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Uterine myoma

Миома матки относится к доброкачественным опухолям с редкой малигнизацией, поэтому прогноз для жизни благо¬приятный. Однако рост миомы может потребовать хирургического лечения с исключением менструальной и репродуктивной функций у молодых женщин. Даже небольшие миоматозные узлы могут обусловить первичное вторичное бесплодие. 

                                                       Uterine myoma

Uterine myomas are the most common benign tumors in the female reproductive tract.

A uterine myoma is a benign growth of smooth muscle in the wall of the uterus. Uterine fibroids affect 70 to 80 percent of women. About 30 percent of women are symptomatic

A uterine myoma is a solid tumor made of fibrous tissue, hence it is often called a 'fibroid' tumor.

Uterine Fibroids are classified according to their location.

 

SUBSEROSAL

 INTRAMURAL

 SUBMUCOSAL

 PEDUNCULATED

 Subserosal fibroids typically develop on the outer uterine wall.

 Intramural fibroid tumors typically develop within the uterine wall and expand from there. These uterine fibroids are the most common.( 95%)

 The least common of the various types of fibroid tumors are submucosal fibroids. These fibroids develop just under the lining of the uterine cavity.

 Pedunculated uterine fibroids occur when a fibroid tumor grows on a stalk, resulting in pedunculated submucosal or subserosal fibroids. These fibroids can grow into the uterus and also can grow on the outside of the uterine wall. Symptoms associated with pedunculated fibroid tumors include pain and pressure as the fibroids can sometimes twist on the stalk.

Many women with uterine myoma (fibroids) have no symptoms and never require treatment. However, 1 out of 4 women of childbearing age do suffer significantly from myoma (fibroid) symptoms. Uterine myoma symptoms may vary depending on the location, size and number of myoma (fibroids ) . Some fibroid tumors don’t produce any symptoms at all, while others can be severely symptomatic.

The most common symptom of uterine myoma (fibroids) is:

* Heavy and prolonged bleeding This may also include clotting and pain. Anemia may result from this extensive bleeding. Abnormal bleeding is the primary uterine myoma symptom requiring women to seek medical advice.

Other uterine myoma (fibroid) symptoms may include:

* Pain in the back of legs This uterine myoma (fibroid) symptom appears as the fibroids press on nerves that extend to the pelvis and legs.

* An abnormally enlarged abdomen--this may be mistaken for weight gain or pregnancy.

* Pelvic pain or pressure This symptom may appear as a result of the bulk or weight of the myoma (fibroids) pressing on other structures in the pelvic area.

* Pressure on the bladder This uterine myoma (fibroid) symptom can cause frequent urination, urinary incontinence or urine retention.

* Pressure on the bowel This can lead to constipation and/or bloating. The constipation may be exacerbated by iron supplements taken for the anemia caused by excessive bleeding.

* Lower back pain

* Pain during sexual intercourse Reproductive problems can also be another uterine myoma (fibroid) symptom. Infertility, recurrent miscarriage, or premature labor during pregnancy can be caused by uterine myoma.

* A feeling of pressure or fullness in the lower abdomen

Large submucosal fibroid tumors may increase the size of the uterus cavity, and can block the fallopian tubes which can cause complications with fertility

Associated symptoms with submucosal fibroids include very heavy, excessive menstrual bleeding and prolonged menstruation.. Untreated, prolonged or excessive bleeding can cause more complicated problems such as anemia and/or fatigue, which could potentially lead to a future need for blood transfusions.

Subserosal myoma can continue to grow outward increasing in size. The growth of a subserosal fibroid tumor will put additional pressure on the surrounding organs. Therefore, symptoms of subserosal fibroid tumors usually do not include abnormal or excessive menstrual bleeding or interfere with a women’s typical menstrual flow. These fibroid tumors instead cause pelvic pain and pressure. Depending on the

severity and the location of the fibroids other complications can accompany this pain and pressure.

When an intramural fibroid tumor expands, it tends to make the uterus feel larger than normal, which can sometimes be mistaken for pregnancy or weight gain. This type of fibroid tumor can also cause “bulk symptoms”: excessive menstrual bleeding, which can cause prolonged menstrual cycles and clot passing and pelvic pain which is caused by the additional pressure placed on surrounding organs by the growth of the fibroid which consequently can cause frequent urination and pressure.

Diagnostic tests include

Transvaginal ultrasonography, sonohysterography, hysteroscopy, and magnetic resonance imaging (MRI), may be helpful in evaluating these tumors. Transvaginal ultrasonography has the lowest sensitivity and specificity, but it is the best initial test based on its noninvasive nature and cost-efficiency. MRI is preferred when precise myoma mapping is required (usually for surgical purposes), but it is the most expensive modality for evaluating fibroid tumors. Sonohysterography and hysteroscopy can be used to evaluate the extent of submucosal fibroid tumors, but these tests are relatively invasive

Knowing the full range of treatment options enables family physicians to counsel patients about the optimal management of symptomatic uterine fibroid tumors. The number of treatment options is increasing and includes expectant management, surgery, uterine artery embolization, ablative techniques, and medical management

Medical management

Because fibroids are hormone sensitive and grow in an estrogenic environment, medical therapies that modify this environment may be successfully used in their management gonadotropin-releasing hormone analogue (GnRH) progesterone antagonists, (Mifepristone) and antiandrogens( DanazolGestrinon) are medical options ,As a result of medical treatment the volume of fibroids reduces by 55%, Medical therapy has tempoary effect, as fibroids typically regrow upon cessation of medical treatment. . A recent study investigated the efficacy and safety of UPA for long-term treatment of symptomatic uterine fibroids by repeated intermittent 3-month open-label courses (10 mg daily Fibroid volume reduction in patients receiving UPA also appears to be maintained in the majority of patients for 6 months after the end of treatment).

Typically, good candidates for medical treatment are women with anemia preoperatively, perimenopausal women who are about to enter menopause, and women with large fibroids in whom size reduction before surgery is desired.

Surgical treatment

Surgery is a reasonable treatment option in the following cases: * Heavy uterine bleeding and/or anemia * Fibroids grow after menopause. * The uterus is misshapen by fibroids and you have had repeatmiscarriages or trouble getting pregnant.

* Fibroid pain or pressure affects your quality of life. * You have urinary or bowel problems (from a fibroid pressing on yourbladder, ureter, or bowel). * There is a possibility that cancer is present. * Fibroids are a possible cause of your trouble getting pregnant.

* Submucosal localisation of myoma

* Intraligamentar myoma

* Cervical myoma

* Rapid growth of tumour

Most common indications for surgical treatment are rapid growth and abnormal uterine bleeding

Surgical treatment includes myomectomy - surgical removal of fibroid tumors while preserving the uterus),and hysterectomy-radical surgical intervention

Myomectomy is a good option for women who wish to preserve their uterus. Myomas may be removed by a laparoscopic approach. The choice of surgical approach is largely dependent on surgical expertise- surgeon should have the ability to suture the uterus with an adequate multilayer closure laparoscopically. Laparoscopic approach appears to take longer in sense of surgery but is associated with a quicker recovery. In cases of uterine myomas laparascopic approach has proven to make minimal damage, but have both: short-term and long-term good results. l trauma with short –term and long-term good results has done laparoscopic approach method of choise in cases with uterine myoma . Temporary closure of uterine vessels decreases blood loss during surgery.

Laparotomy

In a review of available recommendations, most suggest a laparotomy for fibroids exceeding 5 cm to 8 cm, multiple myomas, or when deep intramural leiomyomas are present. Of course, laparoscopic approach is preferred in most cases, but as there is a limit, deviation from which may result in failure. After laparascopic intervention cases of uterine rupture during a subsequent pregnancy have been registered.Hysteroscopic myomectomy should be considered as first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. Hysteroscopic myomectomy is feasible and very effective, and it should be considered in women with symptomatic intracavitary or submucous narrow-based intrauterine myomas.

In women who do not wish to preserve fertility and who have been counselled regarding the alternatives and risks, hysterectomy may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction.

Leiomyomas are listed as the diagnosis for about 39% of the approximately 600 000 hysterectomies performed each year in the United States

Hysterectomy may be performed by laparotomic, laparoscopic and vaginal routes, and preference is given to laparoscopic approach.By laparoscopic route myoma the size of which has reached 24 weeks gestation. can be removed.

Other conservative methods include uterine artery embolisation andMR_guided Focused Ultrasound Surgery,but, they are not performed in Armenia

* Uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE). This is a fairly simple, noninvasive procedure in which small particles are injected into the uterine arteries feeding the fibroids, cutting off their blood supply. Unlike a hysterectomy, this procedure preserves the uterus and helps women potentially avoid surgery. It's been used for years to help stop hemorrhage after childbirth or surgery. Average fibroid volume reduction is approximately 50 % in 3 months and 65 % at 1 year. Uterine volume decreases by approximately 40 % in 3 months. The reduction in the fibroid's size leads to a decrease or resolution in the symptoms they cause. Symptoms improve in 85% to 90% of patients, most of them significantly.

* Focused ultrasound is a non-invasive way to treat uterine fibroids. Using this treatment method in conjunction with image guidance, the physician directs a focused beam of energy through the patient’s skin, superficial fat layer, and abdominal muscles to heat and destroy the fibroid tissue without damaging nearby tissue or the tissues that the beam passes through on its way to the target. The treatment is conducted with the patient awake and uses either magnetic resonance (MR) or ultrasound (US) guidance. This enables the physician to target, control, and monitor the treatment in real time. Not all women are candidates for this procedure. Absolute contraindications include bowel that is in the path of the ultrasound beam, or surgical scars in the beam pathway.

Uterine artery embolization and MRI guided focused ultrasound are contraindicated in women with any of the following conditions:

* Post-menopausal women with fibroid growth or rapid growth at any time (may indicate development of sarcoma); or

* Women who have evidence of current genito-urinary infection and/or malignancy; or

* Women who may wish to become pregnant in the future; or

* Women with a history of prior pelvic X-ray treatments, pelvic malignancy, chronic infections or severe endometriosis.

Limitations of that methods are absent of pathomorfologic diagnosis and high risk of perinonitis