According to statistics, the incidence of fibroids in the population is about 10-30%, but not everyone’s fibroids are in need of surgical treatment. Properly understand fibroids and avoid over-treatment. This article can hopefully be transferred to friends around you to reduce misconceptions.
1.Etiology of fibroids
At present, the understanding of the cause of uterine fibroids is still relatively superficial. Local hormone imbalance may be part of the cause, but the understanding is not deep. However, it is clear that fibroids are a hormone-dependent disease. Usually, if menopause occurs, fibroids will also shrink with the decline of hormone levels.
2.Surgical methods of fibroids
If uterine fibroid removal is considered, it can be performed openly, laparoscopically, through hysteroscopy or through a cathodic procedure. Open surgery is the traditional surgical method, which is usually done in the lower abdomen for about 10cm (depending on the location and size of the fibroids), and is suitable for almost all fibroids, but it is relatively more invasive and slower to recover. Laparoscopic technique is a surgical method that has become popular in the last 20 years. It is a surgical method to remove fibroids through 3-4 incisions of 0.5-2cm in diameter on the abdominal wall and through surgical instruments, and has gained popularity among patients because of the small scars on the abdominal wall and fast recovery after surgery. Some people may ask, how to take out the fibroids if they are so big? Don’t worry, there is now an instrument called myoma crusher which can crush the fibroids and remove them from the small hole. Laparoscopic surgery has become a major treatment modality for uterine fibroids and has gained popularity among patients because of its light pain and quick recovery after surgery. However, the procedure requires high surgical skills of physicians and hospital equipment, so not every hospital can perform this procedure. Not all fibroids can be removed laparoscopically, so what kind of fibroids are suitable for laparoscopic surgery? If there are too many fibroids, the laparoscopic surgery will not be able to reach the small ones due to the lack of touch, so there is a risk of missing them or making the surgery difficult due to too many fibroids. Therefore, at this time, I believe that if the preoperative ultrasound indicates more than 5 fibroids, then laparoscopic surgery should not be insisted upon. In addition, if the fibroids are too large, for example, more than 10 cm, then bleeding during surgery and difficulty in suturing are not considered preferable to laparoscopic surgery, and open surgery should be considered more appropriate. If a patient has a myoma larger than 10 cm and wants to insist on laparoscopic surgery, preoperative application of some drugs to reduce the size of the myoma in order to obtain laparoscopic surgery for the myoma can also be considered, but it is expensive (each GnRH-a injection costs about 2000 RMB and requires 1-2 injections). Hysteroscopic surgery is mainly suitable for fibroids located inside the uterine cavity. Hysteroscopic removal of fibroids requires special equipment and the skill of the surgeon, so it is also a hospital and physician-dependent surgery, usually for submucosal fibroids that are convex to the uterine cavity (type 0-3 fibroids). Hysteroscopic surgery is performed by entering the uterine cavity from inside the vagina, without scars, and recovery is faster, but it requires There are two types of negative surgery, one is for some submucosal fibroids, if the fibroid is completely prolapsed from the uterine cavity into the vagina, it can be removed completely from the vaginal route, and the other type of negative myomectomy is for fibroids located in the uterine ectopia, which is performed through the vaginal wall of the posterior vault into the abdominal cavity. This type of surgery requires a high level of surgical skill, and because the fibroid is incised through the posterior vault, there are special requirements regarding the size and number of fibroids and the location of the fibroids, which are generally suitable for fibroids with a diameter of 7 cm, no more than 2 fibroids, and fibroids close to the bottom. If the patient is suitable for a vaginal surgery, the post-operative pain is less (there are no sensitive painful nerves in the vagina so the pain is less severe), but the risk of post-operative infection is slightly higher because the vagina is a bacterial environment.
3. In what cases should I deal with fibroids?
According to the results of the study, 10% of women in the population have fibroids, and about 30% of women who are going through menopause can be found to have fibroids on physical examination, but most of them are asymptomatic. The other feature is that fibroids are hormone-dependent and will shrink after menopause as estrogen decreases. What kind of fibroids need to be treated surgically? First of all, if the fibroids produce some symptoms, surgery is needed. The main symptoms may include excessive menstrual flow, secondary anemia, pressure on the bladder resulting in frequent urination, or pressure on the rectum resulting in constipation or difficulty in defecation. Once symptoms are present, they need to be treated. If the fibroid is too large, surgery may be considered if it is still far from menopause and is in the process of growing gradually to a certain stage. In addition, if the fibroid is suspected to be malignant, surgery should be considered in order to rule out the possibility of malignant transformation. For young women who have not had children, there is no unified understanding of how large a fibroid should be considered for surgery if they have a need for childbirth, some people think that surgery is needed if it is more than 4cm, others think that surgery is needed if it is more than 7cm. The main concern during pregnancy is the red degeneration that occurs during pregnancy and leads to pain and miscarriage during pregnancy, but the chances are small (about 10-15%) and a number of people can have a pregnancy with tumors. The fibroids may grow larger during pregnancy. Small asymptomatic fibroids do not need to be treated at all if there is no need for childbirth, and the chance of malignancy of the fibroids is low. My opinion is that surgery should not be done because of the risk of surgery and because after myomectomy, more serious adhesions often occur, such as adhesions to the bladder, intestines and pelvic wall, which may or may not produce symptoms of abdominal pain, but have a greater impact on secondary surgery. laparoscopic surgery to manage them. Therefore, if it is possible not to perform surgery, do not do surgery, if you want to operate, it is possible to solve the problem at once as much as possible at once surgical solution.
4, new treatment methods
In recent years, some new treatment methods for uterine fibroids have emerged, and the more frequently mentioned ones are high-intensity focused ultrasound (HIFU) for uterine fibroids and arterial embolization for uterine fibroids. The principle of focused ultrasound is similar to solar foci, by gathering ultrasound energy to a focal point, the local temperature of the focal point rises to more than 60℃, which plays the purpose of ablating fibroids. The other is China’s Chongqing Hefu company, the domestic technology in this area of equipment manufacturing has been quite mature, not inferior to the Israeli technology. From the observation of the current clinical treatment effect, the volume of fibroids can be significantly reduced after 3 months of treatment, the volume can be shrunk by more than 50%, and for symptomatic fibroids, symptom relief can also be obtained, the whole treatment process can be completed in the outpatient clinic, the Israeli company is under the monitoring of MRI, while the equipment of HEFU is currently completed under the monitoring of ultrasound, because it is gathered (To learn more about the treatment, please type in “HEFU” and the system will send you a related popular article.) The principle of arterial embolization is to insert an arterial catheter into the artery of the uterus, and then block the blood supplying artery with some embolic agent, and the fibroids will shrink after lack of blood supply. Both methods preserve the uterus, but the long-term results need to be further evaluated because of the inherent risk of recurrence of fibroids. Studies suggest that 20% of patients require a second surgical management 2 years after surgery. Therefore such conservative treatment methods must be viewed objectively, are not suitable for all patients and are not a foolproof technique. In addition, these two methods should not be considered as the first choice of treatment if there is a suspicion of malignancy because of the lack of pathological results obtained.
5. What kind of surgery should be performed
Regardless of the route of surgery (open, laparoscopic or cathodic), there are two types of surgery for fibroids, one is myomectomy to remove the fibroids leaving the uterus behind, and the other is surgery to remove the uterus, with different indications for the two procedures. The uterus has two roles, one is to give birth to children, and the other is to have menstruation. The uterus has nothing to do with aging, and the estrogen and progesterone in the body are secreted by the ovaries. The choice of the surgical procedure depends mainly on the patient’s age and fertility requirements. For young women with fertility requirements, myomectomy is usually performed. I once performed myomectomy on a patient with 418 fibroids and the patient completed childbirth 2 years later, which means that as long as there are fertility requirements, myomectomy should be chosen to preserve the uterus as much as possible.
In contrast, for patients who are near menopause without fertility requirements, hysterectomy should generally be the appropriate choice. In outpatient clinics, we encounter many near-menopausal patients who strongly request preservation of the uterus. Although this is technically entirely possible, as a physician, we generally do not recommend such a procedure at the risk of recurrence and the difficulty of secondary surgery. Such patients can be considered if they are willing to try the new treatment of aggregated ultrasound or arterial embolization, but any procedure that preserves the uterus is at risk of recurrence. According to the statistics of Peking Union Medical College Hospital, the 5-year recurrence rate after single myoma resection is 15%, and the 5-year recurrence rate of multiple myomas is 30%.
6.Are there any special precautions after surgery?
If fibroids are removed from the uterus, a certain interval of time is needed for another pregnancy, the specific time depends on the situation during the surgery (personal experience is not more than 1 year, too long, the chance of recurrence is too high), if the fibroids are not large and not deep, the contraceptive time can be shorter, but if the large, deep fibroids, the time needed for contraception is longer. In addition, there is a risk of uterine rupture in the event of another pregnancy due to scarring of the uterus after surgery for fibroids, although it is not significant, it is still worthwhile to be alert and to explain the situation to the obstetrician after the pregnancy. If you notice abdominal pain during the pregnancy, you should go to the hospital promptly. There is no special emphasis on diet after surgery. The etiology of fibroids is unclear, and there is no method to prevent the recurrence of fibroids.
7.Is there any possibility of malignant change?
The possibility of malignant transformation of fibroids is not high, the chance is about 0.5%.
(1) Recent increase in size of fibroids.
(2) Ultrasound suggesting abundant blood flow.
(3) Elevated blood LDH. Some recent studies suggest that enhanced dynamic MRI combined with LDH can help identify benign and malignant.
8.Is there any way to prevent uterine fibroids?
Some drugs, such as GnRH-a and progesterone, can reduce the size of fibroids before surgery to facilitate surgery, but they will increase in size after stopping the drugs, so conventional treatment is not recommended.