I. Definition: composed of smooth muscle and connective tissue, common in 30-50 years old, 20% prevalence in reproductive age
II. Pathogenesis-related factors.
Estrogen: local hypersensitivity of leiomyosarcoma tissue to estrogen Progesterone: promotes mitosis and stimulates leiomyosarcoma growth
Genetic factors.
C. Classification
1. Myoma growth site: uterine body myoma cervical myoma. 2.
2. Relationship between leiomyoma and myometrium.
1) Interstitial myomas 60-70% are located in the interstitial muscular wall and surrounded by the muscular layer.
2) Subplasma leiomyoma 20% grows towards the plasma surface of the uterus and protrudes from the surface of the uterus and is covered by the plasma membrane layer. It may form a tipped subplasma myoma, which may degenerate and necrosis or twist and break off to form a free myoma. Those located in the lateral wall of the uterus and protruding into the two lobes of the broad ligament are called broad ligament leiomyomas.
3.) Submucosal leiomyoma 10-15% grow in the direction of the uterine cavity, protruding from the uterine cavity and covered with mucosal layer. It is easy to form a tip, foreign body feeling, and often causes contraction of the uterus and is extruded outside the cervical opening and protrudes into the vagina.
If various types of fibroids co-occur in one, it is called multiple fibroids.
Pathology
1. Macroscopic examination Parenchymal spherical mass with smooth surface and harder texture than myometrium, pressing the surrounding muscle wall fibers to form pseudo-envelope, which can be easily peeled out. The cut surface is gray-white, swirled or woven.
2. Microscopic examination: spindle-shaped smooth muscle cells and unequal amounts of fibrous connective tissue
V. Myxoma degeneration
1.Glassy degeneration: also called transparent degeneration, the swirling structure disappears, uniform transparent-like material
2, cystic degeneration: glassy degeneration continues to develop, myocytes are necrotic and liquefied, and become soft, distinguish from pregnant uterus or ovarian cysts. Cystic cavity appears in the myoma
3, red-like changes: common during pregnancy or puerperium, mechanism is unclear, memory associates reference to inflammatory reaction, redness, swelling, heat and pain that: red: dark red in the profile, cooked beef; swelling: myoma rapidly increases, microscopic examination sees tissue edema; heat: patient may have fever; pain: severe abdominal pain, pressure pain in the uterine area. Another: increased white blood cell count.
4, sarcoma-like changes: malignant changes, 0.4~0.8%, older women. Short-term rapid growth of myoma with irregular vaginal bleeding, or enlargement of myoma after menopause, refer to uterine sarcoma.
5. Calcification: subplasmic leiomyoma with a small tip and insufficient blood supply, as well as postmenopausal women with calcium salt deposition.
Clinical manifestations
1.Symptoms Mostly no obvious symptoms, found accidentally during physical examination, related to the site of myoma and the presence of degeneration, not much related to the size and number of myoma.
1) Increased menstrual flow and prolonged menstrual period: large interstitial myomas and submucosal myomas may cause secondary anemia.
2)Lower abdominal mass: the size of the mass can be palpated in the abdomen in the third month of pregnancy or more; submucosa can be prolapsed outside the vagina
3)Increased leucorrhea: interstitial myoma increases the size of the uterine cavity and increases glandular secretion; submucosal myoma infection, bloody or pus-blood vaginal overflow
4) Compression symptoms: anterior The lower anterior wall or cervical myoma compresses the bladder: frequent urination, urgent urination, difficult urination, urinary retention;
Posterior The posterior wall compresses the rectum, causing symptoms such as lower abdominal cramping and constipation.
Lateral compression of ureter by broad ligament myoma or cervical giant myoma, causing ureteral dilatation or hydronephrosis
5) Others: lower abdominal cramping, lower back pain, aggravation of menstruation, infertility, miscarriage. Red changes: acute lower abdominal pain with vomiting, fever and local pressure pain of tumor; acute abdominal pain caused by twisting of subplasmalemma myoma tip; abdominal pain can be caused when submucosal discharge of uterine body.
2.Signs
It is related to the size, location, number and the presence of degeneration of myoma.
Substantial irregular masses can be found in the abdomen of large fibroids
Gynecologic examination: double diagnosis Uterus is enlarged with irregular surface single or multiple nodular protrusions. A single substantial bulbous mass may be found in the subplasma leiomyosarcoma attached to the uterus with a tissues. The submucosa is located in the uterine cavity, and the uterus is uniformly enlarged and prolapsed from the external cervical opening, and the mass is visible on speculum examination, divided into pink, with a smooth surface and clear margins around the cervix. There may be necrosis, bleeding and purulent discharge in case of infection.
VII. Diagnosis and differential diagnosis
Diagnosis: history, physical signs (double diagnosis), ultrasound, laparoscopy, hysteroscopy, hysterosalpingogram
Differential diagnosis.
1, pregnant uterus: history of menopause, early pregnancy reaction, uterus enlarges and becomes softer with the month of menopause, urine blood HCG, ultrasound.
2, Ovarian tumor: menstrual changes, position in relation to the uterus, ultrasound, hysteroscopy, laparoscopy
3, adenomyosis: history of secondary progressive dysmenorrhea, uniform enlargement, rarely exceeding the size of the uterus in the third trimester of pregnancy, ultrasound. May be combined at the same time.
4, endometriosis, pelvic inflammatory mass, uterine malformation
VIII. Treatment
According to the patient’s age, fertility requirements, symptoms and the location and size of fibroids. The number is considered comprehensively.
1. Follow up observation: Asymptomatic Near menopause Follow up once in 3~6 months
2.Medication For patients with mild symptoms, near menopause and systemic condition not suitable for surgery
1) Gonadotropin-releasing hormone analogue GnRH-a
High-dose continuous or long-term non-pulsatile administration to suppress FSH and LH and reduce estradiol to menopausal level.
Disadvantages: Gradual enlargement to original size after discontinuation, perimenopausal syndrome, osteoporosis, liver function damage.
Representative drugs: leuprolide Goserelin
Indications: ①Reduction of myoma to facilitate pregnancy.
②Pre-operative treatment to control symptoms and correct anemia.
③Pre-operative reduction of fibroids to reduce the difficulty of surgery.
④Early transition to natural menopause in near-menopausal women to avoid surgery.
2) Mifepristone: RU486 12.5mg daily orally for preoperative use or early menopause. Disadvantages: long-term use is easy to antagonize glucocorticoids
3., surgical treatment should be evidence.
1) Excessive menstruation to secondary anemia, drug therapy is ineffective
2) Severe abdominal pain, painful intercourse or chronic abdominal pain, acute abdominal pain caused by torsion of tipped fibroids
3)Symptoms of bladder and rectal compression
4)Myoma can be identified as the sole cause of infertility or recurrent miscarriage
5)Myoma is growing fast and malignancy is suspected
Surgery can be transabdominal, transvaginal, hysteroscopic or laparoscopic.
1) Myomectomy: those who wish to preserve their reproductive function. Transabdominal, laparoscopic, submucosal myoma transvaginal or hysteroscopic, 50% recurrence, 1/3 reoperation.
2) Hysterectomy: no requirement to preserve reproductive function or suspected malignant lesion, preoperative cervical scraping cytology to exclude cervical malignant lesion
Uterine fibroids combined with pregnancy
0.5%-1% of patients with fibroids and 0.3-0.5% of pregnancies
The effect on pregnancy is related to the size of the fibroid and the site of growth.
Submucosal fibroids interfere with fertilization of the egg and early abortion
Large interstitial fibroids may deform the uterine cavity or cause miscarriage due to insufficient blood supply to the endometrium.
Myomas can prevent the descent of the fetal dew, resulting in abnormal fetal position, placenta hypoplasia or placenta praevia, and obstruction of the birth canal during late pregnancy and delivery.
After delivery of the fetus, it may cause postpartum hemorrhage due to adhesion of placenta, large attachment surface or difficulty in expulsion and poor contraction of uterus.
It is prone to redness during pregnancy and the puerperium, but can usually be relieved by conservative treatment.
Postpartum hemorrhage should be prevented as most of the uterine fibroids in pregnancy can be delivered spontaneously.
If the fibroids prevent the fetus from descending, a cesarean section is performed. Whether the fibroids are also removed during the operation depends on the size and location of the fibroids and the patient’s condition.