Treatment of uterine fibroids - pharmacological, surgical, in pregnant women
Uterine fibroids (Latin myomata uteri) are benign tumors of the uterus and often develop in women of childbearing age. Uterine fibroids arise from the muscle tissue of the uterus and are most often located in the body of the uterus. Myomas can occur singly or in groups.
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The treatment of choice is myomectomy, which is the surgical removal of uterine fibroids - usually by laparoscopy. Large fibroids require hormonal treatment of uterine fibroids. For 15 years, uterine fibroids with expressed symptoms can be treated with a minimally invasive method, i.e. embolization of the uterine arteries under the control of an angiograph.
1. Treatment of uterine fibroids - pharmacological
Since the development and growth of uterine fibroids is stimulated by oestrogens, and these processes are influenced by cyclical hormonal changes in the woman's body, many treatments are based on the reduction of estrogen levels. The most commonly used hormonal drugs are gonadoliberin analogues (GnRH), which reduce the tumor mass and limit its blood supply. Ideally drug therapy should lead to complete regression of uterine fibroids. In practice, however, the main task of hormone therapy is to relieve symptoms and reduce the size of tumors.
The doses of GnRH analogues taken depend on the patient's body weight. Their use for 12 weeks reduces the size of fibroids by 25%. Therapy with GnRH analogues alleviates the symptoms of pressure (low back pain, pelvic pain, frequent urination) and eliminates heavy menstruation.
Unfortunately, the symptoms quickly return after discontinuing the therapy. The treatment period should not exceed 6 months due to progressive bone demineralization associated with the decrease in estrogen levels. The best therapeutic effects and the lowest side effect are shown by treatment with GnRH analogues with the simultaneous use of estrogens and progesterone derivatives.
This treatment regimen allows for long-term therapy when surgery is inadvisable or impossible to perform. The contraction of uterine fibroids after the use of GnRH analogues made them the drugs of choice also in the therapy preparing for surgery.
Other pharmacological methods used in the treatment of uterine fibroids are: progesterone derivatives, combined contraceptive pill, antiprogestagens, androgens, gestrinone, non-steroidal anti-inflammatory drugs, IUD levonorgestrel (Mirena) and hormone replacement therapy for uterine fibroids.
Steroid drugs with antiprogestinic activity inhibit ovulation, reduce estrogen levels and reduce the size of fibroids. Androgens, due to their side effects (acne, excessive body hair, weight gain, vaginal dryness) can only be used for six months. NSAIDs are only useful in treating heavy periods caused by fibroids, but not in treating the tumors themselves.
2. Treatment of uterine fibroids - surgical
Submucosal uterine fibroids tend to invade into the uterine cavity. The best method of treating them is hysteroscopic surgery. The degree of endometrial damage depends on how deeply the myoma grows into the muscle membrane. Hysteroscopic surgery enables imaging of the inside of the uterus using a special speculum inserted through the vagina. Operation under the control of a hysteroscope allows you to accurately see the uterine mucosa and its possible lesions. Hysteroscopy is used for the surgical enucleation of fibroids (myomectomy).
A myiomectomy is an operation to remove the fibroids themselves and preserve the uterus. It is an alternative surgical method to hysterectomy, i.e. complete removal of the uterus. Thanks to myomectomy, the woman retains her reproductive capacity and may become pregnant in the future. The course of pregnancy after myomectomy is generally normal. The uterus is rarely ruptured at the site of the postoperative scar.
Surgical enucleation of uterine fibroids also helps to alleviate diseases such as heavy menstruation or pressure symptoms. Currently, myiomectomy is usually performed laparoscopically. Myomas larger than 6 cm are too large and are removed by laparotomy (surgical opening of the abdominal cavity). Removal of uterine fibroids is associated with the risk of possible complications, such as: significant blood loss, postoperative adhesions, the need for caesarean section during delivery, recurrence of fibroids (up to 30% of cases).
A hysterectomy is the surgical removal of the uterus. Hysterectomy is often performed in women with uterine fibroids. Although the operation is fully effective, it makes it impossible to have children in the future. The indication for hysterectomy is the size of the uterus corresponding to the size of this organ after 12 weeks of pregnancy.
Sometimes the only solution is a hysterectomy, i.e. surgical removal of the uterus (123RF)
Such a large uterus may result in the development of malignant leiomyosarcoma, as well as pressure on adjacent organs, mainly the ureters. Hysterectomy is always associated with the cessation of menstruation due to the lack of the uterine mucosa. Laparoscopic techniques for the removal of the uterus are: laparoscopic hysterectomy, laparoscopically assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy. The classic surgery to remove the uterus is performed with a transabdominal or transvaginal approach.
The latest techniques of surgical treatment of uterine fibroids -
- Laser thermotherapy - involves inserting a laser fiber into the vascular bed, which supplies the myoma, using a laparoscope.Due to the thermal heating of the myoma, pathological tissues coagulate. After the procedure, the fibroids decrease or completely disappear.
- Myolysis - involves the insertion of a biopolar electrode into the myoma while checking the laparoscope and switching on the diathermy. When myolysis is used, the electrocoagulation of myomas occurs. There is a risk of uterine rupture in pregnancy with this method.
- Cryomolysis - involves inserting a cryoprobe into the fibroid in order to freeze it.
- Embolization - cuts off the blood supply to the myoma, which results in its loss. The radiologist inserts small plugs of blood clots, spongostan, fiber scraps and tissue adhesives through the catheter to block the lumen of a specific vessel supplying the myoma. Due to the embolization of the uterine artery, the growth of the fibroids is limited. Micron-sized embolization particles are introduced through the catheter under local anesthesia, under X-ray control, through the femoral artery.
3. Treatment of uterine fibroids - in pregnant women
Often, asymptomatic fibroids are diagnosed accidentally by obstetricians during a pregnancy ultrasound. In many cases, fibroids are not a problem for women. They also do not affect the intrauterine growth of the fetus or the manner of delivery. However, they can lead to preterm labor. In the case of fibroids larger than 20 cm, the placenta may detach.
A Caesarean section may be required in women with submucosal fibroids. Termination of pregnancy is rare in very large or numerous fibroids. Surgical removal of uterine fibroids during pregnancy is not recommended due to the high risk of haemorrhage. Sometimes a myomectomy is performed during a cesarean section if the myoma is located above the lower uterus. Prophylactic intervention during pregnancy is rarely indicated. Obstetrician supervision is sufficient in most pregnant women with uterine fibroids.