1ST CITY CLINICAL HOSPITAL

Uterine fibroids are benign growths of smooth muscle and connective tissue. Fibroids can range in size from a small pinhead to very large ones, comparable to a melon. In medical practice, fibroids weighing more than 9 kg have been recorded.

Uterine fibroids, in everyday understanding, is a collective concept. By uterine fibroids, non-specialist women and doctors (to facilitate the patient’s understanding of the situation) understand any benign tumor of the uterus.

However, from a structural point of view, uterine fibroids can be represented by various tissues:

• Leiomyoma is a neoplasm of muscle fibers;
• Fibroma is formed by connective tissue and is quite rare in its pure form;
• Rhabdomyoma is a benign tumor that develops from striated muscle tissue;
• Angiomyoma is a tumor with a well-developed network of blood vessels .

In relation to the muscular layer of the uterus, three types of growth of fibroid nodes are also distinguished:

• Internal or intermuscular fibroids grow in the middle and thick layer of the uterus;
• Subperitoneal or subserous fibroids grow from the thin outer fibrous layer of the uterus, the so-called serous layer. Such fibroids can be either on a wide base or on a narrow stalk.
• Submucosal or submucosal fibroids grow from the wall of the uterus towards the inner lining of the uterus - the endometrium. Submucosal uterine fibroids can also have either a stalk or be broad-based.

Classification of uterine fibroids by the number of nodes:

• A single fibroid is a myomatous node, which is clearly demarcated from the surrounding muscular layer of the uterus by a false capsule formed by compressed muscle tissue. The dimensions of a single node, as a rule, range from a few millimeters to 8-10 cm, rarely more.
• Multiple or multinodular uterine fibroids, consisting of two or more myomatous nodes, in some cases having a bizarre “node on node” arrangement.

Causes and risk factors of uterine fibroids

• Age. Fibroids are most common among women aged 30 to early 50s. After menopause, fibroids usually shrink. About 20-40% of women age 35 and older have fibroids that are large enough to cause symptoms.
• Race. Uterine fibroids are especially common in African American women, who tend to develop fibroids at a younger age than white women.
• Family history and heredity  . A history of fibroids in your mother or sister may increase your risk.
• Hormonal imbalance . Uterine fibroids are formed due to increased production of female sex hormones by the body - estrogens.
• Immunological reasons. Sometimes a violation of the cellular immune system leads to a decrease in the detection of cells with a damaged DNA structure by the body.
• Hypoxic hypothesis. Insufficient oxygen saturation of the uterine tissue causes disruption of the metabolic process and synthesis of uterine cells.
• Other possible risk factors. Obesity  and high blood pressure are possibly associated with an increased risk of developing fibroids.

Symptoms of uterine fibroids

Most patients with fibroids have no symptoms. It is discovered by chance during a gynecological examination or ultrasound.

Common symptoms of uterine fibroids may include:

- Heavy and prolonged menstrual bleeding . The most common symptom is prolonged and heavy bleeding during menstruation. It is caused by the growth of fibroids bordering the uterine cavity. Your menstrual period may also last longer than usual.

- Menstrual pain . Heavy bleeding and clots can cause severe cramps and pain during your period.

- Pressure and pain in the abdomen and lower back . Large fibroids can cause pressure and pain in the abdomen or lower back that occurs between periods and resembles menstrual cramps.

- Problems with urination . Large fibroids can put pressure on the bladder and urinary tract, causing frequent urination or the urge to urinate, especially at night when a woman is lying down. Fibroids can also put pressure on the ureters, which in turn can obstruct or block the flow of urine.

- Constipation . Pressure from fibroids on the rectum can cause constipation.

- Pain during sexual intercourse .

- Enlargement of the uterus and abdomen . As fibroids grow, some women begin to feel them as hard lumps in the lower abdomen. Very large fibroids can cause the abdomen to become enlarged and cause a feeling of heaviness or pressure.

Diagnosis of uterine fibroids

- Gynecological examination and medical history . As mentioned, a gynecologist may discover some fibroids during a pelvic examination.

During a pelvic examination for fibroids, the doctor will check for pregnancy-related indicators and other conditions such as ovarian cysts. You will be asked questions about your family history of fibroids and the length and pattern of your menstrual bleeding. Other causes of abnormal uterine bleeding should also be considered.

- Ultrasound . Ultrasound is the standard imaging method for detecting uterine fibroids. Ultrasound examination can be either transabdominal or transvaginal. In transabdominal ultrasound, an ultrasound probe moves across the abdominal area. In transvaginal ultrasound, a probe is inserted into the vagina.

- Hysterosonography . Along with ultrasound, hysterosonography may be performed, which uses ultrasound along with a saline solution that is infused into the uterus to enhance visualization of the uterus and give much more accurate results in identifying pathologies of the uterine cavity, including tubal patency.

- Hysteroscopy . Hysteroscopy is a procedure that can be used to determine the presence of fibroids, polyps, or other causes of bleeding. It can also be used during surgery to remove fibroids.

The procedure uses a long flexible tube called a hysteroscope. It is inserted into the vagina through the cervix and reaches the uterus. A fiber optic light source and tiny cameras in the tube allow the doctor to examine the cavities in detail. The uterus is also filled with a saline solution or carbon dioxide to inflate the cavities and provide easier viewing.

Hysteroscopy is a non-invasive procedure and does not require any incisions, however, some women report severe pain during the procedure, so local, regional or general anesthesia may be used.

- Laparoscopy . In some cases, laparoscopic surgery may be performed as a diagnostic procedure. Whereas hysteroscopy allows the doctor to view the cavities inside the uterus, laparoscopy allows the doctor to view outside the uterus, including the ovaries, fallopian tubes, and conduct a general examination of the pelvic area.

- Biopsy . In some cases, an endometrial biopsy may be needed to determine if there are abnormal cells in the lining of the uterus that are warning signs of cancer.

- Laboratory tests . A complete blood count may also be needed to check for signs of anemia.

- Exclusion of other possible causes that can cause heavy bleeding. Almost all women, at some point in their reproductive lives, experience heavy bleeding during their menstrual period. Therefore, it is very important to rule out other conditions that cause or may cause heavy bleeding.

Causes and risk factors for heavy menstrual bleeding include:

Treatment of uterine fibroids

A woman's age and the severity of her symptoms are important factors when choosing treatment.

Many women with fibroids choose not to undergo treatment, especially if they are approaching menopause. Fibroids typically grow slowly and stop growing after menopause.

However, if the tumor causes pain, bleeding , or grows quickly, treatment is necessary. Treatment for fibroids includes various medications and surgical methods.

In modern clinical practice, there are 3 approaches to treatment:

1. Waiting tactics. This approach does not require treatment, especially if the woman is close to reaching menopause or the fibroids are not causing any symptoms. Periodic gynecological examinations and ultrasounds can help monitor the condition of fibroids.
2. Drug therapy .

- Anti-inflammatory and painkillers . For pain associated with fibroids, women can use acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen.

- Hormonal contraceptives . Continuous dosed use of oral contraceptives can  normalize and shorten the menstrual period. They are also sometimes used to control heavy menstrual bleeding, associated with fibroids, but unfortunately they do not reduce the growth of fibroids. Recently, new types of continuous-dose oral contraceptives have become available that can reduce the number of menstrual periods a woman has in a year. They block or suppress  estrogen, progesterone, or both.

- Intrauterine devices . An intrauterine device containing progestin-releasing hormone may help control excessive menstrual bleeding called menorrhagia. The Mirena levonorgestrel-releasing intrauterine system is approved for the treatment of menorrhagia and has shown excellent results. Many doctors now recommend Mirena as the first choice for treating heavy menstrual bleeding, especially for women who may be facing a hysterectomy (removal of the uterus).

- GnRH agonists . Taking gonadotropin-releasing hormone and agonists to reduce estrogen and progesterone leads to a reduction in the size of fibroids by stopping ovulation. GnRH agonists block the production of reproductive hormones such as luteinizing hormone (LH) and follicle-stimulating hormone (FSH). As a result, the ovaries stop ovulating and producing estrogen. Simply put, GnRH agonists cause temporary menopause.

GnRH agonists can be used as a drug treatment for fibroids in women who are approaching menopause. They can also be used as a preoperative treatment 3 to 4 months before surgery to reduce the size of fibroids, ultimately performing a minimally invasive surgical procedure.

Zoladex (goserelin) subcutaneous capsules, monthly Leuprolide (Lupron) injections, and Sinarel (nafarelin) nasal spray are used as gonadotropin-releasing hormone (GnRH) agonists.

Before using these drugs, the doctor must be sure that no other complicating conditions are present, particularly leiomyosarcoma (cancer). The use of these drugs may weaken the treatment of malignant neoplasms and lead to serious complications.

Common side effects, which can be very serious in some women, include menopause-like symptoms: hot flashes, night sweats, vaginal dryness, weight gain and depression. The most important concern is possible osteoporosis due to decreased estrogen levels. Women should not take these drugs for more than 6 months. It should be remembered that these drugs alone cannot prevent pregnancy. Additionally, if a woman becomes pregnant while using them, there is some risk of birth defects.

3. Surgery. There are many surgical options, ranging from less invasive to very invasive. These include removal of fibroids - myomectomy, removal of the endometrium - endometrium, reduction of blood supply to the uterus - uterine artery embolization, and removal of the uterus - hysterectomy.

Women should discuss each option with their doctor. Deciding on a specific surgical procedure depends on the location, size, and number of fibroid nodes. Some procedures affect a woman's fertility and are recommended only for women who are not of childbearing age or for those who do not plan to become pregnant.

Indications for surgical treatment of uterine fibroids are:

• Rapid growth of fibroids;
• Heavy bleeding leading to anemia;
• Multiple fibroids;
• Large fibroids;
• Severe pain syndrome;
• Leg torsion or fibroid necrosis;
• The combination of uterine fibroids with an ovarian tumor or endometriosis , or a precancerous condition of the cervix;
• Infertility caused by atypical location of nodes;
• Suspicion of malignant degeneration of fibroids.

Myomectomy

Myomectomy is a surgical procedure aimed at surgically removing only fibroids. In this case, the uterus is not affected, which makes it possible to preserve the woman’s reproductive function. This surgery can also help regulate abnormal uterine bleeding caused by fibroids. Unfortunately, not all women are candidates for myomectomy. If the fibroids are numerous and large, it can lead to significant blood loss.

To perform a myomectomy, the surgeon may use the standard "open" surgical approach - laparotomy, or the less invasive options - hysteroscopy and laparoscopy.

Laparotomy with myomectomy . Laparotomy is performed by making an incision in the abdominal wall and conventional “open” surgery. It is used for subserous fibroids that are very large, numerous, when cancer is suspected, or when laparoscopic techniques are not available or have contraindications. Recovery from a standard abdominal myomectomy takes 6 to 8 weeks. Open laparotomy carries a higher risk of scarring and blood loss, and the risk of recurrence of new fibroids is also higher than with less invasive procedures.

Hysteroscopy . Hysteroscopic myomectomy can be used for submucosal or submucosal fibroids located in the uterine cavity. In this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is inserted into the uterine cavity through the vagina and cervix, after which the doctor uses electrosurgical instruments to remove the tumor.

Laparoscopic myomectomy . Women whose uterus is no larger than it would be at 6 weeks' pregnancy and who have a small number of subserosal nodes may have laparoscopic surgery. Laparoscopy requires only tiny incisions, is performed under image guidance, and has much less recovery time than laparotomy.

Complications of myomectomy are generally the same as for other surgical procedures, including bleeding and infection. This operation is not a method that gives 100% results. Fibroids may reappear after myomectomy.

Uterine artery embolization

Uterine artery embolization (UAE), also called uterine fibroid embolization, is a relatively new treatment for fibroids. EMA of the fibroid deprives it of blood supply, causing the fibroid to shrink. UAE is a minimally invasive method and technically non-surgical therapy. It is much less invasive than hysterectomy and myomectomy and has a shorter recovery time than other procedures. The patient remains conscious, although under anesthesia, during the procedure, which takes about 60 to 90 minutes.

This procedure is usually performed in the following order:

The patient is sedated and a local anesthetic is applied to the skin around the groin.

The interventional radiologist makes a small incision in the skin (about 1 cm) and inserts a catheter into the femoral artery, which feeds the fibroid. Particles of a special embolization drug are injected through the catheter. These particles block the blood supply to the tiny arteries that supply the fibroids, causing the fibroid tissue to die and be replaced by connective tissue. This leads to a significant reduction or disappearance of myomatous nodes.

Patients usually remain in the hospital overnight after the procedure is performed and pain medication is given. Pelvic cramps are common for the first 24 hours after the procedure.

Recovery time after the procedure until returning to work is 1–2 weeks, but shrinkage of fibroids can take from several months to several years.

Most patients experience a brownish vaginal discharge for several days after UAE, which may last until the start of the next menstrual cycle. Regular menstrual cycles resume within 2 to 3 months after the procedure. Heavy menstrual bleeding decreases in the second or third cycle.

Is it possible to get pregnant after uterine artery embolization?

In general, UAE is considered to be an option only for women who do not plan to bear children. Although in clinical practice there have been cases of pregnancy after this procedure. Some evidence suggests that UAE may increase the risk of miscarriage in women who become pregnant. Some women who have UAE have gone through menopause after the procedure. And yet, the onset of menopause in women who have had UAE is more likely after 45 years of age.

Studies on uterine artery embolization show high patient satisfaction rates (over 90%) and low complication rates. Symptoms of menorrhagia, as well as pelvic pain, improve in 85 - 95% of patients within 3 months after treatment. Uterine artery embolization is an effective method of controlling fibroids for most patients. However, some patients may have recurrent fibroids requiring repeat embolization or hysterectomy.

Endometrial ablation

Endometrial ablation destroys the lining of the uterus (endometrium) and is usually done to stop heavy menstrual bleeding. Destruction of the endometrium can be carried out using heat, cold, microwave radiation or other methods. This procedure is not appropriate for large fibroids or fibroids that have grown outside the lining of the uterus. In some cases, it stops menstruation completely. For some women, menstrual bleeding does not stop, but is significantly reduced.

This procedure is usually performed in an outpatient setting and can take as little as 10 minutes. Recovery usually takes several days.

Endometrial ablation significantly reduces the chance of becoming pregnant. However, pregnancy can still occur, although this procedure increases the risk of complications, including miscarriage. Therefore, women who have had this procedure should still use contraception.

Magnetic resonance focused ultrasound (FUS-MRI)

FUS-MRI is a non-invasive procedure that uses high-intensity ultrasound waves to heat and remove uterine fibroids. This is a kind of “thermal ablation”. The procedure is performed using a device, ExAblate, which combines magnetic resonance imaging (MRI) and ultrasound.

During the 3-hour procedure, the patient lies inside the MRI machine. He will be given a mild sedative to help him relax but remain conscious throughout the procedure. The radiologist uses MRI to precisely target the fibroid and directs an ultrasound beam to remove its tissue. MRI also helps monitor the temperature generated by the ultrasound.

FUS-MRI is only suitable for women on the verge of menopause, or who are not planning a pregnancy. It should also be taken into account that this procedure is not suitable for all types of fibroids. Thus, FUS-MRI is not recommended if the distance between the uterine fibroids and the skin exceeds 12 cm, if the beam’s access to the tumor is limited by scars or intestinal loops, the diameter of the fibroids should not exceed 10 cm, and the number of formations should not exceed 6 fibroids. Pregnancy is a complete contraindication.

Hysterectomy

Hysterectomy - is the surgical removal of the uterus. The ovaries may also be removed, although this is not necessary to treat fibroids. Hysterectomy is the only treatment that is 100% effective in getting rid of fibroids and is an option if other treatments have failed or are not possible.

After a hysterectomy, a woman permanently loses the ability to become pregnant, but if the ovaries are removed along with the uterus, the hysterectomy causes immediate menopause.

Types of hysterectomy:

• Abdominal hysterectomy
• Vaginal hysterectomy
• Laparoscopic hysterectomy
• Robotic hysterectomy

An abdominal hysterectomy is best for women with large fibroids, when the ovaries need to be removed, or when cancer is present.

A vaginal hysterectomy requires only a vaginal incision through which the uterus is removed

Robotic hysterectomy is performed using special equipment. This approach is most often used when the patient is diagnosed with cancer, is very overweight, and vaginal surgery is not safe.