A uterine fibroid is a benign growth of muscle tissue in or around the uterus. The muscle tissue in the uterus is classified as smooth muscle. It is different from muscles, such as those in the arms and legs, which are transverse striated muscles and whose contraction we can control. Approximately 35% of all women after the age of 35 have uterine fibroids of varying sizes and numbers.
The exact causes of uterine fibroids are unknown. There are several theories of their occurrence. Most likely it is a combination of several factors, such as hereditary predisposition, imbalance of hormones (estrogens, progesterone), chronic infection, number of births, etc.
How does uterine fibroid manifest itself, what are the symptoms?
Uterine fibroids are often asymptomatic, i.e. they do not bother you at all, but they can manifest themselves with the following symptoms:
heavy
heavy (more blood loss than normal) menstrual periods or irregular bleeding of varying intensity between menstrual periods or after menopause;
lower abdominal pain during or between periods;
problems with getting or carrying a pregnancy;
pressure on neighboring organs (bladder, rectum) and consequently painful reactions or dysfunction, such as chronic constipation or frequent urination.
Location and size of fibromatous nodes
Fibromatous
nodes may have the following locations:
Submucosalm (submucosal) nodules - located partially or completely within the uterine cavity.
Intramural (intermuscular) nodules - located within the muscular layer of the uterus.
Subserosal (subperitoneal) nodes - located on the surface of the uterus.
Nodes on the pedicle - also located on the surface of the uterus but separated from it by a weight, the so-called pedicle.
The number of nodes in the uterus may vary from one to twenty, and the localization of these nodes may also be different. Usually the growth of the node begins in the thickness of the uterine musculature, further, in the process of growth it may occupy the position indicated above. The size of the node can also vary from 1cm in diameter to 20-25cm.
The location of the node affects the manifestation of symptoms. For example, a 1cm diameter node located in the uterine lining will usually show no symptoms. While the same size node located in the uterine cavity, often shows heavy bleeding and sometimes pain.
The size of the node, also makes a difference. A node with a diameter of 1 cm, located on the anterior surface of the uterus, i.e. between the uterus and the bladder, is not likely to be bothersome. A node located in the same area but 5 cm in diameter will cause bladder pain and frequent urination, as well as pain during sexual intercourse.
Treatment of fibromatous nodes
If the fibromatous node or nodes are not bothering you, it is possible that after the necessary examination, your doctor will decide to only monitor you regularly. If you have two or more of these symptoms, your doctor will likely prescribe treatment. Treatment for fibromatous nodules is categorized into the following types:
Medication (medication is prescribed)
Radiological (uterine artery embolization)
Surgical (surgical removal of the nodule(s) or the
uterus)
Medical treatment
This treatment usually addresses symptoms such as bleeding or pain. Some medications increase blood clotting, thereby reducing blood loss, some relieve spasm and pain, but none of them cure fibromatous nodes. The effect of such treatment is temporary. There are a number of strong medications that are widely used to treat fibromatous nodules. These are the so-called gonadotropin-releasing hormone agonists, examples include Zoladex, Buserin, and Differilin. These drugs, indeed, can reduce the size of the nodes, but after the end of taking these drugs, the size of the nodes return to the original size. Most often they are used as a preoperative preparation to reduce the size of the node and thus reduce blood loss. These medications are not recommended to be used for more than 6 months because of their pronounced side effects. To date, there are no drugs that would completely cure fibromatous nodules or prevent the appearance of new nodules after their surgical removal.
Radiologic treatment
Uterine artery embolization is the process of inserting a thin plastic tube (catheter) into an artery that supplies blood to the uterus through a large vessel. From there, this catheter is brought directly to the vessel feeding the nodule. Tiny particles (polyvinylalcohol) or microspirals are injected through this tube, blocking the blood supply. This is how an embolus (equivalent to a blood clot) is formed. Unfortunately, this method also does not get rid of the nodules. With the help of uterine artery embolization, it is only possible to reduce the size of the node by 40-60%, while reducing or eliminating pain syndrome or bleeding. It should be remembered that in the first months after the procedure, there may be increased pain, fever, which is associated with impaired nutrition of the node. This period requires careful medical supervision. The question of the admissibility of pregnancy after uterine artery embolization remains controversial. On the one hand, a number of scientists do not recommend pregnancy, explaining it by impaired blood circulation and possible impairment of placenta and fetus development. On the other hand, there are many reports in the literature of successful pregnancy and delivery after embolization. This operation is especially important when the node is the cause of miscarriage and embolization may be the operation of choice to preserve the reproductive organ.
Surgical treatment
Surgical method is the only way to completely, i.e. radically, remove the nodes. However, it does not guarantee against the occurrence of new nodules. Below are three types of surgical treatment for fibromatous nodules.
Hysteroscopic removal of the node (the operation is performed through the cervical canal from the vaginal side).
Laparoscopic node removal (the operation is performed through punctures in the anterior abdominal wall).
Laparotomy method of nodule removal (through a traditional surgical incision on the anterior abdominal wall).
Among the above methods, the first two are the most preferable, but not always the nodes can be removed with their help. This depends on the size of the node, their localization, the age of the woman, the presence of adhesions, etc.
Hysteroscopic method
This method is used to remove submucosal nodes, i.e. nodes located in the uterine cavity. With the use of anesthesia and with the help of dilators, the cervical canal is opened to a size of about 1 cm. A special telescopic tube is inserted into the uterine cavity. For ease of examination and performance of the operation, the uterine cavity is illuminated and filled with fluid with the help of additional devices. At the end of the telescopic tube there are special instruments connected to an electric current to remove nodules and stop bleeding. The end of this instrument is a loop, which is used to gradually cut/shave off the knot (watch video). The cuts are as thin as a few millimeters. Nodes up to 3 cm are most successfully removed.
Sometimes larger nodes of 3-5 cm require a second operation, as they cannot always be removed in a single operation. Larger nodes cannot be removed because they occupy the entire uterine cavity, obstructing the movement of the telescope and instruments. In such cases, it is possible to use medication to reduce the size of the node (see above Medication treatment) for 2-3 months, followed by surgery. Another treatment option is also possible.
The success of the operation is influenced not only by the size of the node in the cavity, but also by its depth in the uterine muscle. There are three types of submucosal node. Node 0 (zero) type is located in the uterine cavity, only a small part of it is located on the muscular layer. Type I node is characterized by the fact that it is 50%...... located in the uterine cavity and 30%.... in the thickness of the uterine muscle. Type II node is mostly located in the thickness of myometrium and is difficult to remove due to the high risk of perforation (perforation) of the uterus. Node type II is usually removed in several stages.
The main symptom of submucosal (submucosal) nodules is bleeding. This is due to the following reasons:
Submucosal nodes prevent the uterus from contracting during menstruation.
The vessels located on the nodes are usually large and gape during menstruation, thereby causing massive bleeding.
Hysteroscopic removal of a submucosal node usually relieves a woman of both pain and heavy bleeding, as well as infertility if the node was the cause of these problems.
Laparoscopic removal of the nodule
If there is a nodule located inside the muscle layer or above its surface, it is advisable to remove such a nodule laparoscopically. Details of laparoscopic surgery are outlined in the Laparoscopic Surgery section. It also describes which gynecologic surgeries can be performed laparoscopically and how to prepare for them.
The diagram shows the places of incisions/punctures in the lower abdomen. As a rule, 3, sometimes 4, incisions are made. One of them near the navel is 1cm long and the others are 0.5cm lower in the groin areas. A telescopic tube, to which a camera is connected, is inserted through the opening in the area of the navel. Through the remaining incisions, the working instruments are inserted. The fibromatous node is removed and the uterine wall where it was located is either sutured or coagulated (cauterized). After this surgery, you will most likely wake up with three catheters in your body. The first catheter in the ulnar vein is for administering IV solutions. The second is a catheter in your bladder, to control the fluid output and relieve you from having to go up to the bathroom. The third catheter will be inserted into the abdomen to drain excess fluid from the abdomen and control bleeding. Don't be alarmed! This is all to speed up your recovery. Usually all of these "tubes" are removed the next day. As a rule, after such operations, patients stay in hospital for 2-3 days.
Laparotomy removal of a fibromatous nodule
Laparotomy is a traditional surgical incision of the anterior abdominal wall with a length of 10-20cm. This type of surgery is recommended if the size of the node is more than 7-8cm or if there are several nodes of medium or larger size. Of course, not everything is as simple as it seems at first glance. Your doctor will discuss with you all the subtleties of the upcoming operation and justify this or that type of surgery. For example, even large nodes, but on the stem is possible to remove laparoscopically.
Laparotomy provides good access to the uterus and nodes, and therefore more technical convenience to the surgeon. On the other hand, the recovery period is longer and requires more painkillers and other medications. But for the removal of large nodules, this method is the most effective and safe.
The incision is usually made horizontally in the bikini area, i.e. below the navel, 12-14 cm long. This incision heals faster in the postoperative period and cosmetologically more acceptable than vertical. However, if the size of the node is 20cm or more, it is possible that the surgeon will make a vertical incision from the pubis, 20cm long, bypassing the umbilicus.
Despite the fact that this incision is the least attractive to the patient, it is necessary to be sensitive to the choice of the surgeon, as the issues of safety and efficiency should be in the first place.
The postoperative period in laparotomy surgeries lasts longer, in the hospital patients are on average 5-6 nights, but stay on sick leave (ie, reduced ability to work) lasts 4-5 weeks.
It should be remembered that the removal of fibromatous nodes does not guarantee against the appearance of new ones. It depends on many factors. In some cases, the patient insists on removing the uterus for one reason or another. The section Hysterectomy (removal of the uterus) details the peculiarities of this operation.
What complications can occur during or after the operation of fibromatous node removal?
First of all, complications can occur during surgery and after surgery. Complications during surgery include bleeding, wounding of neighboring organs - bladder, intestines, large vessels and nerves, ureter. Unfortunately, this happens, but fortunately it is extremely rare. A competent surgeon recognizes these injuries in time and restores defects in a timely manner. The early postoperative period can be complicated by bladder atony, i.e. when the bladder cannot be emptied. Timely interventions will help to resolve this problem. Bowel paresis, i.e. when the muscles of the bowel loops are sluggish and do not contract. This causes excessive bloating of the intestines (flatulence) and sharp spastic pain in the lower abdomen. Your doctor will usually treat these problems by prescribing a series of medications and certain treatments.
More serious complications are infection of the surgical wound or inflammation in the abdominal cavity. However, these complications are rare due to the wide choice of sufficiently effective antibiotics.
A very formidable postoperative complication is venous thrombosis more often in the lower extremities and pulmonary embolism. In the postoperative period in the blood circulates a large number of substances that increase blood clotting. Due to this there is a very high risk of thrombosis. In order to prevent this from happening, the doctor prescribes special drugs. The dosage of these drugs depends on age, weight and associated diseases. To prevent thrombosis is also very important in the postoperative period to observe the movement regime and drink as much fluid as your doctor tells you.
In the late postoperative period may occur postoperative hernias, adhesions in the abdominal cavity, leading to severe chronic pain or infertility.
In general, the following factors influence the healing process:
1. The type and size of the fibromatous node.
2. Your age.
3. Other comorbidities.
4. Individual body characteristics - immune system and even personality traits and type.
In general, you should allow 3-5 days for recovery after hysteroscopic removal of the nodule, 2-4 weeks after laparoscopic removal, and 4-6 weeks after open surgery. Driving cars is recommended after 10 days at the earliest. Sexual intercourse is allowed either after the next doctor's visit or after 2-4 weeks, if not scheduled.
Important to remember:
After surgery to remove a fibromatous node, the next menstruation may come earlier or later and most likely the bloody discharge will be profuse. Already with the second or third menstruation everything should normalize.
During 2-3 weeks of the postoperative period there may be periodic minor pain in the lower abdomen. It is recommended to take painkillers, under the supervision of your doctor.
The first menstruation can be very painful. The pain may be even worse than before the operation. It is necessary to take pain medication. From the next menstruation onwards, the pain is usually not bothersome.
If you are planning a pregnancy, discuss the duration and type of contraception with your doctor. The period of contraception can vary from four months to one year. It depends on how deep and extensive the node is, whether there was penetration into the uterine cavity during removal, etc. Remember, getting pregnant before the uterine scar has healed increases the risk of uterine scar rupture not only during labor but also during pregnancy.
Fibromatous nodule and infertility.
A nodule in the uterus may be the cause of infertility for the following reasons:
Its action is similar to that of an intrauterine device.
Alters and disrupts the blood flow in the uterine vessels.
Squeezes the uterine cavity, occupying all the available space in the cavity.
Changes the structure and function of the uterine cavity mucosa (endometrium), thereby making the process of introduction (implantation) of a fertilized egg incomplete.
If you have a submucosal nodule and you suffer from infertility, then without a doubt the nodule should be removed by one of the above mentioned types of surgery.