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Submucosal location of uterine fibroid
Uterine fibroids' complications
Torsion of uterine fibroid
Pseudocapsule' and uterine fibroid' vessels rupture
Treatment of uterine myoma
HYDATIDIFORM MOLE (Molar pregnancy)
IV. Control questions and tasks
on the conference of the Department
of Obstetrics and Gynecology with the Course
of Infant and Adolescent Gynecology
“____” _____________200 p.
T.a.The Head of the department, Professor
on the themes singled out for independent study
“Benign tumors of uterus”
For 5 year students of
2 academic hours
Developed by assistant, PhD
I. Scientific and methodical grounds of the theme
Early and active diagnosis of benign tumors and precancerous diseases of female genitalia, their timely and correct treatment are the pledge for solution of cancer problems.
A student must know:
1. Classification of uterine myoma.
2. Methods of examination for diagnosis of uterine myoma.
3. Conservative methods of treatment.
4. Methods of myoma surgery.
5. Classification of uterine myoma.
6. What additional methods of investigation are used for confirmation of the diagnosis?.
A student should be able to:
1. Diagnose benign tumors of uterus.
2. Diagnose precancerous diseases of uterine cervix.
3. Carry out a vaginal speculum-examination, vaginal examination, put up primary diagnosis.
III. Recommendations to the student
Uterine myoma (fibromyoma, leiomyoma) — is a benign tumor which contains varying amounts of muscle and fibrous elements.
Concerning gynecologic diseases benign tumors are found in 10-25% of all the cases, although during the last years the tendency of increasing the quantity of these tumors is observed. The myoma arises seldom in young women. The risk of disease grows after 35-40 years, at the age which is close to climacterium. Later beginning of menstrual function, irregular menstrual cycle, high frequency of induced abortions are present in the past history of the patients. Therefore, 35-40 years women are patients at risk for uterine fibromyoma.
Tumor histogenesis and structure. Uterine myoma belongs to tumors, which are growing from mesenchyma. It has three consecutive stages in its morphogenesis. They are:
The areas of growth are formed mainly around the vessels. These regions are characterized by a high level of metabolism and increased capilary and tissual permeability which stimulate the tumor growing. Uterine fibroid has in its development parenchymal-stromal features of that layer, from which it has been educed, therefore the parenchyma and stroma ratio in a tumor is different. Leiomyoma is developed at predominance of muscle elements, in the structure of fibromyoma fibrous tissue is predominant. The consistency of tumor depends on fibrous and muscle tissue ratio: the more there are muscle fibers, the more the tumor is mild at palpation.
Myomas are classified according to histologic structure as myoma, fibromyoma, angiomyoma and adenomyoma. According to the speed of growing there are the tumors which are growing slowly and quickly. According to histogenesis peculiarities there are distinguished simple and proliferative myomas. Proliferative myomas contain much more atypical muscle elements, where is a great number of plasmatic and lymphoid cells and increased mitotic activity. The incidence of proliferative myomas happen twice more often in the patients with fast growing tumors.
Very often uterine fibroids arise in places of complex interlacing of muscle fibers of uterus — near tubal angles, on uterine center line. The myoma is characterized by the effusive growing. As compared with cancer fibroids they move apart tissue without destroying it. Tumor is growing simultaneously with tissue mass surrounding it. Uterine fibroids have few veins, basic amount of vessels is situated in pseudo-capsule. Uterine fibroids' lymphatic system is atypical without absorbent vessels. Uterine fibroids are deprived of nervous terminals, choline and adrenergic nervous frames.
According to their location in the uterus myomas are classified into:
The fibromyoma can have one fibroid (nodulosus fibromyoma), many fibroids (multiple fibromyoma) and diffuse growth (diffuse fibromyoma).
Hormonal status of the patients with fibromyoma. They are considered hormonally depend tumors because the growth of these tumors is related to estrogen production. In the majority of cases these patients have an hormonal dysfunction of ovaries which is characterised by anovulatory cycles, corpus luteum insufficiency. It leads to hyperestrogenemia and lowering of progesterone level. Small cystic changes in ovaries occur due to hormonal disordes. Uterine endometrium and myometrium are under the influence of estrogenic hormones. Their excessive amount in blood can lead to endometrial hyperplastic processes and cystic changes in myometrium. Such local hyperhormonemia leads to pathological hypertrophy of myometrium. Not only sexual hormones synthesis, metabolism and interaction impairment, but also the state of the myometrial receptors especially large activity of the estrogen receptors as compared with progesterones receptors, take part in a pathogenesis of uterine fibromyoma.
Fibromyoma grows slowly without any proliferative changes at presence of small cystic changes in ovaries with nonsignificant hyperestrogenemia. Fibromyoma growing depends on its type, location, blood supply and patient's age. Fibromyoma grows quickly in young patients, particularly during pregnancy, as the fetoplacental complex synthesizes large amount of estrogenic hormones, which are tumor stimulating growing factor. Quite often fibromyoma accelerates its growing in climacterium, when there is a rearrangement of woman's hormonal system. Ovaries undergo polycystic degeneration at that time.
Clinic. Clinical manifestation of fibromyomas depends on uterine fibroid's location, size of tumour, rate of its growing, and also presence of complications.
Of the most myomas there are not any symptoms at the initial stages. The main symptoms are pain, bleeding, sensation of pelvic heaviness in the lower part of the abdomen, progressive increase in pelvic pressure, infertility, frequent urination, pressure on the rectum. These symptoms most commonly occur during the excessive growth of tumor, and sometimes they testify development of secondary degenerative or inflammatory changes in fibromyoma tissue.
Menstrual function in the patients does not variate in case if tumor is sub-serosal because attached to the uterus by only a stalk or on a wide basis under a peritoneal integument and it is practically outside of uterine borders. Another spectrum presentation includes patients with atypical (subperitoneal) location of uterine fibroids: the tumors from the anterior wall of the uterus and antecervical location can press upon urinary bladder and cause dysuric signs; pressure on the ureters (as they traverse the pelvic brim) leads to hydroureter and sometimes to hydronephrosis. Retrocervical location of uterine fibroid due to intensive growing can spread in all small pelvic, compressing rectum and provoking constipation.
Intraligamentary tumor during its growing moves apart the broad ligament of the uterus. As the ureters are passing in the lower areas of parametrium, the tumor results in pressure upon ureters leading to hydroureters or hydronephrosis.
Cyclic menstruation is present but it is painful (algomenorrhea).
^ is characterized by cramping cyclic menorrhagia which has been changed into acyclic bleeding.
Monthly appreciable bleeding leads to the secondary iron deficiency anemia.
Characteristic dystrophical myocardial changes called "myom' heart" result from the secondary anemia and chronic hypoxia and are often found in patients with fibromyoma. Liver function is frequently broken in these patients. Probably, these changes are the result of steroid hormones metabolism dysfunction. Hypertrophy of the left ventricle, myocardial dystrophy, ischemic heart disease, idiopathic arterial hypertension are also present in these patients. In most of the patients after fibromyoma removal the arterial pressure is reduced to the normal level. This fact confirms the idea of pathogenetic connection of fibromyoma with changes in myocardium and rising of arterial pressure.
Diagnosis. History of the patients includes hereditary predilection (myoma in mother and other reproductive organs tumors in close relatives); menstrual dysfunction, late beginning of menarche and metabolism infringement (obesity, diabetes mellitus). Reproductive dysfunction (infertility, pregnancy loss), induced abortions (mucous and myometrium trauma should lead to endometrial receptor device changes),extragenital diseases, which caused endocrine and ovarian disordes, in particular can be present in these patients.
Bimanual examination in uterine fibromyoma has characteristic signs. It includes the presence of a large midline mobile pelvic mass with the regular contour. The mass usually has a characteristic "hard" feel or solid quantity.
Additional methods of investigation are used for confirmation of the diagnosis.
Pelvic ultrasonography is the most common method to confirm the uterine myomas presence. The ultrasonographer may suggest location, quantity, size of uterine fibroids, their sructure, presence of destructive changes. Dynamic observation enables to supervise efficiency of the conservative therapy, tumor growing, or, on the contrary, its reduction under the influence of treatment.
Prolapse of submucous fibroid (cervical protruding myoma)
Submucous fibromyoma is accepted by uterus as an ectogenic body. Fibroid descent to the inferior portion of uterus, irritating the isthmus receptors. It results in myometrial contractions, cervical dilation and uterus pushes out fibroid into vagina. Pedunculated tumor is connected with uterus. If pedicle is short, it can result in difficult complication — oncogenetic inversion due to prolapse of the submucous fibroid. Speculum examination should be performed for confirmation of this diagnosis: cervical protruding myoma is visible.
Treatment Submucous tumor can be easily removed by the incision of long pedicle by clamping the base through the cervix. The pedicle is then ligated. Such removal of fibroid can lead to uterine perforation when the pedicle is short and wide. These patients need hysterectomy.
Torsion of uterine fibfoid is a very common in subserous location. Clinically it is characterized by crarfiping pain, signs of peritoneal irritation, fever, urinary frequency and symptoms of rectal pressure. In this situation necrosis and infection are common.
^ Myomectomy is more commonly done when abdominal myoma location. Myomectomy should be the operation of choice in case of single subserous pedunculated tumor
Uterine fibroid' necrosis
Necrosis of uterine fibroid results from blood supply disorder of the tumor, occuring due to rapid growing, pregnancy, mechanical accident, and postmenopausal atrophy. It leads to tumor edema and pseudocapsule hemorrhages
Clinically it is characterized by cramping pain which enforces during palpation. Signs of peritoneal irritation are found. Fever and leukocytosis accompany severe degeneration.
Treatment is surgical removal.
Uterine fibroid' suppuration
Uterine fibroid's suppuration arises primarily very seldom. Sometimes it is a result of necrosis. Submucous and interstitial uterine fibroids may be suppurated. The serious septic state demands supracervical hysterectomy (subtotal) or total hysterectomy.
Pseudocapsule' and uterine fibroid' vessels rupture happens very seldom. It is accompanied by severe pain, signs of intraabdominal hemorrhage (hemorrhagic shock).
Uterine myoma and pregnancy
Pregnancy at fibromyoma of uterus comes mainly at subserous and interstitial location of uterine fibroids. Submucous fibroids manifest with pregnancy progressing.
Diagnosis of pregnancy in such patients represents appreciable difficulties. During the pregnancy there is a threat of its interrupting as the result of fibroid blood supply disorder (its necrosis, pseudocapsule hemorrhage). The function of urinary bladder and rectum is broken. Fetal position is frequently incorrect — oblique or transversal one. Breach presentation is common if the myoma does not let the fetal head get into pelvic inlet. Preterm rupture of amniotic fluid, primary and secondary dystocia of labor are common.
Cesarean section should be pcrfoimed if the nodes are placed behind the course of the genital canal and block the plane of pelvic inlet. Vaginal delivery is recommended in all other cases of labor. Postpartum hemorrhage happens in the third period of labor. Uterine fibroid should undergo involution until their complete regress in women with high-grade lactation during the further duration of puerperium.
Treatment of fibromyoma should be operative and conservative.
Indications to operative treatment are: myomatous uterus larger than 12-week of pregnancy, acceleretion of tumor growing, presence of such symptoms as pam, bleeding, secondary anemia; myoma's complications; suspicion on malignant degeneration and combining with endometriosis and endometrial hyperplasia. Operative treatment is performed in case when the patients have contraindication to hormonal treatment. These contraindications are: thromboembolism and thrombophlebitis, varicose phlebectasia, hypertension, operation concerning malignant tumors m the past, no effect from hormones.
^ are divided into radical and conservative — plastic ones.
Radical operations are in uterine removal — total hysterectomy or supracervical hysterectomy
Hysterectomy should be performed in 45-year-old women and older during tumor growing in menopause, presence of cervical and endometrial pathological changes (dysplasia, erosion, polyps, scars), combination of fibromyoma with precanserous lesions of uterine cervix and uterus, endometriosis, cervical and isthmic myoma Supracervical hysterectomy is performed in all other cases
^ are carried out for reduction or preserving of female menstrual and reproductive functions. Their using is justified in young women for anatomo-functional safety of uterus, fallopian tubes, ovaries and ligaments.
Conservative treatment of uterine fibromyoma has been confirmed patho-genetically and is directed on correction of hormonal state, treatment of anemia and metabolic dysorder, inhibition of tumor growing.
Indications. Conservative treatment is recommended at any age, lr case of myoma duration with poor symptoms or without any symptoms, at presence of contraindications to operative treatment.
Conservative therapy includes a diet with the usage of products, which contain A,E,K,C vitamins, such microelements as copper, zincum, lodum, iron, antianemic therapy, vitamin therapy, uterotomc drugs for decreasing of menstrual hemorrhage, lodium drugs should provoke inhibition of estrogenic secretion at ovaries 0,25% solution of potassium iodide should be taken in a dose of 15 ml once or twice per day continuously during 6-10 months. It is nessesary to combine lodium drugs with phytotherapy — 60 ml of potato juice per day .Electrophoresis of 1-2% solution of potassium iodide is commonly used 40-60 procedures are needed for the treatment course.
^ . Gyfotocyn is given intramusculary in the dose of 1 ml during 12-15 days since 5-7 day of menstrual cycle during 6-8 cycles. This medicine is recommended at menorrhagia of the patient at any age.
Androgens could be applied at uterine myoma in the period of penmeno-pause Its effect can be achieved by pituitary gland suppresion Androgens can result in reduction of uterine size, endomenal atrophy, ovaries follicular depressing. Methylandrostendiolum is prescribed 50 mg per day during 15 days in the follicular phase of reproductive cycle for 3 to 4 months. Methyltestosterone is administrated in 2 pills under the tongue three times per day during 20 days with 10-day time-out for at least 3 months.
Hestagens have been used in uterine fibromyoma because of its antiestrogenic effect. First line progestines are Progesterone in a dose of 5-10 mg intramusculary once per day for 10-12 days in luteal phase of a reproductive cycle or 2 ml 12,5 % solution of 17- Hydroxyprogesterone Capronate intramusculary on 12-14 day of a cycle for at least 3 months are prescribed.
Pharmacologic removal of the ovarian estrogen source can be achieved by suppresion of the hypothalamic-pituitary ovarian axis by the use of gonadotropin-releasing hormone (GnRH) agonists. Buzerelinum, gozerelinum and gestrmol belong to the essentially new medicines that are a gonadotropin-releasing luteal hormone agonists. Buzerelinum in a dose of 200 mg is administrated subcutane-ously for the first 14 days of reproductive cycle, then endonasal prescription in the dose of 400 mkg per day for 6 months. Zoladex-Depo is applied subcutaneous in a dose of 3,6 mg once a month for at least 6 months. This treatment is commonly used for 3 to 6 months before the planned hysterectomy, but it can also be used as a temporizing medical therapy until the natural menopause comes. GnRH agonists can not only result in reduction of uterine size, but also lead to a technically easier surgery with significantly diminished blood loss.
Hydatidiform mole is one of the forms of trophoblastic disease (pathology of conceptus) which is characterised by abnormal proliferation of syncytiotro-phoblast and replacement of normal placental trophoblastic tissue by hydropic placental villi. Hydropic villi are up to 3 cm in diameter and look like a mass of grape-like vesicles.
The ethiology and pathogenesis of trophoblastic disease is unknown. Molar pregnancy may be divided into complete mole and incomplete (partial) hydatidiform mole. Complete hydatidiform mole is identified macroscopically by edema and swelling of virtually all chorionic villi with a lack of fetus or amniotic membranes. It is developed during the first weeks of pregnancy. Incomplete (partial) hydatidiform mole is often associated with the identifiable fetus or with amniotic membranes. Grossly, placenta has a mixture of normal and hydropic villi that look like mosaic.
^ of invasive mole (also called chorioidcarcinoma detruens) rests on the demonstration of complete hydatidiform mole. Hydropic villi invade into the myometrium on different distances destroying muscle elements and vessels. It is similar to tumor growing.
Clinic. Hydatidiform mole is characterised by such main symptoms as:
Treatment. In most cases of molar pregnancy the definite treatment is removal of intrauterine contents. Uterine curettage is do by dilation of the cervix followed by suction curettage (large danger for perforation), vacuum aspiration, digital removal of mole (in the case if cervical canal passes 1-2 fingers) with the following curettage.
With cases involving 24 weeks' gestational size, an alternative to suction evacuation is induction of labor by prostaglandin and Oxytocin. Hysterectomy should be performed in case of excessive bleeding. All removed tissues should undergo histologic examination.
After reception of histological research results, that confirm the diagnosis, the woman is sent to oncologist's consultation where they will decide whether chemotherapy (Methotrexatum) is necessary.
1. Clinic of uterus fibromyoma.
2. Diagnostics and differential diagnosis of uterus fibromyoma.
3. Indication to surgery of uterus myoma.
4. Pathogenesis of uterus myoma.
5. Classifications of uterus myoma.
6. What is a hormonal status of the patients with fibromyoma?.
17. Methods of treatment of uterus myoma.
V. List of recommended literature
1. Danforth’s Obstetric and gynaecology.-Seventh edition.-1994.-P.1023-1055
2. Gynecology.-Stephan Khmil, Zina Kuchma, Lesya Romanchuk.-2003.-P.251-263
3.Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.-2000.-P.269-271
Approved on Session of Department of Obstetrics and Gynecology with course of Infant and Adolescent Gynecology_________________ protocol No________
T.a.The Head of Department:_______________ O.A.Andriiets’
|On the conference of the Department||On the conference of the Department|
|On the conference of the Department||On the conference of the Department|
|On the conference of the Department||On the conference of the Department|
|On the conference of the Department||Application form ХV international scientific conference «Ideas of Academician Vernadskyi and Problems of Regional Sustainable Development»|
«Kremenchuk Plavni». The conference fee does not cover meals and accommodation. For foreign participants the conference fee may be...
|Application form ХІV international scientific conference «Ideas of Academician Vernadskyi, Problems of Research and Evaluation of Regional Sustainable Development»|
«Kremenchutski Plavni». The conference fee does not cover meals and accommodation. The conference fee for foreign participants may...
|M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Rickets|