Hysteromyoma

Description:

Hysteromyoma - the benign, hormonal and dependent tumor coming from unstriated muscles of a uterus. The hysteromyoma is found in 15 - 17% of women 35 years are more senior. The term "hysteromyoma" it is most recognized and widely applied as it characterizes a tumor morphogenesis - its development from muscular tissue of a uterus. Other names ("fibroma", "fibromyoma") are recommended to be used for specification of its gistostroyeniye. At fibromas of a uterus elements of a connective tissue stroma prevail, at fibromyomas the equal ratio of cells of muscular and connecting fabrics is noted. Each hysteromyoma, as a rule, is multiple therefore the term "multiple hysteromyoma" is deprived of logical sense.

Hysteromyoma reasons:

A number of hypotheses concerning a hysteromyoma pathogeny is offered. At patients with a hysteromyoma cyclic secretion of luteinizing and follicle-stimulating hormones with a prevalence of the last changes. Metabolism of sexual steroids is broken. In a follikulinovy phase of a menstrual cycle the level of estrone and estriol, and in lyuteinovy - estriol against the background of reduced secretion of progesterone prevails. Growth and development of a hysteromyoma to a considerable measure are caused by disturbances of estrogenretseptorny system of an endometria. In  a hysteromyoma pathogeny a certain place is allocated by disturbance of a peripheral hemodynamics and water and electrolytic balance - to decrease in elasticity of walls of vessels, strengthening of a krovenapolneniye, blood outflow difficulty, increase in potassium concentration in a blood plasma.
In recent years it is established that biologically active substances, so-called growth factors lead to development of a benign tumor of a myometrium. In particular, the level of the epidermal growth factor (EGF) which is contained both in stromal and in epithelial cells of muscular tissue, at a hysteromyoma several times exceeds control indicators.
Except hormonal and immunological concepts of a pathogeny of a hysteromyoma there is also other theory of its origin according to which the hysteromyoma is not a tumor, but a hyperplasia of a myometrium and develops against the background of a normal menstrual cycle. Supporters of the theory of a myogenetic hyperplasia consider that formation of a hysteromyoma comes in sites of a myometrium which differ in a difficult interlacing of muscle fibers (a zone of "dystrophic disturbances") - on the average line of a uterus, near pipe corners, sideways from a neck of uterus. A releaser of hyperplastic process is the fabric (local) hypoxia of muscular elements of a uterus, arising under the influence of various adverse factors and is especially expressed in a zone of "dystrophic disturbances". The hypoxia leads to dedifferentiation of cells of a myometrium therefore they gain ability to proliferation against the background of physiological secretion of sexual steroids. In turn, constant non-regulated proliferation of muscle fibers causes formation of a hysteromyoma.

Hysteromyoma symptoms:

On localization distinguish a hysteromyoma of typical localization - in a body of the womb (95% of cases) and cervical myoma (5% of cases).
Depending on type of growth of myoma in a muscular coat of a uterus distinguish three forms of a tumor: intramural (the tumor is located in the thickness of a uterus wall): submucous (myoma grows towards a cavity of the uterus) and subserous (growth of myoma in the direction of an abdominal cavity). For designation submucosal submucosal, located preferential in a muscular coat (more than on 1/3 volumes of a node), use the term of "an intermuscular hysteromyoma with tsentripetalny growth". With an exophytic growth of myoma from lower parts of a body of the womb or her neck (cervical myoma) the tumor can be located zabryushinno (a retroperitoneal hysteromyoma) or between leaves of a wide sheaf (an intercopular hysteromyoma).
Growth forms of a hysteromyoma differ not only on a morphological structure. So, submucous and intramural tumors are carried to the presents of hysteromyomas as the ratio in them of a parenchyma and a stroma makes 1:2, subserous - to fibromyomas because in these tumors the specified ratio reaches 1:3. Activation of exchange processes is most expressed by Popotentsialny growth potential in submucous myomas that causes a high tendency to a malignancy. Among submucous nodes of myoma distinguish a special form - tumors which are born and burgeon in a cavity of the uterus in the direction of an internal pharynx. The birth of myomatous nodes leads to smoothing and expansions of edges uterine eyes and quite often is followed by a tumor exit out of limits of the last.
The clinical picture at a hysteromyoma is various and depends on age of the patient, duration of a disease, localization and the sizes of a tumor, and also a premorbidal background and existence of the accompanying pathological processes. Parts the hysteromyoma proceeds asymptomatically. At a simptomny fibromyoma refer to the most characteristic clinical manifestations disturbances of a menstrual cycle and functions of adjacent bodies, especially speeded up urination. Pain is, as a rule, localized in lower parts of a stomach and a waist. Subperitoneal myoma is followed by the constant aching pain that is caused by stretching of a peritoneum or compression of neuroplexes of a small pelvis. The acute pain arises at disturbances of blood supply in a tumor. Colicy pains during periods appears in case of submucosal localization of a tumor. Menorrhagias (long periods with plentiful allocations) note in the presence of submukozny nodes, deforming a cavity of the uterus. Metrorrhagias (acyclic uterine bleedings) are more inherent in myoma of intermuscular and subperitoneal localization. Dysfunctions of adjacent bodies it is observed, as a rule, at subperitoneal, cervical and intercopular localization of nodes of myoma, and also in the presence of a tumor of the big sizes. Growth of a hysteromyoma preferential slow, however is sometimes observed also bystry increase in the sizes of a tumor.

Diagnosis:

At abdominal study palpate dense education which goes beyond a small pelvis; during the bimanual research reveal the increased uterus (the sizes estimate it in weeks of pregnancy) with a hilly surface, a dense consistence, sometimes with limited mobility.
At survey of a neck of uterus in mirrors and at a kolposkopiya are easily diagnosed cervical myoma, it is located in a vagina, and the fibromatous node is born. Ultrasonic examination of bodies of a small pelvis allows to determine the sizes, quantity, localization, echogenicity, structure of nodes, to establish existence of the accompanying hyperplasia of an endometria, pathology of appendages of a uterus. Hysteroscopy is applied to identification of submucosal fibromatous nodes, by definitions of a condition of an endometria, in certain cases use a gisterosalpingografiya. Advantage of hysteroscopy is a possibility of performance of a simultaneous biopsy of an endometria, removal of polyps and submucous nodes, an endometria resection. Rather seldom there is a need for a diagnostic laparoscopy, is preferential in need of differential diagnosis (a leiomyoma or a tumor of an ovary). For diagnosis of a hysteromyoma the computer tomography, nuclear magnetic resonance can be executed. One of important researches in a complex of inspection of patients with a hysteromyoma is the histologic research of an endometria and assessment of a neck of uterus which results in many respects define tactics of treatment of patients.
Differential diagnosis is carried out with uterus sarcoma, tumors and tumorous formations of ovaries, by pregnancies, internal endometriosis.

Treatment of the Hysteromyoma:

Treatment multicomponent and in many respects is defined by age of the patient, a condition of her premorbidal background, features pato-and a tumor morphogenesis, localization of myomatous nodes. Treatment of a fibromyoma of a uterus can be conservative and operational. Conservative methods include non-hormonal and hormonal therapy. The hygienic mode, a rational diet, implementation of medicamentous influences for correction of metabolic disturbances are shown practically to all women with this disease. In the presence of the corresponding conditions performing conservative hormonal therapy with the purpose to suspend growth of a tumor and to limit menstrual blood loss is possible. Hormonal treatment consists in purpose of progestogens, androgenic steroids and agonists to a gonadoliberin. Hypooestrogenic states against the background of therapy by agonists of gonadotropic rileasing-hormone (GNRG) lead to delay of a blood-groove in a uterine artery, promotes a growth inhibition and reduction in volume of myomatous nodes. However the question of expediency of hormonal therapy at patients with a hysteromyoma cannot be considered solved. It is long do not recommend to apply various types of medicamentous therapy in connection with possibility of side reactions. In response to the termination of hormonal influence the expansive growth of a tumor can be observed. Exogenous hormones (anti-hormones) appoint the patient with a hysteromyoma in the period of a perimenopauza as an alternative method of treatment, and also for the purpose of preoperative preparation which consists in reduction of volume of a tumor and creating favorable conditions for surgical intervention, restriction of estimated intraoperative blood loss. Haemo static therapy includes intramuscular purpose of drugs which reduce a uterus (oxytocin of 1 ml, Hyphotocinum of 1 ml), the drugs increasing coagulability of blood (10% Calcii chloridum solution on 10 ml intravenously, Vikasolum on 0,1 g 3 times a day), and the drugs suppressing fibrinolitic activity of blood (5% solution of aminocapronic acid on 100 ml daily, дипинон on 2 ml intramusculary 2 times a day within 7 days). In gynecologic practice successfully apply a method of the embolization of uterine arteries (EUA) which essence - carrying out pelvic arteriography from the subsequent selection embolization of small branches of the uterine artery supplying with blood myomatous nodes. As embolizata apply particles of polyvinylalcohol from 350 to 700 in size мк. In myomatous nodes there is a focal heart attack, a sklerozirovaniye and hyalinization. Blood supply of an adjacent myometrium is quickly recovered at the expense of multiple collaterals. At selection of patients for EMA it is necessary to be guided by the following criteria: reproductive age (up to 45 years), clinical manifestations meno-and a metroraggiya or a pain syndrome, a contraindication to hormonal therapy, absence of the expressed anemia, infertility which reason myoma, usual not incubation of pregnancy, a contraindication to surgical treatment is. Among contraindications for carrying out EMA there is pregnancy, acute inflammatory diseases of bodies of a small pelvis, a renal failure, suspicion on malignant process, allergic reactions to a contrast agent, coagulopathies. More than 10 cm in the diameter, the general sizes of a uterus more than 13-14 weeks of pregnancy carry an arrangement of nodes, the node sizes to relative contraindications submucous and subserous (on a leg).
Indications to surgical treatment of a hysteromyoma:
1) big sizes of a tumor (more than 14 weeks of pregnancy);
2) submucous myomas of an arrangement, is followed by long periods with plentiful allocations, anemia;
3) rapid growth of a tumor;
4) subserous myoma (on a leg) at which there is a risk of torsion of a leg of a node with the subsequent development of a necrosis in it;
5) necrosis of a myomatous node;
6) dysfunction of adjacent bodies;
7) cervical hysteromyoma;
8) a hysteromyoma combination to other diseases of generative organs, demanding surgical intervention;
9) infertility (if it is convincingly proved that the hysteromyoma is the reason of infertility).
The volume of surgical intervention depends on age of the patient, existence of the accompanying gynecologic diseases (a condition of an endometria, a neck of uterus, ovaries, uterine tubes), a condition of reproductive function. Surgical treatment can be radical or conservative. Carry a conservative myomectomy, defundation to conservative operative measures, to radical - high supravaginal (supratservikalna) amputation of a uterus, supravaginal amputation of a uterus, a hysterectomy. To the women of reproductive age interested in preservation of generative function carry out organ-preserving operations, namely a conservative myomectomy (enucleation (enucleating) of myomatous nodes). At subserous a tumor arrangement preference is given by laparoscopies. At submucosal localization of a tumor make a myomectomy by a gisterorezektoskopiya method.
Complications. A frequent complication of a hysteromyoma is the tumor necrosis which is followed by a clinical picture of acute inflammatory process up to development of a condition of an acute abdomen. Degenerative changes in nodes of myoma arise preferential against the background of disturbance of system of difficult biochemical processes in the vessels feeding a tumor and also torsion of a leg of subperitoneal myomatous nodes.