Overview
Fibroids are common benign tumors of the female reproductive organs, which are mainly composed of smooth muscle fibers, hence the name fibroids. The incidence of fibroids is high, with approximately 20% of women over the age of 30 suffering from fibroids. It has been suggested that the cause of fibroids may be related to estrogen in the body. According to the growth site of fibroids, they can be divided into interstitial fibroids, subplasmic fibroids, and submucosal fibroids.
Clinical manifestations of uterine fibroids
The clinical manifestations of uterine fibroids are obviously related to the growth site and size of fibroids, and the main clinical manifestations are
1.Vaginal bleeding: It is the most common symptom of fibroids. In case of large interstitial fibroids, the contraction of uterus may be affected, or the endometrial area may increase, which may cause excessive menstruation or prolong menstruation, or in case of submucosal fibroids, there may be irregular vaginal bleeding and dripping.
2.Abdominal mass: It is mostly found in accidental cases or during census, thus women over 30 years old should have regular gynecological checkups every year.
3.Compression symptoms: The growth of fibroids can produce different compression symptoms depending on the location and size of the fibroids, for example, fibroids growing in the anterior wall of the uterus can compress the bladder and cause frequent urination, difficult urination and even urinary retention, compression of the ureter can lead to hydronephrosis, and compression of the rectum can cause constipation.
4. Infertility: It is reported in the literature that about 25-30% of patients with fibroids are infertile, which may be due to various reasons such as compression or distortion of the fallopian tubes and deformation of the uterine cavity, thus preventing the fertilized egg from being laid. In general, women with fibroids that are less than 4 cm in diameter can become pregnant. However, if the fibroids have grown to more than 4 cm in diameter before pregnancy, the chances of degeneration and miscarriage and premature birth increase during pregnancy;
5, abdominal pain: fibroids themselves do not cause pain, but when fibroids degenerate, combined with infection or subplasma fibroids twist, they can cause severe abdominal pain.
6.Increased leucorrhea: submucosal fibroids have superficial surface
Uterine fibroids treatment method
The principle of treatment should be decided according to the patient’s age, symptoms, size, number, location of fibroids, and whether or not to preserve fertility.
1.Expectant therapy: Myoma is small and asymptomatic, usually not treated. Especially for those who are near menopause, with low estrogen level, fibroids can disappear and shrink naturally. Follow up every 3~6 months. If the symptoms are obvious and the fibroids increase in size during the follow-up period, further treatment will be considered.
2.Medication: If the fibroids are <2 months gestational uterus size, the symptoms are mild, and the women who are near menopause or the general condition is not suitable for surgery, medication can be used. The drugs can not be used to cure the fibroids, there are problems with the rebound of fibroid volume after stopping the drugs.
Commonly used drugs are.
1, GnRHa, a synthetic decapeptide compound, can quickly bind with GnRH receptors, due to the reduction of receptors, the pituitary gland down-regulation effect, gonadotropin secretion is reduced, resulting in a decline in ovarian secretion of hormones. According to the literature, after 3-6 months of treatment, the tumor was reduced by 52%-77%, but after 4 months of discontinuation, the tumor returned to its pre-drug size;
2.Mifepristone is a derivative of norethindrone, a progesterone receptor antagonist, which plays an anti-progestational role by competing with progesterone for receptors, and at the same time, the effect of estrogen and progesterone in myoma tissues is significantly reduced, thus reducing the size of myoma. It was reported that the total volume of the uterus was reduced by 38.1% after 3 months of mifepristone treatment, and the volume was basically restored to that before the drug was discontinued 1 year later, suggesting that the short-term efficacy of mifepristone treatment for uterine fibroids is good, but the medium and long-term efficacy is unstable;
3.Nemeton or gestodene is 19 norethindrone steroids, which have strong anti-progestin and anti-estrogen effects, moderate anti-gonadotropin effects and mild estrogenic effects. After 3-6 months of endometrium, the fibroids shrank significantly, and the maintenance time until the fibroids grew up again was longer than that of mifepristone after stopping the drug.
3.Surgical treatment: surgical guidelines 1.Uterus larger than the size of the tenth week of pregnancy; 2.Proposed pregnancy, fibroids larger than 4 cm in diameter; 3.Fibroids growing rapidly in the short term, can not be excluded from malignant changes; 4.Fibroids in the cervical area; 5.Symptoms of discomfort, affecting the patient’s life, such as anemia, frequent urination, abdominal distension, etc.
The choice of surgical procedure should be decided according to the patient’s specific situation. For young infertile patients, myomectomy is performed to give them a chance of pregnancy after surgery. In older patients, hysterectomy is generally recommended. Hysterectomy can be performed open or laparoscopically, depending on the patient’s specific situation.
a. Myomectomy, called excision in some sources, is indicated for unmarried or married infertile people under 35 years of age who wish to preserve their reproductive function. Most of the myomas are removed transabdominally or laparoscopically, and prominent submucosal myomas are removed vaginally or hysteroscopically. There is a possibility of recurrence after surgery, with a recurrence rate of 17% for single fibroids and about 47% for multiple fibroids. Therefore, if pregnancy is needed, pregnancy should be sought as soon as possible after six months after surgery to avoid recurrence of pregnancy.
b.Total hysterectomy, for those with large fibroids, obvious symptoms, ineffective drug treatment, no need to preserve fertility function, or suspected malignant change, sub-total or total hysterectomy is feasible, and those under 50 years old with normal ovarian appearance can keep their ovaries.
4.How long can I get pregnant after myomectomy?
Since the size and growth of fibroids are different for each patient, the time to get pregnant depends on their own situation. Generally, gynecologists usually recommend at least one and a half years to get pregnant in order to reduce the risk of pregnancy, and some even recommend more than two years to get pregnant, in order to give the uterus a long enough recuperation period. However, it has also been reported in the literature that the uterus is very capable of repairing, so if it is a single small fibroid, or a subplasma fibroid that has not entered the uterine cavity, pregnancy is recommended six months after surgery, which can also prevent the problem of postoperative recurrence of fibroids.
5.Fibroids, pregnancy or treatment first?
It needs to be considered according to the patient’s age, fertility situation, the site, size and number of fibroids growth, etc. Since the presence of fibroids may lead to infertility, early miscarriage, postpartum bleeding, rapid growth and degeneration of fibroids during pregnancy, and many other risks.
If the fibroids are submucosal, there is no doubt that the fibroids should be treated before pregnancy – hysteroscopic myomectomy; if the fibroids are young and the diameter of the fibroids is greater than 4 cm, the patient is usually advised to operate as soon as possible and get pregnant 2 years after the operation; if the fibroids are less than 4 cm in diameter, the fibroids are in the base of the uterus, located in the subplasma or myometrium, not compressing the fallopian tubes, not submucosal, not close to the cervix, and age factors cause the desire to have children It is possible to try to conceive, but it must be clear that there are many risks associated with the combination of fibroids and pregnancy, which must be faced once it occurs; red degeneration of fibroids after pregnancy is possible, but the chances are not very high. If they do degenerate, they can be treated conservatively. The fibroids will be treated after delivery.