Uterine fibroids protocol. Clinical recommendations: Uterine fibroids. Get treatment in Korea, Israel, Germany, USA
Risk factors for uterine fibroids
(predisposing) Knowledge of factors
predisposition will allow you to have an idea about the etiology of fibroids
uterus and develop preventive measures. Even though we
consider risk factors in isolation, most often there is their
combination (table 1). The impact of many factors previously attributed
their effect on estrogen and progesterone levels or metabolism, but
it has been proven that this connection is extremely complex, and most likely,
there are other mechanisms involved in the education process
tumors.
It should be noted that the analysis of risk factors for uterine fibroids
remains a difficult task due to the relatively small
the number of epidemiological studies conducted, and on their
results may be influenced by the fact that the prevalence
asymptomatic cases of uterine fibroids is quite high.
The most important aspect
etiology of uterine fibroids - the initiator of tumor growth - remains
unknown, although there are theories of initiation of its tumorigenesis.
One of them confirms that the increase in estrogen levels and
progesterone leads to an increase in mitotic activity, which
may promote fibroid nodule formation by increasing
the likelihood of somatic mutations.
Another hypothesis suggests
the presence of a congenital genetically determined pathology
myometrium in women with uterine myoma, expressed in an increase
the number of REs in the myometrium. Having a genetic predisposition
to uterine myoma indirectly indicates ethnic and family
the nature of the disease.
In addition, the risk
the incidence of uterine fibroids is higher in nulliparous women, for whom,
possibly characterized by a large number of anovulatory cycles, and
also obesity with pronounced aromatization of androgens to estrone in
adipose tissue. According to one hypothesis, the fundamental role in
estrogens play a role in the pathogenesis of uterine fibroids.
This hypothesis is confirmed
clinical trials evaluating the effectiveness of the treatment of fibroids
uterus with agonists of gonadotropin-releasing hormone (aGN-RG), against the background of
therapy observed hypoestrogenemia, accompanied by regression
myoma nodes. However, talking about fundamental
the importance of estrogens, regardless of progesterone, is impossible, since
the content of progesterone in the blood, like estrogen, cyclically
changes during reproductive age, and also significantly
increased during pregnancy and decreased after menopause.
Table
1
Risk factors associated with the development of fibroids
|
early menarche |
Increases |
Marshalletal. |
|
Absence of childbirth |
Parazzinietal. |
|
|
Age (late |
Marshalletal. |
|
|
Obesity |
Rossetal. |
|
|
African American race |
Bairdetal. |
|
|
Taking tamoxifen |
Deligdisch, |
|
|
high parity |
Lumbiganonetal, 1996 |
|
|
Menopause |
Samadietal, |
|
|
Parazzinietal, |
||
|
Taking COCs |
marshalletal, |
|
|
hormone therapy |
Schwartzetal, |
|
|
Nutrition Factors |
Chiaffarinoetal, 1999 |
|
|
foreign estrogens |
Saxenaetal, |
|
|
Geographic factor |
EzemandOtubu, |
Classification (ICD-10)
|
About 00.0 |
Abdominal |
|
About 00.1 |
Trubnaya (1) Pregnancy in the fallopian tube. (2) Fallopian tube rupture due to pregnancy. (3) Tubal abortion. |
|
About 00.2 |
Ovarian |
|
About 00.8 |
Other forms (1) Cervical. (2) In the uterine horn. (3) Intraligamentary. (4) Wall. |
|
About 00.9 |
ectopic |
|
About 08.0 |
Infection |
|
About 08.1 |
Long or |
|
About 08.2 |
Embolism, |
|
About 08.3 |
The shock caused |
|
About 08.4 |
renal |
|
About 08.5 |
Violations |
|
About 08.6 |
Damage |
|
About 08.7 |
Other |
|
About 08.8 |
Other |
|
About 08.9 |
Complication, |
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013
Leiomyoma of uterus, unspecified (D25.9)
obstetrics and gynecology
general information
Short description
Approved by the Protocol of the meeting of the Expert Commission
on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated December 12, 2013
uterine fibroids(leiomyoma - histological diagnosis) - a benign tumor of the smooth muscle fibers of the uterus (1).
I. INTRODUCTION
Protocol name: Uterine fibroids (uterine leiomyoma)
Protocol code: O
Code (codes) according to ICD-10:
D25 Uterine leiomyoma
D25.0 Submucosal uterine leiomyoma
D25.1 Intramural uterine leiomyoma
D25.2 Subserous leiomyoma of uterus
D25.9 Uterine leiomyoma, unspecified
Protocol development date: 04/20/2013
Abbreviations used in the protocol:
MRI - magnetic resonance imaging,
MC - menstrual cycle,
AH - abdominal hysterectomy,
VG - vaginal hystectomy,
LAWG - vaginal hysterectomy with laparoscopic assistance,
OIS - ovarian wasting syndrome.
Protocol Users: obstetrician-gynecologist, oncogynecologist
Classification
Clinical classification (1,2):
1. By localization and direction of growth:
- Subperitoneal (subserous) - the growth of the myomatous node under the serous membrane of the uterus towards the abdominal cavity (intra-abdominal location, intraligamentous location).
- Submucosal (submucosal) - the growth of a myomatous node under the uterine mucosa towards the organ cavity (in the uterine cavity, born, born).
- Intraparietal (interstitial) - the growth of the node in the thickness of the muscular layer of the uterus (in the body of the uterus, in the cervix).
2. 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 irregularities such as menometrorrhagia, 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).
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
The list of basic and additional diagnostic measures:
1. Complaints: menorrhagia (hyperpolymenorrhea, metrorrhagia, pain, anemia (III, 3.4).
2. Physical examination:
- bimanual examination: the uterus is enlarged, nodes are determined, the uterus and nodes are dense (III, 3.4).
3. Laboratory research: decrease in hemoglobin (anemia of varying severity) in the absence of extragenital pathology.
4. Instrumental research:
- Ultrasound examination of the pelvic organs with vaginal and abdominal sensors: size, number, localization, echogenicity, structure of nodes, the presence of concomitant endometrial hyperplasia, ovarian pathology (III, 5).
In doubtful cases, for the purpose of differential diagnosis with ovarian tumors, MRI of the small pelvis is performed (III, 5).
Hysteroscopy is performed to detect submucosal myomatous nodes and pathology of the endometrium (III, 6).
Diagnostic laparoscopy is performed if differential diagnosis is needed (leiomyoma or ovarian tumors) (III).
Dopplerography for the recognition of secondary changes in the myometrium, features of the vascularization of the nodes (5).
At the prehospital level, the following examination methods are carried out:
- examination of complaints,
- vaginal examination,
- determination of hemoglobin,
- Ultrasound of the pelvic organs,
- MRI of the pelvis,
- Dopplerography of nodes and organs of the small pelvis (uterus).
Diagnostic criteria
Complaints and anamnesis
In most women, uterine fibroids have an asymptomatic course, however, 20-30% of patients reveal complaints that are clinical manifestations of complications of fibroids:
- pelvic pain, heaviness in the lower abdomen;
- in the event of complications such as necrosis of the node, heart attack, torsion of the node's leg, a picture of "acute abdomen" may develop. There may be sharp pains in the lower abdomen and lower back, signs of peritoneal irritation (vomiting, dysfunction of the bladder and rectum), leukocytosis, accelerated ESR, fever;
- increased frequency of urination;
- other symptoms of compression of adjacent organs: compression of surrounding tissues by a growing fibroid node, contributes to the occurrence of circulatory disorders with varicose veins, thrombosis of tumor vessels, edema, hemorrhagic infarcts, tumor necrosis, which are manifested by a constantly pronounced pain syndrome, sometimes high body temperature;
- with subserous localization of fibroids, depending on their location, dysfunctions of adjacent organs (bladder, ureters, rectum) may occur;
- with an increase in the size of the tumor for more than 14 weeks of pregnancy, the development of myelopathic and radicular syndromes is possible: in the case of a myelopathic variant, which is the result of spinal ischemia, patients complain of weakness and heaviness in the legs, paresthesia, which begin 10-15 minutes after the start of walking and disappear after a short rest; with radicular syndrome, which develops as a result of compression of the pelvic plexus or individual nerves by the uterus, women are worried about pain in the lumbosacral region and lower extremities, sensitivity disorder in the form of paresthesias.
- uterine bleeding is one of the most common complications. Uterine bleeding contributes to the development of anemia.
Physical examination
Vaginal examination:
- the uterus is enlarged,
- nodes are defined,
- the uterus and nodes are dense (III, 3.4).
Laboratory research:
- decrease in hemoglobin (anemia of varying severity) in the absence of extragenital pathology.
Instrumental research:
- Ultrasound with abdominal and vaginal probes.
- Ultrasound of the thyroid gland.
-
MRI of the small pelvis, laparoscopy, hysteroscopy, dopplerometry of the uterus.
Women with an indeterminate diagnosis of fibroids after transvaginal ultrasound and transvaginal sonohysterography, or who refuse to have transvaginal ultrasonography due to possible discomfort, may be recommended an MRI (C).
For women diagnosed with uterine fibroids, it is advisable to determine the state of the thyroid gland, since in 74% of patients uterine fibroids develop against the background of thyroid pathology (C).
For leiomyomas larger than 12 weeks, transabdominal ultrasound is preferable (C).
The method of transvaginal echography is highly informative for the diagnosis of endometrial hyperplasia, however, with this research method, it is often not possible to determine submucosal uterine myoma and endometrial polyp (A).
The use of transvaginal echography and transvaginal sonohysterography has a greater diagnostic value in determining the localization of submucous nodes compared to hysteroscopy (A). Preliminary transvaginal sonohysterography in women with intrauterine pathology avoids hysteroscopy in 40% of cases (A).
When performing hysteroscopy, the following recommendations should be used:
- more appropriate is the use of saline (A);
- the procedure is performed under anesthesia (A).
Women with an asymptomatic course of fibroids up to 12 weeks in size in the absence of other pathological formations of the pelvic organs require further in-depth examination to identify another pathology that may be associated with the development of uterine fibroids, and, accordingly, it is necessary to treat it. They should see a doctor once a year, or more often if they develop symptoms (C).
Women with asymptomatic fibroids for more than 12 weeks should consult with specialists individually in an agreed monitoring regimen, but at least once a year, and receive conservative therapy (C) in case of refusal of surgery or if there are contraindications to it. Even in the absence of clinical manifestations of the disease, due to the unfavorable prognosis of the course of fibroids larger than 12 weeks, despite the inhibitory effect of hormone therapy for large fibroids, conservative myomectomy is recommended for women interested in preserving reproductive function (C).
Indications for expert advice:
- Consultation of an oncogynecologist in case of suspected endometrial hyperplastic processes or uterine sarcoma.
- Consultation of a therapist for anemia, to determine conservative treatment.
Differential Diagnosis
Differential diagnosis: performed with adenomyosis, ovarian tumors.
Instrumental research methods are used (MRI, hysteroscopy, laparoscopy).
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Treatment
Treatment goals:
- elimination of symptoms of the disease,
- Reducing the size of nodes.
Treatment tactics
Non-drug treatment: does not exist
Medical treatment
Indications for conservative therapy of uterine fibroids:
1. The desire of the patient to maintain reproductive function.
2. Clinically oligosymptomatic course of the disease.
3. Uterine fibroids, which do not exceed the size of 12 weeks of pregnancy.
4. Interstitial or subserous (on a broad basis) location of the node.
5. Myoma, accompanied by extragenital diseases with high anesthetic and surgical risk.
6. Conservative treatment as a preparatory stage for surgery or as rehabilitation therapy in the postoperative period after conservative myomectomy.
Medical therapy is the method of choice in women who are not subject to surgical treatment or who refuse it. It is worth noting that the size of the fibroids returns to its former size within 6 months after cessation of therapy (C).
Drug treatment includes non-hormonal drugs and hormone therapy drugs.
Non-hormonal drugs - predominantly symptomatic therapy: hemostatics (for bleeding) and antispasmodics, non-steroidal anti-inflammatory drugs (for pain), as well as measures aimed at treating pathological conditions that can contribute to the growth of uterine fibroids (thyroid pathology, inflammatory processes of the genitals) and normalizing metabolism substances (antioxidants, antiaggregants, multivitamins, herbal medicine) (C).
hormone therapy- the basis of drug treatment of fibroids, is a corrective hormonal therapy aimed at reducing both systemic and local dyshormonemia (C).
Oral contraceptives reduce the size of fibroids, can reduce menstrual blood loss with a significant increase in hematocrit and other hemogram parameters, and can be used for hemostasis (B).
Progestogens are used in the complex drug treatment of fibroids, which is accompanied by endometrial hyperplastic processes in order to reduce local hyperestrogenemia. Drugs, doses and regimens that provide endometrial stromal suppression are used (dydrogesterone 20-30 mg from 5 to 25 days of the menstrual cycle (MC)), norethisterone (10 mg from 5 to 25 days of MC) and linestrol (20 mg from 5 to 25 days of MC) (IN).
Treatment with GnRH agonists effectively reduces the size of the nodules and uterus, but is used for no more than 6 months due to the development of drug-induced menopause syndrome with long-term use (A). For women with fibroids with endometrial hyperplasia, GnRH (goserelin) is recommended in conjunction with dydrogesterone 20 mg from days 5 to 25 (during the first cycle) (C).
Treatment with GnRH agonists (goserelin) in combination with HRT ("add-back" therapy with estrogens and progestins) leads to a decrease in the size of fibroids, does not cause manifestations of drug-induced menopause and is an alternative treatment for women who have contraindications to surgical treatment or who are informed refusal of the operation (B).
Women diagnosed with fibroids who have spotting while using HRT are advised to reduce their estrogen dose or increase their progesterone dose (C).
Observations regarding the confirmation of the reduction in the size of fibroids with the use of progestogen-releasing IUDs are not enough, however, the positive dynamics of clinical manifestations allows us to recommend this method in the treatment of uterine fibroids (C).
| Level of Reliability and Efficiency | Cessation of symptoms | Node Size Reduction | Maximum duration of use | Possible side effects | |
| COC (for uterine bleeding) | IN | Positive effect | No effect | Not limited in the absence of contraindications from extragenital diseases | Nausea, headache, mastalgia |
| Gn-Rg analogues (triptorelin 3.75 mg once every 28 days) | A | Positive effect | Positive effect | 6 months | Symptoms of drug-induced menopause |
| IUD with levonorgestrel | IN | Positive effect | Impact not proven | 5 years | Irregular spotting, expulsion |
| Progestogens with a pronounced effect on the endometrium (with concomitant endometrial hyperplasia) | IN | Positive effect | Impact not proven | 6 months | Nausea, headache, mastalgia |
| Danazol | A | Little research | Positive effect | 6 months | Androgenic side effect |
Other types of treatment: does not exist.
Surgery
The decision to perform a hysterectomy or myomectomy is made depending on: the age of the woman, the course of the disease, the desire to maintain reproductive potential, the location and number of nodes (C):
For women with a large uterus (greater than 18 weeks) or anemia, GnRH agonists (goserelin, triptorelin) for 2 months are recommended before surgery (B) in the absence of a history of gynecological cancer.
- Women diagnosed with submucosal fibroids and significant bleeding, as an alternative to hysterectomy, also undergo hysteroscopic myomectomy, ablation or resection of the endometrium (B).
- For women under 45 years of age with symptomatic subserous or intramural fibroids who are interested in preserving the uterus, as an alternative to hysterectomy, myomectomy is recommended (C) with mandatory intraoperative histological rapid examination of the removed node.
Laparoscopic myomectomy is not applicable to women planning a pregnancy due to evidence of an increased risk of uterine rupture (C).
There are insufficient data on the effectiveness of the use of oxytocin, vasopressin during surgery to reduce blood loss (B).
There are insufficient data to evaluate the effectiveness of laser inductive interstitial thermotherapy, myolysis or cryomyolysis (C).
Fibroids embolization can be an effective alternative to myomectomy or hysterectomy (C).
Surgical treatment of an incidentally discovered asymptomatic fibroid to prevent its malignancy is not recommended (C).
Combination therapy for fibroids
It consists in the use of surgical treatment in the amount of conservative myomectomy against the background of drug therapy (the use of GnRH analogs in the pre- and postoperative period).
Indications for Combination Therapy(use of agonists and leiomyomectomy):
1. The interest of a woman in the preservation of the uterus and reproductive function.
2. Myoma with a large number of nodes.
3. Myoma with a node larger than 5 cm.
Stages of combination therapy:
Stage I - 2 injections of AGN-RG with an interval of 28 days.
Stage II - conservative myomectomy.
Stage III - the third injection of AGN-RG.
Indications for myomectomy as stage II of combined treatment:
1. Absence of dynamics of reduction in the size of the myomatous node after 2 injections of Gn-RH analogues. Given the literature data on the high risk of malignancy of AGN-RH resistant nodes, it is considered appropriate to perform urgent surgical intervention.
2. Preservation of clinical symptoms (pain, impaired function of adjacent organs, etc.) even with positive changes in the size of the node.
Advantages of surgical interventions against the background of the appointment of AGN-RG:
- reduction in the size of nodes, vascularization and blood loss;
- reduction of operation time;
- reduction of the time of normalization of the functional mass and size of the uterus after conservative myomectomy.
Indications for surgical treatment of fibroids:
1. Symptomatic myoma (with hemorrhagic and pain syndrome, the presence of anemia, symptoms of compression of adjacent organs).
2. The size of the fibroids is 13-14 weeks or more.
3. The presence of a submucosal node.
4. Suspicion of a power failure of the node.
5. The presence of a subserous node of fibroids on the leg (due to the possibility of torsion of the node).
6. Rapid growth (for 4-5 weeks a year or more) or resistance to therapy with GnRH analogues).
7. Myoma in combination with precancerous pathology of the endometrium or ovaries.
8. Infertility due to uterine fibroids.
9. The presence of concomitant pathology of the pelvic organs.
Principles for choosing a hysterectomy access:
1. There are clear indications and contraindications for both abdominal (AH) and vaginal hysterectomy (VH).
2. In some cases, VG with laparoscopic assistance (LAVG) is indicated
3. If the hysterectomy can be performed by any access, then in the interests of the patient, the advantage is determined in the following order: VG> LAVG> AG.
Indications and conditions for performing VG:
- No comorbidity of applications;
- Sufficient mobility of the uterus;
- Sufficient surgical access;
- The size of the uterus up to 12 weeks;
- Experienced surgeon.
Contraindications for VG:
- The size of the uterus is more than 12 weeks;
- Limited mobility of the uterus;
- Concomitant pathology of the ovaries and fallopian tubes;
- Insufficient surgical access;
- Hypertrophy of the cervix;
- Inaccessibility of the cervix;
- Surgery for vesicovaginal fistula in history;
- Invasive cervical cancer.
Conditions in which an advantage is given to the use of AG:
- There are contraindications to VG, LAHD is difficult or risky;
- Mandatory oophorectomy, which cannot be done in any other way;
- Adhesions due to concomitant endometriosis and inflammatory diseases of the pelvic organs;
- Rapid tumor growth (suspicion of malignancy);
- Suspicion of malignancy of a concomitant ovarian tumor;
- Myoma of the broad ligament;
- Doubts about the good quality of the endometrium;
- Concomitant extragenital pathology.
Indications for subtotal hysterectomy (supravaginal amputation of the uterus):
1. In cases where the patient insists on preserving the cervix, in the absence of pathology of the epithelium of the vaginal part of it and the endocervix.
2. Severe extragenital pathology, requiring a reduction in the duration of the operation.
3. Pronounced adhesive process or pelvic endometriosis, due to an increased risk of injury to the sigmoid colon or ureter or other complications.
4. The need for urgent hysterectomy in exceptional cases (the absence of a neck removal step reduces the duration of the operation, is essential when performing urgent surgery).
Scope of surgery in relation to the uterine appendages is based on the principles:
In favor of prophylactic oophorectomy are the following arguments:
- First - in 1-5% of cases there is a need for re-operation of benign ovarian tumors.
- The second - the function of the ovaries after a hysterectomy worsens somewhat and after two years, most women develop ovarian failure syndrome.
The arguments against prophylactic oophorectomy are as follows:
- The first is a high risk of developing surgical menopause syndrome after ovary removal, increased mortality from osteoporosis and cardiovascular diseases, requiring in most cases long-term use of HRT.
- The second is the psychological aspects associated with the removal of the ovaries.
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, which allows to reduce intraoperative blood loss.
Benefits of vascular embolization:
- Less blood loss;
- Low frequency of infectious complications;
- Low mortality rate;
- Reducing the recovery time;
- Preservation of fertility.
Possible complications of embolization:
- Thromboembolic complications;
- Inflammatory processes;
- Necrosis of the subserous node;
- Amenorrhea.
Indications for different types of hysterectomy depending on the clinical situation
Indications/situationsI |
Access |
|||
| vaginal | trial newganal | LAWG | abdominal | |
| Uterine bleeding | A | |||
| Adenomyosis | A | |||
| Leiomyoma: uterus up to 12 weeks | A | |||
| Leiomyoma: uterus 13-16 weeks | IN 1 | A | ||
| Leiomyoma: uterus 17-24 weeks | IN 1 | A | ||
| Leiomyoma: uterus > 22-24 weeks | A | |||
| endometrial hyperplasia | A | |||
| Recurrent cervical or endometrial polyp | A | |||
| Associated mental disorders | A | IN 1 | ||
| Intraepithelial neoplasia of the cervix | A | |||
| Malignant process of the endometrium | AT 2 | IN 1 | A | |
| Benign pathology of the uterine appendages with good mobility | A | IN 1 | ||
| Benign pathology of the uterine appendages with a pronounced adhesive process | IN 1 | A | ||
Notes: A - first choice method, B1 - first alternative method, B2 - second alternative method.
Preventive actions: With there is no specific prophylaxis.
Further management
After hysterectomy, depending on the extent of the operation:
- After subtotal hysterectomy - with appendages, monophasic estrogen-gestagen preparations are recommended; without appendages - prevention of SIA.
- After a total hysterectomy - with appendages, HRT with estrogens is recommended, without appendages - prevention of SIA.
Treatment effectiveness indicators:
- remission induction,
- relief of complications.
Hospitalization
Indications for hospitalization:
Planned hospitalization for surgical treatment.
emergency hospitalization at:
- uterine bleeding
- clinic of acute abdomen (necrosis of the node, torsion of the node's legs),
- severe pain syndrome (cramping pains in the lower abdomen with uterine myoma being born).
Information
Sources and literature
- Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
- 1. Clinical lectures on obstetrics and gynecology, edited by Kayupova N.A., Volume II, 2000 2. Gynecology. National leadership / ed. E.K. Ailamazyan, V.I. Kulakov, V.E. Radzinsky, G.M. Savelyeva. - M.: GEOTAR-Media, 2007. 3. American College of Obstetricians and Gynecologists (ACOG). Surgical alternatives tohysterectomy in the management of leiomyomas. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); May 2000 10 p.m. (ACOG practice bulletin; no. 16). 4. Gynaecological tumours EBM Guidelines. 12.8.2005 5. Clinical recommendations based on evidence-based medicine: Per. from English. / Ed. Yu.L. Shevchenko, I.N. Denisova, V.I. Kulakova, R.M. Khaitova. - 2nd ed., Rev. - M.: GEOTAR-MED, 2002. -1248 p.: ill. 6. Evidence-based medicine. Annual Quick Reference. Publishing house "MediaSphere", issue No. 3. - 2004.
Information
III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION
Evaluation criteria for monitoring and auditing the effectiveness of protocol implementation.
1. Number of surgical interventions for uterine myoma
2. Number of complications
3. Types of operation
List of protocol developers:
Doshchanova A.M. - Doctor of Medical Sciences, professor, doctor of the highest category, head of the department of obstetrics and gynecology, internship at JSC "MUA".
Reviewers:
doctor of the highest category, doctor of medical sciences, professor Ryzhkova S.N.
Indication of no conflict of interest: No.
Indication of the conditions for revising the protocol: when new evidence emerges.
IV. Application
1. Diagnostic follow-up
| № | Basic diagnostic studies | Multiplicity of application | Probability of application |
| 1 | Bimanual study | 1 time | 100% |
| 2 | General blood analysis | 1 time | 100% |
| 3 | Ultrasound with abdominal, vaginal probe | 1 time | 100% |
| № | Additional diagnostic studies | Multiplicity of application | Probability of application |
| 1 | Thyroid ultrasound | 1 time | 33% |
| 2 | MRI of the pelvis | 1 time | 33% |
| 3 | Laparoscopy | 1 time | 10% |
| 4 | Hysteroscopy | 1 time | 10% |
| 5 | Dopplerometry of the uterus | 1 time | 70% |
| № | Main | Quantity per day | Application duration | Probability of application |
| 1 |
Hormonal Therapy: Estrogen-gestagenic preparations |
1 tablet per day |
6 months |
33% |
| 2 | Gn-Rg analogs (triptorelin) | 3.75 mg 1 time on day 28 | 6 months | 33% |
| 3 | Danazol | 400mg per day | 6 months | 33% |
| № | Additional | Quantity per day | Application duration | Probability of application |
|
Navy with levonorgestrel |
1 time | 5 years | 33% | |
| 2 |
Gestagens (COC-dydrogesterone, norethisterone, |
20-30mg from 5th to 25th day MC 10mg from days 5 to 25 MC |
6 months | 33% |
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RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2016
Uterine leiomyoma (D25)
obstetrics and gynecology
general information
Short description
Approved
Joint Commission on the quality of medical services
Ministry of Health and Social Development
dated June 9, 2016
Uterine fibroids (leiomyoma)- monoclonal benign tumor of the smooth muscle fibers of the uterus.
Correlation between ICD-10 and ICD-9 codes
| ICD-10 codes | ICD-9 codes |
|
D25 Uterine leiomyoma D25.0 Submucosal uterine leiomyoma D25.1 Intramural uterine leiomyoma D25.2 Subserous leiomyoma of uterus D25.9 Uterine leiomyoma, unspecified |
39.7944 Endovascular embolization of vessels of pelvic organs, uterine arteries. 68.4110 Laparoscopic conservative myomectomy or hysteroresection of submucous nodes. 68.51 Laparoscopic vaginal hysterectomy. 68.411 Laparoscopic total hysterectomy. 67.30 Other types of excision or destruction of the affected area or tissue of the cervix. 67.39 Other methods of excision or destruction of the affected area or tissue of the cervix. 68.31 Laparoscopic supravaginal hysterectomy. 68.41 Laparoscopic total abdominal hysterectomy. 68.29 Other types of excision or destruction of the affected area of the uterus. 68.30 Supravaginal abdominal amputation of the uterus. 68.39 Other and unspecified abdominal hysterectomies. 68.40 Complete abdominal hysterectomy. 68.49 Other and unspecified total abdominal hysterectomies. 68.50 Vaginal hysterectomy. 68.59 Other vaginal hysterectomies. 68.81 Extirpation of the uterus with ligation of the internal iliac arteries. 68.90 Other and unspecified hysterectomy. 69.09 Other types of dilatation and curettage of the uterus. |
Protocol development date: 2013 (revised 2016).
Protocol Users: GP, obstetrician-gynecologists, oncologists.
Level of evidence scale:
The relationship between the strength of the evidence and the type of scientific research.
| Level of Evidence | Classification of recommendations | ||
| I | Evidence from at least one carefully randomized controlled trial | A | High level of evidence for clinical preventive action. |
| II-1 | Data from well-designed controlled trials without randomization | IN | Good level of evidence for clinical preventive action |
| II-2 | Data from well-designed cohort studies (prospective or retrospective) or case-control studies, preferably from multiple medical centers or research groups | WITH | This evidence is conflicting and does not allow for a specific recommendation for or against clinical preventive action. |
| II-3 | Evidence obtained by comparing the number or location of the site with or without intervention. Obvious results in uncontrolled studies (such as the results of penicillin treatment in the 1940s) can also be included in this category. | D | Good level of evidence not recommending clinical preventive action |
| III | Expert opinions based on clinical experience, demonstrative studies, or expert committee reports | E | High level of evidence against the use of clinical preventive actions |
| L | Insufficient level of evidence (in quality or quantity) to make a recommendation, but other factors may influence the decision |
Classification
By localization and direction of growth:
subperitoneal (subserous) - the growth of the myomatous node towards the abdominal cavity under the serous membrane of the uterus;
submucosal (submucosal) - the growth of the myomatous node in the direction of the organ cavity under the uterine mucosa;
intraparietal (interstitial) - the growth of the node in the thickness of the muscular layer of the uterus.
According to FIGO(2011).
According to clinical manifestations:
Asymptomatic uterine fibroids (50-80% of cases) - without clinical manifestations;
Symptomatic uterine fibroids (20-50% of cases) - with clinical manifestations.
Diagnostics (outpatient clinic)
DIAGNOSTICS AT OUTPATIENT LEVEL
Diagnostic criteria (LE - III)
Complaints:
Abnormal uterine bleeding
· pelvic pain;
heaviness in the lower abdomen;
an increase in the abdomen;
dysfunction of the bladder (dysuria);
bowel dysfunction (dyschesia)
infertility.
Anamnesis:
Significant moments of the anamnesis are:
absence of pregnancy and childbirth;
early menarche,
increase in the frequency of menstruation;
the duration of dysmenorrhea;
burdened heredity;
Increased body weight
· arterial hypertension;
· diabetes;
age (peak incidence 40-50 years).
Physical examination:
Bimanual vaginal examination:
The uterus is enlarged in size, with uneven contours due to dense nodes.
Laboratory research:
KLA - decrease in hemoglobin (anemia of varying severity) in the absence of extragenital pathology.
Instrumental Research:
Ultrasound (transvaginal, transabdominal, transvaginal sonohysterography with contrast):
- sensitivity and specificity 98-100%. (UD - A);
- small heterogeneous echo signals within the boundaries of the myometrium;
- hypoechoic and heterogeneous echostructure of the uterus with uneven contours;
- a sign of malnutrition of the myomatous node is the presence of cystic areas within the fibroids.
NB! with uterine fibroids larger than 12 weeks, it is preferable to perform transabdominal ultrasound (LE - C).
NB! transvaginal sonohysterography with contrast (introduction of physiological saline into the uterine cavity), has a high diagnostic value in submucosal nodes and allows differentiation from endometrial polyps.
NB! submucosal uterine fibroids have less echogenicity than polyps and the surrounding endometrium, and careful examination allows visualization of its "continuation" in the surrounding myometrium.
MRI - in the presence of atypical forms of formations of the small pelvis and abdominal cavity. (UD - C).
Diagnostic algorithm:
Diagnostics (ambulance)
DIAGNOSTICS AT THE STAGE OF EMERGENCY AID
Diagnostic measures:
Complaints:
bleeding from the genital tract, pain in the lower abdomen.
Physical examination:
pallor of the skin and visible mucous membranes;
Decreased blood pressure, tachycardia.
Inspection and palpation of the abdomen:
sparing position of a woman;
pain on palpation of the lower abdomen;
Positive symptoms of peritoneal irritation with torsion of the node's pedicle and node necrosis.
Diagnostics (hospital)
DIAGNOSTICS AT THE STATIONARY LEVEL
Diagnostic criteria at the hospital level: see outpatient diagnostic criteria.
Diagnostic algorithm:
List of main diagnostic measures:
· UAC.
List of additional diagnostic measures:
Ultrasound of the small pelvis transvaginally and / or abdominally,
hysterosonography of the small pelvis;
· hysteroscopy;
MRI of the pelvis.
NB! In a hospital setting, all types of treatment and diagnostic measures can be carried out with reasonableness and indications, taking into account the existing underlying and concomitant diseases within the framework of existing clinical protocols.
Differential Diagnosis
Differential diagnosis and rationale for additional studies
| Diagnosis | Rationale for differential diagnosis | Survey | Diagnosis Exclusion Criteria |
| Adenomyosis | Same clinical picture |
ultrasound, MRI Histological examination |
Characteristic is the absence of blood flow in the CDI mode in adenomyosis, thickening of the transition zone of the endometrium; |
| Uterine cancer/Uterine sarcoma | No specific symptoms | Anamnesis, ultrasound, MRI | Rapid growth of the tumor, atypical sonographic picture and on MRI, as fuzzy borders and germination in adjacent organs |
| Endometrial polyp | No specific symptoms | ultrasound, MRI | Well-circumscribed polypoid mass with a structure similar to the endometrium. |
Treatment abroad
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Treatment
Drugs (active substances) used in the treatment
| Ascorbic acid |
| Gestodene |
| Danazol (Danazol) |
| Desogestrel (Desogestrel) |
| Dextrose (Dextrose) |
| Dienogest (Dienogest) |
| Iron sulfate (Ferric sulfate) |
| Ibuprofen (Ibuprofen) |
| Potassium chloride (Potassium chloride) |
| Calcium chloride (Calcium chloride) |
| Naproxen (Naproxen) |
| Sodium acetate |
| Sodium acetate trihydrate |
| Sodium bicarbonate (Sodium bicarbonate) |
| Sodium chloride (Sodium chloride) |
| Tranexamic acid (Tranexamic acid) |
| Ulipristal |
| Ethinylestradiol (Ethinylestradiol) |
Treatment (ambulatory)
TREATMENT AT OUTPATIENT LEVEL
Treatment tactics
Treatment of women with fibroids/leiomyomas should be individualized based on symptoms, size and location of fibroids, age, patient preference, need for fertility or uterine preservation, availability of therapy, and physician experience (LE-IIIB).
Non-drug treatment: No.
Medical treatment:
Indications for drug therapy of uterine fibroids:
The desire of the patient to maintain reproductive function;
uterine fibroids, which do not exceed the size of 12 weeks of pregnancy;
Myoma, accompanied by extragenital diseases with high anesthetic and surgical risk;
drug therapy as a preparatory stage for surgery or as rehabilitation therapy in the postoperative period after conservative myomectomy.
Effective treatment for women with abnormal uterine bleeding caused by fibroids includes: levonorgestrel-containing intrauterine systems (LE-I) gonadoliberin analogues, (LE-I) selective progesterone receptor modulators, (LE-I) oral contraceptives, (LE-II-2 ) progestins, (LE - II-2) and danazol (LE - II2).
NB! Effective treatments for symptomatic uterine fibroids are selective progestin receptor modulators and gonadotropin-releasing hormone analogues. (UD - I).
NB! Treatment with a-GnRH effectively reduces the size of the nodes and uterine bleeding, but is used for no more than 6 months due to the development of drug-induced menopause syndrome with long-term use (LE - A).
NB! Ulipristal acetate effectively stops uterine bleeding, reduces the volume of uterine fibroids and increases the time of preoperative preparation of patients, which is important in the presence of anemia in patients and / or the presence of concomitant extragenital pathology (LE - A).
NB! OC and IUD-LNG are effective against uterine bleeding, but are ineffective in reducing the volume of myomatous nodes.
NB! Danazol - reduces the volume of nodes by 20-25%, effectively reduces the amount of heavy menstrual bleeding, but there is not enough data on the effectiveness of long-term therapy for fibroids.
NB! Medical therapy is the method of choice in women who are not subject to surgical treatment or who refuse it. It is worth noting that the size of the fibroids returned to the previous within 6 months after cessation of therapy (LE - C).
List of essential medicines:
ulipristal acetate - 5 mg;
A-GnRg - 11.25 mg;
IUD with levonorgestrel - 52 mg;
· Danazol;
ethinylestradiol dienogest 2 mg;
ethinylestradiol gestodene 75 mg;
ethinylestradiol desogestrel 150 mcg.
NSAIDs;
iron preparations;
trenax.
Algorithm of actions in emergency situations at the outpatient level:
Other types of treatment provided at the outpatient level: no
Table 1. Drug comparison table:
| Name of drugs | UD |
Termination Symptoms |
Node Size Reduction | Maximum duration of therapy | Possible side effects |
| Ulipristal acetate | A | + | + | 4 courses for 3 months | Headache, nausea, mood changes, PAEC |
| A-GnRg | A | + | + | 6 months | Symptoms of drug-induced menopause |
| Navy with LNG | IN | + | - | 5 years | Irregular spotting, expelsion |
| COOK | IN | + | - | Not limited if there are no contraindications from the EGP | |
| Danazol | A | Little research | + | 6 months | Androgenic side effect |
| Progestogens with a pronounced effect on the endometrium | IN | + | Impact not proven | 6 months | Nausea, headache, mastalgia |
consultation of an oncogynecologist - in case of suspicion of endometrial hyperplastic processes or uterine sarcoma.
· consultation of the therapist - in case of anemia, to determine the conservative treatment.
Consultations of related specialists in the presence of extragenital diseases.
Preventive actions: No.
Patient monitoring:
Women with asymptomatic fibroids up to 12 weeks in size in the absence of other pathological formations of the pelvic organs require further in-depth examination to identify another pathology that may be associated with the development of uterine fibroids, and, accordingly, it is necessary to treat it;
· they should see a doctor once a year, or more frequently if symptoms occur (LE-C);
Women with asymptomatic fibroids for more than 12 weeks should consult with specialists individually in an agreed monitoring regimen, but at least once a year and receive conservative therapy (LE-C) in case of refusal of surgery or if there are contraindications to it.
reduction in the size of uterine fibroids or lack of growth of nodes;
prevention of recurrence of the disease.
Treatment (ambulance)
TREATMENT AT THE EMERGENCY STAGE
Drug treatment provided at the stage of emergency emergency care:
Infusion therapy with crystalloids for massive bleeding:
a solution of sodium chloride;
sodium acetate;
sodium bicarbonate;
potassium chloride;
sodium acetate trihydrate,
potassium chloride;
Ringer Locke's solution
a solution of glucose.
Anesthesia for severe pain syndrome:
ibuprofen 5 mg/2 ml, ampoules; tablet, 5 mg.
Antifibrinolytic therapy - to reduce blood loss:
trenax tablets 250 mg, 500 mg; 5 ml ampoule.
Treatment (hospital)
TREATMENT AT THE STATIONARY LEVEL
Treatment tactics
Non-drug treatment: No.
Medical treatment:
Antibacterial prophylaxis of postoperative infectious complications;
Antibiotic therapy for emergency hospitalization due to necrosis or torsion of the pedicle of the node;
Adequate analgesic therapy;
infusion therapy with crystalloids and colloids according to indications;
anemia correction;
prevention of thromboembolic complications in the postoperative period.
List of Essential Medicines
Antifibrinolytic drugs:
tranexamic acid tablets 250 mg, 500 mg; 5 ml ampoule.
Iron preparations:
dry iron (II) sulfate + ascorbic acid tablet 320 mg/60 mg;
iron (II) sulfate heptahydrate + ascorbic acid syrup, 100 ml, iron sulfate drops, 25 ml, vials.
Colloidal and crystalloid solutions(in total volume up to 1500-2000 ml):
a solution of sodium chloride;
sodium bicarbonate;
potassium chloride;
sodium acetate trihydrate;
potassium chloride;
a solution of glucose.
Analgesics:
naproxen tablets 0.25 mg and 0.5 mg;
ibuprofen 5 mg/2 ml, ampoules; tablet, 5mg.
List of additional medicines:
SMPR (ulipristal acetate 5 mg);
Blood transfusion (as indicated).
NB! Anemia should be corrected prior to elective surgery (LE: II-2A). Selective progesterone receptor modulators and gonadotropin-releasing hormone agonists are effective in correcting anemia and should be used before surgery (LE-I-A).
NB! The use of vasopressin, bupivacaine and epinephrine, misoprostol, pericervical tourniquet, or thrombin matrices reduce blood loss during myomectomy and should be considered (LE-I-A).
Surgical intervention
Surgical planning should be based on an accurate determination of the location, size, and number of myomas [EL-III-A]. In cases where morcellation is necessary to remove a myoma from the abdomen, the patient should be informed of the possible risks and complications, including the fact that, in rare cases, fibroids may contain malignant elements and that laparoscopic morcellation can spread cancer, potentially making them worse. prognosis [LE - III-B].
Curettage of the uterine cavity:
Indications:
with uterine bleeding
Hysterectomy
Indications:
women who have completed their childbearing function;
rapid growth of fibroids in menopause in women not using hormone replacement therapy (even in the absence of symptoms);
Suspicion of leiomyosarcoma.
NB! In women with asymptomatic uterine fibroids, with a low level of suspicion of a malignant process, hysterectomy is not indicated.
NB! Hysterectomy should not be recommended as a prevention of possible future growth of fibroids.
Types of hysterectomy:
· vaginal hysterectomy;
· abdominal hysterectomy;
there are clear indications and contraindications;
· VG with laparoscopic assistance.
NB! The choice of the type of hysterectomy, regardless of access (vaginal, laparoscopic or laparotomic), should be based on the experience, preferences of the surgeon and the objective status of the patient (size and number of myomatous nodes, previous surgical interventions, extragenital pathology, etc.). Whenever possible, the least invasive treatment approach is preferred.
Myomectomy
Indications: Women suffering from miscarriage or infertility, with the presence of one or more myomas deforming the uterine cavity (most often submucosal fibroids), myomectomy can improve fertility and a successful pregnancy outcome.
NB! Myomectomy, as a surgical method of treatment, allows you to preserve fertility, effectively eliminating the symptoms associated with uterine fibroids. [UD -C].
This is a treatment option for women who would like to preserve an organ or fertility but are at risk of possible further intervention (EL-II2). There is no evidence that laparoscopic myomectomy is superior to laparotomy [LE-C]. Myomectomy is an alternative to hysterectomy for women who wish to preserve the organ, regardless of childbearing plans. Women should be informed of the risk of possibly expanding the scope of surgery to hysterectomy during elective myomectomy. This will depend on the intraoperative findings and the course of the operation.
Hysteroscopic myomectomy
Indications: symptomatic intracavitary uterine fibroids, submucosal fibroids (types 0, I and II), up to 4 to 5 cm in diameter.
NB! It should be carried out with caution in cases where the thickness between the uterine myoma and the serosa is less than 5 mm.
Laparoscopic myomectomy:
Indications: fibroids in complex locations (lower segment or cervix), multiple nodes and/or large nodes (> 10 cm).
Laparoscopic myomectomy has advantages over laparotomic myomectomy in terms of less blood loss, postoperative pain, fewer overall complications, faster recovery, and significant cosmetic benefit [LE-B]
Uterine ruptures during pregnancy and in childbirth after laparoscopic myomectomy are associated with inadequate closure of deep defects in intramural fibroids or excessive use of electrosurgical energy [LE–S]. Compliance with the 6-month interval from myomectomy to the onset of pregnancy contributes to a better recovery of the myometrium.
Other types of treatment:
Embolization of the uterine arteries:
Indications: symptomatic uterine fibroids, if desired, by patients who wish to preserve the organ, but do not plan to become pregnant in the future.
NB! Women choosing UAE for the treatment of fibroids should be counseled about the potential risk, reduced fertility, and pregnancy outcomes [EL-II-3A].
High Intensity Focused Ultrasound with MRI Assistance (FUS Ablation)
Indications: uterine fibroids less than or equal to 10 cm and total uterine size less than or equal to 24 weeks .
Indications for expert advice:
Indications for transfer to the intensive care unit and resuscitation:
acute cardiovascular and respiratory failure;
acute DIC syndrome;
disturbances of consciousness, convulsions;
the early postoperative period.
Treatment effectiveness indicators:
reduction in the size of uterine fibroids (with UAE, FUS ablation);
Reduction or disappearance of symptoms of the disease;
Removal of uterine fibroids and / or uterus.
Further management
There is no specific prevention. Patients are advised to consult a doctor if there is abnormal uterine bleeding, abnormal discharge from the genital organs and other symptoms of recurrence of uterine fibroids after treatment.
Hospitalization
Indications for planned hospitalization:
symptomatic fibroids (with hemorrhagic and pain syndrome, anemia, symptoms of compression of adjacent organs) in women who have completed their reproductive function;
Fibroids size 13-14 weeks or more;
The presence of a submucosal node;
Suspicion of a power failure of the node;
The presence of a subserous node of fibroids on the leg (due to the possibility of torsion of the node);
rapid growth (4-5 weeks a year or more) or resistance to α-GnRH therapy);
Fibroids in combination with a hyperplastic process of the endometrium and / or an ovarian tumor;
Infertility and / or miscarriage due to uterine fibroids, deforming the uterine cavity.
Indications for emergency hospitalization:
· uterine bleeding;
Clinic of an acute abdomen (necrosis of the node, torsion of the legs of the node);
Severe pain syndromes (cramping pains in the lower abdomen with uterine myoma being born).
Information
Sources and literature
- Minutes of the meetings of the Joint Commission on the quality of medical services of the MHSD RK, 2016
- 1. SOGC CLINICAL PRACTICE GUIDELINE. The Management of Uterine Leiomyomas. J Obstet Gynaecol Can 2015;37(2):157–178 2. Munro MG, Critchley HO, Broder MS, Fraser IS. The FIGO Classification System (“PALM-COEIN”) for causes of abnormal uterine bleeding in non-gravid women in the reproductive years, including guidelines for clinical investigation. Int J Gynaecol Obstet 2011;113:3–13 3. http://bestpractice.bmj.com/best-practice/monograph/567/diagnosis/differential.html 4. SOGC guideline on the management of uterine fibroids in women with otherwise unexplained infertility 2015 5. Uterine fibroids: a course on organ preservation. Newsletter / V.E. Radzinsky, G.F. Totchiev. - M.: Editorial staff of Status Praesens, 2014.
Information
Abbreviations used in the protocol
| ESR | - | erythrocyte sedimentation rate |
| ultrasound | - | ultrasonography |
| MRI | - | Magnetic resonance imaging |
| HRT | - | hormone replacement therapy |
| a- GnRH | - | gonadotropin-releasing hormone agonists |
| COOK | - | combined oral contraceptives |
| OK | - | oral contraceptives |
| Navy | - | intrauterine system |
| ICE | - | syndrome - intravascular coagulation syndrome |
| VG | - | vaginal hysterectomy |
| AG | - | abdominal hysterectomy |
| NSAIDs | - | non-steroidal anti-inflammatory drugs |
| EMA | - | uterine artery embolization |
| HELL | - | arterial pressure |
| APTT | - | activated partial thromboplastin time |
| PV | - | prothrombin time |
| ALT | - | alanine aminotransferase |
| AST | - | aspartate aminotransferase |
| SMRP | - | selective progesterone receptor modulator |
| EGZ | - | extragenital pathology |
| PAEC | - | Progesterone Receptor Modulator Associated Endometrial Changes (changes in the endometrium associated with an antagonistic effect on progesterone receptors) |
List of protocol developers with qualification data:
1) Doshchanova Aikerm Mzhaverovna - Doctor of Medical Sciences, Professor, Doctor of the Highest Category, Head of the Department of Obstetrics and Gynecology on internship at JSC "Astana Medical University".
2) Toktarbekov Galymzhan Kabdulmanovich - obstetrician-gynecologist of the highest category, branch of the CF "UMC" NSCMD.
3) Tuletova Ainur Serikbaevna - PhD, doctor of the first category, assistant of the department of obstetrics and gynecology of JSC "Astana Medical University".
4) Mazhitov Talgat Mansurovich - doctor of medical sciences, professor, JSC "Astana Medical University", clinical pharmacologist of the highest category.
Conflict of interest: No.
List of reviewers: Kaliyeva Lira Kabbasovna - Doctor of Medical Sciences, Head of the Department of Obstetrics and Gynecology No. 2, RSE on REM "S.D. Asfendiyarov".
Indication of the conditions for revising the protocol: Revision of the protocol 3 years after its publication and from the date of its entry into force, or if there are new methods with a level of evidence.
Attached files
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UTERINE MYOMA: DIAGNOSIS, TREATMENT AND REHABILITATION
AGREED
Chief freelance specialist of the Ministry of Health of Russia in obstetrics and gynecology, Academician of the Russian Academy of Sciences L.V. Adamyan
21/09 from 2015
APPROVE
President of the Russian Society of Obstetricians and Gynecologists V.N. Serov
21/09 from 2015
Team of authors:
|
Adamyan |
Deputy Director of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov" of the Ministry of Health of Russia, Chief Freelance Specialist in Obstetrics and Gynecology of the Ministry of Health of Russia, Academician of the Russian Academy of Sciences, Professor |
|
Andreeva |
Head of the Department of Endocrine Gynecology of the Federal State Budgetary Institution "Endocrinological Research Center" of the Ministry of Health of Russia, Professor of the Department of Reproductive Medicine and Surgery of the Moscow State Medical and Dental University named after A.I. Evdokimov, Doctor of Medical Sciences |
|
Artymuk |
Head of the Department of Obstetrics and Gynecology, Kemerovo State Medical Academy, Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Belotserkovtseva |
Head of the Department of Obstetrics, Gynecology and Perinatology, Surgut State University, Chief Physician of the Surgut Clinical Perinatal Center, MD, Professor |
|
Refugee |
Head of the Department of Operative Gynecology, Federal State Budgetary Scientific Institution "Research Institute of Obstetrics and Gynecology named after D.O. Ott", Doctor of Medical Sciences, Professor |
|
Gevorkyan |
|
|
Glukhov |
Associate Professor of the Department of Obstetrics and Gynecology, SBEI HPE "Ural State Medical University", Ministry of Health of Russia, Deputy Chief Physician for Obstetrics and Gynecology, MBU CGB N 7, Yekaterinburg, Ph.D. |
|
Gus |
Head of the Department of Functional Diagnostics of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov" of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Dobrokhotov
|
Head of the Department of Obstetrics and Gynecology N 2 of the Medical Faculty of the SBEI HPE "Russian National Research Medical University named after N.I. Pirogov" of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Jordania
|
Leading Researcher of the N.N. n., professor |
|
Zayratyants
|
Head of the Department of Pathological Anatomy, Moscow State Medical and Dental University named after A.I. Evdokimov of the Ministry of Health of Russia, Chief Pathologist of Roszdravnadzor for the Central Federal District of the Russian Federation, Vice President of the Russian and Chairman of the Moscow Society of Pathologists, Laureate of the A. I. Strukova RAMS, Doctor of Medical Sciences, Professor |
|
Kozachenko |
Leading Researcher of the Gynecological Department of the Department of Operative Gynecology and General Surgery of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after academician V.I. Kulakov" of the Ministry of Health of Russia, Associate Professor of the Department of Reproductive Medicine and Surgery of the State Budgetary Educational Institution of Higher Professional Education "Moscow State University of Medicine and Dentistry named after A.A. .I. Evdokimova" of the Ministry of Health of Russia, MD |
|
Kiselev |
Professor of the Department of Reproductive Medicine and Surgery, Moscow State Medical and Dental University named after A.I. |
|
Kogan |
Head of the 1st pathoanatomical department of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov" of the Ministry of Health of Russia, Professor of the Department of Pathology of the Research Center of the State Budgetary Educational Institution of Higher Professional Education "First Moscow State Medical University named after I.M. Sechenov", Ph.D. .sci., professor |
|
Kuznetsova |
Chief Researcher of the Research Department of Women's Health of the Scientific and Educational Clinical Center of the First Moscow State Medical University named after I.M. Sechenov of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Kurashvili
|
Professor of the Department of Medical Physics, National Research Nuclear University "MEPhI", MD |
|
Levakov |
Head of the Department of Complex and Combined Methods for the Treatment of Gynecological Diseases of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov" of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Malyshkina
|
Director of the Ivanovo Research Institute of Motherhood and Childhood named after V.N.Gorodkov of the Ministry of Health of Russia, MD |
|
Maltseva
|
Head of the Department of Obstetrics and Gynecology, Kazan State Medical Academy, Chief Freelance Obstetrician-Gynecologist in the Volga Federal District, Doctor of Medical Sciences, Professor |
|
Marchenko
|
Leading Researcher of the Department of Gynecological Endocrinology of the Federal State Budgetary Institution "Scientific Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov" of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Murvatov |
Head of the Gynecological Department of the Main Military Clinical Hospital of the Ministry of Internal Affairs of Russia, Colonel of the Medical Service, Associate Professor of the Department of Reproductive Medicine, Moscow State Medical and Dental University named after A.I. Evdokimov, Ph.D. |
|
Pestrikova
|
Head of the Department of Obstetrics and Gynecology, SBEE HPE "Far Eastern State Medical University" of the Ministry of Health of Russia (Khabarovsk), Chief Freelance Obstetrician-Gynecologist in the Far Eastern Federal District, Doctor of Medical Sciences, Professor |
|
Popov |
Head of the Department of Endoscopy, GBUZ MO "Moscow Regional Research Institute of Obstetrics and Gynecology", Doctor of Medical Sciences, Professor |
|
Protopopov
|
Head of the Department of Perinatal and Reproductive Medicine, SBEI DPO "Irkutsk State Medical Academy of Postgraduate Education", Doctor of Medical Sciences, Professor |
|
Samoilov |
Deputy Chairman of the Cabinet of Ministers of the Chuvash Republic - Minister of Health and Social Development of the Chuvash Republic, Head of the Department of Obstetrics and Gynecology, FGOU HPE "Chuvash State Medical University named after I.N. Ulyanov", Doctor of Medical Sciences, Professor |
|
Sonova |
Head of the Department of Gynecology, Department of Reproductive Medicine, SBEE HPE "Moscow State University of Medicine and Dentistry named after A.I. Evdokimov" of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Tikhomirov
|
Professor of the Department of Obstetrics and Gynecology, Faculty of Medicine, SBEE HPE "Moscow State University of Medicine and Dentistry named after A.I. Evdokimov" of the Ministry of Health of Russia, MD |
|
Tkachenko |
Head of the Department of Obstetrics and Gynecology of the Federal Educational Institution of Higher Education, SBEE HPE "Volgograd State Medical University" of the Ministry of Health of Russia, Chief Freelance Obstetrician-Gynecologist of the Volgograd Region, Doctor of Medical Sciences, Professor |
|
Urumova |
Head of the Gynecological Department of the FGBUZ "Clinical Hospital N 123 of the Federal Medical and Biological Agency" of Russia, Ph.D. |
|
Filippov
|
Deputy Director of the Department of Medical Assistance to Children and the Obstetrics Service of the Ministry of Health of Russia, Professor of the Department of Obstetrics and Gynecology, IPO SBEI HPE "Moscow State Medical University named after I.M. Sechenov" of the Ministry of Health of Russia, Doctor of Medical Sciences, Professor |
|
Khashukoeva |
Professor of the Department of Obstetrics and Gynecology, Faculty of Medicine, SBEE HPE "Russian National Research Medical University named after N.I. Pirogov" of the Ministry of Health of Russia, MD |
|
Chernukha |
Professor |
|
Yarmolinskaya
|
Leading Researcher of the Department of Endocrinology of Reproduction of the Federal State Budgetary Institution "Scientific Research Institute of Obstetrics and Gynecology named after D.O. Ott", Professor of the Department of Obstetrics and Gynecology N 2, SBEE HPE "North-Western State Medical University named after I.I. Mechnikov" of the Ministry of Health of Russia, Dr. .m.s. |
|
Yarotskaya
|
MD |
The following authors took part in the work:
Baranov B.C. (St. Petersburg), Ivashchenko T.E. (St. Petersburg), Osinovskaya N.S. (St. Petersburg), Obelchak I.S. (Moscow), Panov V.O. (Moscow), Pankratov V.V. (Surgut), Grishin I.I. (Moscow), Ibragimova D.M. (Moscow), Khachatryan A.S. (Moscow)
Reviewers:
|
Pasman |
Head of the Department of Obstetrics and Gynecology of the Faculty of Medicine of Novosibirsk State University, Head of the Laboratory of Immunology of Reproduction of the Institute of Clinical Immunology of the Siberian Branch of the Russian Academy of Medical Sciences (Novosibirsk) Doctor of Medical Sciences, Professor |
|
Shtyrov |
Professor of the Department of Obstetrics and Gynecology, Faculty of Pediatrics, SBEE HPE "Russian National Research Medical University named after N.I. Pirogov" of the Ministry of Health of Russia, MD |
|
Faizullin |
Head of the Department of Obstetrics and Gynecology, SBEI HPE "Kazan State Medical University" of the Ministry of Health of Russia, Chairman of the Society of Obstetricians and Gynecologists of the Republic of Tatarstan, Honored Scientist of the Republic of Tatarstan, Doctor of Medical Sciences, Professor |
ANNOTATION
ANNOTATION
uterine fibroids
- a benign, monoclonal, well-demarcated, encapsulated tumor originating from the smooth muscle cells of the cervix or body of the uterus - one of the most common benign tumors of the female genital area, which occurs in 20-40% of women of reproductive age. Localization of uterine fibroids is the most diverse. Most often, subserous and intermuscular (intramural) location of myomatous nodes is diagnosed, the number of which can reach 25 or more, and the size can increase significantly. Submucosal (submucosal) arrangement of nodes is observed less frequently, but it is accompanied by a more vivid clinical picture.
These guidelines present current data on the etiology, pathogenesis, clinical picture, diagnosis, as well as new options for surgical treatment and the role of hormone therapy in the complex treatment of uterine fibroids.
1. EPIDEMIOLOGY, ETIOLOGY, PATHOGENESIS AND RISK FACTORS
Uterine fibroids are the most common benign tumor among women in most countries of the world. It is believed that uterine fibroids are diagnosed in 30-35% of women of reproductive age, more often in late reproductive age, and in 1/3 of patients it becomes symptomatic.
As a result, uterine fibroids become the leading cause of hysterectomy in many countries, for example in the US it is the basis for approximately 1/3 of all hysterectomies, which is approximately 200,000 hysterectomies annually. In Russia, according to various sources, uterine fibroids are the cause of hysterectomy in 50-70% of cases with uterine diseases.
Despite the high prevalence of the disease, until recent years, relatively few fundamental studies have been aimed at identifying the causation and pathogenesis of uterine fibroids due to the rarity of its malignant transformation. However, despite the benign course, uterine fibroids are the cause of a significant decrease in the quality of life in a significant part of the female population. Clinical manifestations of the tumor are associated with uterine bleeding, pain, compression of adjacent organs, violation of not only their function, but also fertility, including infertility and miscarriage.
The causes of uterine fibroids are unknown, but the scientific literature contains a wealth of information related to the epidemiology, genetics, hormonal aspects, and molecular biology of this tumor.
Factors potentially associated with the genesis of the tumor can be roughly divided into 4 categories:
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Predisposing or risk factors; |
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Initiators; |
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promoters; |
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Effectors. |
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Risk factors for uterine fibroids (predisposing)
Knowing the predisposition factors will allow you to have an idea about the etiology of uterine fibroids and develop preventive measures. Despite the fact that we consider risk factors in isolation, most often there is a combination of them (Table 1). Many factors have previously been attributed to estrogen and progesterone levels or metabolism, but the relationship has proven to be extremely complex and there are likely other mechanisms involved in tumor formation. It should be noted that the analysis of risk factors for uterine fibroids remains a difficult task due to the relatively small number of epidemiological studies conducted, and their results may be influenced by the fact that the prevalence of asymptomatic cases of uterine fibroids is quite high.
The most important aspect of the etiology of uterine fibroids - the initiator of tumor growth - remains unknown, although theories of initiation of its tumorigenesis exist. One of them confirms that an increase in the level of estrogens and progesterone leads to an increase in mitotic activity, which can contribute to the formation of fibroid nodes, increasing the likelihood of somatic mutations. Another hypothesis suggests the presence of a congenital genetically determined pathology of the myometrium in women with uterine myoma, expressed as an increase in the number of ER in the myometrium. The presence of a genetic predisposition to uterine fibroids indirectly indicates the ethnic and family nature of the disease.
In addition, the risk of uterine fibroids is higher in nulliparous women, who may be characterized by a large number of anovulatory cycles, as well as obesity with a pronounced aromatization of androgens to estrone in adipose tissue. According to one hypothesis, estrogens play a fundamental role in the pathogenesis of uterine fibroids.
This hypothesis was confirmed by clinical trials evaluating the effectiveness of treatment of uterine fibroids with gonadotropin-releasing hormone (aGn-RH) agonists; during therapy, hypoestrogenemia was observed, accompanied by regression of myomatous nodes. However, it is impossible to talk about the fundamental importance of estrogens regardless of progesterone, since the content of progesterone in the blood, like estrogen, changes cyclically during the reproductive age, and is also significantly increased during pregnancy and reduced after menopause. Thus, clinical and laboratory studies suggest that both estrogens and progesterone may be important growth promoters of fibroids.
Table 1
Risk factors associated with the development of fibroids
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Factor |
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early menarche |
Increases |
Marshalletal. 1988a |
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No history of childbirth |
Parazzinietal. 1996a |
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Age (late reproductive period) |
Marshalletal. 1997 |
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Obesity |
Rossetal. 1986 |
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African American race |
Bairdetal. 1998 |
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Taking tamoxifen |
Deligdisch, 2000 |
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high parity |
Reduces |
Lumbiganonetal, 1996 |
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Menopause |
Samadetal, 1996 |
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Smoking |
Parazzinietal, 1996b |
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Taking COCs |
Marshalletal, 1998a |
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hormone therapy |
Schwartzetal, 1996 |
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Nutrition Factors |
Chiaffarinoetal, 1999 |
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foreign estrogens |
Saxenaetal, 1987 |
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Geographic factor |
EzemandOtubu, 1981 |
3. TERMINOLOGY AND CLASSIFICATION
________________
* The numbering corresponds to the original, hereinafter in the text. - Database manufacturer's note.
Terminology
. Information about uterine fibroids was available from ancient healers. In the study of the remains of ancient Egyptian mummies, cases of calcified nodes of uterine fibroids were identified. Hippocrates called them "womb stones".
0. submucosal nodes on the leg without an intramural component.
I. Submucosal nodes on a wide base with an intramural component of less than 50%.
II. Myomatous nodes with an intramural component of 50% or more.
According to the recommendations of the European Society of Human Reproduction (ESHRE), fibroids up to 5 cm should be considered small, fibroids over 5 cm should be considered large.
International classification of diseases of the tenth revision (ICD 10):
D25 Leiomyoma of the uterus,
D25.0 Submucosal uterine leiomyoma,
D25.1 Intramural leiomyoma,
D25.2 Subserous leiomyoma
D25.9 Leiomyoma, unspecified.
D26 Other benign neoplasms of uterus
D26.0 Benign neoplasm of cervix
D26.1 Benign neoplasm of uterine body
D26.7 Benign neoplasm of other parts of uterus
D26.9 Benign neoplasm of uterus, part unspecified
O34.1 Tumor of the uterine body (in pregnancy) requiring medical attention of the mother.
4. CLINICAL PICTURE
5. DIAGNOSIS
Ultrasound diagnosis of the uterus
The main method of screening and primary diagnostics in gynecology, the "gold standard" of instrumental diagnostics in this area, without a doubt, has been and remains ultrasound. At the same time, the reliability of the ultrasound results depends not only on the experience and knowledge of the diagnostician, but also on his manual skills in using the ultrasound probe, i.e. Ultrasound is a rather subjective or "operator-dependent" method. It is impossible not to note the objective limitations of the method - the need to have acoustic windows of the required size in the study area, which is not always possible.
However, ultrasound with the help of transabdominal and transvaginal sensors is a method of primary diagnosis of uterine fibroids, and it is also widely used for dynamic monitoring of the development of the tumor process, selection of patients and evaluation of the effectiveness of various types (conservative and/or surgical) therapeutic effects. On the basis of prognostic acoustic signs, echography provides an opportunity not only for topical diagnosis of myomatous nodes, but also for their structure, hemodynamics and, accordingly, the severity of proliferative processes, differentiation with other pathologies of the myometrium (adenomyosis, sarcoma, etc.).
Modern 3/4D technologies allow obtaining additional information on spatial localization in relation to the uterine cavity of intermuscular with centripetal growth and submucosal nodes in the coronal scanning plane.
echohysterography against the background of the installed fluid and dilution of the walls of the uterine cavity, it significantly expands the possibilities of contouring the node, thereby detailing its localization in the uterine cavity. So, with an intermuscular-submucosal location of the node, a clear structure of the endometrium is revealed, and with its submucosal localization, the latter is completely located in the uterine cavity. Additional information obtained during echohysterography facilitates the choice of therapeutic measures.
Along with the echographic picture of the structure of the myoma node with color Doppler mapping (CDC) evaluate the qualitative and quantitative parameters of its blood flow. In the vast majority of cases, non-mosaic blood flow is recorded along the periphery and only in 1/3 - inside it. With the so-called proliferating nodes, the type of blood flow is diffuse or mixed. Evaluation of the quantitative parameters of blood flow in CDI allows us to assume the histotype of the tumor. Thus, the blood flow velocity () in simple and proliferating fibroids is low and ranges from 0.12 to 0.25 cm / s, and the resistance index (RI) is 0.58-0.69 and 0.50-0.56 respectively. The high speed of arterial mosaic blood flow (0.40 cm/sec) in combination with low resistance index (RI0.40) makes it possible to suspect uterine sarcoma.
X-ray examination, computed tomography and magnetic resonance imaging in the diagnosis of uterine fibroids
At present, X-ray studies previously used to visualize the pathology of the uterus and its appendages (gas and bicontrast X-ray pelviography, intrauterine pelvic phlebography, etc.) are of a historical nature and have not been developed due to the emergence of other modern radiation research methods. Traditional x-ray studies are used in limited cases and most often only for the diagnosis of tubal infertility - hysterosalpingography.
The use of modern multislice computed tomography (MSCT or CT), especially with artificial contrasting, allows not only to determine the state and relationship of the pelvic organs, bone structures and pelvic vessels with high resolution, but also to diagnose the presence of bleeding in the acute period, as well as to introduce into gynecology methods of interventional radiology. CT of the pelvic organs is performed more often with the patient in the supine position.
However, methods of radiation diagnostics using ionizing radiation in gynecologists, and especially when examining girls, girls and women of reproductive age, for obvious reasons, are undesirable due to radiation exposure, which means that in the vast majority of clinical cases they should be used only with strict clinical indications, the inability to replace them with safer methods or when carrying out low-traumatic therapeutic measures, such as selective salpingography and X-ray surgical recanalization of the proximal fallopian tubes in case of their obstruction, embolization of the uterine arteries in the treatment of uterine fibroids, etc.
Spiral/multispiral computed tomography
In SCT with intravenous contrast enhancement, fibroids are defined as a soft tissue formation that causes deformity and/or protrusion beyond the outer contour of the uterus or deforms the uterine cavity. Uterine fibroids have a well-defined capsule and a homogeneous structure with a soft tissue density of 40-60 HU.
With multislice spiral CT of myomas with the introduction of radiopaque agents, it is possible to obtain data on the state of the small pelvic vessels, which is very important for identifying the main supplying vessel when planning the X-ray surgical treatment of fibroids by uterine artery embolization.
Multiple myoma is defined as a single conglomerate of soft tissue density with even clear contours, oval in shape with a homogeneous internal structure. With large fibroids, compression and deformation of the bladder and ureters can be observed. With the development of degenerative-necrotic changes, the structure of the fibroids becomes heterogeneous, with zones of reduced density due to impaired blood supply. With submucosal fibroids in the center of the uterus, a soft tissue formation is determined that repeats the configuration of the uterine cavity. Its contours are even, clear, surrounded by a hypodense rim of the endometrium, pushed back by the node. In the parenchymal contrast phase, the myomatous node clearly stands out against the background of the surrounding myometrium. Often, calcifications are formed in the myomatous nodes in the form of single inclusions and massive areas.
Magnetic resonance imaging
Myomatous nodes on MP tomograms are represented by formations with clear boundaries, with even or slightly bumpy contours. As a rule, a characteristic feature of myoma nodes on MRI in the first phase of the menstrual cycle is a low intensity of the MP signal on T2WI, close to the MP signal from skeletal muscles. Less often, myomatous nodes are detected in the form of formations with an average intensity of the MP signal, isointense to the myometrium, due to the pronounced content of collagen and the characteristics of the blood supply. For small nodes, their homogeneous structure is more characteristic. The minimum diameter of the detected nodes is about 0.3-0.4 cm. For smaller formations, similar to myomatous nodes in MP-characteristics, uterine vessels that have fallen into the tomograph section in cross section can be taken. The characteristics of myoma nodes can change due to not only a sharp change in blood flow during menstruation, but also degenerative processes in the node. Less commonly, cystic transformation is determined, as well as hemorrhages in the myomatous node, more characteristic of large nodes, which, as a rule, have a heterogeneous structure.
In general, MRI of the pelvic organs, regardless of the phase of the cycle, can reveal 5 types of myomatous nodes:
1 - with a homogeneous hypointense MP signal, similar to skeletal muscles;
2 - with a heterogeneous predominantly hypointense structure, but with areas of hyperintense inclusions due to degeneration with the formation of edema and hyalinosis;
3 - with an isointense MP signal, similar to myometrial tissue, due to the low content of collagen;
4 - with a high MP signal due to cystic degeneration;
5 - with varying MP-signal on T2WI and high, with varying degrees of intensity, on T1WI with degenerative changes with hemorrhage.
Fibroids with degenerative changes (hyaline, cystic) have a characteristic patchy or homogeneous appearance with a heterogeneous signal intensity. When calcified, the fibroid appears as a mass with a uniformly high signal intensity, clearly delineated by a low-intensity ring from the surrounding myometrium.
6. TREATMENT
The tactics of managing patients with uterine myoma include observation and monitoring, drug therapy, various methods of surgical intervention and the use of new minimally invasive approaches. For each patient, an individual management strategy is developed, i.e. the approach must be strictly personalized.
6.1 Surgical treatment
Indications for surgical treatment
Most patients with uterine fibroids require surgical treatment. Indications for surgery are detected in approximately 15% of patients. The generally accepted indications for surgical treatment are: heavy menstrual bleeding, leading to anemia; chronic pelvic pain, significantly reducing the quality of life; violation of the normal functioning of the internal organs adjacent to the uterus (rectum, bladder, ureters); large tumor size (more than 12 weeks of the pregnant uterus); rapid tumor growth (increase by more than 4 weeks of pregnancy within 1 year); tumor growth in postmenopausal women; submucosal location of the fibroid node; interligamentous and low (cervical and isthmus) location of fibroid nodes; violation of reproductive function; infertility in the absence of other causes.
As a rule, surgical treatment is performed in a planned manner in the first phase of the menstrual cycle (day 5-14). Emergency surgery is necessary in case of spontaneous expulsion ("birth") of the submucosal myomatous node, with degenerative changes in the tumor due to circulatory disorders, accompanied by signs of infection and the onset of "acute abdomen" symptoms, as well as with the ineffectiveness of ongoing antibacterial and anti-inflammatory therapy. Degenerative changes in myomatous nodes that naturally occur during tumor development, often detected using a variety of visualization of additional research methods (ultrasound, MPT, CT) and not having the above symptoms, are not an indication for surgical treatment. Multiple uterine fibroids of small size, which do not lead to symptoms, are also not an indication for surgery. Some national guidelines (ACOG Pract. Bull. N 96, 2008) dispute the need for surgical treatment only on the basis of clinically diagnosed rapid tumor growth outside the menopausal period (B).
Volume of surgical treatment
A patient with uterine myoma who is indicated for surgery should have full information about the advantages and disadvantages of radical and organ-preserving surgical treatment. The final decision on the scope of the operation and access should be made by the patient herself together with the surgeon (attending physician), signing an informed consent for the operation and awareness of the possibility of complications.
Hysterectomy.
The only method of surgical treatment that leads to a complete cure (radical) is an operation in the amount of a total hysterectomy - extirpation of the uterus. (level of evidence IA). Subtotal hysterectomy (supravaginal amputation of the uterus) is not a completely radical intervention, but it can be performed after confirming the condition of the cervix (colposcopy, biopsy if indicated) (level of evidence IA). When combined with adenomyosis, given the lack of a clear boundary of the disease, supravaginal amputation is not recommended, since incomplete removal of the above pathological processes is possible, which in the future may cause another operation (removal of the stump of the cervix and other pelvic organs - the distal ureter), since this is a more complex intervention due to the development of adhesive-cicatricial processes involving the bladder. And although recurrences of fibroids in the stump of the cervix rarely occur, in 15-20% of patients after surgery of this volume, cyclic bleeding from the genital tract is observed, which indicates incomplete removal of myometrial and endometrial tissues. The total volume of hysterectomy provides not only a radical cure for uterine myoma, but also the prevention of the occurrence of any disease of the cervix in the future. In countries that do not have comprehensive cytological screening, total hysterectomy should be considered as one of the measures to prevent cervical cancer. Hypothetical assumptions about the benefits of subtotal hysterectomy compared to total hysterectomy in terms of negative effects on urinary tract function, sexual function and the impact on quality of life in general have not been confirmed in numerous multicenter randomized trials. According to the American Congress of Obstetricians and Gynecologists (ACOG Comm. Opin. N 388, 2007), subtotal hysterectomy should not be recommended as the best option for hysterectomy in benign diseases. The patient must be informed about the absence of scientifically proven differences between total and subtotal hysterectomy in their effect on sexual function, as well as the possible recurrence of fibroids and the occurrence of other benign and malignant diseases in the cervical stump, for the treatment of which surgical treatment is necessary in the future.
Operation Access
The data of modern evidence-based medicine indicate that the best surgical approach for removing the uterus is the vaginal approach. Vaginal hysterectomy is characterized by shorter duration, blood loss and frequency of intra- and postoperative complications. However, to use this access for uterine myoma, a number of conditions are necessary: sufficient capacity of the vagina and uterine mobility, small size and mass of the tumor (less than 16 weeks and 700 g), the absence of a pronounced adhesive process in the pelvic cavity and the need for combined operations on the uterine appendages and/or abdominal organs. In the absence of conditions for performing a vaginal hysterectomy, a laparoscopic hysterectomy should be performed. Laparotomic hysterectomy, which does not have any advantages over the laparoscopic and vaginal counterpart, is only necessary for a small number of patients with extremely large tumors (more than 24 weeks and 1500 g) or when anesthesia is contraindicated. Laparotomic hysterectomy can also be performed in the absence of technical capabilities and conditions for endoscopic surgery (equipment, surgical team). The above limits for the size and weight of the uterus when it is removed by vaginal or laparoscopic access are conditional and depend on the experience of each particular surgeon. Regardless of the approach, a total hysterectomy should use an intrafascial technique that maximizes the integration between the pelvic fascia and the supporting ligaments of the uterus.
Myomectomy
Although a total hysterectomy is a radical operation, it should not be recommended for young women or those who wish to preserve the uterus and/or reproductive function. If there are indications for surgical treatment, these categories of patients perform organ-preserving operations - myomectomy. Indication for myomectomy is also infertility or miscarriage in the absence of any other reasons than uterine fibroids. The relationship between uterine fibroids and infertility has not been clearly defined. However, the results of a number of studies with a high level of evidence have shown that myomatous nodes in contact with the uterine cavity can be the cause of infertility. There is evidence of improved ART outcomes after myomectomy in women with unspecified infertility. To date, none of the existing diagnostic methods can identify all pathological foci either before surgery or during its process. The risk of recurrence (perhaps in most cases - persistence) is higher in the presence of multiple fibroids. With a single node, it is 27%, the risk of reoperation associated with relapse is 11%, and with multiple nodes, 59 and 26%, respectively.
Operation Access
The choice of access for myomectomy is a rather difficult task, depending not only on objective factors such as the size of the tumor, its localization, the multiplicity of pathological changes, but also on the experience of a particular surgeon.
Submucosal myomatous nodes (0-II type ESGE), not exceeding 5-6 cm in diameter, are removed hysteroscopically using a mono- or bipolar resectoscope or intrauterine morcellator. If it is technically impossible to completely remove a type II node, a two-stage operation is indicated. During a 3-month break between the stages, the patient is prescribed therapy with aGN-RH, which helps to reduce the uterus and migrate the unremoved remnants of the node into the uterine cavity. Hysteroscopic myomectomy may be an alternative to hysterectomy in postmenopausal women in whom, due to uterine contraction, myomas located near the cavity migrate into it. In premenopausal women who are not interested in preserving reproductive function, it is advisable to combine hysteroscopic myomectomy with endometrial resection.
Patients with single myomatous nodes of subserous and interstitial localization, even if they are significant in size (up to 20 cm), it is advisable to perform laparoscopic myomectomy. The indicated maximum diameter of the node is a conditional limit, especially when it is subserous. The same approach to the choice of access should be followed in the presence of multiple subserous myomas. In all cases, the wound on the uterus must be sutured in layers, as well as with vaginal or laparotomy myomectomy. An extracorporeal knotting technique should be used that provides a sufficient degree of thread tension and full alignment of the wound edges. Laparoscopic myomectomy can be combined with hysteroscopic in patients with an association of subserous and submucous nodes.
The disadvantages of laparoscopic access are the lack of the possibility of palpation search for intermuscular nodes and their enucleation using additional incisions in the myometrium in the bed of the main node. With multiple interstitial fibroids or associations of multiple nodes of various localizations, it is advisable to perform laparotomy myomectomy.
In all cases of born or born submucosal tumors, myomectomy is performed by vaginal access. In the presence of single subserous and intermuscular nodes located on the posterior wall of the uterus or in its bottom, it is possible to perform myomectomy by vaginal access through the posterior colpotomy opening. In this way, fibroids up to 8-12 cm in diameter can be removed using the node fragmentation technique. Vaginal access is most suitable for fibroids that are located partially or entirely in the vaginal part of the cervix.
Assisted Surgical Technologies
One of the main problems of myomectomy is the control of intraoperative bleeding. To reduce blood loss, both vasoconstrictive agents (vasopressin) and various methods of mechanical occlusion of the vessels supplying the uterus (twisting, clamps, ligation, coagulation or embolization of the uterine arteries) are used. In some countries, vasoconstrictors are banned due to reports of fatal cardiovascular complications after topical use of these drugs. In any case, when using these drugs, it is necessary to warn the anesthetist, given the vascular effect to increase blood pressure.
The second important problem of myomectomy is the occurrence of postoperative adhesions. To date, the most successful methods of preventing adhesions are considered barrier methods (mesh, gels, solutions), which provide a temporary delimitation of the wound from the adjacent anatomical structures.
New are the proven use of abdominal conditioning during endoscopic surgery with a controlled regime of temperature, humidity and supplemental use of oxygen.
Postoperative management
After a total hysterectomy, the only restriction for the patient is the refusal to have sexual activity for 1.5-2 months. Patients after subtotal hysterectomies should regularly undergo cytological examination of the cervical epithelium.
Patients after myomectomy should be protected from pregnancy for 6-12 months, depending on the depth of damage to the uterine wall during surgery. Oral contraceptives should be recognized as the most appropriate method of protection. Pregnancy is allowed after 1 year.
Postoperative anti-relapse treatment of aGN-RH is not indicated, as it reduces the blood supply to the uterus and therefore impairs wound healing.
The issue of insolvency of the uterine scar after endoscopic myomectomy, which is raised in modern domestic literature, requires careful analysis. In the foreign literature, there is only one work, which analyzed 19 cases of uterine rupture in the period from 17 to 40 weeks of pregnancy after myomectomy from 1992 to 2004. Only in 3 cases (18%), the fibroid nodes were more than 5 cm in diameter, and in 12 cases (63%) did not exceed 4 cm in diameter. Wound hemostasis was performed without coagulation only in 2 cases (10%). In 7 (37%) the wound was not sutured. None of the women died, 3 fetuses (18%) died at 17, 28 and 33 weeks of gestation. There are only 2 reports of uterine rupture during pregnancy after hysteroscopic myomectomy.
In addition, the cause of postoperative bleeding may be problems of the blood coagulation system, for example, von Willebrand's disease. They can be stopped by embolization of the uterine arteries. For the first time, embolization of the uterine arteries and vascular collaterals in obstetric and gynecological practice was used in the VNITs OZMIR of the USSR Ministry of Health in 1984 (L.V. Adamyan).
Since the late 70s, X-ray endovascular embolization of the uterine arteries has been used in obstetric and gynecological practice:
- to stop bleeding in the postpartum period;
- with cystic drift;
- after caesarean section;
- for conservative myomectomy and hysterectomy;
- to stop bleeding in inoperable malignant neoplasms;
- for preoperative devascularization of vascular tumors and arteriovenous anomalies in order to facilitate their removal and reduce blood loss.
Uterine artery embolization in the treatment of uterine fibroids
Currently, a promising X-ray surgical intervention in the treatment of fibroids is endovascular embolization of the uterine arteries.
Many patients categorically refuse surgical or hormonal treatment, which is due to the psycho-emotional status of the patient or the desire to preserve their own reproductive function.
Over the past decade, uterine artery embolization as an independent method for the treatment of uterine fibroids has attracted particular interest. The minimally invasiveness of endovascular intervention performed under local anesthesia, the effectiveness of the method leading to a decrease or disappearance of the symptoms of uterine fibroids, the preservation of the reproductive function of a woman, a short hospital stay are important and determining factors for the patients themselves.
Indications for uterine artery embolization: symptomatic uterine fibroids.
Uterine artery embolization (UAE) is an alternative to surgical treatment (level of evidence B).
Contraindications for uterine artery embolization: pregnancy, inflammatory diseases of the pelvic organs in the acute stage, allergic reactions to a contrast agent, arteriovenous malformations, undifferentiated tumor formation in the small pelvis, suspected leiomyosarcoma.
Instrumental and laboratory research before the procedure include all those accepted for elective surgical treatment, including:
bacterioscopic examination of the vaginal microflora (if inflammatory changes are detected, it is necessary to carry out antibiotic therapy - local application is possible in order to reduce inflammatory complications of UAE) ( level of evidence B);
oncocytological examination of endo- and exocervix;
ultrasound examination of the organs and vessels of the small pelvis with the determination of the blood flow velocity in the uterine, ovarian arteries and their branches. To assess the parameters of blood flow through the vessels of the uterus, ultrasonic triplex angioscanning (USAS) is used, including scanning of vessels in B-mode, Dopplerography and color Doppler blood flow mapping;
hysteroscopy and separate diagnostic curettage, followed by histopathological examination - with ovarian dysfunction, an increase in the median m-echo that does not correspond to the day of the menstrual cycle;
consultation of a gynecologist, interventional radiologist. UAE should be performed by experienced interventional radiologists who are familiar with the technique of the procedure, as well as the peculiarities of the blood supply to the myoma nodes ( level of evidence C);
when a tumor of the ovary or one of the nodes is detected with a multiple growth pattern of the subserous type on a thin base, operative laparoscopy is performed - removal of the ovary formation before UAE, followed by histopathological examination, and removal of the myomatous node after UAE in order to reduce the volume of blood loss and the risk of "lacing" the node into the abdominal cavity.
Special cases
usually takes no more than a few minutes. [email protected], we'll figure it out.
3.1 Conservative treatment.
It is not recommended to prescribe drugs for asymptomatic fibroids, with the exception of large tumors.
Recommendation level A (level of evidence 1a).
The appointment of medications or surgical treatment is recommended in the presence of abnormal uterine bleeding, anemia, pain in the pelvic area and associated endometrial hyperplastic processes.
Level of persuasiveness of recommendations C (level of evidence - 4).
Comments. It should be understood that the sole purpose of drug treatment is to alleviate or eliminate the symptoms associated with uterine fibroids, regression of myomatous nodes.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) is recommended for dysmenorrhea in patients with uterine fibroids.
Recommendation strength level B (level of evidence - 2a).
Comments. For uterine fibroids, these drugs may reduce significant menstrual blood loss, but are less effective than tranexamic acid**, danazol, or a levonorgestrel intrauterine system (LNG-IUD).
It is recommended to use antifibrinolytics, in particular tranexamic acid**, as non-hormonal first-line drugs for abnormal uterine bleeding.
It is recommended to use progestogens to reduce the amount of abnormal uterine bleeding and increase hemoglobin levels, as well as to prevent endometrial hyperplastic processes associated with uterine myoma.
Recommendation strength level B (level of evidence - 2b).
Comments. Progestogens have no effect on stabilizing or reducing the growth of fibroids, but they are used for a short time. Direct intrauterine delivery of progestogens is a widely used convenient method that provides high compliance and avoids the effect of the primary passage of the steroid through the liver. LNG-IUD reduces blood loss and restores hemoglobin levels in uterine myoma without affecting the dynamics of myomatous nodes. The effectiveness of treatment with oral progestogens depends on the mode of administration. With a cyclic mode (from the 14th to the 26th day of the cycle), the efficiency is 0-20%, with a 21-day mode (from the 5th to the 26th day of the cycle) - 30-50%. The use of progestogens as part of low-dose COCs reduces symptoms by 40-50%.
It is not recommended to use progestogen therapy in the presence of submucosal uterine fibroids.
Recommendation strength level B (level of evidence - 2b).
It is recommended to use gonadotropin-releasing hormone (GnRH-a) agonists as a preoperative treatment for patients with uterine fibroids and anemia (hemoglobin< 80 г/л), а также для уменьшения размеров миомы для облегчения выполнения оперативного вмешательства или при невозможности выполнения операции эндоскопически или трансвагинально. Длительность предоперационного лечения ограничивается 3 мес .
Strength of recommendation A (level of evidence 1a).
Comments. AGN-RG are one of the effective drugs that can not only reduce the symptoms caused by uterine myoma, but also temporarily affect the volume of myomatous nodes, while, unfortunately, the duration of treatment is limited to 6 months due to side effects (hypoestrogenia, loss of mineral density bone tissue) and are mainly used as a method of preoperative preparation. Add-back therapy (support therapy) with estrogens in adequate doses does not significantly affect the symptoms associated with fibroids and its volume during therapy with aGN-RH.
Progesterone antagonists (mifepristone) are not recommended for the conservative treatment of uterine fibroids.
Level of persuasiveness of recommendations C (level of evidence - 4).
Comments. Mifepristone has an antiproliferative and proapoptotic effect on leiomyomas, and after the cessation of treatment, the regrowth of myoma nodes is less pronounced than after therapy with aGN-RH. For uterine fibroids, a dose of mifepristone 50.0 mg is registered. However, this dose, which, according to the instructions for use of the drug, must be taken daily, for a long time, often leads to endometrial hyperplasia and causes menometrorrhagia. In addition, the reduction in the size of uterine fibroids is insignificant, which, together with the hyperplastic process and bleeding, currently limits the use of this drug.
It is recommended to use ulipristal acetate (selective progesterone receptor modulator) as a drug therapy for uterine fibroids for the preoperative treatment of moderate and severe symptoms of uterine leiomyoma (primarily uterine bleeding) and as monotherapy for 3 months. , if necessary, with a holding after 2 months. Repeated course within 3 months. In women of reproductive age over 18 years. Monotherapy with ulipristal acetate may prevent the need for surgery.
Comments. Ulipristal acetate affects the size of the myomatous node (reduces), without causing side hypoestrogenic effects. Stopping bleeding is of great positive importance, which is especially important for anemia due to menometrorrhagia. Ulipristal acetate induces benign histological changes in the endometrium, which disappear after the end of therapy. Take 1 tablet 5 mg per day for 12 weeks. Treatment with ulipristal acetate leads to a decrease in menometrorrhagia already during the first 7-10 days of therapy and, often, amenorrhea. The resumption of a normal menstrual cycle occurs, as a rule, within 4 weeks. After completion of the course of treatment. It is possible to conduct several courses with a break of 2 months. 10%%.
3.2 Surgical treatment.
Surgical treatment of uterine fibroids is recommended for heavy menstrual bleeding, leading to anemia; chronic pelvic pain, significantly reducing the quality of life; violation of the normal functioning of the internal organs adjacent to the uterus (rectum, bladder, ureters); a large tumor size (more than 12 weeks of the pregnant uterus); rapid tumor growth (increase by more than 4 weeks of pregnancy within 1 year); tumor growth in postmenopausal women; submucosal location of the fibroid node; interligamentous and low (cervical and isthmus) location of fibroid nodes; reproductive dysfunction; infertility in the absence of other causes.
Recommendation grade A (level of evidence 1a).
Comments. Most patients with uterine fibroids require surgical treatment. Surgical treatment is performed in a planned manner in the first phase of the menstrual cycle (5-14th day). If it is necessary to carry out hemostasis, fibrinogen-thrombin local hemostatic agents should be used. Barrier methods (mesh, gels, solutions) are considered the most successful methods of preventing adhesions, which provide temporary separation of the wound from adjacent anatomical structures.
An emergency operation is recommended in case of spontaneous expulsion (“birth”) of the submucosal myomatous node, with degenerative changes in the tumor due to circulatory disorders, accompanied by signs of infection and the onset of symptoms of an “acute abdomen”, with the ineffectiveness of ongoing antibacterial and anti-inflammatory therapy.
Comments. Multiple uterine fibroids of small size, which do not lead to symptoms, are not an indication for surgery.
It is recommended to perform an organ-preserving operation - myomectomy - for young women, as well as for those who wish to preserve the uterus and / or reproductive function. Indication for myomectomy is also infertility or miscarriage in the absence of any other reasons than uterine fibroids. .
Recommendation grade B (level of evidence 2a).
Comments. The only method of surgical treatment that leads to a complete cure (radical) is an operation in the amount of a total hysterectomy - extirpation of the uterus. Subtotal hysterectomy (supravaginal amputation of the uterus) is not a completely radical intervention, but it can be performed after confirming the condition of the cervix (colposcopy, biopsy if indicated). When combined with adenomyosis, given the lack of a clear boundary of the disease, supravaginal amputation is not recommended, since incomplete removal of the above pathological processes is possible, which in the future may cause another operation (removal of the stump of the cervix and other pelvic organs - the distal ureter), since this is a more complex intervention due to the development of adhesive-cicatricial processes involving the bladder. And although recurrences of fibroids in the stump of the cervix rarely occur, in 15-20% of patients after surgery of this volume, cyclic bleeding from the genital tract is observed, which indicates incomplete removal of myometrial and endometrial tissues.
It is recommended to remove submucosal myomatous nodes, not exceeding 5-6 cm in diameter, hysteroscopically using a mono- or bipolar resectoscope or intrauterine morcellator.
Recommendation grade B (level of evidence 2b).
Comments. If it is technically impossible to completely remove the node, a two-stage operation is indicated. During a 3-month break between the stages, the patient is prescribed therapy with aGN-RH, which helps to reduce the uterus and migrate the unremoved remnants of the node into the uterine cavity. Hysteroscopic myomectomy may be an alternative to hysterectomy in postmenopausal women in whom, due to uterine contraction, myomas located near the cavity migrate into it. In premenopausal women who are not interested in preserving reproductive function, it is advisable to combine hysteroscopic myomectomy with endometrial resection.
It is recommended to perform laparoscopic myomectomy in patients with single myoma nodes of subserous and interstitial localization, even if they are significant in size (up to 20 cm).
Recommendation grade A (level of evidence 1b).
Comments. The specified maximum diameter of the node is a conditional limit, especially when it is subserous. The same approach to the choice of access should be followed in the presence of multiple subserous myomas.
It is recommended to carry out myomectomy by vaginal access in all cases of submucosal tumors born or born.
Recommendation grade B (level of evidence 2a).
