Fibroids of the uterus
Uterine fibroid is a formation that appears in the smooth muscle structures of the uterine wall and has some signs of a benign tumor. Fibroids of the uterus are diagnosed in a third of gynecological patients, more often in 20 - 40 years. In recent years, due to the intensive development of the diagnostic direction in medicine. And, accordingly, an increase in the number of women surveyed, the number of detected, especially asymptomatic, fibroid uterus increases.
There are many incorrect myths about the origin, treatment and consequences of uterine fibroid disease. To have a competent understanding of this pathology, it is necessary to understand how fibroids form and grow.
The female womb has a very important and unique ability - it keeps the developing fetus during its maturation and pushes it out during childbirth. In order for these processes to proceed normally, there is a very powerful muscle layer in the uterine wall - the myometrium. It is formed by three intertwining layers of smooth muscle fibers, which seem to spiral into a spiral. The muscular skeleton is strengthened by connective and elastic tissues. Myometrium "works" not only during childbirth, but also during menstrual bleeding, when small uterine movements release the uterus from accumulated blood and fragments of the exfoliated mucosa.
Myometrium is located in the middle of the muscular wall between its outer( perimeter) and internal( endometrium) layers. Perimetry is an extremely strong serous tissue, in fact, it is part of the peritoneum, which protects the uterus from external unwanted effects. Endometrium is a multilayered mucous layer lining the uterine cavity from the inside. The superficial, functional, endometrial layer is constantly renewed under the influence of ovarian hormones. In the period of menstrual bleeding, he completely rejects and leaves the uterus.
The uterine fibroid is born in the myometrium, more often in the form of a node. If several nodes are formed, the fibroid is called plural. The size of the uterine fibroid is not always related to its "age".Nodular uterine fibroid may look like several myoma nodes of different size, localization and stage of "maturity".
After fibroma appears in myometrium, events can develop according to several scenarios:
- Fibroma remains "in place", that is, within the boundaries of the muscular wall - the interstitial( intramural) form.
- The node begins to grow inward, that is towards the endometrium. As a result, a significant part of the fibroid forms a protrusion in the uterine cavity - a submucous( submucous) form.
- Fibroma rushes to the outside under the peritoneum - subserosal form.
Dimensions of uterine fibroids and its location, as well as the rate of growth, significantly affect the clinical manifestations of the disease. Often a small fibroma present in the uterus is asymptomatic and is diagnosed accidentally.
The most frequent symptoms of fibroma include menstrual dysfunction( menorrhagia), pelvic pain of varying intensity and localization, a change in the normal functioning of adjacent organs( dysuria, constipation).
The causes of uterine fibroids continue to be studied, but at the moment the connection of the appearance of fibroma against the background of hormonal dysfunction is established, this allows to classify fibroma as a group of benign hormone-dependent diseases.
Contrary to the popular belief among patients, uterine fibroid is not a true tumor, but only has some common features with it. It is more correct to call it a tumor-like formation. One of the significant differences between uterine fibroid and tumor is its ability to decrease and even disappear, which is what happens with most of the fibroids in women entering the climacteric period.
It is possible to suspect the presence of uterine fibroid with a primary gynecological examination, and ultrasound scanning helps confirm this assumption.
There are many options for the therapy of uterine fibroids - from hormonal to surgical. And sometimes a dynamic observation is established for fibroma. The decision on the method and timing of therapy is always taken after a complete examination and the cause of the appearance of this pathology.
Causes of uterine fibroid
Among specialists, it is customary to consider uterine fibroids hormone-dependent tumor-like formation and indicate not the causes of its appearance, but the presence of predisposing factors for its appearance.
A decisive role in the development of uterine fibroids is due to hormonal imbalance, namely, an increase in the concentration of estrogens and a decrease in the content of progesterone. According to the hormonal theory, any pathological processes of dyshormonal nature can provoke the growth of fibroma nodes, they are all grouped into three main pathogenetic variants:
1. A uterine variant in which fibroma occurs in women with normally functioning ovaries, that is, the amount of hormones in their blood is notGoes beyond the limits of the norm, and the appearance of fibroids is associated with a disruption in the work of the uterine receptors, which must "catch" these hormones. Such conditions are often formed after trauma of the mucous layer lining the uterine cavity, during scraping or traumatic diagnostic manipulations. Less often they are diagnosed on a background of hypoplasia of the uterus.
2. Ovarian version."Classic", more common, the option of forming fibroids on the background of hormonal dysfunction of the ovaries. It occurs in women with infectious and inflammatory diseases( salpingoophoritis, oophoritis), with cystic ovarian changes and other ailments that lead to a violation of normal secretion of estrogen and / or progesterone.
3. The central variant. The hormonal function of the ovaries is controlled by the pituitary and hypothalamus. When dysfunction of the central nervous system on the basis of severe stress, trauma, neurological disorders, vegetative-vascular disorders, the control organs start to work incorrectly, and the ovaries receive distorted regulatory signals.
It should be noted the role of extragenital pathology, which can change the normal function of the ovaries - liver disease or endocrine disorders.
Among patients with uterine fibroids, a hereditary predisposing factor is often traced, when a "tumor" is diagnosed in several women in the family. Obviously, the defect of hormonal regulation is fixed genetically and can be transmitted to subsequent generations.
Nodular uterine fibroid during the life passes through several stages of development, namely:
- Formation of the rudiments of the node. Active growth of smooth muscle and fibrous cells in a certain area of ​​myometrium. At this stage, the fibroid is limited to 3 cm in size and has no clinical manifestations.
- The stage of maturation. The active growth of fibroma begins, and it acquires all the signs of an "adult" nodal formation.
- "Aging" of fibroids. The nodes stop active growth, dystrophic processes begin in their tissues.
Fibroids of the uterus in each case has features of growth, development and even aging. If it grows slowly and is present in the uterine wall almost asymptomatically, it is called simple. Multiple, fast-growing nodes, accompanied by active clinical manifestations, are called proliferative fibroids.
It should be noted that the presence of hormonal dysfunction is not an absolute cause of the development of uterine fibroid. This means that if a woman has a natural hormonal balance, she has a risk of developing fibroids, but not always she does appear. Thus, uterine fibroid remains a pathology at the stage of close research.
Symptoms and signs of uterine fibroid
Uterine fibroid is perhaps a unique formation, since it has no clear clinical symptoms, it has an unpredictable growth direction and is capable of changing size up to complete disappearance of the nodes.
Contrary to the erroneous opinion, the severity of clinical manifestations is affected not so much by the size of the fibroid as its localization. In addition to the above-described types of location of the nodes, there are atypical forms of uterine fibroid localization:
- interconnected, when the nodes are located between the sheets of the wide uterine ligament;
- cervical fibroma is found in the wall of the cervical canal;
- retroperitoneal, very rare, localization of fibroids.
The uterine fibroid is formed for a long time and does not always manifest itself with any bright symptoms. Nodes with multiple fibroids do not appear at the same time, therefore there are nodes of different size, location and stage of development in the uterus, and the disease clinic consists of the symptoms that each node causes.
Multiple fibroma does not disturb the patient for a long time if small nodes remain within the muscular wall, that is, they are located interstitially. But even a small unit node, which appeared in the submucosal layer( submucous fibroma), is often the reason for emergency hospitalization.
Despite the variety of forms and possible clinical signs, most of the uterine fibroids have several of the following similar symptoms:
- Menstrual irregularities.
The presence of nodal formation in the uterine wall always affects the functioning of the uterine musculature, that is, the ability to fully reduce it during menstrual bleeding. Monthly on a background of a fibroma acquire features of a hyperpolymenorea when the quantity of plentiful days increases, and the volume of a hemorrhage increases. However, such menstrual dysfunction is not always so pronounced that the patient seeks a doctor. Quite often copious monthly ones are perceived for a slight deviation, therefore they are eliminated independently with the help of hemostatic medicines or folk medicine( herbal medicine).Over time, as the growth and development of fibroids, menstruation becomes even more abundant and prolonged, often bleeding loses its cyclical nature.
A significant constant loss of blood without appropriate therapy provokes an anemia clinic, which leads to a disruption of the habitual life rhythm.
The nature of menstrual bleeding is largely determined by the localization of the uterine fibroids nodes. The most unfavorable is the sub-serous location of the fibroid. Sometimes a small submucosal node can provoke serious uterine bleeding.
- Pain.
It is difficult to determine the exact characteristics of pelvic pain in uterine fibroids, as each of the nodes can squeeze the nerve endings at the site of its localization and provoke pain in adjacent areas.
Interstitial small nodes, as a rule, either do not cause painful sensations, or provoke soft, aching pains. Submucosal fibroids can cause such intense pelvic pain that it is taken for emergency surgical pathology( clinic of "acute abdomen").This arrangement of fibroids is considered the most unfavorable in terms of possible complications. Regardless of the size and growth rate, submucous fibroids always provoke a vivid clinic. Menstruation quickly become abundant and often lose cycle.
The submucous knot that swells into the uterine cavity not only deforms it, but is also perceived as a foreign body, from which the uterus strives to get rid of, that is, to expel outwards. For this, the muscular wall begins to shrink forcefully, provoking sharp pains resembling labor pains, and severe bleeding. Figuratively this process is called the "birth of a submucosal node", it requires immediate hospitalization and surgical intervention.
- Dysfunction of adjacent organs. If the fibroid increases the size of the uterus significantly, the latter begins to put pressure on the bladder and / or rectum, causing a disruption in their functioning.
- Infertility.
Fibroids of the uterus and pregnancy sometimes exclude each other. Primary infertility is diagnosed in every third patient who has fibroids of the uterus.
The cause of infertility in fibroids can be those hormonal disorders that led to the appearance of nodes. In this case, fibroma and infertility have common causes.
However, for every fifth infertile women, it is provoked by fibroids, so it happens when it is located in a way that prevents the appearance or development of pregnancy. So, if the nodes are in the corners of the uterus, where the lumen of the fallopian tubes opens, the chances of pregnancy sharply decrease.
Simultaneously, existing uterine fibroid and pregnancy are an unfavorable combination due to possible negative consequences. The fate of pregnancy against the background of fibroids is determined by the size, location of the nodes, as well as hormonal changes in the body of the pregnant woman. In the first two months, the hormonal system of a pregnant woman undergoes a significant restructuring, at which time the fibroma can begin to grow rapidly, but in subsequent months the growth of the nodes is blocked, and pregnancy can develop without complications. Predicting what the scenario of uterine fibroid behavior in pregnancy will be is extremely difficult, but it can be predicted in advance, that is, before its onset.
Uterine fibroids are often asymptomatic for many years and are diagnosed accidentally. During an examination with fibroids, the enlarged uterus of a more dense consistency is often palpated. If the site is located subperitoneally, it is sometimes defined as a dense formation on the uterus. Small fibroids of the uterus can not change its size for a long time.
The most reliable( 95.7%) data on the presence of fibroma can be obtained with ultrasound scanning. Ultrasound - the criteria for fibroma are the increase in size and deformation of the contours of the uterus, the presence of dense formation( single or multiple) in the uterine wall. Ultrasound examination also allows to determine the exact localization of nodes and the nature of their growth. If the fibromus is submucous, a significant deformation of the uterine cavity is visualized by protrusion of the nodes into its lumen.
If the diagnosis of fibroids is not obvious, a diagnostic hysteroscopy is used to refine it, which more accurately determines the submucosal nodes.
Uterine fibroids have the ability to relapse. New nodes appear in the event that the cause of their appearance is retained. Therefore, diagnostic search always implies not only the detection of nodes. A study of the hormonal profile and a study for the presence of infectious and inflammatory gynecological ailments is conducted.
Treatment of fibroids of the uterus
Often the diagnosis of uterine fibroids greatly frightens the patients, as they mistakenly believe that the only method of therapy is surgical removal of uterine fibroid. Meanwhile, not all fibroids should be operated on.
The main criterion for choosing a method of treatment is the size of uterine fibroid. They correlate with the size of the uterus during pregnancy. If the fibroid increases the size of the uterus to 12 or more weeks of pregnancy, the decision is made in favor of surgical treatment.
Also on the need for surgical treatment, fibroids indicate:
- too rapid growth of uterine size( more than four weeks per year);
is a large subserous fibroma;
- complicated fibroma( torsion of the "legs", necrosis and destruction of the tissues of the node);
- located in the cervix of the uterus;
- a born submucosal node;
is a concomitant, pronounced hyperplastic process in the endometrium;
- a negative effect of pre-conservative therapy.
The basis of conservative therapy is hormonal treatment. It is always selected individually after studying the patient's hormonal profile. The ratio of hormones is selected in such a way that it is as close as possible to the individual physiological norm of the patient. The duration of taking hormonal drugs is also determined according to the clinical situation, but it always lasts no less than six months.
With preserved menstrual rhythm in the absence of acyclic bleeding, gestagens are used: Duphaston, Norethisterone, Utrozestan, Progesterone and the like. If there is a violation of the menstrual rhythm and the appearance of acyclic bleeding, it becomes necessary to restore the normal ratio of estrogens and gestagens, therefore, combined estrogen-progestational agents are appointed: Janine, Yarina and analogues.
Particularly closely monitor the condition of fibroma in patients who have crossed the 45-year mark. If the uterine fibroid does not tend to self regress, it is necessary to eliminate the estrogenic effect on the nodes in order to stop their further growth. Androgenic drugs successfully cope with this task: Sustanon-20, Testosterone and analogues.
Symptomatic treatment accompanies hormonal therapy and is designed to eliminate concomitant disorders.
On the positive dynamics on the background of treatment says the decrease in the size of the nodes or their disappearance, the restoration of the normal menstrual cycle.
Operation with uterine fibroids
The removal of uterine fibroids is possible in several ways. Each of the available has certain advantages and disadvantages, so the final choice always belongs to the surgeon.
Removing fibroids very rarely implies removal of the uterus. Usually, only the node itself is eliminated( removed), and the organ remains.
If the fibroids can not be isolated in isolation, the uterus can also be preserved by performing a semi-radical operation - defundation( literally - removal of the bottom) of the uterus. The essence of it is reduced to the removal of fibroids together with the part( bottom) of the uterus, where it is located. The rest of the body continues to function, as before.
Total removal of the uterus( hysterectomy) is more often performed by patients entering the climacteric period. In other cases, radical intervention is carried out only after the possibility to save the organ is excluded or in the presence of serious complications.
It takes a long time to form the fibroids, so any woman has the opportunity to detect it at early preclinical stages. Timely diagnosis of uterine fibroids can prevent its further growth, and, most importantly, avoid surgery.
