The first thing I usually say to patients who are diagnosed with uterine fibroids: “Don’t worry, everything will be fine” – and this is not a slyness, not a desire to give false hope, but a sincere positive statement. Unfortunately, we have to admit that the” monster ” of this disease was made by our gynecological community, which clothed myoma in various frightening forms and applied to it quite disproportionate aggressive methods of treatment.
If you have already encountered this problem, you may have noticed that there is no generally accepted concept for this disease: treat? to watch? getting pregnant? to operate? Doctors in their conclusions contradict each other, medical literature is full of General formulations, from which it is impossible to understand what exactly to do in your situation. You know why? Because the diagnosis of “uterine fibroids” combines a very wide variety of conditions that require maximum specificity in order to be able to effectively help you. Simply put, the phrase “uterine fibroids” carries no more information than the word “problem”. This situation allows different doctors to show this ” problem “from the angle at which they see it themselves, or as they want to see it, while often not fully understanding the essence of the”problem” itself. Below we will talk about why this happens.
The phrase “uterine fibroids” carries no more information than the word “problem”.
For example, for gynecologists-surgeons, uterine fibroids are the main substrate of their activity. At the same time, non-operating gynecologists can observe the myoma for a long time at the beginning, using various medications from time to time that have insufficient effectiveness, and then simply transfer the patient to the hands of the surgeon. Often, in all these actions, there is not only an understanding of the nature of the disease, the features of its course, but also a clear vision of the specific situation.
The diagnosis of “uterine fibroids” is quite serious. Be sure to choose a trusted specialist and do not forget to get a “second opinion”.
In order not to be afraid and tame a dangerous predator, a person studies its nature, evaluates its habits, notices the peculiarities of behavior, and only in this way fear and excitement disappear, and in return, the behavior becomes predictable and able to manage the situation. If you don’t know all these nuances, then fear determines everything. You have probably seen how calmly the trainer enters the cage to the tiger, without flinching at every movement. And how would you react to a paw suddenly raised by an animal? The difference is that the trainer not only knows what the tiger’s movements mean, but can also predict its behavior by sensing its nature. Unfortunately, it is fear and ignorance that often determine treatment tactics, which are often overly aggressive or inadequate – in fact, this is what you have to deal with.
I will try to tell you about uterine fibroids so that you understand the nature of this disease, realize its true significance for your body, so that you have your own intuitive understanding of how you can help cope with this disease in your particular case.
WHAT IS UTERINE FIBROIDS?
So, uterine fibroids are a chronic disease of the uterus, characterized by the appearance of nodes consisting of modified smooth muscle cells. This disease is limited in time by the reproductive period of a woman, that is, fibroids do not occur before the beginning of menstruation and are subject to reverse development after menopause. Please note that I wrote that this is a disease of the uterus, not the reproductive system as a whole. The fact is that each node is formed from a defect that occurs in one cell of the uterine muscle membrane, and is not the result of” hormonal disorders”, as it is written in most of our textbooks. The growth of formation from a single cell that has received a defect is characteristic of a tumor; in fact, uterine fibroids are still considered a benign tumor, but it does not meet all the criteria for the tumor process, so in recent decades, fibroids are increasingly called a tumor-like disease.
Myoma is formed from a defect that occurs in one cell of the uterine muscle membrane, and is not a consequence of hormonal disorders, as is commonly thought.
One of the most important differences between uterine fibroids and a benign tumor is that it does not have the risk of becoming a malignant neoplasm. The rarest malignant tumor of leiomyosarcoma develops independently, and not by transformation from uterine fibroids. This is how we discard one of the most terrible “masks” of fibroids – the “mask of malignancy”, because of which a huge number of women unnecessarily lost their uterus. In fact, the figures are frightening: on average, in our country, about 800 thousand Queens are removed per year, in the US – 600 thousand, and in all these cases due to the presence of uterine fibroids.
But let’s go back to the defective cell from which the fibroids node begins to grow. One researcher defined this process: he called the division of the myoma progenitor cell “the pregnancy of a single cell in a non-pregnant uterus.” In fact, the cell acquires the same properties as cells in the uterus during pregnancy, when they actively divide, increasing the size of the uterus. There is not enough space for newly formed cells, in addition, they have a broken system of relationships between themselves, so dividing cells do not just thicken the wall of the uterus, but form a spherical structure.
Myoma-pregnancy of a single cell in a non-pregnant uterus.
The growth of the germ node is stimulated by sex hormones, and this is obvious, since the cells of the uterus muscle are initially sensitive to hormones, since they need to be divided during pregnancy, and this property is preserved in the defective cell. There are two types of female sex hormones – estrogens and progesterone. These two hormones work together: estrogens prepare cells, making them sensitive to progesterone, which has its main effect. The division of a smooth muscle cell triggers progesterone. Since our defective cell is “pregnant”, it has an increased sensitivity to progesterone, which stimulates its division. Actually, because of this, uterine fibroids cells actively divide during the second phase of the cycle and during pregnancy – that is, when the level of progesterone increases significantly.
It’s time to tear the second “mask” from this disease-uterine fibroids do not appear due to” an imbalance of sex hormones with a predominance of estrogens”, but grow from a defective cell that decides that it is” pregnant”, this, in turn, makes it highly sensitive to progesterone.
Misinterpretation of the nature of this disease has led to widespread” treatment ” of uterine fibroids with the drug dufaston – in fact, pure progesterone. It was assumed that progesterone suppresses the effects of estrogens that stimulate the growth of fibroids. As a result, the nodes in this “treatment” grew, and then due to the ineffectiveness of drug therapy, the patient was admitted to the surgeon’s table. The relatively recent appearance of esmia (a progesterone receptor blocker) – a drug that deprives fibroids of the effects of progesterone alone, which leads to a decrease in nodes, should, in fact, have brought dufaston’s apologists to reason, but who is still there, and I continue to meet this drug in prescriptions.
The fibroids in any case can not be treated with antiseptic!
I think that the question is long overdue: what causes a defect in the cell, causing it to divide and form a node of fibroids? Unfortunately, this is unknown. There are several theories, but they don’t look convincing enough. One of them suggests that the cells get a defect during intrauterine development, since the smooth muscle cells of the uterus have a long unstable period up to the 38th week of pregnancy, and various factors can have a negative impact on it. The cells that receive the defect in this way are activated after the beginning of menstruation and give growth to the nodes of fibroids.
According to another theory, the cells of the uterus muscle normally begin to divide during the second phase of the cycle, preparing for a possible pregnancy. If pregnancy does not occur, the newly formed cells must die, a scientific phenomenon called apoptosis. Some cells may not die and remain in a state of active division. Perhaps some of them still die in subsequent cycles, but some remain and give rise to the formation of nodes. It is assumed that inflammatory diseases of the uterus, operations on the uterus, abortions, and scraping can contribute to this process. Many menstrual cycles as a result of a small number of pregnancies or late first deliveries are also considered as a damaging factor that can accumulate cells that are precursors of uterine fibroids.
The causes of uterine fibroids are many: from abortions and inflammation to a small number of pregnancies and late deliveries.
The beginning of myomatous node formation does not mean that the process has started, and active progressive growth will continue. The fate of the germ can be different. A node may begin to grow and stop, for example, at the size of 2-3 mm and then disappear completely; others may grow to 10-15 mm and also not grow for years, and then increase by 30-40 % and again maintain a stable size for a long time. There are nodes that begin to grow and do so quite rapidly – up to a few centimeters per month. Growing nodes can reach 20 cm or even more. The node may be one in the uterus, but more often the fibroids are multiple.
Separately, you should describe the” suicidal ” behavior of nodes. At some point in the growth process, the blood flow through the vessels that feed the fibroids is disrupted, and as a result, it “dies”. The node develops local necrosis, which is not dangerous for the surrounding tissue. Below we will consider one of the methods of treatment, in which such a mechanism of” suicide ” nodes is the basis of the therapeutic effect. As a result, the node not only stops growing, but also decreases in size by an average of 50%, fibroids are replaced by connective tissue, and a dense calcified capsule is formed around the node. Often in the process of degeneration, decay cavities filled with liquid are formed in the node; such a node can grow no longer due to cell division, but due to the accumulation of liquid in these cavities, but this phenomenon is quite rare.
Many nodes in the uterus die in the third trimester of pregnancy, as the main blood flow is directed to the fetus, and the uterine wall and fibroids are significantly “stolen”.
Most often, independent node death occurs after childbirth. Most likely, this is due to the fact that in the third trimester of pregnancy, the main blood flow of the uterus directs the fetus and significantly steals the uterine wall and fibroids growing in it. This leads to their death. Often, six months after delivery, control ultrasounds show reduced nodes with no blood flow on average by 50%, surrounded by a calcified capsule.
Thus, judging by the described “habits”, uterine fibroids can exhibit a wide variety of behaviors, and it is almost impossible to predict which scenario it will choose. Attempts to use the severity of blood flow in the nodes as a criterion for predicting the growth rate were not successful, I met many nodes with active blood supply, the size of which did not change from year to year. This may be due to the fact that blood vessels can pass through the node in transit without supplying the tissue with blood, especially if this tissue has previously undergone degenerative changes and is mainly represented by dense connective tissue fibers.
Some myoma nodes may die on their own.
Now that you understand that some of the nodes can die, and induced termination of blood supply of the node is the basis of one of the methods of treatment of uterine fibroids (more about this below), you can imagine how absurd is the situation in which the patient is admitted to the hospital with a diagnosis of “uterine cancer, a blood disorder site,” and she carried a therapy aimed at the restoration of blood flow, that is, “save” fibroids, instead of just numbing the patient (the process is accompanied by pain and sometimes fever) and letting the nodes die to the end. Now the saddest thing is the widespread practice. Unfortunately, such actions are prescribed in the clinical recommendations. Ask why? Because there is no understanding of the nature of the disease, the essence of the processes occurring in the nodes, and there is a fear of invented complications. Some doctors, and, unfortunately, a large part, believe that necrosis in the node can lead to inflammation of the uterus and peritonitis, which is fundamentally wrong.
Unpredictability in the behavior of fibroids is important to consider when evaluating a specific clinical situation. No matter what the doctors tell you, it is impossible to predict how fibroids will behave in the future from a single ultrasound, and it is only possible to notice a growing trend from a series of ultrasounds with a time interval, but in some cases, despite the previous growth, there may be no further progression of the disease.
Now that you know how knots can behave, it’s time to get to know them better and find out what they are and how they can affect a woman’s quality of life.
CLASSIFICATION OF UTERINE FIBROIDS
Myomatous nodes are classified by location and direction of growth. Below I will list the names of nodes, and in the picture you can understand how they are located in the uterus:
- Interstitial nodes are located strictly in the wall of the uterus;
- subserous nodes grow outside the uterus;
- submucous nodes grow in the uterine cavity;
- cervical (cervical fibroids) nodes are localized either in the cervix or in the isthmus;
- interstitial nodes are located in the broad ligament of the uterus.
There are six types of uterine fibroids.
Nodes can have an intermediate position. Such nodes, for example, called intramurals-subserous. Depending on the direction in which the node grows, there are centripetal growth and centrifuge growth, that is, in the first case, the node grows towards the uterine cavity, in the second – in the direction of the outer shell of the uterus.
Submucous and subserous nodes are further classified depending on how much they penetrate into the uterine cavity or protrude outwards. Everything is simple: zero type – a node is fully within the uterine cavity or outside (subserous node of null type is also called a node on a stem); the first type node by 50% is in the cavity or outside the uterus, rest in the wall of the uterus; the second type – all the same, only the node performs 30 %.
The structure of the nodes of uterine fibroids may consist more of modified smooth muscle cells or contain a lot of fibrous tissue, which is typical for older nodes or nodes with impaired blood supply. These nodes are also called uterine fibroids.
Remember, at the very beginning I wrote, the first thing I say to patients with uterine fibroids: “Don’t worry!» In fact, this disease in most cases is not dangerous at all. In 60% of women, fibroids do not manifest themselves in any way, that is, the disease is asymptomatic. In General, uterine fibroids are one of the most common gynecological diseases: myomatous nodes are found in more than 87% of women, that is, almost all representatives of the fair sex, but symptoms are detected only in 30-35 %. What happens with the rest of the fibroids? As a rule, these are small nodes, some of which, after passing through pregnancy and childbirth, die, others simply do not grow, or grow slowly during the reproductive period of a woman, without reaching a clinically significant size. After menopause, the nodes stop growing and shrink. That is, myoma nodes can accompany a woman throughout the reproductive period, without creating any trouble for her.
In 60% of patients, fibroids are asymptomatic and absolutely not dangerous. Moreover, this disease is one of the most common in gynecology – it affects up to 87% of women.
WHAT IS THE MANIFESTATION OF UTERINE FIBROIDS?
The most common complaint associated with uterine fibroids is abundant, often prolonged menstruation, which leads to anemia. Bleeding during menstruation is typical for submucous nodes, that is, nodes that deform the uterine cavity, and large intramural nodes, as well as in situations where many nodes of different localization significantly increase the uterus. To understand the reason for abundant monthly periods in this disease is quite simple: nodes disrupt the process of reducing the uterus during menstruation, which is necessary to stop bleeding, and if the uterus is enlarged in size, then the actual size of the uterine cavity, that is, the amount of rejected endometrium, also increases.
Women may not notice serious blood loss.
Not all women are able to adequately assess the volume of their blood loss during menstruation. I often hear the phrase: “my whole life I have abundant periods and now they are the same” or “I would not say that my monthly period is abundant”, but the analysis may show a picture of pronounced anemia, that is, serious blood loss is simply not noticed by women. Therefore, an objective criterion for increasing the abundance of menstruation can only be a General blood test, an analysis for iron and ferritin (indicative of the presence of iron in the tissues-depot).
Gradually developing anemia is very insidious. Since there are no contrasting sensations, a woman may not notice how fatigue increases, memory decreases, sleep is disrupted, hair begins to fall out, and skin condition worsens. Often with these complaints, patients first turn to therapists, and it is these doctors who send them to the gynecologist, where it turns out that there is a uterine fibroid. I have had patients with hemoglobin 48 (at a rate of 120 to 140) who led a virtually normal lifestyle and showed no General complaints, except for slight weakness and heavy menstruation, and probably would not have reached the gynecologist themselves if they were not urgently sent for examination by a GP. Women often notice how dramatic the situation is with their health only after the treatment of uterine fibroids, when normal hemoglobin levels are restored and monthly periods become normal in volume. I often hear the phrase: “I Didn’t notice it before, because I didn’t live, but just existed, it seemed like it should be – constantly tired, angry and pale, and now everything has become wonderful.”
Given what was discussed above, you can understand why in some cases, neither the woman herself nor the doctor can reliably assess the abundance of menstruation. This is important, since the fact of the presence or absence of complaints is important for the choice of treatment tactics for fibroids. Asymptomatic fibroids do not require immediate treatment, we will talk about this later, but “asymptomatic” must be proved by objective methods. For example, a 42-year-old patient with multiple uterine fibroids comes to my office and says that she has no complaints and, according to the latest ultrasound, the nodes do not grow. The character of the monthly describes as “always been plentiful and now the same as they have been all my life.” Here you can release the patient for another six months under observation, but the blood test shows that the hemoglobin is reduced to 80. In-depth questioning reveals complaints of weakness, malaise, hair loss. “But who doesn’t get tired now?” the patient retorts. It is obvious that this situation cannot be observed further, and there are indications for the treatment of uterine fibroids, not anemia. Yes, here you can often find a fairly common situation when a patient independently or on the advice of a doctor begins to take iron preparations, without eliminating monthly blood loss. At the same time, in blood tests, iron and hemoglobin indicators are restored, but the depot in the tissues is usually not. Thus, in effect, the patient endlessly pumps the punctured tire instead of plugging the hole through which the air escapes. Obviously, as soon as the air stops entering the tire, it will immediately deflate. The same thing happens with the body.
The normal level of hemoglobin for a woman is from 120 to 140.
If you have heavy bleeding, be sure to add a General blood test and do an ultrasound – all this will help to detect uterine fibroids.
Thus, the first and main symptom of uterine fibroids – heavy menstruation-may not be noticed by the patient, so it requires objective evidence-an assessment of the level of hemoglobin. Here it is necessary to make a small remark: the decrease in hemoglobin levels may be due to other reasons (nutrition, bleeding from the gastrointestinal tract, tumors, etc. therefore, if you are sure that you actually have non-abundant menstruation, the uterus is small, the nodes are mostly subserous, there is no deformation of the uterine cavity, and the hemoglobin is reduced – you need to look for the cause elsewhere, and you do not have indications for the treatment of uterine fibroids.
The next common symptom is pressure on the bladder, less often-on the rectum and abdominal enlargement. The uterus is anatomically located between the bladder and rectum. It is obvious that with its increase, especially with the formation of volume formations on its surface, this can not but affect the work of neighboring organs. In order for such symptoms to appear, the uterus must significantly increase in size. In addition to the size of the uterus, the appearance of these symptoms is also affected by the size of the pelvis and the position of the uterus inside the pelvis. That is why some patients have compression symptoms early enough, already with a small increase in the uterus, and in others the uterus can reach the navel, and urination will remain normal.
Actually, the increase in the abdomen is determined to a greater extent by the patient’s Constitution and the thickness of subcutaneous fat on the anterior abdominal wall. In full patients, the enlarged uterus may not appear on the surface of the abdomen for a long time.
Indirect symptoms of the appearance of uterine fibroids are an increase in the abdomen (may not be visible for a long time in full patients) and frequent urge to urinate.
Pressure on the bladder leads to increased urination. It is important to remember that this symptom can also be in other gynecological diseases, for example, when the front wall of the vagina is lowered. Since the indications for the treatment of uterine fibroids depend on the presence or absence of complaints, it is necessary to assess what exactly leads to a violation of urination. For example, a patient may have a small asymptomatic, untreated uterine fibroids, and frequent urination is caused by the lowering of the vaginal wall. In this case, indications for the treatment of uterine fibroids may not be.
Abdominal pain is also referred to as a manifestation of uterine fibroids, but this is a very non-specific symptom. In fact, some nodes may occasionally hurt, especially if they develop degenerative processes, but in the vast majority of cases, uterine fibroids should not give pain.
Separately, it is worth highlighting the influence of uterine fibroids on conception and gestation. I note immediately that not all fibroids affect the possibility of pregnancy and its further course. About 10 % of all pregnancies occur with uterine fibroids without any complications. Therefore, you should not immediately be afraid if you were diagnosed with such a diagnosis, and you just went to the doctor in order to prepare for pregnancy. In fact, it often happens that fibroids are first detected when such an appeal to the gynecologist. Let’s look in detail at exactly how fibroids can interfere with pregnancy.
UTERINE FIBROIDS AND PREGNANCY
So, the uterus has a cavity in which pregnancy occurs. Obviously, if the myoma node is located in the uterine cavity or deformes it, pregnancy will either not occur, or there is a high risk of its termination, since the growing node (and nodes grow during pregnancy under the influence of progesterone) will reduce the space in which the fetus will develop. A special problem can be created by nodes on the border with the uterine cavity: if the placenta develops in this place, the subject node will not allow it to provide a full blood supply, which will affect the nutrition of the fetus.
Nodes in the cavity of the uterus incompatible with pregnancy.
Thus, the presence of nodes in the uterine cavity that deform the uterine cavity or are subject to the cavity is an indication for the treatment of uterine fibroids.
Another situation is that the nodes are located far from the uterine cavity, these are intramural, intramural-subserous and subserous-in this case, the size of the nodes and their number are important. Large nodes, 6-8 cm or more, in the process of growth can “steal” the fetus, pulling the blood flow from the arteries of the uterus to themselves. Accordingly, in such cases, there are serious risks of termination of pregnancy. Subserous nodes on a thin base are associated with another risk: during pregnancy, the node leg may twist, which will cause node necrosis. This necrosis is already dangerous, and there will be a need for emergency surgical treatment, which is not very desirable during pregnancy.
Not all nodes interfere with the onset and bearing of pregnancy.
Let me explain the difference between the two mechanisms of node necrosis. Let me remind you that I mentioned earlier that necrosis in the node is a favorable phenomenon that leads to the death of the node without the threat of complications. “Benign necrosis” is the result of cessation of blood supply to site through the arteries within the site, in other words, from the inside, that is, disturbed nutrition of only abnormal tissue, and surrounding healthy tissue is not affected. When the leg of the node is twisted, the arteries that supply blood to the outer wall of the leg, the serous membrane, are squeezed, and in this case, necrosis spreads to it, and this is already dangerous with the development of peritonitis and the separation of the node.
In this case, which nodes are not dangerous for pregnancy? Small intramural and intramural-subserous nodes up to 4-5 cm, subserous nodes on a wide base of small size. The cervical and isthmus nodes also do not affect pregnancy. Of course, it is important to consider not only the size and localization of nodes, but also their number. Many small nodes in total can create a problem for the course of pregnancy.
Separately, you should describe the behavior of uterine fibroids during pregnancy. From the very beginning, the nodes will start to grow, and on average they can increase by 25 % over the entire pregnancy. Therefore, do not be afraid if the ultrasound shows you the fact of node growth – this is normal. Closer to childbirth, the growth of nodes slows down, a lack of blood supply affects them, it is almost completely directed to the fetus. The presence of fibroids does not mean that you will have indications for a cesarean section: in the vast majority of cases, uterine fibroids do not interfere with childbirth through the natural sexual pathways. If you still have obstetric indications for a cesarean section, it is not advisable to remove the nodes during this operation. On the one hand, this complicates the operation itself, increases blood loss and is associated with great risks. On the other hand, the removal of nodes leaves additional scars on the uterus and is associated with the risk of relapse, that is, the appearance of new fibroids with a frequency of 7-14% per year. As I wrote above, after passing through pregnancy, most of the nodes “die”, losing blood supply, so the problem of uterine fibroids can be solved by the very fact of pregnancy, without additional trauma to the uterus and the risk of new nodes.
Uterine fibroids are not always an indication for a cesarean section, since most often they do not interfere with the passage of the child through the birth canal.
Here, in fact, are all the manifestations of uterine fibroids that can affect the quality of life of a woman and interfere with the implementation of reproductive function. Before coming to the important part – ways to treat this disease-it is necessary to consider the question of how to diagnose uterine fibroids. Diagnosis of uterine fibroids, as a rule, does not cause any difficulties, but there are nuances that deserve special attention.
DIAGNOSIS OF UTERINE FIBROIDS
The simplest, but at the same time the most uninformative way to diagnose uterine fibroids is an examination on a chair. In this case, the doctor feels the uterus through the anterior abdominal wall and may find that it is enlarged, its surface is bumpy, individual nodes may be palpated. On the basis of such an examination, we can only say that there is a fibroid and it increases the uterus according to a certain period of pregnancy.
The easiest way to diagnose uterine fibroids is an examination in a chair. However, this method is extremely inaccurate and uninformative.
Yes, it is by this conditional criterion that this disease is first diagnosed. This criterion is very subjective, not only because the doctor can not accurately estimate the size with his hands, but also for a number of reasons. The uterus may have a different position inside the pelvis, and if, for example, it is located high, its size may be estimated more than it actually is. With excessive deposition of subcutaneous fat on the abdomen, palpation of the uterus is difficult. Nodes may be located on the uterus asymmetrically, for example, on the sides, which makes it difficult to identify the exact compliance with the conditional term of pregnancy.
If the nodes are small and do not increase the overall size of the uterus, the examination on the chair may be completely uninformative. Although this diagnostic method can be considered outdated in General, since it does not carry almost any specific information, it is still actively used. Moreover, the classification of uterine fibroids according to the pregnancy period is still used in determining indications for surgical treatment. Thus, an increase in the uterus according to the pregnancy period of more than 12 weeks is an indication for its removal. Of course, in modern conditions, this approach is completely unacceptable.
The” gold standard ” for diagnosing uterine fibroids is ultrasound. The possibilities of this method are quite sufficient. I think that it does not make sense to describe the process of ultrasound, but the description of the results deserves special attention. As a rule, the Protocol specifies the size of the uterus and separately describes the nodes, indicating their localization and size, but it is extremely rare to find a graphic image of nodes in the walls of the uterus. Such topography is of great importance when choosing a method for treating uterine fibroids or evaluating the possibility of pregnancy.
The gold standard for diagnosing uterine fibroids is ultrasound.
For example, the doctor writes “on the anterior wall of the intramural-subserous node size of 5 cm”, but this description may correspond to a very large variety of localizations, which may affect the assessment of the situation and further tactics. Even a very detailed description will not be able to replace the graphical layout of nodes. I always Supplement the ultrasound Protocol with a similar drawing, and this gives a clear understanding of the problem not only for me, but also for the patient herself. The diagram immediately shows how the uterus is changed, how much and in what exact place the cavity is deformed, how deep the nodes lie in the wall of the uterus. Often, looking at the drawing, the patient herself understands that, for example, the surgical removal of all nodes, proposed to her by another doctor, will cause a serious injury to the uterus, and, most likely, not all nodes will be able to be removed. Without such graphics, the ultrasound report was just a text that could be interpreted in any way. Such transparency is sometimes unprofitable for some doctors, as it allows them to make convenient and profitable conclusions, so I urge you to always ask the doctor who performs your ultrasound to make a drawing of your nodes with the designation of their exact localization.
If the size of the uterus is large enough and it is impossible to fully assess it during ultrasound, MRI comes to the rescue. This method is very informative, there are no restrictions on the size of the uterus for it. MRI can be used as the most accurate method of diagnosis in all cases of uterine fibroids, but in most cases it is an excessive method, ultrasound is quite sufficient. MRI is still an auxiliary method.
Ultrasound + MRI allow you to fully assess the location of nodes in the uterus.
In General, ultrasound and MRI are quite sufficient to fully assess the fibroids. It should be noted that none of these methods allows you to suspect the presence of a malignant tumor-leiomyosarcoma (the rarest soft tissue tumor). Therefore, various indications of some “specific signs” of malignancy, which you can find in the texts of the protocols – are nothing more than a doctor’s imagination. You may be pointed to the presence of” low-resistant blood flow”, some features in the description of the node – all this is not a specific sign of a malignant process, if we are talking about uterine fibroids. It has been repeatedly proved that it is impossible to diagnose leiomyosarcoma by ultrasound and MRI, the diagnosis can only be established by histological examination of the remote node.
Diagnostic scraping is indicated only if endometrial pathology was detected during ultrasound.
Often, after the diagnosis of “uterine fibroids”, the doctor recommends diagnostic scraping. There is no need for this procedure as part of the diagnosis of this disease. Diagnostic scraping will only be shown if you have detected signs of endometrial pathology (the lining of the uterus), namely a polyp or hyperplasia, during the ultrasound. To evaluate this uterine tissue, scraping is used, since the fibroids tissue cannot be obtained during scraping, except in cases when the node grows into the uterine cavity. Therefore, such an appointment in the absence of endometrial pathology is more formal, blindly following the recommendations made a long time ago, when the attitude to uterine fibroids was extremely suspicious.
Conducting a hysteroscopy (examination of the uterine cavity with a miniature camera) in the vast majority of cases is also excessive and is only important in the presence of submucous nodes (growing into the uterine cavity), but in this case, hysteroscopy is combined with subsequent resection of the node, if possible.
What is not necessary for the diagnosis of uterine fibroids? You do not need hormone tests, this is a completely unnecessary examination, since it does not carry any additional information. I hope you remember that uterine fibroids are not the result of a violation in the “hormonal background”, but grow from a single defective cell. Such an appointment is still made by doctors who have old ideas about the nature of this disease.
No cancer markers have been created for uterine fibroids; the markers that patients are often asked to make have nothing to do with this disease. Most often it is SA125 and REA. These are rather non-specific markers that have more to do with the ovaries, but it is important to remember that the level of CA125 can increase in the presence of endometriosis and, in particular, adenomyosis (endometriosis of the uterus). Adenomyosis often accompanies uterine fibroids, or for uterine fibroids take the nodular form of this disease. So if you survey at a hysteromyoma you have an analysis of CA125 and it was increased, then worry not, for the fibroids this is irrelevant, but may indirectly indicate the presence of adenomyosis, especially if the analysis was taken immediately after the end of menstruation.
There are no cancer markers for uterine fibroids. Those that are often prescribed to patients have nothing to do with this disease.
Examination for infections can be carried out regardless of the presence of uterine fibroids, but the presence of these infections does not affect the development of fibroids and will not affect further treatment tactics.
If we talk about laboratory diagnostics, then first of all it is necessary to make a General blood test and assess the level of iron and ferritin. These data are more important for assessing the condition of a patient with uterine fibroids than the values of hormones or the presence of infections (of course, when they are detected, treatment is mandatory). Let me remind you that it is the hemoglobin and iron indicators that will help you objectively assess the presence of blood loss as the main symptom of this disease.
MRI shows a large size of the uterus.
Let’s sum up a little: in the vast majority of cases, ultrasound is enough to diagnose uterine fibroids. When the uterus is very large, ultrasound complements MRI. As a result, you should not only have a Protocol with a detailed description of the nodes, but also a drawing with their exact location in the uterus. From laboratory diagnostics, a General blood test and evaluation of iron and ferritin indicators are sufficient. With this kit, you can go to the doctor to choose a treatment method.
PRINCIPLES OF TREATMENT OF UTERINE FIBROIDS
Treatment of uterine fibroids is not necessary in all cases, that is, the fact that you have uterine fibroids does not mean that you necessarily need to take something or remove it.
In the treatment of this disease, there are 5 tasks.
- Eliminate heavy menstruation and, accordingly, blood loss, leading to iron-deficiency anemia.
- Eliminate pressure on the bladder or rectum.
- To stop the progressive growth of nodes.
- Ensure the possibility of pregnancy and gestation.
- Provide the possibility of hormone replacement therapy.
Please note, and this is very important: uterine fibroids themselves are not a separate goal in the treatment of this disease. When you go to the doctor, you need to set the task not to cure you of uterine fibroids, but to solve one of the five tasks outlined above. A lack of understanding of this principle leads to the fact that fibroids are often treated either too aggressively, or in cases where there is no indication for this.
Physiotherapy and phytotherapy are ineffective in the treatment of fibroids.
Before describing the currently existing methods of treating uterine fibroids, I would like to list those methods that are ineffective against this disease.
Here is a list of them:
herbs (herbal medicine);
- physical therapy (radon baths, etc.);
- Dietary supplements (Indinol, epigalate, etc.).
Of course, you may have heard from friends or read that these methods helped someone get rid of uterine fibroids, but let’s look at what we can talk about in this case.
Uterine fibroids are not coughs, skin rashes, or lameness, meaning that this disease does not appear externally. As we have already mentioned above, uterine fibroids are a very General concept, and any deformity can be hidden under this term: a tiny node, or a uterus enlarged by nodes to the size of a full-term pregnancy. What can the patient have to prove the diagnosis? This is the ultrasound Protocol, often without photos, and the conclusion of the gynecologist, less often – MRI data. How objective is this data? With the exception of MRI, everything else can be very different from the real situation.
Patients often come to me with ultrasound protocols performed by different doctors in different clinics. Descriptions of the uterus and nodes in these protocols may differ significantly. After that, you do an ultrasound yourself, and it seems that you are looking at some other person, and not the one whose protocols you have just read. In some cases, the nodes are taken as foci of adenomyosis, somewhere the size of the node is measured inaccurately, some nodes are omitted altogether.
I always tell patients that the myoma node does not have an exact geometric shape – it is not a circle or a square. The shape of the myoma is more reminiscent of potatoes. The more bizarre the shape, the more difficult it is for different doctors to make the same measurements, that is, to choose the same section and place measurement markers in the same way. This is the recommendation to do an ultrasound at the same specialist and preferably on the same device, since the type of device also makes its own adjustments to the size.
The shape of the uterine fibroids resembles a potato, so it is very difficult to measure its actual size in the same way. Hence the rule: always do an ultrasound with the same specialist.
When you hear a story from the series “I cured fibroids with leeches/herbs/homeopathy”, do not rush to believe it blindly. The truth, as they say, is in the details. What exactly did the narrator cure? How many nodes did she have, what size, localization, how much did they decrease, how did her symptoms change and whether she had them, who controlled the regression of nodes and so on? Over the years of treatment for uterine fibroids, I have seen patients who allegedly “cured” something in non-traditional ways. Someone initially had fibroids (luckily was on hand ultrasound images), the other control measurements were made clearly inaccurate etc. let me Remind you that some of the nodes may long not to grow, some even die alone, and to attribute these natural processes therapy is not necessary.
The “successful” effect of all sorts of non-traditional methods of treating uterine fibroids is explained quite simply: almost 60 % of the treatment of uterine fibroids is not required.
Of course, there is also a placebo effect, which is allocated up to 14-18 %, so with a strong belief in the treatment, some result can be achieved, but fibroids never completely disappear. Myoma is a dense newly formed tissue, so the maximum that can happen to it as a result of treatment is the death of all its cells and their replacement with connective tissue, while the size of the node can be reduced to 80 %, but it can not disappear completely.
Every time you are faced with another “unique treatment method” or you are promised the effect of some leeches or herbs, remember that the treatment of uterine fibroids is required only in 30-35 % of cases, nodes may not grow for a long time and die independently, that is, you may not be shown any treatment at all, and you are simply forced to unnecessary spending and actions.
In addition to completely ineffective methods of treatment, there are those that generally do not have a pronounced or persistent effect on uterine fibroids. These are GC, Mirena intrauterine system, GnRH agonists, fuz-ablation.
Hormonal contraceptives do not treat uterine fibroids, that is, they are not even able to cause a decrease in its size. There is evidence that taking contraceptives can reduce the likelihood of fibroids by 27 %, meaning that it is possible to take a preventive, but not a therapeutic role. In addition, contraceptives can control the manifestation of the main symptom of uterine fibroids – heavy menstruation. Against the background of their reception, menstruation becomes sparser, and in a prolonged mode – even less often. At the same time, such symptomatic treatment may not affect the growth of nodes in any way: they may gradually increase or not grow, it is impossible to predict this process, so avoiding heavy periods while taking HC is a temporary measure, like analgesia for a broken arm.
The situation is very similar with the Mirena intrauterine system. This spiral contains a capsule with the hormone levonorgestrel, which is gradually released into the uterine cavity over a period of five and a half years. This leads to thinning of the endometrium, which provides a contraceptive effect, in fact, this is one of the purposes of this spiral. Mirena cannot affect the growth of nodes, but it can effectively fight menstrual bleeding, as well as ha, in fact, being a symptomatic agent. It is important to understand that if you put this spiral, and you have abundant menstruation turned into a meager long-term discharge (this often happens against its background), this does not mean that the next ultrasound will not tell you that the nodes and uterus have grown, and you need to do something. At the same time, remember that uterine fibroids themselves may not grow for a long time, this explains the “healing effect” of “Mirena”, which you may have heard or read about.
“Mirena” does not treat fibroids, but eliminates menstrual bleeding.
GnRH agonists, perhaps known to you as buserelin, Zoladex, diferelin, lyukrin-depo, and so on, have long been almost the only medical treatment for uterine fibroids. These drugs create a temporary menopause in a woman’s body, during which, against the background of ovarian failure and, consequently, a decrease in the level of all sex hormones in the blood, the uterus and fibroids nodes decrease. The problem is that this phenomenon is temporary, artificially creating menopause for more than six months is dangerous because of the risk of bone destruction, and the woman herself can be difficult to tolerate such treatment. As soon as the menstrual cycle is restored after treatment, the size of the uterus and nodes returns to their original values, and often even begins to grow more actively than before. It turns out that there is no sense, as in the fairy tale “12 months”, in the middle of winter to arrange spring, since it is still a temporary measure. Previously, after such treatment, they tried to prescribe ha or install a Mirena spiral to stabilize the achieved results, but the effect was not good enough.
Artificial menopause is reversible, the nodes will grow again and continue to grow.
Let’s return to the analogy with the fairy tale “12 months”: temporary menopause was used only for a specific purpose – just before the operation to remove myomatous nodes. Reduced in size, the uterus and nodes are easier to operate, blood loss during the operation is reduced, and the time of its execution is also reduced. Thus, simply prescribing GnRH agonists without subsequent surgical treatment is completely meaningless, since the achieved result will be temporary.
Ultrasound treatment of fibroids is not always possible. And this procedure has a short-term effect. The probability of relapses is very high.
FUZZ-ablation is a method that was very much hoped for when it appeared. The essence of it is that under the control of MRI, distant melting of the node is performed by a focused beam of ultrasonic waves. In other words, it became possible to physically affect the neoplasm without entering the abdominal cavity, in fact, without contact. Ultrasound waves imperceptibly pass through all the layers of the anterior abdominal wall and locally heat the pathological tissues to a high temperature, which causes them to melt. What could be better? However, this was only the first impression. Upon further study of the method, it turned out that the nodes are not equally sensitive to such effects, that is, the fibroids should have a special structure, also located only in certain parts of the uterus, for example, there should be no scars on the anterior abdominal wall, etc. During one procedure, it is possible to melt only one node, the process itself is quite long, it takes about four hours. And most importantly, this method only leads to a temporary decrease in the size of the node – the Central part of the fibroids is not melted to the level of healthy tissues, and around the node there is something like a “crust of bread with the crumb removed”, but this is enough to make the node, which was initially reduced, begin to grow again. It turns out that a lot of conditions are necessary for the application of FUZZ ablation:
• not all nodes are sensitive to ultrasound;
• only one node can be melted at a time, and this is a fairly long process;
• in the end, a temporary effect is achieved – the node grows again.
Therefore, FUZZ-ablation was gradually abandoned, and now there are almost no articles on this topic in the scientific literature of foreign countries. In our country, several major Federal centers still offer fuz-ablation, even quotas are issued for it, but my advice to you: do not waste time on this method of treatment. Unfortunately, in the vast majority of cases, you will have to solve the problem of uterine fibroids again.
Fuz-ablation did not meet the expectations placed on it, and its use was abandoned in many countries of the world.
Well, we have reviewed all the methods of treating uterine fibroids, which, in my opinion, are not worth spending your time, effort and money on. How can this disease be cured in modern conditions? In fact, there are only three methods of treating uterine fibroids that can effectively solve the problem in all cases.
- Surgical treatment-myomectomy.
- Uterine artery embolization.
- Esmia is a drug that blocks progesterone receptors in tissues.
These three methods of treatment are able to solve all five problems of treating uterine fibroids, which I described above.
The essence of these three methods of treatment can be represented as follows: we can cut out the nodes of fibroids, deprive them of blood supply, which will lead to their death, and rid them of the influence of the main hormone that stimulates their growth, progesterone.
Before considering these treatments separately, let’s formulate the concept of treating uterine fibroids.
CONCEPT OF TREATMENT OF UTERINE FIBROIDS
- Uterine fibroids do not require treatment in all cases, but only if indicated.
- Treatment of uterine fibroids should not be more severe than the manifestations of the disease itself.
- Treatment of uterine fibroids should be exclusively organ-preserving, except in rare cases.
- Treatment of uterine fibroids should provide the effect for the longest possible time.
- Treatment of uterine fibroids should preserve a woman’s reproductive function, if she is interested in it, even theoretically.
Using this concept, you can choose in each specific clinical situation which of the three treatment methods will be the most effective and safe. When we narrow the range of possible treatment methods to three, and put the “concept of treatment” as the basis for choosing a treatment method, then there is the possibility of an objective approach, that is, not based on the personal preferences of the doctor and his capabilities.
Now let’s describe these three methods of treating uterine fibroids.
SURGICAL TREATMENT OF UTERINE FIBROIDS
The essence of surgical treatment of uterine fibroids is to remove the node (s) with various accesses. There is a laparotomic approach, in which the anterior abdominal wall is cut and the hands are operated on. Laparoscopic myomectomy involves performing the operation with special manipulators inserted through small holes in the abdomen under the control of a miniature camera. Hysteroresectoscopy is a method of removing nodes from the uterine cavity, while a thin instrument is inserted through the cervix into the cavity and the node is cut in layers, also under the control of a video camera.
Surgical removal of uterine fibroids-temporary restoration of the uterus for pregnancy.
Removal of uterine fibroids nodes through a large incision on the anterior abdominal wall has been practiced for more than 100 years, laparoscopic technique for more than 20 years. The technique of such operations is honed and allows you to remove almost any number of nodes from the uterus. The problem of blood loss during such operations is solved by temporarily blocking the arteries that supply the uterus with blood. special means are used to reduce the likelihood of adhesions.
Simply put, you can always find a surgeon who will remove all the nodes from your uterus with any access and save your organ. In Russia, there are many surgeons who have perfected laparoscopic operations to such a level that they can remove dozens of nodes from the uterus in conditions of temporary interruption of its blood supply, which reduces the risk of blood loss. There are even more surgeons who can remove all nodes with laparotomic access. That is, the supply in this conditional “market” significantly exceeds the demand. So when the doctor begins to convince them that remove nodes not possible, no guarantees for the preservation of the uterus, high risk of bleeding, may be it is about the ability of this particular doctor, not medicine in General, so you should not give this value. Once again, you can find a talented surgeon in “two clicks”, since they are most often actively represented on the Internet. Of course, none of these great surgeons operate for free, and most often even expensive, but it will not be difficult to find the optimal doctor for the price.
If your doctor tells you that node removal is not possible, you should get a second opinion. Better change your doctor.a
Now let’s figure out what exactly the problem is solved by the surgery. This method completely removes all nodes from the uterus, that is, it quickly solves the task. Next, to make it clearer, I will begin to draw a parallel with the military operation to capture the occupied city. In this case, surgical removal of nodes is an assault with the use of heavy military equipment, as a result of which the enemies are defeated, but the city is damaged accordingly. If all the enemies were in one building on the periphery of the city-this is quite acceptable losses, and if they were dispersed throughout the city-this is already significant destruction. But who judges the winners at the end of the fight? First, they celebrate the victory, and only then evaluate its price.
A surgical operation to remove uterine fibroids is like a military campaign using heavy equipment: Yes, the enemies will be defeated, but the city can be seriously damaged.
This image perfectly reflects the consequences of removing nodes from the uterus. On the control ultrasound after discharge, in fact, there are no nodes in the uterus and everything seems to be safe. If we were talking about one superficial node, this is true, but if 10-20 nodes are removed from the uterus, how many scars will there be on such a uterus? Even if they were perfectly stitched and provide the strength of the uterine wall, does the surgeon tell you that the risk of recurrent node growth is quite high – 7-14 % per year? That the more nodes removed, the higher the risk of recurrence, since it is the injury to the uterine muscle that is supposed to stimulate the growth of fibroids?
Operations on the pelvic organs, even in spite of ongoing prevention, are accompanied by the formation of adhesions that can disrupt the patency of the fallopian tubes, lead to infertility and/or increase the risk of ectopic pregnancy. Yes, this does not happen so often, much depends on the adhesive readiness of the body, which is impossible to predict, but such consequences of node removal should also be discussed, assessing the ratio of benefits and risks.
Will they tell you before the operation that any surgical intervention is a lot of risks? There are anaesthetic complications, the risk of injury to neighboring organs, peritonitis, intestinal obstruction, intra-abdominal bleeding, pulmonary embolism, etc. This is not a “horror story”, but the everyday life of a surgical hospital, even if it is engaged only in elective surgery. In any hospital, the percentage of postoperative complications is calculated annually, and all surgeons know about it. Maybe that’s not just what experienced surgeons say: “A good operation – the one that didn’t happen”?
You may wonder: why did I present a surgical method of treatment in such black colors, while putting it in the first place among the methods of treating uterine fibroids? I just wanted patients to be able to objectively evaluate the method offered to them, and not cut off from all sides of the attractive wrapper.
Remember, in the concept of treating uterine fibroids, I wrote that ” the treatment of the disease should not be harder than the disease itself, and the effect of treatment should be maintained for a long time.” These two criteria are not always met by the surgical method of treatment. Here are two clear clinical examples that can illustrate my point.
The patient is planning a pregnancy, and she was found to have a subserous node on a thin base measuring 5-6 cm. She has no complaints, but the risk of emergency surgery during pregnancy is high. She is performed laparoscopic removal of this node – a short, fairly easily tolerated intervention, after which the patient can become pregnant in 2-3 months. In this case, the risk of complications during pregnancy correlates with the risk of surgery, and the long-term effect is not necessary, since the patient is going to get pregnant.
Treatment of uterine fibroids should not be harder than the disease itself.
The patient is planning a pregnancy in the future, she was diagnosed with multiple uterine fibroids, from complaints-a little more abundant menstruation. It is performed to remove all nodes, and this is a serious long-term operation with a high risk of complications. In the next few years after the operation, the patient does not get pregnant, but on the control ultrasound, the growth of new nodes is detected. In this case, the choice of surgery as a treatment method, according to the concept, was incorrect. The surgery itself was harder than slightly heavy menstruation, and the effect of the treatment did not last long.
With the “concept of treatment of uterine fibroids” in mind, it will not be difficult to evaluate the treatment offered to you in terms of its compliance with all points. The surgical method of treatment has its own unique niche, which we will discuss below. I am against the one-sided idea of its irreplaceability in any situation with which the patient is treated.
An experienced gynecologist, confident in his skill, seeing a uterus with fibroids, is ready to “go into battle”: a young woman who has not given birth will offer a myomectomy, a woman closer to menopause – removal of the uterus, since it is not needed, and other diseases may develop in it. Someone may be denied the operation if there are no complaints yet or the nodes are small. Here is a clear example of a one-sided application of the method, without taking into account the principles of the concept, which is more focused not on solving the problem “here and now”, and then at least the grass does not grow, but on the treatment of uterine fibroids throughout the reproductive period of a woman.
The surgical method is effective. But it is not always shown.
About surgery, I think, the explanation is given in detail, and it does not make sense to describe the methods of removing nodes. The main thing is clear that depending on the skill of the surgeon, you can remove any number of nodes from any uterus. Surgery is a powerful tool that should not be used in all cases, since its destructive effect also affects healthy uterine tissues (scars, adhesions), and, in addition, this effect is short-lived.
Depending on the skill of the surgeon, you can remove any number of nodes from any uterus.
It is time to touch on the most difficult method of treating uterine fibroids – embolization of the uterine arteries.
UTERINE ARTERY EMBOLIZATION
Yes, in fact, this is the first characteristic we want to give to this effective, relatively simple, one might even say elegant method of treatment, the appearance of which caused great concern in the gynecological world, which is already falling asleep from the absence of any revolutionary changes. The biggest concern was not the method itself, which had been known for many decades: the special treatment was due to a completely different circumstance, but this is best described from the beginning.
Since ancient times, a dangerous complication of childbirth has been known – postpartum atonic bleeding that occurs after the placenta is separated. This bleeding is very strong, and it is extremely difficult to stop it – the uterus does not contract, and blood flows from dilated vessels in a stream. To save women, they acted on the principle “it is better to live without a uterus than to die with a uterus” and performed emergency removal of the uterus, which sometimes saved women in labor, but not always. In the late XIX – early XX century, in order to stop such bleeding, the uterine arteries, as well as other arteries that supply the uterus with blood, were bandaged. This not only proved to be an effective method, but also saved women the opportunity to have children in the future.
Endovascular surgery is a method of treating various diseases by accessing diseased organs through the vascular bed.
It has been shown that ligation of the uterine and other uterine arteries is not dangerous, does not affect menstrual and reproductive function, and can be routinely used to stop bleeding. In the late 1970s, a new medical specialty-endovascular surgery – began to develop actively. This type of surgery allows you to insert a thin catheter into the vascular bed through a puncture of any major artery and contrast the vascular network. Perhaps you have heard about coronary angiography-a method that studies the state of the heart’s blood vessels? So, this is what endovascular surgeons do. In addition to the simple study of the vascular network, various actions can be performed through the inserted catheter, for example, stenting can be performed in the same heart, that is, to expand the lumen of a narrowed vessel. The reverse process is embolization, in which special emboli (particles) are used to close the lumen of pathologically overgrown vessels that feed the neoplasm. Accordingly, embolization easily stops bleeding, clogging the lumen of bleeding vessels.
Since vascular access is easy and fast, endovascular surgeons began to actively help obstetricians fight postpartum bleeding, and later their services were used by gynecological surgeons, asking them to perform an EMA before the operation to remove nodes to reduce blood loss. Everything would have remained peaceful and orderly, but an unforeseen circumstance occurred, which, as often happens in medicine, served as a discovery.
One of the patients of the French doctor Jacques Henri Ravin after performing her EMA temporarily refused the operation, and when she came back to the doctor a few months later, she told him that she had stopped bothering her bleeding, and during the ultrasound it turned out that the size of the uterus and nodes had decreased. This led the doctor to think that EMA could become a self-sufficient method of treating uterine fibroids without the need for subsequent surgery.
Continuing his experiments, in 1994, Jacques Henri Ravina published the first report in the Lancet about the effective use of uterine artery embolization in 36 patients with uterine fibroids, concluding that this method can be not only an auxiliary, but also an independent method of treating uterine fibroids. As they say, this is where it all started.
Uterine artery embolization has been shown to be effective in the treatment of fibroids since 1994.
To assess the scale of the threat that the EMA method has become for gynecologists, it should be pointed out that operations for uterine fibroids occupy the main place among all operations performed in gynecology, which is about 80 %. Therefore, the appearance of a method of treating this disease in the hands of a representative of another medical specialty was perceived with hostility. The whole situation looked defiant: the method that “served” the surgeons, suddenly “declared” its independence, self-sufficiency and, most importantly, showed the need for subsequent surgical intervention. Then everyone was offended.
If earlier no one paid much attention to the embolization of the uterine arteries, they did it and did it like an enema before surgery, then they attacked this method as their worst enemy. Who had enough imagination for what: and uterine necrosis was imagined by gynecologists, and nodes that fell off into the abdominal cavity; remembering the possible presence of a connection between the uterine artery and the ovarian artery, they began to intimidate patients with early menopause and irreversible infertility. At that moment, somehow magically, the entire gynecological community, which actively criticizes the method, suddenly forgot that for more than 100 years it has mercilessly bandaged the uterine and ovarian arteries for bleeding, which saves a woman not only an organ, but also menstrual and reproductive functions. Apparently, the monopoly on female reproductive organs was and, alas, still is above all else.
The EMA was opposed, as it reduced the number of operations.
The widespread popularization of the method did not help even the fact that the EMA in 2004 was performed by Condoleezza Rice – then the US Secretary of state, that is, this procedure was chosen as the safest and most effective compared to traditional surgery. Of course, EMA then and now is not a marginal method of treatment, at the moment this technique is routinely used around the world along with all the others, just somehow reluctantly, some gynecologists inform patients about its existence. Most often, women themselves find information about EMA on the Web and are actively interested in it from their doctors. Meanwhile, dissatisfaction with the existence of a competitive method of treatment in the hands of doctors of another specialty continues: more civilized – in America and some European countries, and quite unintelligent-in particular, in our country.
EMA is a good alternative to surgery. Doctors are reluctant to offer it, since the procedure can only be performed by endovascular surgeons, not gynecologists.
The main problem with EMA is that it is performed exclusively by endovascular surgeries, not by gynecologists. If the uterine artery embolization were in the hands of gynecologists, there would be no problem. It is much easier to make an EMA in 10-15 minutes than to spend 1.5–2 hours in the operating room in a fairly high voltage. In order for a gynecologist to perform this procedure, it is necessary to get a new specialty, which takes 2-3 years off work – a feat that no one has yet decided to do.
Taking into account all the above, it is clear that patients with uterine fibroids, in fact, have become hostages of the conflict of interests of doctors of two specialties, in fact, that is why in the vast majority of cases, patients learn about EMA from the Internet, and not at a doctor’s consultation.
What is uterine artery embolization? The essence of the technique is to stop blood flow through both uterine arteries, which leads to the death of all myomatous nodes in the uterus without exception, while the uterus does not suffer in any way. When the neoplasm ceases to be supplied with blood, it develops necrosis, as a result of which the pathological tissue is replaced by connective tissue, “shrinks”, which is accompanied by a decrease in its size.
After embolization of the uterine arteries, fibroids die, as they do not receive blood flow. The uterus remains intact, as it has additional sources of blood supply.
The dreaded word “necrosis” should not cause you any alarm. This is an exclusively local process that does not go beyond the boundaries of the neoplasm. The program of this “necrosis” is embedded in the body as a basic function that is activated at the right moment. The entire process goes through successive stages and ends with the” sealing ” of the remaining tissue with a calcified capsule. So, for example, after cured tuberculosis in the lungs remain “foci of Rut” – small calcinates detected by x-rays.
The most important question is why after stopping the blood supply to the uterine arteries, only the nodes of the fibroids die, and not the entire uterus? The fact is that the uterus in addition to the uterine arteries has additional sources of blood supply, but the fibroids do not. It is this vulnerability of the fibroids that allows this method to exist.
By the way, the uterine arteries do not permanently stop supplying the uterus with blood: within a month, new vessels grow out of the uterine artery, bypassing the blocked ones, and everything becomes as before.
To cause necrosis of the uterus is extremely difficult to do this in addition to the masterbatch to block some more of the arteries that never happens during the procedure EMA; remind gynecologists for over 100 years, quietly fallopian bandage to stop bleeding, and it does not cause necrosis of the uterus.
The second important question is why after embolization, the nodes growing outside the uterus do not” fall off ” into the abdominal cavity. I have already touched on this issue, but it is worth repeating here. Blood supply to the outer lining of the uterus – a kind of package in which the uterus is located-is not associated with the uterine blood flow, so during the embolization process, its blood supply is not affected in any way. The process of necrosis of surface nodes occurs inside this package, so as a result, the nodes simply shrink and, on the contrary, attach more tightly to the uterus – the shell, Contracting, presses them to it. Now, if we went into the abdominal cavity and tied the outside leg of the knot-in this case, in fact, it would ” fall off “into the abdominal cavity after a while.
A very different fate awaits the nodes, growing in the uterine cavity or distorting it. After embolization, these nodes are completely moved into the uterine cavity, and there they begin to melt. The node begins to gradually flow out of the genital tract in the form of unusual secretions, which may be accompanied by an increase in temperature. In the end, it comes out, that is, it is no longer found in the uterus. This process is called” birth “or” expansion ” of the node.
The” birth ” of a node is its outflow from the uterine cavity after embolization.
Nodes located in the walls of the uterus and outside, can not go anywhere. They remain in the uterus as reduced in size rounded formations surrounded by a calcified capsule. In structure, they are no longer fibroids, they are just connective tissue.
Often, doctors, assessing the result of an EMA, say that the nodes in your uterus, although reduced, but remained, and they need to be removed. This is a fundamental misconception of the process. First, it is no longer a uterine fibroid, it is what is left of it – not living tissue, but sealed in a capsule. Secondly, let me remind you that the mere fact of having uterine fibroids is not the goal of treating this disease. If the node does not prevent the patient from living, getting pregnant and not growing, it should not be touched. Only in a small number of cases do we remove nodes after the EMA; as a rule, these are initially huge nodes that, even when reduced, continue to remain large and interfere with the patient.
The need to remove nodes after an EMA is extremely rare.
By the way, how many percent can the node decrease as a result of the EMA? It depends on its composition. If the fibroids contain many vessels, mainly consisting of muscle fibers, the regression can reach 80 %. As a rule, these are small, actively growing nodes up to 8-10 cm. The opposite situation is a node with individual vessels, it is more composed of dense connective tissue; such a node can decrease by 10-15 %. Most often these are large old nodes, but there may be small nodes that, as I wrote above, can independently lose blood supply and die. It is believed that on average, nodes are reduced by 40-60 % of the original size, and this is enough. The total volume of the uterus is reduced by 50-60 %.
How does EMA work? The procedure does not require General anesthesia and is generally completely painless. In the upper third of the right hip, just below the inguinal fold, the femoral artery is punctured under local anesthesia. The catheter is inserted into the left uterine artery under the control of an x-ray machine. Next, a contrast agent is introduced, which allows you to see the pathological vascular network. After that, a suspension of micro-balls, 800-900 microns in size, is inserted through the catheter, which jam the lumen of the vessels. These balls are called emboli, they consist of a special polymer that is completely inert, that is, does not come into any contact with the surrounding tissues. Their main goal is to jam the lumen of blood vessels and stop the blood supply to the nodes of fibroids. After completing the embolization of the left uterine artery, the catheter is installed in the right-and there repeat the same actions. At the end of the procedure, the catheter is removed and the puncture site is closed with a small “seal”. In most cases, the EMA takes 10-15 minutes, and the x-ray time is no more than 2-3 minutes, while the radiation dose is less than with a normal chest x-ray.
Uterine artery embolization takes 10-15 minutes, while surgery takes 2-4 hours.
The most common questions patients have are caused by emboli. It is unclear what happens to them in the future, whether they can get somewhere wrong or shift. I answer all your questions at once. Emboli are absolutely not dangerous for the body, they do not have any toxic effects and do not even cause an inflammatory reaction. They remain forever in the uterus in the structure of what remains of the nodes, and there they are sealed with connective tissue and can not move anywhere. Emboli are also not able to get somewhere wrong, since they fly strictly into the uterine artery with a blood current under a pressure of 120 mm Hg. I often give this example: a catheter can be compared to a filling hose at a gas station, installed in the gas tank of one car; obviously, you can not fill the next car with gasoline, because at least you need to remove the hose and move it to this neighboring car. Movement of emboli against the blood flow is impossible. It’s like putting a boat in a rough mountain river: obviously, it can’t swim against the current. When the diameter of the vessel becomes smaller than the size of the embolus, it is tightly wedged into the lumen and gets stuck in it forever. Stopping the blood flow starts the process of thrombosis, and the vessel is sealed with a blood clot, which, I assure you, will not move anywhere, since it has an embolus on one side, and blood pressure on the other. Blood clots are dangerous in the veins, since in this part of the vascular system, the movement of blood goes to the heart, and the lumen of the vessels does not decrease, as in the arteries, but on the contrary, increases. Allergic reactions to emboli do not occur. In General, the total volume of emboluses introduced during EMA is no more than a pinch, and in other medical situations, titanium plates, pins, and implants are inserted into the human body, and this does not affect health in any way. To sum up: emboluses are safe, they get when injected exactly where it is necessary, they can not move, they remain in the body forever, and this does not have any effect on it.
When it hits a narrow spot in the bloodstream, the embolus is tightly wedged into the lumen and gets stuck in it forever. Stopping the blood flow starts the process of thrombosis.
Back to the EMA procedure: after closing the puncture hole with a special seal, a normal patch is applied to the skin, and the patient is transferred to the ward. The right leg after the puncture can not be bent for 2.5 hours, and you can get up after four hours. After the end of the EMA, as a rule, there are pains in the lower abdomen that require careful anesthesia. To do this, a special scheme has been developed: taking painkillers begins in advance, while using drugs that affect all the mechanisms of pain formation. With this approach, the pain syndrome after EMA is moderate and does not cause emotional discomfort. Most often, the pain lasts for the first 6-9 hours after the end of the procedure, but it can also be delayed.
The day after the EMA, a special period begins, which is called “post-embolic syndrome”. It is based on the reaction of the body to developing necrosis in the nodes, that is, to increasing intoxication. I describe “post-embolic syndrome” as a mild flu on the background of painful meager periods. Actually, this is what happens: the temperature rises to 38-39 degrees, the lower abdomen aches, and there is a small bloody discharge from the genital tract. Actively, this condition lasts for 3-4 days, and then begins a progressive recovery, and, as a rule, by the 7-8-th day after the EMA, the patient recovers completely. During the next month, moderate pain in the lower abdomen, temperature increase to subfebrile numbers, and a decrease in exercise tolerance may still persist. Most often, patients who have undergone EMA return to work a week after the procedure.
Postembolic syndrome lasts 7-8 days.
COMPLICATIONS OF UTERINE ARTERY EMBOLIZATION
Of course, all patients are concerned about complications of uterine artery embolization, especially in the context of the number of frightening myths that this method has grown over the years in our country.
Let’s start once again discard the most ridiculous “horror stories”, which I already wrote above: uterine necrosis after EM is impossible, nodes from the uterus do not fall off, peritonitis and sepsis do not happen, and no one climbs on the wall from hellish pain.
To be honest, the most common complication of EMA in modern conditions can be considered a bruise at the site of a femoral artery puncture – and that’s it. All other complications are General medical, that is, for example, an allergic reaction to a drug or a drop in blood pressure in response to local anesthesia with lidocaine.
Uterine necrosis is not possible after EMA.
There is a lot of debate around the risk of ovarian damage during EMA, which leads to early menopause, as well as the possibility of damage to the endometrium (the lining of the uterus), which can lead to infertility. I specifically put these two questions in one block, since it is based on these hypothetical complications that many gynecologists do not recommend EMA to women planning pregnancy.
Let’s start with an easy-to-understand question: endometrial damage. Yes, in fact, endometrial damage is possible if you embolize the uterine arteries with very small embolisms of 300-500 microns in size. Let me remind you that we use emboluses of 800-900 microns. Small emboluses can get into the thin spiral arteries of the uterus that supply the endometrium with blood, and damage it. The size of emboluses is extremely important for the safe conduct of EMA, but often this information is not communicated to patients. In many cases, when I have consulted patients who have had an EMA performed in other clinics, neither the discharge nor the words did not tell what kind of drug was used for embolization.
The choice of emboluses is extremely important. Spherical emboli in 800-900 microns are considered safe.
The second situation in which there is a risk of endometrial damage is the so-called “edge” nodes. Don’t look for this term anywhere else, it was introduced by me based on 15 years of experience of observing patients who have undergone EMA. The “edge” node is an intramural or intermuscular node, closely fitting to the uterine cavity and even slightly deforming it. Medically, it can be called intramural with centripetal growth, but this name does not fully reflect the essence. If the node along one of the walls closely adheres to the endometrium, there is a risk that in this zone the endometrium may suffer in the process of embolization, even large embolisms. This does not always happen, I can’t tell you the exact percentage, since I did not conduct a study, but in cases when this happened (I will immediately say that these are isolated cases), the nodes had exactly this position. If a woman is planning a pregnancy and she has such a node, the risks of endometrial damage should be minimized, so I do not recommend EMA in such cases. Esmia therapy was effective for such nodes, but more on this later. If the patient is no longer planning a pregnancy, an EMA with this type of node is not a contraindication, in fact, it is even recommended.
If the patient has “marginal” nodes, the EMA can only be done if the woman is no longer planning a pregnancy, since there is a risk of endometrial damage.
The endometrium has been sorted out; I hope that now you have objective answers to the unfounded intimidation of doctors, especially reproductologists, that after the EMA, all patients do not grow the endometrium. It is time to clarify the issue of ovarian damage.
It is known that the largest number of patients with uterine fibroids are women over the age of 40, and the average age of menopause in our country is 45 years. Several years before menopause, there may be periods of irregular menstruation as a reflection of the depletion of the ovaries before they stop working completely. The presence of uterine fibroids, which often leads to copious long – term menstrual bleeding, may hide premenopausal changes behind these symptoms, that is, in the absence of this disease, the process of ovarian extinction would be more noticeable-there would be rare meager menstruation. This is one of the explanations for the cases when the patient noted that after the performed EMA, she began menopause, that is, most likely there was a natural onset of menopause, which could not begin due to the presence of uterine fibroids.
Here are some more important data obtained from the research: the level of anti-Muller hormone (AMH), which reflects the remaining ovarian reserve, does not change after the EMA. In all cases, the onset of menopause was observed exclusively in women over 45 years of age, and no cases were observed in women under 40 years of age. The frequency of menopause after EMA in women over 45 years of age is on average 3-5 %. At the same time, there are temporary, they are also called “transient”, disorders of the menstrual cycle that occur after EMA. Clinically, this condition is very similar to menopause (no monthly periods, there are hot flashes), but this condition passes within a few months, and the cause of its occurrence is still unknown.
The exact relationship between EMA and early menopause has not been established.
To be honest, there is still no precise understanding of the mechanism of menopause development after uterine artery embolization. This complication happens so rarely that it is difficult to find at least some pattern that unites all these cases. For 15 years in my practice, menopause associated with EMA occurred in no more than 20-25 patients, and during this time, more than 6 thousand procedures were performed.
It is easiest to explain the occurrence of menopause by damage to the ovaries by embolisms that can get into their bloodstream during embolization through the junction of the uterine and ovarian arteries, which occurs in different versions in some patients. However, there is a study that has shown that even targeted embolization of the ovarian arteries (in some conditions) does not lead to a violation of their work.
Unfortunately, there was no simple explanation. The extreme rarity of this complication should not be a limiting factor when deciding whether to choose EMA as a method of treating uterine fibroids in cases where this method has all the indications. The fact that the development of menopause after EMA is extremely rare and exclusively in women over 45 years of age, allows you to safely apply EMA in women planning pregnancy.
If the doctor “scares” you, get the opinion of a second specialist.
Here, in fact, are all the main complications associated with uterine artery embolization. Agree, if you understand in detail the method and the essence of possible complications, this method ceases to be “scary and unpredictable”, as it is seen through the eyes of individual doctors. Try to always ignore the emotional speech of doctors about the “terrible consequences” associated with officially recognized worldwide methods of treatment. I am always amazed when listening to another patient’s story about EMA, which the gynecologist told her. “You at least understand what you are going to do: terrible unbearable pain, rotting organ inside you, premature menopause, still then come to us to remove the uterus, if you can save you at all.” Personally, I find it difficult to imagine how any clinic that conducts EMA could work at all, assuming that the words said by this doctor are at least half true. This is how they imagine this “secret prison”, where patients are tortured, and then discharged home, so that they are then on the verge of life and death saved by those gynecologists who invent all this.
MEDICAL TREATMENT OF UTERINE FIBROIDS. ESMIA DRUG
We still have the last method of treating uterine fibroids – the drug esmia.
Before I tell you about this drug, I need to make an important remark. At the time of writing, the use of esmia is temporarily suspended. This is due to several cases of liver damage against the background of ongoing treatment. This situation with medications is not so rare. The purpose of these measures is to clarify whether liver damage is a consequence of taking esmia or a feature of specific patients. Most likely, the drug will be allowed to use again in the near future. While there is a recommendation to check the liver indicators every month against the background of ongoing treatment and do not include new patients in therapy.
For the medical treatment of uterine fibroids, the drug esmia is used. However, its use is currently temporarily suspended in Russia.
Back to esmia. Let me remind you: the main hormone that stimulates the growth of uterine fibroids is progesterone. It turned out that if you deprive the fibroids of the effects of this hormone, it not only stops growing, but also decreases in size. To achieve its effect, the hormone must communicate with a special place in the cell, which is called the receptor. This can be compared to a key and a keyhole. If we put a match in this hole, the key can’t open the lock. So does a drug that blocks the receptors, in particular progesterone, preventing it from realizing its effect. Esmia is just such a progesterone receptor blocker, it has no other effects.
Esmia has different effects on old and young nodes, so its appointment “all in a row” is impractical – in some cases, the drug will simply be ineffective.
Obviously, if there are a lot of progesterone receptors in the node, then esmia will be very effective, and the fibroids may decrease to 60-70 %, but if there are very few receptors in the node, then there may be no regression at all. The largest number of receptors theoretically should be in small fresh, actively growing nodes, and the least – in the old, consisting mainly of connective tissue fibrous nodes. In addition, the closer the nodes are to the uterine cavity, the higher the probability that there will be more receptors in contrast to the subserous nodes. All this determines the indications for the appointment of this drug.
It is thoughtless to assign esmia to all in a row, that is, for any number, size, and location of nodes. Actually, because of this, this drug has quite a bad reputation, if you judge by reviews on the Internet. Many people write that there was no effect from taking the drug, and do not advise taking it.
I believe that esmia is optimal in two cases: when small nodes (up to 2-3 cm) are detected for the first time in young women – in this case, the drug can not only reduce their size, but also prevent their further growth for a long period – as well as in the presence of small “edge” nodes, which I wrote about above, considering them as a contraindication for EMA. Esmia therapy in this case allows you to reduce the node and eliminate the deformation of the cavity before planned pregnancy. There is no exact data on how long the effect of such therapy lasts, but some studies show that the nodes do not grow for several years. We can assume that esmia can not only reduce the node, but also “stun” it for a long time. However, unlike the EMA effect, the node does not die completely, that is, it can start growing again in the future.
Esmia is a tablet-based drug that is taken continuously, one tablet a day for 12 weeks. Against the background of taking it, menstruation stops, but not because you are going through menopause, but because the mechanism that causes menstruation is turned off. That is why at the end of taking the drug, some patients develop endometrial hyperplasia (thickening of the uterine mucosa), which passes independently after the first menstruation. Another important clarification that is often of concern to patients.: esmia is a non-hormonal drug, on the contrary, it stops the effect on the body of one of the sex hormones (progesterone), which is produced within 10-12 days in the second phase of the cycle, that is, this drug does not cause any “hormonal” consequences that women are so afraid of.
Esmia is a non-hormonal drug.
After the first 12 weeks, the result of treatment is evaluated. If the node (s) has decreased, another course of therapy should be performed, which is prescribed two months after the end of the previous one. Courses are conducted as long as there is a progressive decrease in nodes, but no more than four courses.