Uterine fibroids (leiomyoma, leiomyomatosis) is a gynecological disease, the characteristics of which are expressed in the appearance and further development of tumor-like nodes in the fibroids (muscle tissue) of the uterus. It is a common disease among women: up to 20% of cases of this disease are detected in reproductive age, and up to 35% of cases in premenopausal age. Thanks to the improvement in the quality of diagnostics, more women are now able to diagnose fibroids in the early stages, corresponding to approximately 7-8 weeks of pregnancy, however, despite this, the most common treatment option remains removal of the uterus.

Nodes of a benign tumor in the uterus can be either single or multiple; various sizes. In most cases, the course and development of the disease occurs without obvious clinical manifestations and fibroids are discovered by chance during a regular examination by a gynecologist.

In this article we will also examine in detail why uterine fibroids are dangerous and how to treat them.

Etiology and pathogenesis of the disease

Scientists cannot come to a clear opinion on the causes of uterine fibroids, since they are differential in nature. Meanwhile, one of the main factors contributing to the development of fibroids is considered to be a hormonal imbalance in the functioning of the ovaries and disturbances in the synthesis of estrogen. This theory is supported by the fact that when using hormonal contraceptives with estrogen, the tumor rapidly increases in size. It should be noted that the disease occurs in patients with normal hormonal levels.

Additional risk factors are also noted: surgical termination or difficult pregnancy, endometriosis, adenomyosis, cysts and polyps in the ovaries, excess weight, malfunctions of the body’s endocrine or immune system.

Some scientists believe that there are certain areas of the uterus that are at increased risk for tumor development: the sides of the cervix, areas along the miduterine line, and the origin of the fallopian tubes. Under external influence of unfavorable factors, a lack of oxygen is observed in these areas, which leads to the growth of muscle tissue and the appearance of fibroids.

Hormone addiction

Modern medicine cannot unambiguously answer the question of what uterine fibroids are and what are the causes of their occurrence. The prerequisites for its appearance arise during embryonic development during the formation of smooth muscle tissue. At this time, all processes in the body are very much dependent on the influence of external factors, such as environmental influences or the influence of maternal factors (this includes heredity). As a result, mutated cells may appear in the myometrium, which continue their development after the girl’s first menstruation.

The active development of the disease is due to hormonal processes in the body, which is why the pathology is almost never diagnosed in girls before the first menstruation and in women after menopause (in the latter case, the production of hormones naturally decreases and if the disease was diagnosed earlier, it tends to regress in such conditions ). That is, only with an excess of estrogen does the fibroid begin to grow. However, diagnosing an imbalance of hormonal regulation is quite difficult - for this you need to do a complete hormonal analysis of the patient.

Symptoms

The etiopathogenesis of the disease is quite complex, therefore, if the neoplasm in the uterus is small millimeter in size, then it is almost impossible to detect obvious clinical symptoms of the development of the disease. Typically, diffuse signs of the disease can be detected during a routine medical examination or during diagnostic studies indicated in connection with the presence of other gynecological diseases. Initially, the patient does not worry about anything; complaints can appear only when the nodular fragments in the uterus are large. Most often, the patient's abdominal circumference increases (while body weight does not change), and nagging pain appears, unrelated to menstruation. When the tumor is large, nearby internal organs are compressed.

This results in frequent urination or prolonged constipation. The regularity of the menstrual cycle is disrupted, hemorrhagic syndrome is observed and the possibility of metrorrhagia is high.

Even if the above symptoms are present, it is impossible to say with an absolute guarantee that the patient has uterine fibroids. This clinical picture is typical for endometriosis, uterine cancer and other gynecological diseases.

Diagnosis of the disease

At the initial stage of the disease, with a small size of the myomatous node, which corresponds to 6–7 weeks of pregnancy, most often the disease is very difficult to diagnose. Its growth leads to an increase in the size of the uterus, which is comparable to the process of its enlargement during pregnancy. Nevertheless, the primary and most effective way to diagnose the disease is a regular gynecological examination with ultrasound.

In some cases, hysterography is used - a certain substance is introduced into the uterine cavity, which comes into contact with neoplasms and allows them to be seen on an x-ray.

Varieties

The disease manifests itself in the form of single or numerous nodes based on muscle fibers. There are several types of fibroids, dividing them according to the direction of growth of the nodules:

• Interstitial or intramural is the most common type of disease; forms and grows in the thickness of the muscle wall.
• Submucosal or submucosal (according to ICD - D25.0) - grows from the muscle towards the endometrium, into the uterine cavity. Often causes spontaneous abortions.
• Subserous (ICD code - D25.2) - the node has a wide base and a long stalk, grows under the outer membrane of the uterus towards the abdominal cavity. Most often it is not the cause of menstrual irregularities.
• Intraligamentous - appears between the muscle ligaments in the uterus.

Quite often you can see a diagnosis according to ICD D25.9 - which indicates the impossibility of classifying the disease during the initial examination.

In addition, there are three stages during this gynecological disease:

1. Stage of accelerated growth: the tumor marks its boundaries in those areas of the soft tissue of the uterus that are actively saturated with many small vessels and have a high metabolic rate.
2. The tumor can be distinguished in the form of a nodule, but only with a large visual magnification of the picture (microscopically); at the moment it has a fibrous structure and is practically no different from other fabrics.
3. The tumor can be distinguished with the naked eye; it is formed into a node with defined boundaries. In it, large cells adhere tightly to each other.

Classification of myomatous neoplasms

In most cases, fibroids are located in the uterus, less often in the cervix. Often we have to deal with multiple neoplasms. Single ones are less common.

In the direction of node growth

First of all, they are divided into neoplasms with typical (1) and atypical (2) localization.

The first type of neoplasm is usually classified as subserous myoma - a tumor with a longitudinal base or pedunculated. It is located on the surface of the uterine body and grows towards the peritoneum. The nodes can be attached to the intestines, omentum and other organs and systems located in close proximity. They form a secondary blood supply.

Submucosal fibroids also belong to the first type of neoplasm; grows under the mucous membrane towards the uterine cavity. May have a longitudinal stable base or leg.

Interstitial fibroids also have a typical localization. Its nodes are located in the muscular walls of the uterus.

The second type of neoplasm is usually classified as interligamentous (subserous) fibroid.

By location relative to the uterine axis

In turn, all neoplasms of types 1 and 2 (classified according to the direction of growth) can be divided into:

• Corporal - located in the body of the uterus, the most common type.
• Isthmic or isthmic - causes pain in the immediate vicinity of the bladder.
• Cervical or cervical - all nodes grow in the vagina and carry with them a large infectious load and complications.

World Health Organization classification

1. Angiomyoma is a myomatous node saturated with blood vessels.
2. Rhabdomyoma is a benign neoplasm that consists of striated muscle tissue.
3. Fibromyoma – has the ability to change its structure over time. With age, its tissue becomes coarser and grows in quantity.
4. Leiomyoma; in turn, is divided into:

• Conventional – a mature neoplasm, which depends on the level of hormones in the body. It has a dense consistency and clear boundaries. Does not destroy the walls of blood vessels and grows towards the soft tissues.
• Cellular - has a soft consistency and clear boundaries, located inside the wall of the uterus. The growth of such a neoplasm increases during pregnancy.
• Bizarre - consists not only of round muscle cells, but also huge cells of an uneven wavy shape. There are practically no mitoses in such a tumor and their growth is not observed in it.
• Epithelial (epithelial) - based on the walls of blood vessels and muscle tissue. It is quite rare.
• Metastasizing is an extremely rare type of tumor. Capable of metastasizing into the cracks of blood vessels. If its cells come off, then along with the blood flow they can enter other hollow organs, causing new myomatous nodes.
• Proliferating or growing - in the thickness of the tumor or in its vicinity it has zones of proliferation, from which it slowly merges with nearby tissues.
• Malingizing - has atypical cells and their nuclei.

Complications of the disease

First of all the disease is fraught with tissue necrosis and further myomalacia. As its size increases, the tumor is able to compress the blood vessels that feed it - lack of nutrition for the tumor contributes to its death. This process is accompanied by an increase in body temperature, an increase in the level of leukocytes in the blood, swelling and disruption of the functioning of internal organs. If during the course of the disease the leg of the myomatous node becomes twisted, the patient may feel acute spasmodic pain.

Treatment of uterine fibroids should be timely. If you do not start it immediately, then there is a high probability of disruption of the reproductive organs. If the inflammatory process nevertheless spreads to other internal organs, then the need arises to remove the uterus. Despite advanced diagnostic methods in obstetrics and gynecology, which allow early diagnosis of the disease, hysterectomy is one of the most common treatment methods.

There is a high probability that fibroids will develop from a benign neoplasm into a serious oncological disease due to a severe decrease in immunity. The process of this transformation usually takes quite a long time - it is “frozen” exactly as long as the woman’s immunity is actively working.

It should be noted: in order to avoid many consequences, women with uterine fibroids are strictly not recommended to sunbathe.

Some types of myomatous formations contribute to an increase in the amount of discharge during menstruation, which in turn causes anemia. In addition, there is a high risk of infertility, and pregnant women risk losing the fetus.

Treatment methods

As mentioned earlier, greater success in treating the disease can only be counted on when it is started in a timely manner. The choice of which method to use - conservative or surgical - depends on many factors, such as the size of the tumor, the severity of the symptoms of the disease, and the age of the patient. First of all, patients with this diagnosis are under regular supervision by a gynecologist.

If the disease proceeds without pronounced clinical symptoms, then there is a high probability of prescribing conservative treatment, which is based on regular use of hormonal medications. During menopause, fibroids resolve on their own and regression of the disease is observed, so a conservative treatment method (since it does not eliminate the tumor, but only restrains its growth) is more often used for older women. For women of young reproductive age who plan to give birth in the future, doctors try to choose conservative surgical treatment. It preserves the reproductive function of the internal organs.

Surgical

Most often, when treating uterine fibroids, specialists resort to surgical treatment methods. They can be divided into conservative (if the tumors are directly removed) and radical (removal of the uterus completely or with preservation of the appendages and cervix). When the tumor size is 7–8 centimeters, it is preferable to use laparoscopic removal methods.

The extent of surgical intervention used depends on the patient’s age, desire to become pregnant and the presence of concomitant diseases. Surgery is necessary if:

• tumor size is more than 10 centimeters;
• the tumor grows at an accelerated pace;
• the duration and intensity of menstruation is critically increased;
• the tumor is located in the cervix;
• tissue necrosis is observed;
• acute threat to reproductive function.

The most commonly used methods of surgical treatment are hysterectomy and laparotomy, as they enable rapid rehabilitation of the body in the postoperative period, preserve reproductive function and have minimal visible traces of surgery.

A fairly effective method of treating uterine fibroids is uterine artery embolization. The essence of this method is that, using a probe in the uterus, you need to find bundles of blood vessels that feed the myomatous node. Next, introduce a micropreparation into them, which helps to clog them. Since the power supply to the node stops, its growth slows down and over time it decreases in size.

Conservative

They are most often used for older patients (close to menopause), if the tumor is slow in growth and has a relatively small size. The general condition of the patient is without pronounced clinical symptoms.

Drug treatment is selected depending on the cause of the disease and the symptoms shown. Most often these are hormonal drugs that are necessary to restore the regulation of hormonal levels and normalize menstruation. If inflammatory processes occur, then antibiotics may be prescribed. Iron supplements and complex vitamins can be prescribed against anemia. Their combination restores the regeneration of damaged cells and helps boost immunity.

Hormonal medications are prescribed only after a complete hormone analysis. It is unacceptable to violate the dosage regimen, interrupt a course of medication, change the dosage of medications on your own, or skip taking pills.

The basic principles of conservative treatment are as follows:

• primary cleansing of the body from possible sexually transmitted infections and harmful bacteria;
• activation of the immune system;
• adjustment of the established diet;
• normalization of metabolic processes in the body and the emotional state of the patient;
• treatment of anemia and normalization of the frequency, duration and intensity of menstruation.

Quite often, combined oral contraceptives (Novinet, Mercilon, Ovidon and others) are used in the conservative drug treatment of uterine fibroids. These drugs reduce the symptoms of the disease, minimize bleeding and pain. However, they cannot help combat the reduction in the size of the myomatous node.

FUS ablation

This treatment method is partly innovative. In it, the ultrasound beam concentrates on the nodes of myomatosis, actually “evaporating” them. It is used together with MRI diagnostics, which helps to see the overall picture more accurately and observe all the changes that occur in real time.

The procedure takes place in an outpatient clinic and has a short recovery period for the body; There are no side effects and reproductive function is preserved.

A little about traditional methods

For an inexplicable reason, many women, after being diagnosed, try to find some folk remedy to treat their disease. If we talk about fibroids, this is most often douching or cotton swabs soaked in decoctions of medicinal herbs.

Unfortunately, the use of these means may not only not change the situation, but also make it even more deplorable. It is important to remember that before trying any treatment method, you need to consult with your doctor.

Prevention of disease occurrence

If the disease was detected in time and adequate treatment of the first signs of the disease was immediately started, then we can talk about favorable prognoses for the patient, up to the possibility of conceiving a child (if organ-preserving treatment was chosen), although it will not be possible to completely get rid of fibroids. The rapid growth of a tumor can lead to removal of the uterus even for young nulliparous women - the main factor when choosing this treatment method can only be the desire to save the patient’s life.

A guarantee of the absence of relapses is only adequate hormonal therapy and regular monitoring by a gynecologist.

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A detailed comparative analysis of the results of examination of women with uterine fibroids complicated by hemorrhagic syndrome during hormonal therapy (main group - n=43) and patients in whom complications were not observed during conservative treatment of uterine fibroids with hormonal drugs (comparison group - n=33) is presented. . The control group was represented by practically healthy women (n=27). The state of the immune system was assessed by the content of cytokines IL-1β, IL-2, IL-4, IL-6, γ-INF, TNF-α and the apoptosis marker Fas-L in serum blood of women, using the solid-phase immunoassay method. Additionally, an examination was carried out to detect IgG and IgM antibodies to pathogens of urogenital infections (chlamydia, ureaplasmosis, trichomoniasis, cytomegalovirus and herpetic infections) using the enzyme-linked immunosorbent assay (ELISA). It was established that the occurrence of hemorrhagic syndrome during hormonal therapy for uterine fibroids is associated with chronic urogenital infections that contribute to disorders of the immune status, reduction of the function of Th1 and Th2 lymphocytes, significant inhibition of apoptosis, which dictates the need for a more detailed examination of women with this pathology in order to improve methods of conservative treatment of uterine fibroids and reduce the incidence of complications and insufficient effectiveness of hormonal therapy.

complications of hormone therapy.

urogenital infection

cytokines

uterine fibroids

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5. Mukasheva S.A., Manambaeva Z.A., Kenbaeva D.K. Clinical and immunological parallels in uterine fibroids // Bulletin of the Kyrgyz-Russian Slavic University. – 2013. – T. 13, No. 6. – P. 169-171.

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7. Radzinsky V.E., Arkhipova M.P. Uterine fibroids: problems and prospects of the beginning of the century // Medical Council. – 2014. – No. 9. – P. 30-33.

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Protecting the reproductive health of the female population remains one of the priorities of modern healthcare. The most common tumors of the female reproductive system include uterine fibroids (MM), the frequency of which varies from 20 to 40% and ranks second in the structure of gynecological diseases. The problem is becoming increasingly socially significant given the trend towards late pregnancy planning and the rejuvenation of the population of patients with MM . As is known, many scientists consider changes in the endocrine system to be the basis of tumor pathogenesis. At the same time, the question remains debatable: whether MM is a truly hormonally dependent disease or has an inflammatory genesis. Research in recent years has proven the important importance of dysbiotic disorders, sexually transmitted infections and dysfunction of the immune system in the pathogenesis of MM.

Among the numerous treatment options for MM in women of fertile age, preference is given to organ-saving methods, including conservative myomectomy using hysteroscopy, laparoscopy and laparotomy, embolization of the uterine arteries, remote tumor destruction with MR-controlled focused ultrasound (FUS ablation of myomatous nodes). But even the use of minimally invasive organ-saving surgical techniques do not guarantee 100% effectiveness of treatment. Literary sources state that the probability of disease recurrence after conservative myomectomy within 5 years is 45-55%. And the share of hysterectomies performed for MM in the structure of surgical interventions reaches 60.9-95.3%. In this regard, priority in the treatment of MM remains with hormonal therapy, used both as neo- and adjuvant, and as an independent treatment option. However, despite the huge selection of hormonal drugs, often, against the background of their use, patients with MM experience side effects and complications (menstrual irregularities, metrorrhagia, an increase in the size of myomatous nodes), which dictates the need for further study of the pathogenetic features of the course of the disease to optimize existing methods of conservative therapy.

Purpose of the study: to study the characteristics of the immune system and the causes of its dysfunction in patients with uterine fibroids complicated by hemorrhagic syndrome.

Material and methods of research: under our supervision there were 76 women with MM, the size of which did not exceed a 12-week pregnancy, with predominantly intramural and subserous localization of nodes, and with indications for conservative treatment. The main group consisted of 43 patients with MM and clinical hemorrhagic syndrome on the background of hormone therapy. In the comparison group (n=33), no complications were observed during conservative treatment of MM with hormonal drugs. The control group was represented by practically healthy women (n=27). All patients underwent a standard clinical and laboratory examination and ultrasound scanning with an abdominal and vaginal sensor on a HITACHI-5500 device using broadband, ultra-high-density convex sensors 3.5-5.0 MHz and cavity sensors 5.0-7.5 MHz. The state of the immune system was assessed by the content of cytokines in the blood serum of women. The study was carried out using solid-phase immunoassay. To determine interleukins (IL-1β, IL-4, IL-6), interferon (γ-INF) and tumor necrosis factor (TNF-α), we used Vector-BEST reagent kits, Novosibirsk. To determine interleukin IL-2, a set of reagents from Biosource, USA was used. To determine the Fas ligand (Fas-L), a set of reagents from Medsystems, Austria, was used. Additionally, an examination was carried out to detect IgG and IgM antibodies to pathogens of urogenital infections (chlamydia, ureaplasmosis, trichomoniasis, cytomegalovirus and herpetic infections) using enzyme-linked immunosorbent assay (ELISA).

Statistical processing of the research results was carried out using the Statgraphics (Statistical Graphics System) application package developed by STSC Inc.

Research results and discussion. The age of the subjects varied from 21 to 42 years and on average was 30.5±4.3 years in the main group, 31.2±5.4 years in the comparison group, 30.2±5.5 years in the control group , which did not have significant intergroup differences. General characteristics of the groups are presented in Table 1. A detailed study of the anamnesis showed a high frequency of genital pathology in patients with MM (Table 1). The proportion of chronic inflammatory diseases of the genital organs in the main group and in the comparison group exceeded that of the control group by 8 times, menstrual disorders such as hypermenorrhea, polymenorrhea, menorrhagia and metrorrhagia - by 20 times, benign diseases of the cervix - by 18 times. The use of intrauterine devices (IUDs) for contraception was monitored only in groups of women with MM. In addition, it should be noted that only every second patient with MM was able to realize reproductive function, while in the control group women who gave birth prevailed, and the frequency of spontaneous abortions was significantly higher in patients of the main group and the comparison group (Table 1).

Table 1

General characteristics of the groups of examined women

Indicator under study	Main group		Comparison group		Control group
Obstetric and gynecological history
Spontaneous abortion
Disorders of the ovarian-menstrual cycle
Chronic inflammatory diseases of the genitals
Ectopic cervix
Using an IUD
Extragenital diseases
Obesity
Diseases of the cardiovascular system
Diseases of the gastrointestinal tract

The most prevalent extragenital pathologies in MM were obesity, diseases of the cardiovascular system and gastrointestinal tract (Table 1). The data obtained are consistent with the opinion of most researchers about the importance of risk factors in the occurrence of MM. At the same time, the incidence of somatic and genital pathologies in the main group and the comparison group was comparable. A distinctive feature of the group of women with MM complicated by hemorrhagic syndrome was the presence of anemia of varying severity (97.7%).

For the purpose of hormonal therapy for MM, patients in both groups received Buserelin-depot (3.75 mg every 4 weeks), the duration of drug use varied from 1 to 6 months. In the main group, complications in the form of persistent hemorrhagic syndrome (from minor to heavy uterine bleeding) after the start of hormone therapy were noted by 26 women (60.5%) during the first month, 17 (39.5%) - from 2 to 3 months.

The results of the ultrasound examination showed that the size of the uterus in the groups of women examined ranged from 6-7 to 12 weeks of pregnancy. According to ultrasound data, the average volume of the uterus in the main group was 394.2±178.6 cm³, in the comparison group - 396.7±172.3 cm³ (P>0.05). The most common localization of nodes was subserosal-interstitial and interstitial, less often - subserous (Fig. 1). The number of myomatous nodes varied from 3 to 6, and the sizes of MM nodes ranged from 2.5 to 5 cm.

Rice. 1. Localization of myomatous nodes in groups of examined women

The additional use of Dopplerography in the work made it possible to determine the nature of vascularization of myomatous nodes. In patients with MM complicated by hemorrhagic syndrome during hormone therapy, the hypervascular type of tumor predominated, which confirms a previous study by I.E. Rogozhina et al. The authors found that the main diagnostic criteria for a comprehensive ultrasound examination of MM complicated by uterine bleeding are the hypervascular type of myomatous nodes, as well as an increase in the maximum blood flow velocity and the peripheral resistance index in the uterine arteries. In the main group, characteristic signs of Doppler sonography were recorded in our work in 90.7% of observations (n=39), and in the comparison group - in 30.3% (n=10).

A) b)

Rice. 2: a) hypervascular and b) hypovascular type of blood supply to uterine fibroids

The results of the study of the immune system showed a significant decrease in all studied cytokines in patients with MM, with a more pronounced decrease in indicators found in the group of patients with clinical hemorrhagic syndrome (Table 2). The concentrations of IL-1β, IL-2, IL-4, IL-6 and γ-INF in patients in the comparison group decreased by 1.3 times compared to control data, and the content of TNF-α decreased by 1.5 times (P<0,05). В основной группе уровнипро- и противовоспалительных цитокинов снижались в 1,4-2 раза.

Table 2

Results of a study of the immune system in groups of examined women

Study parameter (pg/ml)	Main group	Comparison group	Control group

* P - significance of differences with the control group (P<0,05);

#P - reliability of differences with the comparison group (P<0,05).

The ratio of γ-INF/IL-4 in patients with MM decreased slightly in comparison with the control group (from 3.6 to 3.5), and in the combination of MM with hemorrhagic syndrome to 3.3, which indicates a reduction of predominantly Th-1 lymphocytes compared to Th-2 cells and suppression of the cellular immune response to a greater extent in MM. A number of researchers also associate the progression of the tumor process with immunosuppression and the inability of cells to undergo apoptosis. When studying the apoptosis marker in the Fas-L cell population (Table 2) in groups of examined women, we noted a decrease in its level from 0.30±0.05 pg/ml in the control group to 0.21±0.02 pg/ml - in the comparison group, with a progressive decrease in its content (2 times) in the blood serum of patients with MM in combination with hemorrhagic syndrome. Decrease in Fas-L concentration in MM (P<0,05) относительно показателей контрольной группы свидетельствует о снижении цитотоксического киллинга, осуществляемого Т- и NК-клетками, что способствует медленному прогрессированию заболевания и согласуется с мнением И.С.Сидоровой .Выявленные прогрессирующие нарушения синтеза цитокинов и угнетение апоптоза при ММ, осложненной геморрагическим синдромом на фоне гормонотерапии, послужили основанием для поиска причин возникновения дисфункции иммунной системы у данного контингента больных.

Considering the high incidence of chronic inflammatory diseases of the genitals in patients with MM, we included in the examination plan for women an enzyme-linked immunosorbent test (ELISA) to detect IgG and IgM antibodies to pathogens of urogenital infections.

The ELISA results showed that in the comparison group, chlamydia was diagnosed in 14 patients (42.4%), ureaplasmosis - in 19 (57.6%), herpes viral infection - in 15 (45.5%). Moreover, using ELISA in women with good tolerance to hormone therapy, only IgG to causative agents of urogenital infections was detected. In the main group, IgG and IgM antibodies to chlamydial infection were found in 34 examined women (79.1%); ureaplasma - in 35 (81.4%), and chronic trichomoniasis, herpetic and cytomegalovirus infections were diagnosed in all cases (Fig. 3).

Rice. 3. Results of examination of women using ELISA

to pathogens of urogenital infections

It should also be noted that the detection of IgM to pathogens of urogenital infections in patients of the main group indicated the activation of a chronic inflammatory process of the genitals, the manifestation of which, in our opinion, was hemorrhagic syndrome in the form of uterine bleeding of varying severity. In addition, it can be assumed that the prescription of hormonal drugs for the conservative treatment of MM against the background of chronic endometritis of a specific etiology has a potentiating immunosuppressive effect on the woman’s body, increasing the frequency of side effects and complications.

Conclusion. The results of a study of the cytokine profile in patients with MM complicated by uterine bleeding during hormone therapy indicate pronounced disturbances in the immune status, reduction in the function of Th1 and Th2 lymphocytes and, as a consequence, a significant inhibition of apoptosis in this pathology, which may contribute to further tumor growth and progression diseases. The occurrence of hemorrhagic syndrome during hormone therapy for MM is more typical for the hypervascular type of tumor (90.7%). The significant importance of the infectious factor and sexually transmitted infections in the pathogenesis of complications of conservative treatment of MM has been revealed. It has been established that hemorrhagic syndrome against the background of hormone therapy for MM is associated with exacerbation of chronic urogenital infections, which dictates the need for a more detailed examination of women with this pathology in order to improve methods of conservative treatment MM, reducing the incidence of complications and increasing efficiency.

Reviewers:

Salov I.A., Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology, Faculty of Medicine, Saratov State Medical University named after. V.I. Razumovsky" of the Ministry of Health of Russia, Saratov;

Vasilenko L.V., Doctor of Medical Sciences, Professor of the Department of Obstetrics and Gynecology, Faculty of Education and Training, State Budgetary Educational Institution of Higher Professional Education "Saratov State Medical University named after. V.I. Razumovsky" of the Ministry of Health of Russia, Saratov.

Bibliographic link

Khvorostukhina N.F., Stolyarova U.V., Novichkov D.A., Ostrovskaya A.E. CAUSES OF IMMUNE SYSTEM DYSFUNCTION IN PATIENTS WITH UTERINE FIBROID COMPLICATED BY HEMORRHAGIC SYNDROME // Modern problems of science and education. – 2015. – No. 4.;
URL: http://site/ru/article/view?id=20803 (access date: 02/01/2020).

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One of the most common gynecological diseases is uterine fibroids. Statistical studies show that this tumor occurs at least once in every fourth woman in Russia. What are uterine fibroids? This is a pathological change in the muscle epithelium, as a result of which a node is formed in the smooth muscles of the uterus. The sizes of tumors vary significantly in size, they can reach from several millimeters to 10 cm. The record in the entire history of studying the disease belongs to fibroids, which weighed 63 kg. Why does uterine myomatosis occur? What preventative measures can you take to protect yourself from fibroids?

Causes and prevention

The pathogenesis of uterine fibroids is still poorly understood, despite the widespread occurrence of this disease. Scientists have discovered the following prerequisites that can trigger the development of fibroids:

• multiple surgical abortions that disrupt the integrity of the muscular epithelium of the uterus, resulting in the formation of nodes;
• hormonal disorders - in 70% of cases, fibroids are found in women older than middle age after menopause;
• circulatory disorders in the pelvic organs caused by a sedentary lifestyle;
• increased body mass index, obesity;
• endocrine diseases;
• diabetes mellitus;
• menstrual irregularities, pain and late onset of menstruation;
• miscarriage before the due date.

There is a direct connection between the formation of fibroids and a woman’s hormonal levels. Gynecology is sensitive to all disturbances in the functioning of the endocrine system.

In the case of a lack of estrogen, the likelihood of fibroids increases, in the case of an excess of progesterone, it decreases. Balanced production of estrogen and progesterone does not guarantee the absence of fibroids, but reduces the possibility of its occurrence. Often fibroids are found in women with hemorrhagic syndrome, a blood clotting disorder, so women with this disease should be especially attentive to their well-being. Very small fibroids cause virtually no symptoms, so ultrasound should be used for detection. For preventive purposes, during a routine examination by a gynecologist, women over 45 years of age should insist on an ultrasound, especially if they are concerned about changes in the nature of menstruation. Based on what signs can you suspect fibroids?

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Symptoms of uterine myomatosis

Types of uterine fibroids according to the number of tumors are divided into:

• single;
• multiple.

Preventive examinations by a gynecologist are recommended for all women over 35 years old - this is the only way to detect fibroids at an early stage of tumor formation. As the size of the node increases, the signs will vary depending on the specific type of tumor.

Proliferating uterine fibroids are a type of nodes that, due to their cellular composition, grow faster than others, that is, their development is carried out due to the very rapid division of tumor cells. Classification of uterine fibroids by location:

1. Submucosal. The tumor is located close to the surface of the muscle tissue, has a thin stalk, and can spread from the uterine cavity to the cervix, and then to the vagina. The growth of nodes can only occur inside the uterus, without leaving its cavity. Due to the tumor, the menstrual cycle lengthens and is accompanied by an increased volume of discharge. Often before the onset of menstruation, women feel severe pain in the lower abdomen, reminiscent of contractions in nature.
2. Interstitial. The tumor lies deep in the layers of muscle tissue. The negative impact of this type of fibroid leads to a lengthening of the menstrual cycle and makes periods more abundant. Damage to the uterus prevents normal contractions during menstruation, resulting in pain, cramping and discomfort.
3. Subserous. The tumor is attached to the outside of the muscular corset of the uterus on the side of the abdominal cavity. In most cases, the node is attached to a long stalk, which can twist, causing the death of the tumor body. This creates a risk of necrosis directly in the abdominal cavity. Without timely diagnosis and treatment, myoma necrosis develops peritonitis, which poses a threat to the woman’s life.
4. Intraligamentary fibroid. Usually these are multiple small nodes in the tissues of the broad ligament of the uterus.
5. Cervical fibroids. All nodes are located only in the neck, including the main node.

In terms of prevalence, 60% of all diagnosed fibroids are found in the deep layers of the muscular corset. There is also a mixed type of fibroid, in which multiple nodes have different locations. The etiology and pathogenesis of uterine fibroids allow us to conclude that only timely medical intervention can stop the growth of tumors and protect a woman from complications such as peritonitis. Treatment with traditional methods is a waste of time that could be used for real help. What are the most common complaints with uterine fibroids?

• painful and prolonged PMS;
• pain at the beginning and during menstruation;
• pain even in the absence of menstruation;
• nature of the pain: pulling, aching, spasmodic, sharp, stabbing, pulsating;
• during twisting of the legs, the pain becomes very intense and sharp;
• the presence of a tumor increases the duration of the cycle;
• the volume of discharge increases;
• large nodes put pressure on the urethra, which makes it difficult to completely empty the bladder;
• nodes can put pressure on the wall of the rectum, which leads to a narrowing of the lumen and makes defecation difficult;
• the presence of multiple nodes makes it difficult for the egg to attach, for this reason infertility develops;
• hemorrhagic syndrome in combination with increased volume of menstrual bleeding leads to anemia.

In nulliparous women, due to the less elasticity of the walls of the uterus, there are often complaints of a feeling of pressure in the lower abdomen or discomfort from the presence of some object.

Any change in the nature of menstruation compared to usual should be a reason to consult a gynecologist.

If you suspect fibroids, you should consult a qualified doctor and not use traditional medicine. Tumor regression, if possible, occurs when hormonal levels change. Correction is carried out only under the supervision of a competent specialist.

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Complications of myomatosis

The most life-threatening complication is necrosis of the tumor body, which can develop due to compression or twisting of the stalk or due to a decrease in the volume of blood supplying the tumor. Vasoconstriction causes oxygen starvation, and then tissue death. As a result, the tumor begins to decompose directly next to the living tissues of the body.

Decomposition products enter the blood, cause symptoms of intoxication and provoke an inflammatory process. If the tumor is located outside the uterus, peritonitis develops, which requires urgent hospitalization in the intensive care unit. If the tumor is located in the cervix or in the uterine cavity, necrosis is accompanied by heavy bleeding and severe pain, in which case the woman is hospitalized in the gynecological department. Necrosis can trigger the development of sepsis. In what cases should you immediately contact an ambulance?

• if there is acute pain in the lower abdomen;
• if massive bleeding occurs;
• if the temperature rises above 39 degrees, it is accompanied by nausea, headache, weakness and pain in the lower abdomen;
• if a woman who has complained of abdominal pain suddenly loses consciousness and cannot be revived.

Most deaths are caused by women not seeking help from a doctor at the first sign of fibroids. Large tumors create serious discomfort when urinating and defecating. Urine stagnation occurs because the bladder does not empty completely. Against the background of compression of the rectum, constipation regularly appears, feces accumulate in the intestines, which leads to secondary absorption and intoxication. Large tumors should be eliminated as soon as possible to ensure normal excretion of urine and feces from the body. Another common complication that contributes to the diagnosis of fibroids is the inability to become pregnant. In order for an egg to attach to the wall of the uterus, a place that is smooth and rich in blood vessels is required, which could provide the fetus with all the necessary nutrients.

If the walls of the mucous membrane are affected by nodes, the egg does not find a suitable site for attachment and leaves the uterine cavity along with the planned menstruation. If a woman fails to become pregnant after a year of regular sexual activity without contraception, she should consult a gynecologist and find out the cause of infertility. According to statistics, most small uterine fibroids are discovered precisely when patients complain of lack of pregnancy.

By location and direction of growth:

Subserous - growth of a myomatous node under the serous membrane of the uterus towards the abdominal cavity (including intraligamentous, intraligamentary location); such nodes may have a wide base or a thin stalk connecting them to the myometrium.

Submucosal (submucosal) - the growth of a myomatous node under the mucous membrane of the uterus towards the uterine cavity, deforming it (birth, birth).

Intramural (interstitial) - growth of a node in the thickness of the muscular layer of the uterus (in the body of the uterus, in the cervix).

According to clinical manifestations:

Asymptomatic uterine fibroids (70-80% of cases).

Symptomatic uterine fibroids (20-30% of cases) - clinical manifestations of symptomatic uterine fibroids (menstrual cycle disorders such as menometrorrhagia, hyperpolymenorrhea, dysmenorrhea; pain syndrome of varying severity and nature (pulling, cramping); signs of compression and/or dysfunction of the pelvic organs ; infertility; recurrent miscarriage; secondary anemia).

Indications for surgical treatment of fibroids:

1. Symptomatic fibroids (with hemorrhagic and pain syndrome, the presence of anemia, a symptom of compression of adjacent organs).

2. The size of fibroids exceeds the size of a pregnant uterus for 12 weeks.

3. Presence of a submucosal node.

4. The presence of a subserous fibroid node on a stalk (due to the possibility of torsion of the node).

5. Rapid tumor growth (4-5 weeks a year or more).

6. Growth of nodes in postmenopause.

7. Myoma in combination with endometrial or ovarian pathology.

8. Infertility due to uterine fibroids or recurrent miscarriage.

9. Presence of concomitant pathology of the pelvic organs

10. Cervical localization of the myomatous node.

11. Malnutrition, node necrosis.

Surgical treatment

The decision to perform hysterectomy or myomectomy is made depending on: the woman’s age, the course of the disease, the desire to preserve reproductive potential, the location and number of nodes.

Our clinic performs uterine artery embolization. Embolization is a promising method for the treatment of symptomatic uterine fibroids - both as an independent method and as a preoperative preparation for subsequent myomectomy in women of reproductive age, which can reduce the amount of intraoperative blood loss.

The "gold standard" of treatment uterine fibroids In Western Europe and the USA, myomectomy is recognized - surgical removal of uterine fibroids. During this operation, “husking” of myomatous nodes is performed, followed by their removal and careful suturing of the uterine body. A characteristic feature of a myomatous node is the presence of a capsule around it. Therefore, removal (“husking”) of the node can be performed within the capsule without damaging the surrounding myometrial tissue.

Organ-saving operations are performed via transvaginal and transabdominal approaches. The first includes: vaginal myomectomy and hysteroresectoscopy of myomatous nodes.

Transabdominal access includes laparotomy, minilaparotomy and laparoscopy.

The undoubted advantages of laparoscopic and minilaparotomy approaches are: minimal trauma, better cosmetic effect, lower likelihood of developing adhesions, shorter hospital stay and postoperative rehabilitation. However, when myomatous nodes are larger than 8 cm in size and have intraligamentary localization, there is a high risk of bleeding from the bed of the myomatous node, which can lead to massive blood loss and access conversion; in this case, laparotomy access is optimal.

There are the following approaches to perform hysterectomy:

vaginal;

laparoscopic;

laparoscopically-assisted vaginal;

hysteroresectoscopic;

combined.

I would especially like to dwell on the vaginal approach for hysterectomy, in which hemostasis options are possible: traditional ligation of ligaments and vessels, hemostasis using electrosurgical techniques, which significantly reduces the time of surgical intervention, reduces intraoperative blood loss, reduces the degree of tissue trauma, and postoperative pain.

The advantages of vaginal access are:

Less invasive access;

Cosmetic effect – absence of wounds on the anterior abdominal wall;

Short periods of hospital stay;

Short rehabilitation periods;

Low incidence of postoperative complications and absence of complications in the late postoperative period.

Usage laparoscopic The technique for performing it has advantages similar to vaginal access: low invasiveness, cosmetic effect, short hospital stay in the postoperative period.

The use of combined (laparoscopic and vaginal) access allows you to solve problems that cannot be solved for each access when used in isolation, such as: adhesions of the pelvic and abdominal organs, endometriosis, diseases of the uterine appendages, poor uterine descent (including in nulliparous women) .