Submucosal uterine fibroids. Features of the diagnosis and treatment of submucosal uterine fibroids Submucosal node in the uterus how to treat

submucosal fibroids- a benign hormone-dependent tumor located in the submucosal layer of the uterus and formed by smooth muscle cells of the myometrium. Almost half of the cases are asymptomatic. It can be manifested by menorrhagia, increasing anemia, cramping pains in the lower abdomen during menstruation, inability to become pregnant or bear a child. To diagnose the disease, transvaginal ultrasound, hydrosonography, hysteroscopy, dopplerography and pelvic angiography are used. Depending on the characteristics of the course, one of the methods of conservative, combined, surgical organ-preserving or radical treatment is chosen.

General information

Submucosal or submucosal fibroids (leiomyoma) are diagnosed in 32% of all cases of detection of myomatous nodes. The disease affects women of reproductive age and never occurs in girls before their first menstrual period. It is most often detected in patients aged 33-40 years. In recent years, there has been a tendency towards "rejuvenation" of the pathology and the detection of submucosal nodes in patients aged 20-25 years. After the onset of menopause, submucosal fibroids usually do not develop, and already existing nodes regress. There is a close interdependence between the disease and the problem of infertility - in every fifth woman who cannot become pregnant, the presence of myomatous nodes is the only pathology of the reproductive system.

Causes of submucosal fibroids

The most likely causes of submucosal nodes are hormonal imbalance and changes in the sensitivity of smooth muscle cells of the myometrium to the action of female sex hormones. The development of submucosal leiomyoma can lead to:

• hereditary predisposition. The proliferation of myometrial cells provokes a genetically determined change in their sensitivity to estrogen and progesterone.
• Hypothalamic-pituitary disorders. Hormonal imbalance occurs when the level of follicle-stimulating (FSH) and luteinizing (LH) hormones changes. The disorder can be observed with vascular and traumatic brain injuries, significant psycho-emotional stress.
• Changes in the endocrine function of the ovaries. The level of secretion of estrogen, progesterone and the normal ratio between these hormones is disturbed in inflammatory diseases (oophoritis, salpingitis, adnexitis), trauma, tumors.
• Traumatic damage to the myometrium. The sensitivity of smooth muscle cells changes due to frequent abortions, invasive medical and diagnostic procedures.
• The action of extragenital factors. Violation of the production of female sex hormones is observed in diabetes mellitus, thyroid damage, and some other endocrine diseases. The level of estrogen in the blood can increase against the background of obesity, since adipose tissue cells are able to produce this hormone.
• Uncontrolled use of hormonal contraceptives. With prolonged use of contraceptive drugs, the secretion of sex hormones that regulate the ovulatory cycle may be disrupted.
• Stagnation in the pelvis. According to a number of authors, the causes of hormonal imbalance are venous stasis due to the lack of regular sexual discharge and a sedentary lifestyle.

It should be noted that not in all of these situations, women develop submucosal fibroids. Therefore, the search for triggering factors for the development of the disease is still ongoing.

Pathogenesis

First, under the influence of provoking factors near the microvessels in the muscular layer of the uterus, an active zone is formed, in the cells of which metabolic processes are accelerated, tissue permeability increases. Subsequently, the smooth muscle cells of this zone begin to accumulate in microscopically and macroscopically defined nodes. Over time, the sensitivity of the proliferating tissue to the action of hormones decreases, and its own autocrinoparacrine growth mechanisms are launched. Nutrition of submucosal myomas is provided by vessels that have lost their adventitious membrane. The growing submucosal node increases the area of ​​rejection of the endometrium and reduces the ability of the myometrium to contract, which provokes more abundant, prolonged and painful menstrual bleeding.

Classification

Submucosal fibroids differ in the number of nodes, localization, size and structure. The following criteria are used to classify the disease:

• Number of nodes. There are single and multiple submucosal fibroids.
• Dimensions. Submucosal tumors up to 20 mm in size (up to 4-5 weeks of pregnancy) are considered small, from 20 to 60 mm (from 4-5 to 10-11 weeks) - medium, more than 60 mm (12 weeks or more) - large.
• Location. In most cases, neoplasms are localized in the body of the uterus, in 5% - in the cervical region.
• Morphology. Depending on the type of cells and the activity of their proliferation, simple submucosal fibroids, proliferating nodes and presarcomas are isolated.

Symptoms of submucosal fibroids

Symptoms depend on the age of occurrence, size and intensity of growth of the node. In the initial stages, there are usually no symptoms, the neoplasm becomes an accidental finding during a gynecological examination or ultrasound. The first most characteristic sign of the growth of the submucosal node is menorrhagia - heavy menstrual bleeding with blood clots, the duration of which exceeds the duration of normal menstruation. Bloody discharge can also be observed in the intermenstrual period. Due to private significant blood loss, anemia develops with general malaise, pallor of the skin, dizziness, headaches, and decreased performance.

Pain in the submucosal location of the node, according to experts in the field of gynecology, is observed in 20-50% of patients. They usually occur during menstruation, are cramping in nature, localized in the lower abdomen and can be given to the lower back. Unlike subserous fibroids, submucosal tumors usually do not affect nearby organs. In 10-40% of cases, there is a violation of the reproductive function - the inability to become pregnant or spontaneous abortion.

Complications

Submucosal fibroids can be complicated by massive uterine bleeding, the development of severe anemia. With a significant deformation of the uterine cavity, the risk of infertility, miscarriages, pathological pregnancy and childbirth increases. In 7-16% of cases, the node undergoes dry or wet necrosis. In the presence of an ascending infection, the submucosal fibroid may fester or abscess, while the patient has a fever, chills, pain in the lower abdomen, and the general condition changes. The most formidable complication is the "birth" of the submucosal node, which is accompanied by "dagger" cramping pains in the lower abdomen, bleeding, and the risk of infection. Malignant degeneration of the tumor is rare (in 1.5-3% of cases).

Diagnostics

Since the clinical symptoms of submucous myoma are nonspecific and not expressed in all patients, physical and instrumental examinations play an important role in the diagnosis. The survey plan usually includes:

• Gynecological examination. Bimanual palpation reveals an enlarged uterus.
• Transvaginal ultrasound, hydrosonography, dopplerography. The techniques allow to determine the size, type and structure of the nodes, to identify the pathology of the endometrium, to assess the thickness of the smooth muscle layer and the intensity of blood flow.
• Hysteroscopy. In the uterus, an oval or round formation with a smooth, pale pink surface or multiple pedunculated nodes hanging in the form of "clusters" in its cavity is found.
• Angiography of the pelvic organs. Visualization of the circulatory system of the uterus makes it possible to confirm the absence of neovascularization in a timely manner to differentiate a benign node from malignant neoplasia.
• X-ray television hysterosalpingography. Reveals a change in the shape of the uterine cavity with areas of enlightenment or filling defects. Currently rarely used.
• MRI and CT of the uterus. Methods are used to accurately assess the topography of myomatous nodes.

Since submucosal fibroids are characterized by the development of anemia, a complete blood count often reveals erythropenia and a decrease in hemoglobin levels. The disease must be differentiated from pregnancy, polyps, sarcomas, internal endometriosis of the uterine body. If necessary, an oncogynecologist, an endocrinologist is involved in the examination.

Treatment of submucosal fibroids

When choosing medical tactics, the woman's age, her plans to preserve reproductive function, the size, location and intensity of growth of the nodes, the severity of the clinical picture and the presence of complications are taken into account. Patients with tumors of stable size in the absence of menorrhagia, pain syndrome, preserved reproductive function are recommended for dynamic observation with an annual examination by a gynecologist. In other cases, choose one of the methods of conservative, combined or surgical treatment.

Drug therapy is indicated for tumors up to 3 cm in size, moderate menorrhagia, and slow growth of neoplasms. Patients are recommended drugs that inhibit the secretion of female sex hormones, eliminating one of the main causes of tumor formation - hormonal growth stimulation. Such therapy is usually supplemented with symptomatic agents. Especially effective is conservative treatment in premenopause, which is replaced by natural menopause. As a rule, patients are prescribed:

• Drugs that inhibit the secretion of gonadotropins. With the use of antigonadotropins and agonists of gonadotropic releasing hormones (A-GnRT), the size of the nodes is stabilized or even reduced, and blood loss during menstruation is reduced.
• Oral or intrauterine hormonal contraceptives. Shown in women of childbearing age to stabilize the effect achieved by inhibiting the secretion of gonadotropins.
• Hemostatics and drugs that reduce the uterus. Used to reduce blood loss in menorrhagia.
• Fortifying means. To improve overall well-being, vitamin-mineral complexes and iron preparations are prescribed.

Combined treatment is the best option for patients who want to preserve reproductive function in the presence of a single node or multiple formations larger than 50 mm in size with clinical symptoms and a tendency to slow growth. With this method, the appointment of A-GnRT precedes and completes a conservative myomectomy. The use of hormonal drugs on the eve of the intervention can reduce the size of benign submucosal nodes, reduce blood loss, reduce the duration of the operation and postoperative recovery.

Surgical treatment is recommended if the node reaches a large size (from 12 weeks of pregnancy), grows rapidly (increase by 4-5 or more weeks per year, especially during menopause and menopause), is accompanied by increasing anemia, pain and the development of complications (including infertility). Depending on the course of the disease and the woman's reproductive plans, the following types of interventions can be selected:

• Organ-preserving operations. Myomatous nodes are removed by hysteroresectoscopy (transcervical myomectomy) using mechanical, laser or electrosurgical instruments, or destroyed using high-frequency focused ultrasound (FUS ablation) or cryomyolysis. Embolization of the uterine arteries allows you to limit the nutrition of the tumor and lead to its resorption.
• radical interventions. With an unfavorable course of the disease, a woman is recommended transvaginal, laparoscopic, laparotomic defundation of the uterus, subtotal (supravaginal) or total hysterectomy.

Forecast and prevention

With timely detection and adequate treatment, the prognosis of submucosal fibroids is favorable. During menopause, the tumor usually regresses. The effectiveness of uterine artery embolization is up to 50%. Conducting organ-preserving interventions allows you to restore reproductive function in women of childbearing age. The postoperative period, depending on the volume of the operation and the type of access, lasts from 7 to 24 days. The follow-up period after hysterectomy is 5 years. After myomectomy, due to the possibility of recurrence, women are observed for life. The main methods of preventing the disease are the rational prescription of hormonal contraceptives, the restriction of invasive interventions, and the treatment of diseases in which hyperestrogenemia is observed.

Any woman, having heard the diagnosis of uterine fibroids, is likely to be alert and afraid for her own health. Especially when it comes to a woman of reproductive age who is planning to conceive a child. Let's consider what danger this diagnosis is fraught with and how the submucosal node of the uterus can affect the conception and bearing of the baby.

What it is

Myoma of the uterus is a benign neoplasm that develops in its muscular layer. Despite the threatening name, fibroids almost never degenerate into cancer. It is approximately 20-22% of all gynecological pathology. The real numbers are much higher, because some women have it asymptomatically and no one knows about its existence.

There are the following classification options for fibroids:

1. According to the number of myoma nodes:

• single;
• multiple.

1. According to the localization of the node in relation to the myometrium:

• submucous myoma. It grows towards the uterine cavity. It can descend into the uterus and even exit into the vagina, the so-called "born" node;
• intermuscular. It is located in the thickness of the muscular layer of the uterus;
• subserous. It grows towards the abdominal cavity.

1. By node location:

• body of the uterus. Occurs in 95% of cases.
• cervix. It happens rarely, but causes serious problems with conception.

Why is it developing?

There is no proven cause for the development of a myomatous node. Contributing factors include:

• genetic predisposition. Burdened heredity is an optional but common factor in the development of a benign tumor;
• hormonal imbalance. Excess significantly increases the risk of developing a myomatous node;
• excess weight. Excess body weight leads to hormonal changes, an increase in the number and, as a result, contributes to the appearance of fibroids;
• inflammatory and traumatic damage to the uterus (after abortion, infectious diseases, etc.);
• hypodynamia and inactive lifestyle.

In some cases, fibroids appear even in the absence of the influence of these factors, so there is no clear reason for the development of this disease.

Clinical signs and symptoms

In some cases, the pathology does not manifest itself in any way and is found only on a planned ultrasound scan by a gynecologist. In other situations, myomatous nodes of various localization manifest themselves as severe symptoms and significantly complicate the life of the patient. So, submucosal uterine fibroids can manifest themselves:

1. Bleeding. The release of blood occurs in the middle of the menstrual cycle. Such regular bleeding leads to the development of chronic anemia, which in the future can give the following symptoms: weakness, fatigue, pale skin, digestive problems, etc.
2. Prolonged heavy menstruation and cycle failures.
3. Pain in the abdomen, a feeling of pressure and fullness - all this can be associated with an actively growing fibroid.
4. Violation of the function of neighboring organs. The rectum and bladder are adjacent to the uterus, so such nodes (especially subserous and intermuscular ones) can cause a breakdown in the functioning of these organs. A woman complains of frequent urination, problems with stool, etc.
5. Infertility. A myomatous node can cause problems, both with conception and with bearing a child.
6. If the fibroid is located on the leg, then the pedicle of the node may be twisted. In these cases, symptoms of severe intoxication, severe pain and peritonitis develop.

Important! Not every fibroid presents with typical symptoms. Most of these neoplasms are detected by chance during a visit to an ultrasound of the pelvic organs.

How to diagnose?

Ultrasound diagnostics helps to determine the presence of single and multiple myomatous nodes. This study allows you to estimate the number of formations, their size and location. On ultrasound, the myomatous node looks like a rounded focus with reduced echogenicity.

In some cases, MRI and other research methods are used for detailed diagnosis. Some types of fibroids can be identified by a specialist by touch during a gynecological examination.

Principles of treatment

The approach to treating the problem is chosen by the doctor, taking into account the size, number of nodes and the presence of symptoms. If the size of the tumor is small and the disease is asymptomatic, then some specialists prefer expectant management and monitor the development of the tumor in dynamics. Others believe that even small fibroids should be treated conservatively.

Conservative treatment

Conservative therapy of fibroids is aimed at eliminating contributing factors: weight loss, treatment of sexual infections, stabilization of the psycho-emotional state, etc.

The following groups of drugs are used as drug therapy:

• gonadotropin-releasing hormone agonists. They help to reduce the synthesis of estrogens, due to which the growth of the node stops, and its size becomes smaller. The effect is expressed only during medication, there are a number of severe side effects;
• oral contraceptives, synthetic progestogens. Currently, their role in the treatment of fibroids is being criticized. The conducted studies prove the absence of obvious changes in the size of fibroids;
• homeopathy and medicinal herbs. They are used to treat the disease, but their effectiveness has not been clinically proven.

Another group of drugs is not aimed at treating fibroids, but at eliminating developing complications, such as pain, bleeding, etc. Painkillers and hemostatic drugs are used.

Important! In some cases, embolization of the uterine artery, which feeds the myomatous node, is carried out. In such cases, the growth of the tumor stops, and it is replaced by connective tissue. Used for single fibroids with good blood supply.

FUS ablation

This method of treatment is based on the action of high-focus ultrasound irradiation. Under the influence of such radiation, irreversible changes occur with the node, and it is destroyed under the influence of high temperature. At the same time, healthy cells remain intact.

These fibroids can be treated with this method, which contain a sufficient amount of connective tissue, therefore, before the procedure, the type of node is calculated using MRI.

This is a low-traumatic, organ-preserving method, which practically does not give complications. May not be used in all cases.

Surgery

In cases where the tumor reaches an impressive size, its symptoms worsen the patient's condition or threaten his life, surgery is performed. Myoma can be removed laparoscopically (access through the anterior abdominal wall) or hysteroscopically (through the uterine cavity).

With the ineffectiveness of such removal and other indications (multiple fibroids, massive bleeding), they resort to complete removal of the uterus (hysterectomy).

Uterine fibroids of various localization can prevent a woman from becoming a mother and cause a number of unpleasant complications. To exclude this pathology, you need to undergo a planned ultrasound and, if necessary, carry out appropriate treatment.

Myoma, or uterine leiomyoma, is one of the most common diseases of the genital organs in women of reproductive and premenopausal ages. Among all gynecological operations performed for bleeding from the genital organs, 20% are bleeding caused by leiomyomas.

They are usually multiple, less often - single, and of considerable size. The nodes can be located in different parts of the uterus in the muscular layer - intramural, under the mucous membrane - submucosal uterine fibroids, under the peritoneum - subserous, between the broad ligaments of the uterus - intraligamentary.

Types of submucosal fibroids and their clinical manifestations

They account for about 1/3 of all localizations of leiomyomas (in relation to the uterine layers). The causes and pathogenesis, risk factors for the occurrence and development of submucosal fibroids are presumably the same as for similar formations of other localizations. However, due to good blood supply and high metabolic processes, the former are characterized by rapid growth.

They are considered the most unfavorable type of leiomyomas, since the frequency in their presence reaches 35%, and in cases of pregnancy, there is a high probability of spontaneous abortion, miscarriage or premature birth, malposition of the fetus, premature placental abruption, complications in childbirth. In addition, the treatment of submucosal formations almost always requires the use of surgical methods.

Submucosal leiomyomas originate from the myometrium (the muscular layer of the wall), but their growth is directed under the mucous membrane, into the uterine cavity. With instrumental examination (hysteroscopy, ultrasound), they are defined as a section of the wall that “bulges out” inward (to a greater or lesser extent). At the same time, its dimensions, the size of the base, as well as the ratio of submucosal and intramuscular volumes are determined. The main classification is based on the volume of the node in relation to the myometrium:

1. Type 0 - these are nodes that are completely located in the uterine cavity and are connected to its wall only by the leg.
2. Type I - fibroids on a wide base, less than 50% of which is in the myometrium, in the wall (intramurally)
3. Type II - formation, more than 50% of the volume of which is located intramurally.

This classification makes it possible to correctly assess the clinical situation, decide on the choice of a surgical method and decide on the need for preoperative preparation in the form of conservative treatment.

Clinical manifestations and diagnosis

The main provoking factors for the development of submucosal fibroids:

• hereditary predisposition;
• chronic inflammatory processes with frequent relapses in the pelvic organs;
• gynecological instrumental procedures and operations, accompanied by traumatization of the mucous membrane and myometrium - diagnostic curettage, abortion.

The most frequent and main symptoms of the submucosal location of fibroids, even of a small volume, are:

1. Uterine bleeding of a pathological nature. They can be manifested by excessively heavy bleeding with blood clots during menstruation (menorrhagia), long and heavy menstruation with short intervals between them (hyperpolymenorrhea), non-cyclical bleeding not associated with menstruation (metrorrhagia). Such blood loss leads to secondary iron deficiency anemia, often accompanied weakness, dizziness and headaches, fatigue, dysfunction of the heart and myocardial dystrophy.
2. Painful menstruation (algomenorrhea).
3. Pain in the lower abdomen, which is sometimes cramping.
4. Constant pelvic pain of variable intensity, pain in the lumbar region, which becomes permanent as the node grows.
5. Liquid with an unpleasant odor, sometimes brownish discharge, which may appear when the node is malnourished and necrosis.
6. Infertility, spontaneous abortions, miscarriage (spontaneous termination from the 22nd to the 37th week).

Large submucosal fibroids, especially types "0" and "I", are dangerous for their "birth" and eversion of the uterus. During menstruation, her pharynx expands, in which, upon examination, the gynecologist can detect the lower pole of the node. In this case, there are pronounced cramping contractions and "pushing out" of the fibroids by the type of labor pains and attempts. During birth, the knot can drag the uterus along with it and turn it out. Such a complication is dangerous with heavy bleeding and infection of the uterine cavity.

Diagnostic methods

Treatment of submucosal uterine fibroids depends on the correct diagnosis, completeness of information about the location of the fibroids and its condition.

Echography (ultrasound) using a transabdominal sensor is the most accessible and convenient non-invasive diagnostic method. Informativity is 93-96%. When examining an enlarged uterine cavity, an oval or rounded formation is determined with regular contours and peripheral compaction of the capsule type, characteristic of the processes of sclerosis and fibrosis. In the presence of necrosis, the heterogeneity of the fibroid structure is determined, and in older women, it may contain zones of calcification.

Transabdominal transducers are the most optimal for evaluating formations of 10 cm or more. The use of transvaginal (vaginal) convex probes with high resolution makes it possible to detect submucosal leiomyomas 3-4 mm in size. Ultrasound three-dimensional (3D) examination has even greater informative possibilities.

hydrosonography(ultrasound with the additional use of a contrast solution) makes it possible to more accurately determine the size and localization of nodes, the degree of deformation of the inner wall of the uterus, as well as to conduct differential diagnosis with focal forms of adenomyosis and endometrial polyps, which are characterized by less echogenicity.

Doppler ultrasound- allows you to see the features of the blood flow inside and around the myomatous formation, assess the degree of blood supply and changes in the structure, predict its further development. This greatly facilitates the choice of treatment tactics.

Representing a visual or on-screen examination of the uterine cavity by introducing an optical system of an endoscopic device (hysteroscope) into it. Devices with 5-150-fold magnification have been developed that allow diagnosing even small nodes, determining the nature of their surface, consistency, base width, seeing extensive or small-point hemorrhages, dilated and elongated blood vessels under a thinned layer of the mucous membrane, etc.

Separate scraping mucous membrane of the cervical canal and uterine cavity. It makes it possible to draw certain conclusions about the degree of proliferation (growth) of the endometrium and the presence of estrogen-dependent fibroids, which is associated with increased activity of estrogen- and progesterone-dependent receptors. This determines the need for the use of gestagenic hormonal drugs (combined oral contraceptives, GnRH agonists, mifepristone, etc.) before and after surgery.

Treatment of submucosal fibroids

Recently, a certain place in the treatment of submucosal fibroids has been taken by such conservative methods as:

• focused ultrasound ablation under the control of magnetic resonance imaging (FUS-MRI ablation), which consists in the non-invasive destruction of leiomyoma by means of focused ultrasound waves;
• embolization of the uterine arteries - their occlusion with polyvinyl alcohol in order to stop the blood supply to the myomatous nodes;
• the use of medications - analogues of gonadotropin-releasing hormone, mifepristone, etc.

However, these techniques are used as independent methods in exceptional cases. They are mainly used to reduce the volume of the node and reduce the severity or completely eliminate the symptoms of fibroids in order to prepare for surgical treatment.

At the birth of a node in the vagina, it is possible to simply unscrew it and remove it. In almost all other cases, the presence of submucosal leiomyoma is a direct indication for conservative myomectomy (with a node size of less than 17 mm) or radical surgery. Surgical methods:

1. Myomectomy through the abdominal wall.
2. Transvaginal hysteroscopic myomectomy.
3. Two-stage myomectomy.
4. Radical subtotal or total hysterectomy, which consists in supravaginal amputation of the uterus (removal without a neck) or its extirpation (complete removal), respectively.

Conservative one-stage myomectomy through the abdominal wall consists in the simultaneous removal of the tumor by laparotomy access (with an incision in the anterior abdominal wall) or by means of a laparoscopic technique, which is the most optimal and modern. At the same time, in both cases, access to the neoplasm itself is provided by dissection of the myometrium, followed by the formation of a scar in it. Despite the obvious advantages of the method as a whole and the possibility of removing relatively large tumors, its main disadvantage is the threat of uterine rupture during subsequent pregnancy due to the presence of a scar in it.

Transvaginal simultaneous hysteroscopic myomectomy consists in the removal of submucous leiomyomas "0" and "I" types with a slight intramural (in the muscle layer) component through the vagina through the optical instrument of the hysteroscope. It is impossible with multiple nodes of other localizations and in the presence of pronounced forms of adenomyosis. The operation can be performed in one of three ways:

1. Mechanical, which consists in cutting the capsule and twisting the formation. The procedure is characterized by a short duration (up to 15 minutes), does not require additional special equipment, a liquid medium that can lead to an overload of the vascular bed. In addition, it excludes the possibility of vascular damage and burns of neighboring areas, which can be with the electrosurgical technique. However, despite the possibility of removing nodes of even significant size, the method is applicable only to type 0 fibroids and less often to type I mobile formations with a very small intramural volume.
2. Electrosurgical hysteroresectoscopy, for which a hysteroresectoscope is used with special loops for cutting tissue and cylindrical or spherical electrodes designed to coagulate bleeding vessels in the bottom of the wound. The operation can be carried out by the method of evaporation (vaporization) or resection of fibroids. In the second case, it is excised and removed in parts. The most convenient localization of the neoplasm for this method is the fundus, lateral walls of the uterus and the mouth of the fallopian tubes.
3. Contact or non-contact laser method using a solid-state laser with a wavelength of 1064 nm.

Two-stage conservative myomectomy carried out in the presence of submucosal formations of the "II" type, the submucosal component of which is less than 50%. The essence of the method is to combine the laparoscopic method with electrosurgical or laser hysteroresectoscopy.

The principle of managing patients with submucosal fibroids using hormonal therapy

Conservative myomectomy of submucosal nodes is an effective surgical method of treatment that provides a favorable postoperative period with short hospital stays. In combination with targeted hormonal therapy, it contributes to the restoration of a normal menstrual cycle, the ability to become pregnant and the prevention of recurrence of the disease.

Myoma of the uterus is a benign neoplasm in the organ, which can be of various types. Depending on the structure, histology and location, it presents a different danger. Submucosal uterine fibroids are one of the most troublesome. Its course is usually quite severe, with severe symptoms. You can learn more about this neoplasm from the article below.

Collapse

Definition

Submucous nodes are benign (non-oncological) neoplasms. However, they are considered quite unfavorable. They are formed in the submucosal layer of the uterus and protrude into its cavity (sometimes slightly, sometimes strongly). Can cause severe symptoms. Reduce the chance of pregnancy.

They vary in size (from a few millimeters to several centimeters). They usually have a round shape and a wide base. Rarely are solitary. Multiple tumors are more common.

The picture shows where the submucosal fibroid is located

Depending on the size and severity of the symptoms, they may require urgent treatment. In some cases, treatment of small nodes is not performed. The type of therapy differs depending on many factors and is selected by the attending physician. The photo below shows what the node looks like.

Submucosal fibroids after removal

Prevalence

Myoma is one of the most common diseases of the female reproductive system. According to various sources, 50-70% of women have this neoplasm. However, women aged 35 to 50 are most susceptible to it. But recently there is a tendency to reduce the age of patients with this diagnosis. There is no exact information about the reasons for this trend.

At the same time, submucosal uterine fibroids are more common than all other types of fibroids. This is due to the fact that the cells of the mucosa and endometrium are divided most actively (compared to muscle cells, for example). In this regard, the formation of fibroids in this tissue layer of the organ is more likely.

Subspecies

Quite often there is a subspecies of this neoplasm. This is an interstitial submucosal uterine fibroid. Such a diagnosis is made when the tumor is located in two tissue layers of the organ at once. Its main part is in the submucosal layer, the smaller one is in the muscular layer. This situation is more unfavorable, but occurs infrequently.

The main difficulty is the removal of this type of submucosal node. It is necessary to make an incision in the abdominal wall. With large sizes of fibroids, this cannot be done laparoscopically. Requires abdominal surgery.

The reasons

Uterine fibroids with a submucosal node are hormone-dependent. That is, the main reason for its development is a hormonal failure in the body. With excessively active production of estrogen, cells in the uterus begin to actively divide. As a result, a tumor is formed. For this reason, it often co-exists with endometriosis, a condition in which the endometrium grows.

If estrogen levels remain consistently high, the tumor continues to grow. In menopause, its growth stops, as the production of estrogen stops. Other reasons that increase the likelihood of a node appearing are:

1. Hypodynamia and obesity;
2. stress;
3. Improper nutrition;
4. Bad ecology;
5. Abuse of bad habits;
6. Lack of intimate life (especially after 25 years).

Fibroids with submucosal growth tend to increase rapidly. This is due to the fact that they have an active blood supply. Therefore, leaving them untreated is quite dangerous.

Symptoms

Submucosal uterine fibroids have the most striking symptoms compared to other types of neoplasms. Severe symptoms are sometimes an indication for surgery. Although sometimes it can be completely asymptomatic. But if the signs appear, they are usually of the following nature:

• Pain in the lower abdomen and lower back. May or may not be associated with the menstrual cycle;
• Increased bleeding during menstruation. The presence of bleeding that is not associated with menstruation. Violation of the menstrual cycle (lengthening, shortening, failures). In rare cases, the intensity of menstruation is significantly reduced;
• An increase in the abdomen with a large neoplasm. Due to the fact that fibroids stretch the abdominal wall;
• With large neoplasms on the anterior wall of the uterus - frequent urination. On the back wall of the uterus - problems with defecation. This is due to the fact that fibroids compress neighboring organs.

This type of neoplasm is most often diagnosed in a timely manner. Whereas other asymptomatic fibroids are often found in an already advanced form.

Complications

Is it scary not to treat such a neoplasm at all? In the absence of therapy, the presence of a node can cause unpleasant consequences:

• Infertility due to the fact that the embryo cannot attach to the walls of the uterus. Or due to the fact that a large knot physically blocks the access of sperm to the egg;
• Problems in the urinary system. Frequent urination;
• Chronic constipation, difficulty with bowel movements;
• High chance of infection. Inflammatory processes may develop;
• The likelihood of degeneration into a malignant tumor. It is quite low (only 2%), but, nevertheless, it is present;
• Node necrosis is a condition requiring urgent surgical intervention;
• Anemia, hemorrhagic shock as a result of significant blood loss during uterine bleeding. Also during menstruation.

The consequences can be very serious. And even irreversible. For this reason, it is impossible to postpone the appeal to the doctor and the start of treatment.

Pregnancy

Pregnancy with submucosal fibroids is unlikely. The embryo cannot attach itself to the wall. But even if this happens, it will be dangerous for both the fetus and the mother. Submucosal uterine fibroids and pregnancy are a bad combination. This is fraught with the birth of a child with pathologies. Severe hypoxia may develop. In addition, the tone of the uterus increases, therefore, at all stages of gestation, there is a possibility of miscarriage or premature birth.

Pregnancy with fibroids is very complicated

The birth process can also be complicated. There may be heavy bleeding.

Diagnostics

The disease is diagnosed by a number of methods. The most informative is MRI or CT. But they are quite expensive. The most frequently ordered studies are:

1. allows you to determine the position and size of fibroids;
2. – visual examination by a gynecologist using a colposcope;
3. If cervical localization is suspected, a neoplasm can be diagnosed using gynecological mirrors;
4. To determine the tissue composition, the material is taken laparoscopically for histology.

If surgery is necessary, then a number of other diagnostic procedures are sometimes required. For example, analysis for tumor markers. Almost always, a blood test for hormones is performed.

Treatment

The submucosal node in the uterus can be successfully operated on or treated hormonally. The difference in approaches is significant.

• (without surgery) is used for small and medium fibroids. Taking hormonal drugs temporarily stops the production of estrogen. As a result, an artificial menopause develops. The node stops growing, and sometimes decreases;
• Surgical treatment involves the removal of a node or the entire uterus (see). It is selected depending on the patient's condition and the development of the disease.

Rarely done. It consists in a focused impact on the myoma by ultrasound. It is expensive, but it is a good way to treat a node without surgery. carried out with the active growth of fibroids or uterine bleeding.

Dimensions

Whether an operation is needed or not, the doctor determines in each case. Usually, this is guided by the size of the fibroids. Small ones up to 2 cm are almost never operated on. Middle nodes are removed only if there are severe symptoms. Or with a tendency to active growth. Usually, large and very large tumors require removal. The sizes for surgical intervention range from 6-10 cm.

You can read more about when the operation is performed in the article "". It also describes the varieties and features of this process.

Consequences of removal

The consequences of removing a fibroid are often much less dangerous than its presence. The rehabilitation period does not take too long. With laparoscopic or abdominal removal of the node, the ability to become pregnant is restored after a few months.

Removal of uterine fibroids

Infertility is only possible if the uterus is completely removed. But such an intervention is extremely rare. And only in very advanced cases.

Submucosal uterine myoma is a benign neoplasm of the female genital organs with localization in the submucosa.

Uterine fibroids are a fairly common gynecological disease among women over thirty years of age. Recently, there has been a trend towards an increase in the incidence of this disease in younger women. In this regard, there is an acute problem of preserving reproductive function in this category of patients.

Classification

Uterine fibroids occur as a result of hypertrophy of muscle and connective tissue elements.

Myomatous nodes are multiple and single, from a few millimeters to tens of centimeters. By location relative to the sections of the uterus, they distinguish:

Types of submucosal fibroids

About a third of cases are fibroids with submucosal localization.

Important! Submucosal fibroids are considered the most unfavorable type of benign tumors. Due to sufficient blood supply, they can reach considerable sizes in a short period of time. The danger of this type of benign neoplasm is to increase the frequency of infertility. They account for about 35% of all diagnosed cases. When pregnancy occurs, the risk of miscarriage, spontaneous abortion, premature birth, malposition of the fetus, complications in childbirth increases. Therefore, it is important to diagnose the disease in a timely manner and carry out the necessary treatment.

The classification of submucosal formations is based on the volume they occupy in relation to the myometrium, which helps in choosing the tactics of the treatment. Allocate:

• 0 type - the nodes are located completely in the body of the uterus;
• Type 1 - 50% is in the thickness of the myometrium, and the rest is in the cavity;
• type 2 - more than 50% is located in the thickness, and a smaller part in the cavity;
• Type 3 - there is no layer of myometrium between the endometrium and the tissues of the tumor node.

Therefore, submucosal uterine fibroids type 2 is a benign neoplasm of the female genital organs, localized in the submucosa, mostly located in the thickness of the myometrium.

The causes and pathogenesis of submucosal fibroids of the second type, like other types, have not yet been accurately studied. There are several hypotheses about what factors can serve as an impetus for the development of the disease. It is known that the excess in the body of female sex hormones - estrogens, in most of the identified cases, is predisposing to the appearance of this type of formation.

Frequent abortions, complications in childbirth, inflammatory diseases of the female genital organs, hereditary predisposition, lack of pregnancy and childbirth in women under the age of 30, late onset of menstruation, endocrine disorders (diabetes mellitus, thyroid disorders), overweight, frequent stress, prolonged use of hormonal contraceptives can also lead to the development of the disease.

In each individual case, the heredity, lifestyle, and health of the patient should be studied. Knowing the possible causes will help prevent recurrence in the future.

Symptoms

Important! The disease can be asymptomatic for a long time. The clinical picture is most pronounced when the nodes reach a significant size. Regular visits to the gynecologist (at least once a year) and the implementation of recommendations will allow you to identify the disease at an earlier stage.

Patients with type 2 submucosal fibroids mainly present with the following complaints:

• for menstrual irregularities;
• prolonged and heavy menstrual bleeding with small intervals between them (hyperpolymenorrhea);
• the appearance of clots during menstruation (menorrhagia);
• painful menstruation (algomenorrhea);
• the appearance of intermenstrual bleeding (metrorrhagia);
• weakness and general malaise, due to the occurrence of iron deficiency anemia due to prolonged menstruation;
• cramping pains in the lower abdomen. The node is alien, so the uterus is trying to get rid of it - hence the pain of a cramping nature. Sometimes it can go out on its own, which is always accompanied by severe pain and heavy bleeding. This is especially true for large nodes of types 0 and 1;
• an increase in the abdomen, due to the rapid growth of myoma.

In the case when the submucosal formation reaches a very large size, the cycle of menstruation is disturbed, and in the subsequent menstruation may not stop at all.

In case of malnutrition of the tumor, in case of its bending, torsion of the leg, an acute condition occurs that requires immediate medical attention.

Submucosal fibroids in most cases lead to infertility, so it is very important for everyone to know the manifestations of the disease. The earliest diagnosis in women of reproductive age allows you to save the opportunity to become pregnant.

Diagnostics

A doctor can suspect the presence of a pathology already at the stage of a gynecological examination, by asking the patient about her complaints and directly during examination on the chair. By palpation, you can directly feel the node itself, with its large enough size, the uterus will be enlarged. Pressing directly on the area where the tumor is located can cause pain.

Non-invasive instrumental methods are used for diagnosis:

• Ultrasound (ultrasound diagnostics). With the help of a transabdominal or transvaginal sensor, the neoplasm is well visualized, how and where it is located, its size and features are determined. This is a completely painless and fairly informative diagnostic method.
• Doppler ultrasound allows you to determine the features of blood flow in the formation and its surrounding area;
• Hydrosonography. It is based on the use of ultrasound with a contrast agent. Allows you to differentiate the myomatous node from the uterus.
• CT (computed tomography). The use of computed tomography makes it possible to detect the disease at the earliest stages. Often this method is used to evaluate large tumors.
• MRI (magnetic resonance imaging). Allows you to get a three-dimensional image in three projections. The most sensitive diagnostic method, however, is one of the most expensive. MRI provides the most accurate and reliable information about a tumor.
• Hysterography (X-ray). This method in modern medicine is used less and less. On x-ray, the neoplasm looks like a defect with clear contours. The disadvantage of the method lies in the difficulty of differentiating the submucosal node from the polyp, the nodular form of adenomyosis and uterine cancer.

Of the invasive methods, diagnostic hysteroscopy is used. By introducing an endoscopic device into the uterine cavity, the location of the myomatous node, the nature of the surface, the width of the base, and the consistency are determined.

Treatment

Thanks to the advent of laparoscopic and endoscopic myomectomy, it became possible to remove the myomatous node without removing the uterus, therefore, it is possible to preserve reproductive function.

The laparoscopic method is an access to the abdominal cavity, when instruments and a laparoscope (an optical system that allows the surgeon to display an image of the internal organs on the screen) are inserted through small incisions (up to 10 mm). Operation using a laparoscope is less traumatic, postoperative complications are rarely observed, patients are rehabilitated faster and the cosmetic defect is so small that it is almost invisible.

Important! Surgical removal of submucosal fibroids is the most effective treatment tactic. If you refuse surgical treatment in the early stages of tumor growth, then later the likelihood of a radical operation to remove the tumor along with the uterus increases.

In the treatment of type 2 submucosal fibroids, a two-stage conservative myemectomy is used. It is based on the use of the laparoscopic method in combination with electrosurgical and laser hysteroresectoscopy. Hysteroresectoscopy is the introduction of a special electrocoagulator (or laser) apparatus through the vagina and cervical canal. During the operation, the tumor is removed in layers, minimally affecting healthy tissues. An important point in preparing for the operation is the use of hormonal therapy, which will stop the menstrual function and, due to the reduction of the endometrium, the size of the node itself decreases.

Radical surgery is based on the removal of the uterus with a cervix (total hysterectomy) or without a cervix (subtotal hysterectomy).

The prognosis after surgical treatment is favorable.

Complications

After the treatment, complications such as:

• Disease relapse. After removal of the formation, it is necessary to monitor and avoid possible causes that caused the disease. The presence of harmful factors can lead to re-growth of the tumor. Especially in the risk group of women during menopause. The resulting hormonal changes during this period can again start the process of tumor growth.
• Scars on the uterus during the surgical removal of multiple formations can cause uterine rupture during pregnancy. When planning a pregnancy, it is better to wait a period of about six months after the operation. In some cases, doctors may order a caesarean section to reduce the risk of this complication.

Prevention consists in maintaining a healthy lifestyle, reasonable protection against unwanted pregnancy, timely contacting specialists in case of hormonal disorders, diseases of the female reproductive system, following all recommendations, annual examination.

Video: umbucous uterine fibroids - treatment

Video: uterine fibroids. Removal of submucosal nodes