old and in 40% of women over 50 years old. Types are intramural (intramuscular), submucosal (submucosal) and subserous. Initially, the tumor occurs intermuscularly, then, depending on the direction of growth, intramural (in the thickness of the uterine wall), submucosal (growing towards the endometrium) and subserous (growing towards the abdominal cavity) FM develop

    • Intramural FM appear most frequently as isolated encapsulated nodes of various sizes. FM located in the broad ligament of the uterus is called intraligamentous
    • Submucosal FM – tumor nodes are connected with the myometrium only by a thin stalk, therefore they can protrude far into the uterine cavity and even fall out through the cervical canal (born submucous node on the stalk). Submucosal FM traditionally grows rapidly and is often accompanied by changes in the overlying endometrium and bleeding.
    • Subserous FM – also often form a stalk and can reach a significant size without causing any symptoms. As a rule, such FMs are mobile; these will need to be distinguished from solid adnexal lesions. Pedunculated knots are often fixed to the omentum or to the mesentery of the small intestine. FM can receive additional blood supply from the place of secondary attachment. In the process of FM growth, an additional source of blood supply can become the main one. With stem necrosis (for example, as a result of torsion), FM becomes dependent on a secondary source of blood supply, turning into a parasitic FM.

Etiology and pathogenesis. FM appears as a result of local proliferation of SMCs. As the structure of FM grows, fibrous elements begin to predominate.

    • FMs develop from immature SMCs
    • Uterine contractions that create areas of tension within the myometrium may serve as a stimulus for the growth of these undifferentiated cells.
    • Many areas of tension within the myometrium lead to the development of multiple FM
    • Although the content of estrogens in the blood is traditionally not changed during FM, their development is closely

associated with hormonal imbalance, incl. with hyperestrogenism

    • FM does not often appear before puberty and after menopause
    • In postmenopause, the growth of FM stops, but they do not often regress
    • FM growth accelerates during pregnancy
    • FM is often found in association with conditions that accompany hyperestrogenism (eg, anovulation, polyps, and endometrial hyperplasia)
    • FM can also occur in women with a normal menstrual cycle, i.e. without hormonal disorders. Pathomorphology
    • macroscopic picture. FM is considered an encapsulated formation, since it is clearly delimited and does not infiltrate nearby tissues, although there is no capsule as such (there is a pseudocapsule). The pseudocapsule consists of fibrous and muscular tissues of the uterus. Since blood vessels run along the periphery of the node, the central part of the tumor is subject to degenerative changes. On the cut, the tumor tissue is smooth, dense, pinkish-white (color depends on the degree of blood supply). On the plane of the tumor – trabecular striation in the form of curls
    • microscopic picture. Formed by bundles of SMC and connective tissue elements, twisted and intertwined in the form of loops
    • Degenerative changes in FM can be caused by impaired blood flow (arterial or venous), infection or malignant transformation and lead to changes in the macro- and microscopic characteristics of the tumor.
    • Hyaline degeneration is the most common type of degeneration in almost all FM. Overgrowth of fibrous elements leads to hyalinization of fibrous tissue and, ultimately, to calcification.
    • Cystic degeneration can sometimes be the result of necrosis, but traditionally cystic cavities appear as a result of hyaline degeneration.
    • Necrosis. The usual underlying cause of necrosis is poor blood supply or infection. A special type of necrosis – red degeneration – occurs more often during pregnancy. The lesion has a dull reddish color due to aseptic necrosis with local hemolysis
    • Mucoid swelling. If the blood supply is disturbed, especially in large nodes, the areas of hyalinization may undergo mucoid (myxomatous) degeneration; the lesion has a soft gelatinous consistency. Further degeneration can lead to complete liquefaction of the node and its cystic degeneration.
    • Sarcomatous degeneration of the tumor occurs in less than 1% of cases. At the same time, leiomyosarcoma cells are detected in the center of benign pseudo-encapsulated FM.

Clinical picture

    • Abnormal menstrual bleeding (usually hypermenorrhea), the intensity of bleeding gradually increases, which can lead to severe anemia
    • Severe bleeding occurs either due to necrosis of the endometrium covering the submucosa of the FM, or due to stretching of the uterine cavity, an increase in the menstrual plane and a decrease in the contractility of the myometrium with extensive growth of intramural FM 
    • Often, FM is combined with polyps and endometrial hyperplasia, which can also cause pathological bleeding.
    • In some cases, intermenstrual bleeding is also possible. FM does not affect the balance of sex hormones in the body and, therefore, the regularity of the menstrual cycle.
    • Pain. Uncomplicated uterine FM is traditionally painless. Acute pain is due to torsion of the pedicle or necrosis of the FM node. Cramping pains are characteristic of submucosal FM, protruding far into the uterine cavity.
    • Compression of the pelvic organs traditionally occurs if the myomatous uterus or node reaches a size corresponding to 10-12 weeks of pregnancy or more
    • Increased urination due to pressure on the FM of the bladder
    • Urinary retention occurs when the uterus is retroverted due to myomatous growth, while the cervix moves anteriorly to the region of the posterior urethro-vesical angle and presses the urethra against the pubic joint
    • Hydroureter, hydronephrosis and pyelonephritis are caused by compression of the ureters by intraligamentous nodes
    • Constipation and difficulty in defecation can be caused by large nodes located on the back wall of the uterus.
    • Infertility. FM can prevent the egg from moving through the fallopian tube and conceptus implantation
    • Large intramural FMs located at the corners of the uterus often overlap the interstitial part of the fallopian tube
    • Endometrium over submucosal FM may be in a different phase of the cycle than the rest of the endometrium
    • Women with submucosal or intramural FM are more likely to have miscarriages and preterm births.

Diagnostics

    • Palpation of the abdomen. FM are palpated in the form of dense nodes of irregular shape. With sarcoma, edema and degeneration of FM, the nodes are traditionally soft and painful. During pregnancy, the uterus is soft in consistency. t Examination of the pelvic organs. The most characteristic symptom is an enlarged uterus. It is usually asymmetrical, with irregular outlines and mobile in the absence of adhesions.
    • Submucosal FM is characterized by a symmetrical enlargement of the uterus
    • Some subserous myomatous nodes may not be associated with the body of the uterus and move freely in the abdominal cavity. In these cases, it will be necessary to carry out a differential diagnosis with tumors of the uterine appendages and extrapelvic neoplasms.
    •  FM, localized in the neck, and submucosal FM on the stem can protrude far into the lumen of the cervical canal; sometimes submucosal FM can be seen at the level of the cervical orifice or vaginal opening
    • Bimanual examination is carried out after 3-6 months
    • Palpation of the recto-uterine ligaments is performed to detect endometriosis, often combined with FM.
    • With FM, blood loss is increased during menstruation, so patients have regular blood tests. For the correction of IDA, iron products are prescribed
    • Ultrasound of the pelvic organs is used in cases where the enlarged uterus fills the pelvic cavity, making physical examination difficult, as well as to detect hydronephrosis resulting from compression of the urethra by the myomatous uterus
    • If submucosal FM is suspected, hysterosalpingography or hysteroscopy is traditionally performed.
    • CT/MRI
    • With the rapid growth of myomatous nodes, it will be necessary to exclude malignant degeneration.

Differential Diagnosis

    • Uterine pregnancy
    • ovarian tumor
    • Tumor of the caecum or sigmoid colon
    • Appendicular abscess
    • diverticulitis
    • Nephroptosis.

Treatment:

observation. With FM of small size and the absence of clinical symptoms, periodic examination of patients (with stable symptoms – after 6 months, with newly diagnosed cases, with large tumor volumes – after 2-3 months). Diet. The diet will need to include sunflower, corn, soybean oil containing polyunsaturated fatty acids, vitamins of group B. Recommend the use of mineral waters – Essentuki 4, Essentuki 17, Borjomi, Smirnovskaya – 30 minutes before meals, alternating with taking apple, beetroot, plum or potato juice. Conservative treatment

    • Indications: small size of the tumor (up to the size of a 12-week pregnancy in women of reproductive age, 14-15-week pregnancy in premenopause), itramural or subserous localization. Before prescribing conservative treatment, it is necessary to carry out colposcopy, separate curettage of the mucous membrane of the cervix and body of the uterus.
    • Absolute contraindications: suspicion of sarcomatous degeneration, birth of a submucosal node, necrosis, torsion of the legs of the subserous node, combination of FM with ovarian tumors, uterine cancer and other diseases requiring immediate surgical treatment.
    • GnRH agonists of prolonged action, which suppress the secretion of gonadotropins and thereby cause pseudomenopause, can be prescribed l / c 1 r / month for 6 months. The following GnRH agonists are used: Sinarel nasal spray, Zoladex Depot, Lupron Depot
    • With this mode of administration, the size of the FM is reduced by 55%
    • After stopping treatment, FM traditionally begins to increase again.
    • Uterine fibromyoma contraindications: history of osteoporosis, it is not recommended to prescribe long courses to young women because of the likelihood of developing osteoporosis Side effects: acute symptoms characteristic of menopause (hot flashes, night sweats, insomnia, emotional lability and osteoporosis).
    • Women over 45 years of age are shown the appointment of androgens, sedative products.
    • Vitamin A from 5 to 25 days of the menstrual cycle for 12 months, vitamins of groups B, K, E, C.
    • Correction of concomitant pathology, for example, IDA.
    • Physiotherapy – electrophoresis with potassium iodide, copper or zinc, electrical stimulation of the cervix, cervicofacial and endonasal ionogalvanodiathermy.
    • Balneological factors – iodine-bromine, radon, pearl baths.
    • Phytotherapy – horsetail, shepherd’s purse, Chernobyl, calamus, etc. Surgery
    • Indications
    • Bleeding caused by FM, especially in cases of severe anemia. Hypermenorrhea is characteristic of submucosal or intramural FM 
    • Severe pain suggesting necrosis or torsion of the myoma stem
    • Enlargement of the myomatous uterus to a size corresponding to a 12-week pregnancy (impaired kidney function, difficulty in examining the uterine appendages)
    • Violation of the functions of neighboring organs
    • Submucosal FM
    • Non-carrying of pregnancy
    • Rapid tumor growth – at 4-5 weeks of pregnancy for 1 year
    • Pain syndrome with intraligamentous location of the node.
    • The type of surgical intervention depends on the woman’s age, symptoms, and also on the desire to have babies in the future.
    • Myomectomy – removal of single or multiple FM with preservation of the uterus; this operation is traditionally performed on women who want to get pregnant and have no contraindications
    • If a dissection of the uterine wall is required to remove submucosal FM, then in the future delivery through natural routes is contraindicated
    • Complications – bleeding during and after surgery, as well as early or late intestinal obstruction due to adhesions between the intestine and uterus after myomectomy
    • The likelihood of recurrence of FM after myomectomy depends on the age of the woman, as well as on the volume of the initially performed myomectomy.
    • The probability of pregnancy after myomectomy is 40%.
    • Hysterectomy is indicated if a woman does not plan to have more babies
    • It is necessary to carry out a diagnostic curettage of the uterine cavity to accurately determine the cause of bleeding (FM or endometrial cancer)
    • Hysterectomy completely eliminates the risk of recurrence of FM
    • There is no convincing evidence of an increased risk of developing cancer in an ovary that was not removed during a hysterectomy, so women younger than 40-45 years old will need to save their ovaries.
    • Semi-radical methods of surgical treatment are used to preserve menstrual function in premenopausal women.
    • Defundation of the uterus is performed in cases where the location of the myomatous node allows you to save the body of the uterus without its bottom
    • High supravaginal amputation of the uterus – the body of the uterus is cut off significantly above the internal os
    • Patchwork method according to the AS of the Blind. in case of supravaginal amputation of the uterus, the endometrium flap is cut out and left.

Forecast

    • After myomectomy in previously infertile patients, 40% become pregnant
    • The recurrence of FM within 10 years after surgery is observed in 30% of cases. Pregnancy with FM occurs in 3-4% of patients
    • With small tumor volumes, pregnancy and childbirth can proceed without pathology.
    • In the I and especially in the II trimesters, there is a rapid growth of the myomatous node. Growth in the third trimester is negligible
    • Complications
    • Threatened miscarriage (30% of cases)
    • Toxicosis
    • Untimely outpouring within the fetal waters
    • Hypotrophy, fetal hypoxia, deformation of various parts of the fetus
    • Malposition of the fetus in the uterus
    • Anomalies of labor activity. Reduction. FM – uterine fibromyoma Synonym. Leiomyofibroma ICD. D25 Uterine leiomyoma

Literature. Uterine fibroids: pathogenetic. and therapist, aspects. Savitsky GA. St. Petersburg: Way, 1994

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