Article last updated 12/07/2019

Often, after a preventive examination by a gynecologist, many women are given a terrible diagnosis - uterine fibroids. As this disease progresses in the body, it leads to severe complications, therefore, in advanced stages, the only correct method of treatment is removal of the uterus for fibroids.

But don't despair. Now there are various gentle treatment methods that preserve reproductive function. In each specific case, the gynecologist must assess the size and location of the tumor and tell the patient about acceptable treatment options.

On early stage benign tumor (fibroids) responds well to conservative treatment drug treatment. But if the tumor does not respond well to drug therapy and the tumor grows, doctors prescribe surgery.

In severe cases, emergency radical measures may be required when the fibroid is removed along with the uterus. Surgical intervention can quickly relieve a woman from the painful symptoms of the pathology, but at the same time the ability to become pregnant is completely lost.

Reviews from doctors about the removal of the uterus for fibroids confirm that after the operation, the quality of life of women improves significantly. Hysterectomy relieves the patient from permanent uterine bleeding, which sometimes have to be stopped with curettage (cleaning) of the uterine cavity.

Large blood losses lead to iron deficiency anemia, which requires serious therapy. Sometimes you even have to do a blood transfusion.

Against the background of severe pain and depression, psycho-emotional problems appear. In addition, if there is a suspicion of the development of oncology, this is a direct indication for removal of the uterus for fibroids.

Before removing the uterus for fibroids, the doctor must conduct a thorough examination. At wide choice Based on various surgical techniques, based on medical statistics, hysterectomy is most often prescribed.

More than a million such operations are performed in Russia every year. For young women, as a rule, attempts are made to preserve the uterus.

Important! The absolute indication that determines the urgency of surgery is the transformation of a benign neoplasm into a cancerous tumor.

Gynecologists come to the conclusion that it is necessary to remove the uterus if:

• Pronounced symptoms of pathology lead to health problems.
• Myoma has reached a significant size, exceeding 12-14 weeks of pregnancy.
• The patient suffers from severe pain or constant bleeding.
• Chronic pelvic pain.
• The presence of numerous myomatous nodes.
• The increase in tumor volume led to uterine prolapse.
• There is a risk of tumor necrosis as a result of twisting of its stalk.
• The fibroid is very large and puts pressure on nearby organs.
• The last stage of endometriosis.
• Recurrent polyps.
• The patient's age is close to menopause.

The above indications make you seriously think about maintaining your health. That is why the attending physician must assess all the risks and offer the patient the most optimal treatment method.

Operation methods

If, after diagnosis, the attending physician suggests removing the fibroid along with the uterus, it is necessary to determine the method of surgical intervention.

Supravaginal amputation of the uterus is often performed without removing the appendages. Only the body and cervix are removed through a vaginal incision. The issue of preserving the ovaries is also acute. Ideal option is to preserve both the ovaries and the cervix.

Types of surgery

Laparoscopy– is a gentle operation. The surgeon makes three microscopic punctures on the abdominal wall. Next, a laparoscope - a surgical instrument in the form of a long needle - is inserted into the hole and the necessary manipulations are carried out. The surgery is performed under general anesthesia.

Laparotomy- dissection of the anterior wall of the peritoneum. After the operation, the incision leaves a small but noticeable scar. Over time, the seams will become less noticeable, but will not disappear completely. Laparotomy is performed under general anesthesia, the rehabilitation period is about two months. Nowadays this type of surgery is rarely practiced in medicine, since it is possible to use less traumatic methods.

Hysteroscopy– is prescribed most often. The fibroids are removed using a hysteroscope, which is inserted through the cervical canal. At the same time, the abdominal wall remains intact, which eliminates damage and shortens the rehabilitation period. According to patients, this is the most best method treatment of fibroids.

Hysterectomy– complete amputation of the uterus, the most serious and complex operation. Severe complications often occur after this surgery. Every thousandth operation ends in death. It is worth noting that hysterectomy with preservation of the appendages practically does not cause hormonal changes in the body. Hormonal levels normalize over time, and the patient’s libido is completely preserved. The rehabilitation period will take several months. Psycho-emotional recovery is also important.

Is abdominal hysterectomy dangerous?

Surgical removal of uterine fibroids is a forced measure that requires careful preparation and control over the operation. Regardless of the methods of extirpation, there is always a high probability of occurrence side effects and complications. The possible consequences after emergency removal of the uterus with fibroids greatly frighten many women.

The worst thing that can happen is the death of the patient. In 90% of cases, death occurs due to complications during the administration of anesthesia.

Sometimes mechanical damage to the vessels, nerves and organs surrounding the uterus occurs. The human factor plays an important role in the successful completion of an operation. Even the most qualified surgeon is not immune to mistakes. Laparoscopic hysterectomy is complicated by large blood losses. It is very difficult to ligate vessels and stop bleeding with endoscopic instruments.

Extirpation of uterine fibroids- a rather complex operation, during which blood and particles of talcum powder from surgical gloves can enter the cavity. This leads to the formation of adhesions and can cause intestinal obstruction in the patient. The situation can only be corrected through repeated intervention.

Peritonitis, inflammation of the mucous membranes abdominal cavity, abscesses - all these negative consequences arise due to non-compliance with the extirpation technique and improper treatment of the wound after surgery.

It is important to understand that even in the absence of complications, recovery of a woman’s body after removal of uterine fibroids lasts at least two months.

Why is hysterectomy dangerous for a woman in the future?

The effects of hysterectomy can take quite a long time to appear.

Unfortunately, more than 70% of women develop post-hysterectomy syndrome after surgery.

Most often, this condition occurs against the background of a reduced level of estrogen in the patient’s body. Most doctors agree that only if you have two ovaries, you can delay the development of menopause as much as possible (by 5-6 years) with a hysterectomy. But at the same time, the younger the patient, the earlier she may experience estrogen deficiency.

Low levels of the hormone estrogen are an impetus for the development of diseases of cardio-vascular system. Thus, for women under 50 years of age who have undergone an extirpation procedure, the risk of developing cardiac pathologies increases significantly.

According to statistics, removing the uterus increases the likelihood of developing thyroid and kidney cancer. It is impossible to predict exactly what consequences await a woman after extirpation. Patients note the manifestation of such signs of menopause as: unstable psycho-emotional state, insomnia, feeling of heat. Already at the age of forty, a woman can experience all the “delights” of postmenopause.

Impaired metabolism, in particular calcium deficiency - common reason development of osteoporosis. Estrogen deficiency causes vaginal dryness and significantly reduces the quality of sexual life. The woman stops experiencing orgasm, the number of sexual acts decreases significantly. The natural functioning of the urinary system is disrupted.

More than 20% of patients develop urinary incontinence. Failures in the functioning of a woman’s endocrine system lead to obesity (every third patient suffers).

Alas, not every woman understands the dangers of having a hysterectomy, which is why many take their health so lightly. Further consequences of surgical removal of the uterus along with fibroids will persist for many years.

Alternative methods

Numerous complications during and after the operation prompted scientists to develop safer methods for treating fibroids. There are several commonly practiced alternative ways to combat fibroids:

• FUS ablation is an experimental approach to removing fibroids. The operating principle of this method: myomatous formations are exposed to ultrasound radiation.
• Myomectomy– surgical removal of fibroids. The surgeon removes the fibroids while preserving the uterus.
• UAE (uterine artery embolization)- an alternative treatment in which special balls - emboli - are inserted into the uterine cavity. They block blood flow in myomatous formations, thereby causing the process of their necrosis and death.

Important! Complications after extirpation can be different, but the most tragic thing women experience is the inability to become pregnant and give birth to a baby in the future.

Also, do not forget about the psycho-emotional side of the issue. Many women after surgery feel some inferiority; it is especially difficult to establish intimate contact with a partner to the same extent. Removal of the uterus, according to patients, is more difficult to tolerate at a young age.

Features of the postoperative period

How long the recovery period will take depends on the surgical treatment chosen. Complex abdominal surgery involves the longest recovery period. Definitely, a woman will have to reconsider her usual rhythm of life for some time and change her diet.

Only strict adherence to the rules of rehabilitation provides some guarantee of the absence of postoperative complications. If all recommendations are followed unquestioningly, then after four months the patient will be able to return to her normal life.

To reduce the risk of side effects and speed up the recovery process, you need to undergo a number of rehabilitation measures:

• Kegel exercises. Removal of the uterus can provoke a change in the location of the pelvic organs. Natural functioning is disrupted Bladder and intestines. The patient suffers from constipation and urinary incontinence. The pelvic muscles weaken so much that the vagina may simply fall out. You can correct the situation with Kegel exercises.

• Hormone replacement therapy helps prevent the development of menopause in a woman. The list of mandatory medications includes medications with a high content of the hormone estrogen. They can be in the form of tablets, patches, ointments or gels.

• Diet and nutrition regimen. With hormonal imbalances, there is always a high risk of gaining excess body weight. To avoid this, you should reconsider your diet, giving preference useful products with minimal fat and salt content.

It is worth noting that in women who have undergone extirpation, menopause in most cases occurs much earlier. But with the help of hormonal therapy, the manifestation of unpleasant symptoms can be reduced. It is also important to lead an active lifestyle and under no circumstances give up sexual relations. If there are no postoperative complications, then after a month and a half you can have sex. Don’t isolate yourself and don’t reject the support of your loved ones.

Removal of the uterus is not a death sentence, as some women believe. Careful adherence to all the doctor’s recommendations guarantees that the patient’s quality of life will not change, but may become better and take on a new meaning. Before surgery, a positive psycho-emotional attitude is extremely important, then you will be able to return to normal life much faster.

S. B. Golubchin, Doctor of Medical Sciences professor, obstetrician-gynecologist, 1958.

Obviously, there are no women who would happily accept the news that they are going to have a hysterectomy. And why, in fact, explain to a woman why it is not necessary to remove the uterus? This question may even seem absurd, but, unfortunately, only at first glance.

Every year, about a million women in Russia undergo hysterectomy, and in most cases the indication for this is uterine fibroids. The average age of women undergoing this operation is 41 years; By modern standards, this is the most active and eventful age of a woman. The amazing thing is that in 90% of cases these women could be cured without removing the uterus. In other words, they performed an unnecessary operation.

And the most shocking thing: from Vladivostok to Kaliningrad, from year to year, like a spell, the same words of gynecologists are heard, sending women to have their uterus removed: “Why do you need a uterus, that you’ve clung to it so much. You've already given birth - why do you need to walk around with this bag of knots? This is a simple operation - you'll see, you won't even notice anything except relief. You have no choice: other treatments are ineffective! You can, of course, try, but you will still come back to us - and we will cut it out for you.” These words, alas, have an effect, and as a result, according to statistics, we have about a million removed uteruses a year...

Or maybe they are right? And removal of the uterus is actually a reasonable method of treating this disease and there are no consequences from such treatment? So many gynecologists cannot be mistaken! Unfortunately, they can.

The main reason for such a long dominance of therapeutic radicalism in the treatment of uterine fibroids is that for too long uterine fibroids have been considered, although benign, to be a tumor process, and the tumor, as the canons of surgery say, must be removed. Indeed, there is a list of organs without which a person can more or less exist. And from the point of view of many gynecologists, the uterus is almost in first place on this list.

For some reason, it is believed that having realized her reproductive function, a woman can part with the uterus completely painlessly, that is, a unique monofunctional relationship has been developed towards this organ. Wrong attitude. At the same time, it is quite obvious that there are no unnecessary organs in the body, and the uterus, in addition to the reproductive function, also has others, a certain part of which is clear to us, and some of which have not yet been fully studied in detail. To simplify, we can say that, being integrated into the whole organism, the uterus maintains a natural physiological balance.

A person can exist without one kidney, a lung, or part of the intestines, but everyone understands that this existence is no longer a completely full-fledged person, so why is a woman without a uterus considered healthy in the minds of a number of doctors? Indeed, it has been known for many years that removal of the uterus entails the development of the so-called posthysterectomy syndrome - a symptom complex of disorders of the endocrine, nervous, cardiovascular and other systems that occurs after removal of the uterus and is associated with this removal through a direct cause-and-effect relationship. Separate place The consequences are psychological - the presence of a uterus is a subconscious element of femininity, belonging to the female gender. The presence of a uterus gives a woman constant inner confidence that she can give birth to a child. And even if she definitely does not want to have more children, permanent deprivation of this function may be emotionally unacceptable for her.

Consequences of hysterectomy

From a medical point of view, removing the uterus can have a number of quite serious consequences.

According to a large study carried out in Sweden (over several decades, a scrupulous analysis of the medical histories of more than 800 thousand (!) women who had undergone hysterectomy was carried out), a significant increase in the risk of developing cardiovascular diseases(heart attacks and strokes) if the uterus was removed before age 50. This study was very large-scale, since an analysis of the consequences was carried out over a period of more than 30 years.

In other words, removing the uterus entails serious health problems and increases the risk of diseases that can lead to disability and even death. It is important that both doctors and patients do not associate the appearance of these diseases with the removal of the uterus, since these complications do not develop in the near future after surgery, but a year or later.

Here is a list of possible negative consequences after hysterectomy:

• Cardiovascular diseases. At the same time, it was found that the risk of developing diseases can be both in the case of removal of the ovaries and when they are preserved, but it was noted that when the ovaries are removed, the severity of serious consequences for the heart and blood vessels increases. See details.
• After removal of the uterus, the risk of developing kidney, breast and thyroid cancer increases. See details.
• Depression, irritability, insomnia, memory impairment, and hot flashes occur.
• Increased fatigue is noted.
• Urinary disturbances (frequent urination, urinary incontinence) may occur.
• Some women report joint pain.
• The risk of fractures increases due to the possible development of osteoporosis.
• The frequency of problems in sexual life increases (decreased libido, pain during sexual activity, disappearance of vaginal orgasm, decreased intensity of orgasm, vaginal dryness).
• Prolapse of the vaginal walls is more likely to occur.
• Possible weight gain (development of metabolic syndrome, development of endocrine diseases).
• Hair loss may occur.

Operational risks

In addition to the long-term consequences of hysterectomy, you need to know about possible consequences the surgical intervention itself:

• Anesthesia complications.
• Injury to neighboring organs and great vessels during entry into the abdomen (especially typical for laparoscopic operations) and the operation itself.
• Intraoperative bleeding, or delayed bleeding from a postoperative wound.
• Inflammatory complications.
• Intestinal obstruction (a dangerous complication - repeated surgery is necessary).
• Peritonitis.
• Pulmonary embolism.

In addition, after such a surgical intervention, a rehabilitation period is required, which often lasts up to two months. This is what a “simple operation” to remove the uterus, so easily offered by doctors to women with uterine fibroids, actually looks like.

For many patients whose friends or relatives have had a hysterectomy, as a rule, nothing needs to be explained. They themselves often say the following phrase: “I will absolutely not remove the uterus! I saw what my mother (friend, sister, colleague) had become. I don’t need that!”

Of course, there are exceptions when women are happy to have their uterus removed. Most often, these are women who, before removal of the uterus, had significant problems (excessive prolonged bleeding, pain, frequent urination, etc.). After the uterus was removed, they got rid of these symptoms, and “in contrast” it seems to them that everything has changed for the better. Sometimes they simply do not pay attention to the developing changes in their body, and most often they simply do not connect them with the removal of the uterus.

In a small proportion of women, all of the listed symptoms may not be so pronounced that the woman pays attention to it. This may be due to the fact that the ovaries retained sufficient blood supply and there was no significant drop in hormone levels.

Remove the uterus and save the ovaries?

Here it is necessary to point out another deceit of gynecologists who suggest removing the uterus as soon as possible. They often emphasize the fact that after the operation the ovaries will remain and continue to function fully; only the uterus is removed - “a no longer necessary sac for bearing children, filled with knots.” It is not true! In the process of removing the uterus, in any case, the blood supply to the ovaries is disrupted, since one of the important routes of blood supply to the ovary is crossed - a branch of the uterine artery.

After the operation, the ovaries try to compensate for the missing blood supply, but in most cases this does not work, and in the absence of blood supply, degenerative processes begin in the ovary, leading to a decrease in hormone production.

In general, one can continue ad infinitum to argue in favor of preserving the uterus, but I would like to express the main idea: the doctor does not have the right to decide for the patient which organs she needs, and which ones she, in principle, can do without, guided only by considerations of her own benefit and misleading her.

The doctor’s lack of knowledge about all currently available methods of treating the disease is his great disadvantage, from which his patients suffer; concealment or deliberately false informing the patient about alternative methods of treatment should be considered nothing less than a crime.

Remember that in modern conditions In the vast majority of cases, uterine fibroids can be treated without removing the uterus. Only the presence of serious concomitant gynecological diseases can justify removal of the uterus; in all other cases, there is no need to remove this organ.

And as a conclusion

Below we would like to give a detailed quote from the monograph of the outstanding gynecologist M.S. Aleksandrov “Surgical treatment of uterine fibroids”, which was published - attention! - back in 1958*.

In our desire to preserve an organ, we proceed from the physiological teachings of I.P. Pavlov that dysfunction of any one organ cannot but affect the entire organism as a whole, causing various changes and disorders in it. Thus, premature cessation of ovarian-menstrual function in young and middle-aged women has a negative effect on metabolism and inevitably causes loss and premature aging of the body.M. K. Petrova has proven that dysfunction of the endocrine glands is inextricably linked with the state of the nervous system and often leads to pronounced nervous disorders and severe mental illness.

Ovarian-menstrual function is necessary for the normal state of the body. We believe that premature, and even more so artificial, cessation of menstruation due to removal of the uterus has a very serious impact on the woman’s body as a whole and on her nervous system in particular.

Childbearing function is no less important for a woman. There are many examples when a woman suffering from primary or secondary infertility is ready to undergo any surgery to restore reproductive function. Infertility often brings discord into family life.

Unfortunately, we must note that operations for benign tumors are usually performed radically, with the removal of the entire organ, even if only part of it is affected by the tumor. This provision is based on assumptions about the possibility of degeneration of a benign tumor into a malignant neoplasm and the independent occurrence of a malignant tumor in the remaining part of the organ. Therefore, some surgeons even now, when removing cystic ovarian tumors, do not treat the ovarian tissue with enough care, excising the latter as much as possible, and sometimes even removing the ovary completely. Removing most of the ovarian tissue along with the tumor causes irreparable harm to the woman, disrupting normal hormonal function, causing the absence of menstruation and depriving the woman of the opportunity to become pregnant.

During operations for fibroids, it is usually customary to necessarily remove the uterus, regardless of the age of the patient being operated on, which deprives the woman of ovarian-menstrual and reproductive function. Unfortunately, only some obstetricians and gynecologists recognize the advisability of using conservative operations.

The etiology of the cancer disease has not yet been clarified, and we believe that the radicalism of the operation cannot protect against subsequent cancer damage to organs that were completely unchanged before. Therefore, is there any common sense in categorically refusing to use conservative methods of surgical intervention, giving preference to radical ones when removing benign tumors? We believe that there is no, and we do not see any reason to operate only radically on benign tumors and thereby deprive women of their inherent physiological functions, dooming them to subsequent suffering. This especially applies to young and middle-aged women.

We can say with full responsibility that during operations for benign tumors they should be radically removed, and in terms of preserving the organ itself, maximum conservatism must be exercised.

We believe that one of the main principles of modern gynecology should be reconstructive surgery. “Modern operative gynecology should be based on the principles of therapy that fully or partially preserves the organ and its function, and this necessitates the need to clarify the indications and contraindications for surgical treatment and the development of methods of reconstructive surgery in gynecology” (A. B. Gillarson).

*Quoted from the publication: M. S. Alexandrov. Surgical treatment of uterine fibroids, - State Publishing House of Medical Literature "Medgiz", - 1958 Moscow.

Let us emphasize once again that this text was written fifty years ago, and, as you understand, it was comprehended even earlier. It is sad to admit that during this time practically nothing has changed, that the same huge army of gynecologists remains, obsessed with surgical radicalism, and the voices of doctors insisting on preserving the organ are practically unheard or are quickly forgotten, as happened with the work of M.I. Alexandrova. And this despite the fact that right now we have in our arsenal excellent methods of organ-preserving treatment of uterine fibroids!

Years go by, and every year about a million women in our country undergo hysterectomy for fibroids; the percentage of operations decreases extremely slowly. It's sad, isn't it?

This question is very often asked to a gynecologist by a patient diagnosed with uterine fibroids - a tumor that is an accumulation of bundles of muscle and connective tissue growing inside or outside an organ. The reasons for its occurrence are not fully understood, but there is no doubt that the growth of this benign tumor is stimulated by the hormone estrogen. Hormonal imbalance, disturbances in the cellular immune system, as well as hereditary predisposition are also important.

Since fibroids arise in the thickness of the muscular wall of the uterus, at the beginning of its development it is always intermuscular. Subsequently, if the growth of the myomatous node occurs outward towards the serous membrane of the uterus, the node turns into a subperitoneal node on a wide base or on a narrow stalk. In the subperitoneal (subserous) variant, the fibroid node can sometimes be located far from the uterus, in its ligaments (intraligamentary). In rare cases, such fibroids may separate from the uterus and lie free in the abdominal cavity. If the growth of a fibroid node occurs in the direction of the uterine cavity, the node turns into submucosal (submucosal). A myomatous node can be single with sizes ranging from a few millimeters to 8-10 cm, rarely larger.

Multiple uterine fibroids consist of two or more myomatous nodes, the relative position of which can give the uterus an irregular shape. Numerous symptoms of uterine fibroids, depending on the location, size, and state of blood circulation in the node, can be reduced to 3 groups: menstrual dysfunction, pain, reproductive dysfunction.

In what cases can fibroids be observed and not operated on?

There is no universal answer. When resolving this issue, we take into account the desire of the woman herself, the presence and severity of complaints, the woman’s age and reproductive plans (desire to have children in the future), decreased quality of life, size, location of myomatous nodes, etc. The decision is made jointly with the woman based on full discussion and consideration of possible alternatives. You can resort to conservative treatment methods. True, today they are not effective enough. Hormonal drugs new generations make it possible to stop the growth of fibroids if the tumor consists predominantly of muscle fibers and when there are receptors in the muscle layer of the uterus that allow them to “catch” these hormones and give a response. This therapy will help some, but not others. Treatment with non-steroidal anti-inflammatory drugs slightly reduces pain and bleeding.

With the onset of menopause, fibroids usually shrink. And if a woman with this disease who is approaching menopause contacts the specialists of the Department of Gynecology and Gynecological Oncology at EMC, we usually suggest not to rush into surgery. She should be monitored and checked every six months to make sure that the fibroids are not growing rapidly.

Uterine fibroids: indications for surgery

The absolute indications for surgical treatment of uterine fibroids, regardless of the patient’s age, are:

the size of fibroids exceeds the size of the uterus during pregnancy 12-14 weeks;

rapid growth of uterine fibroids (per year by an amount corresponding to 4-5 weeks of pregnancy);

uterine bleeding with a decrease in hemoglobin due to heavy blood loss;

pronounced pain syndrome;

secondary changes in the node (necrosis, infection);

the presence of submucosal or subserous nodes of any size on long stalks, with a high probability of being prone to twisting;

cervical, interligamentous, “born” node;

infertility, miscarriage, incl. as preparation for the IVF program;

severe dysfunction of neighboring organs (frequent urination, prolonged constipation). Due to pressure on the back wall of the bladder, reflux occurs (reflux of urine into the ureter), increasing the risk inflammatory diseases(for example, exacerbation of chronic pyelonephritis), dilation of the ureters and renal pelvis up to secondary hydronephrosis.

Surgical treatment of uterine fibroids

The choice of the scope and access of surgical intervention depends on the size and location of the myomatous node, the patient’s age, and her desire to preserve reproductive and menstrual functions. In any case, when treating young women, we are guided by the principle: “Remove fibroids - save the uterus!” However, we must not forget that myomectomy, being a conservative, organ-preserving, reconstructive plastic surgery, has a certain percentage of fibroid recurrence, which in some cases requires re-operation.

The EMC Clinic of Gynecology and Oncogynecology performs laparoscopic myomectomy, which has virtually no restrictions on the size of uterine fibroid nodes, hysteroresectoscopic removal of submucous uterine fibroids, and combined laparoscopic-hysteroscopic myomectomies. The issue of hormonal preoperative preparation of patients is decided individually. In case of multiple myomatous nodes, the uterine wall is incised above the surface of each of them, the nodes are fixed with special instruments and removed. The vessels in the bed of the node are coagulated (turned into clots), after which a complete layer-by-layer reconstruction of the uterine wall is performed by suturing using modern absorbable suture material. Adequate layer-by-layer restoration of the integrity of the uterine wall is the key to the success of laparoscopic myomectomy. Patients who have undergone myomectomy will be able to begin preparing for pregnancy 6-12 months after surgery (the issue is decided individually). Most of these interventions can be performed laparoscopically, with the exception of very large nodes that occupy the entire abdominal cavity.

In some cases, the method of choice may be embolization (blockage) of the vessel feeding the fibroid, as a result of which the growth of the node stops and it “shrinks”. Targeted treatment of the site with focused high-energy ultrasound is also possible. For pre- and postmenopausal women, uterine artery embolization and extirpation (complete removal) of the uterus with or without appendages are indicated. If the fibroid does not grow and does not cause discomfort, then treatment is not recommended.

Myoma is a benign tumor, but if it is large, the complications can be very serious. The abdomen increases, as during pregnancy, the shape of the uterus is disrupted, and the volume of the cavity is reduced. The cervical canal may be blocked. The physiological processes occurring in the reproductive system are disrupted. The woman's general health deteriorates. When choosing a treatment method, take into account various factors, the most reliable and gentle method is selected. Assessing the size of the fibroids is important, since there must be good reasons for the operation.

Content:

Types of fibroids

The neoplasm originates in the muscle tissue of the uterus and gradually increases in size due to abnormal cell division. Unlike a malignant tumor, fibroids do not spread to other organs; they grow much more slowly. At first, the cells develop abnormally only in the muscle tissue, and then the tumor spreads beyond its boundaries. Depending on the direction in which it grows, the following types of fibroids are distinguished:

1. Submucosal - it is formed deep in the muscular layer (myometrium), grows towards the mucous membrane of the uterine cavity, which is why it is called “submucosal”.
2. Subserous (subperitoneal) originates in the outer muscular layer, grows towards the serous membrane separating the uterus from the abdominal cavity. Knots can have a wide base or a thin stem.
3. Interstitial (intramuscular) - develops in the middle of the muscle layer, without going beyond its limits.

When assessing the degree of danger of a tumor and choosing a treatment method, specialists take into account its location. In most cases, myomatous nodes are located in the body of the uterus (corporal type), but sometimes they are also in the cervix (cervical fibroids).

The tumor can be single or multiple, in the form of several nodes. For a specialist choosing a treatment method, great importance have the size of uterine fibroids.

How are sizes determined?

The growing tumor stretches the uterus, which leads to a gradual increase in the abdomen (similar to its growth during pregnancy). The size of the fibroids is estimated based on the week of pregnancy the size of the abdomen corresponds to.

The exact size of the tumor in centimeters can be determined using ultrasound. Even fibroids smaller than 1 cm in size are detected using this method. Ultrasound is performed either through the anterior wall of the abdominal cavity or through the vagina. This allows you to identify and measure fibroids of any location and size.

IN difficult cases when a small tumor is located, for example, between ligaments, the hysterography method is used (x-ray of the cavity with the introduction of contrast liquid). Hysteroscopy (examination using an endoscope inserted into the uterine cavity through the vagina), diagnostic laparoscopy (an optical device is inserted into the uterine cavity through a puncture on the anterior wall of the peritoneum) and MRI are also used to examine fibroids and assess their size.

All myomatous nodes, depending on their size, are divided into three categories:

Sometimes uterine fibroids reach a size at which the belly appears as at 37 weeks of pregnancy.

In addition to size, the tumor growth rate is also taken into account. A tumor is considered to grow quickly if its size increases by 2-2.5 cm (or 5-6 weeks) per year. In this way, the growth of small and medium fibroids is assessed. If they are small and grow slowly, then conservative treatment is possible. For sizes larger than 8 cm (or 15 weeks), the nodes are removed.

In addition to the size of the tumor and the speed of development, when prescribing treatment, the severity of symptoms, the woman’s age, and her intention to have children are taken into account.

The danger of large fibroids

There are uncomplicated and complicated forms of the disease. Possible complications are:

• necrosis of the myomatous node - an acute painful condition in which torsion of the leg occurs, disruption of the blood supply to the fibroid;
• formation of cystic cavities (threat of purulent inflammatory processes);
• compression of blood vessels and nearby organs;
• malignant degeneration (into sarcoma).

Myoma can reach a diameter of 25 cm. A large tumor located outside, on the anterior wall of the uterus, compresses the bladder, which leads to difficulty urinating or, conversely, can cause urinary incontinence. In addition, the appearance of fistulas connecting the cavities of the uterus and bladder is possible.

If a large fibroid is located on the back surface of the uterus, bowel movements become difficult and constipation occurs.

A large node can compress the inferior vena cava, making it difficult for blood to move from the lower body to the heart. In this case, the woman experiences shortness of breath and rapid heartbeat even at rest. In the presence of many average and large nodes(myomatosis) there are constant uterine bleedings not associated with menstruation. This leads to anemia.

Video: Complications with large nodes. When and how is surgical removal performed?

When is surgical treatment used?

Surgery for uterine fibroids is mandatory in cases where there is rapid growth - up to 2 cm (4 weeks) in diameter over the course of a year, and also if the tumor has a stalk and there is a danger of twisting it.

An absolute indication for surgical removal of fibroids is the appearance of uterine bleeding and severe anemia in a woman. This is possible due to impaired muscle elasticity with the development of large myomatous nodes in it and deterioration of contractility.

Myoma must be removed surgically if it is the cause of infertility or miscarriages. The operation is also prescribed if a woman experiences severe pain in the abdomen, rectum, or bladder, as they are compressed and blood circulation is disrupted.

Video: Treatment of fibroids using hysterectomy and uterine artery embolization

What types of surgery are there?

When choosing a method for performing an operation, the size of uterine fibroids and its location are of primary importance. In each specific case, the doctor makes a decision on the method of tumor removal, the possibility of preserving organs and menstrual function.

Myomectomy

This is an operation in which only the tumor is removed, the uterus is preserved. Most often, this method is used to treat women under 40 who would like to maintain the ability to give birth to a child.

Tumor removal is carried out in various ways.

Laparotomy- This is the removal of fibroids located deep in the muscle tissue or under the outer lining of the uterus by making an incision in the abdomen above the pubis. The tumor is removed. The risk of infection and complications is minimal. This method is especially effective when there are many nodes and there is an increased likelihood of damage to large vessels. It is much easier to prevent bleeding during open surgery. In addition, removal of myomatous nodes can be carried out quickly.

Laparoscopy– removal of fibroids through 3 small holes in the abdomen using optical instruments. Carbon dioxide is first introduced into the uterus to create conditions for more free manipulation of instruments and to avoid cuts. The image is displayed on the screen, which allows you to control the process.

The advantage of the method is that the wound heals quickly, the operation is low-traumatic, and there is no stitch left after it. It is performed under general anesthesia. The disadvantage is that there is still a minimal chance of internal cuts, so the woman is under medical supervision for 3-4 days. Sometimes, if the myomatous node is located on the posterior or lateral outer surface of the uterus, it is removed through a puncture in the posterior wall of the vagina.

Addition: If necessary, this method can remove large myomatous nodes in pregnant women. In this case, the fetus is not injured, pregnancy proceeds normally.

Hysteroscopic myomectomy. A method that is used to remove fibroids in the cavity itself. It is carried out using an optical instrument (resectoscope) through the vagina. The method is not used if a woman has inflammatory diseases of the genital organs or cervical defects.

Hysterectomy

Removal of the uterus completely or with preservation of the cervix. This operation is performed in the most severe cases, when there are many large nodes, the fibroid occupies the entire cavity, and there is severe bleeding. At the same time, the hemoglobin level is critically low, and there is a high probability of the tumor degenerating into sarcoma. Most often, such operations are performed on women after 45 years of age.

The uterus is removed in several ways: through an incision in the lower abdomen, through punctures in the abdominal wall (laparoscopic method), through the vagina. After the operation, a woman cannot have periods. But if the ovaries are not removed, other symptoms of menopause may be absent. The possibility of sexual activity after surgery remains.

Video: Methods for removing fibroids while preserving the uterus

Minimally invasive methods of treating fibroids

When treating fibroids using these methods, no incisions or punctures are required.

Embolization of the uterine arteries. The method is that through the inguinal artery, using a catheter, “plugs” made of plastic or gelatin are brought to the vessels of the fibroids, which block the flow of blood. Due to lack of nutrition, the tumor gradually decreases. The procedure is performed under local anesthesia.

FUS ablation(focused ultrasound). Removal of fibroid nodes is carried out using a directed ultrasonic flow, which causes heating and evaporation of nodes located in the muscle. The process is controlled using a magnetic resonance imaging scanner. In this case, no anesthesia is required; the functions of the uterus are completely preserved. The method is effective even in the presence of large nodes.

Video: Vaporization of fibroids using FUS ablation

Possibility of pregnancy with fibroids

Large fibroids (more than 15 weeks) cause infertility if they block the tubes or cervix, creating obstacles to the movement of sperm. If there are nodes no larger than 3 cm in diameter (that is, less than 8 weeks), pregnancy is possible. If the nodes do not increase, then their existence does not affect the course of pregnancy and fetal development. Complications arise when a tumor grows in the uterine cavity, filling it, complicating the development of the fetus. Often this ends in miscarriage.

Sometimes, if the fetus is already large enough and begins to experience a lack of nutrition due to the pressure of fibroids on the vessels, a caesarean section is performed and subsequent removal of the uterus. C-section This also has to be done if the fibroid occurs in the cervix or covers it.

Uterine fibroids are the reaction of a woman’s body to the influence of damaging factors, which is manifested by the formation of myomatous nodes. Women have heard that for uterine fibroids, surgeons perform an operation - they remove the organ. When myomatous nodes are detected in the uterus, many patients experience fear and develop a depressive state. There is no need to worry, because fibroid removal surgery can be avoided.

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You will be scheduled for an appointment with leading advanced specialists. They use an innovative organ-preserving method of treating fibroids - uterine artery embolization. This operation is performed under local anesthesia and allows you to get rid of the symptoms of fibroids and save the uterus. You have the opportunity to receive an urgent consultation if you send the results of preliminary studies

Modern views on the causes of uterine fibroids

According to many gynecologists, uterine fibroids are a benign tumor. reproductive system, which grows from immature muscle cells of the uterine wall. It occurs in 32-40% of women of reproductive age. Recently, there has been a tendency towards “rejuvenation” of this disease. Uterine fibroids are increasingly being detected in young women and young girls. Many gynecologists are excessively wary of cancer and, in case of uterine fibroids, perform surgery - removal of the uterus.

The doctors of the clinics with which we cooperate adhere to the modern theory of the origin of uterine fibroids. Myoma is not a tumor, despite the fact that it has signs of a tumor process. This is a reaction female body for frequent menstruation. The rudiments of fibroids can be formed during intrauterine development female fetus. Of these, when hormonal levels change during the appearance of the first menstruation, the growth and progression of myomatous nodes begins.

The risk of malignancy of these formations is no higher than the probability of developing a cancerous tumor from intact cells of the muscular layer of the uterus. For this reason, our doctors do not remove the uterus during fibroid surgery, but preserve the female reproductive organ. Endovascular surgeons perform a minimally invasive procedure called uterine artery embolization.

Methods for removing uterine fibroids

How to remove uterine fibroids? The leading method of treating fibroids today remains surgery to remove the uterus. 50% of all hysterectomies performed in the world are due to this pathology. Doctors at our clinics believe that the operation of removing the uterus for fibroids is performed in most cases without compelling reasons and perform embolization of the uterine arteries.

Uterine fibroids are widely used as surgical methods for treating uterine fibroids. various options myomectomy:

• abdominal;
• laparoscopic;
• transcervical.

Doctors for uterine fibroids perform myolysis using ultrasound, thermal ablation of myomatous nodes with focused ultrasound. Our specialists use a minimally invasive method for uterine fibroids – uterine artery embolization.

In 80-90% of patients with uterine fibroids, radical operations are performed: subtotal and total hysterectomy. These surgical interventions are accompanied by the following negative consequences:

• significant surgical trauma;
• blood loss;
• loss of reproductive function in patients.

How are uterine fibroids removed? In most cases, hysterectomy is performed using a classic laparotomy approach. The least traumatic operation is hysterectomy, which is performed via vaginal access. The complication rate of this operation is 70% lower compared to laparotomy. Hysterectomy is also partially or completely performed laparoscopically.

After hysterectomy with preservation of the ovaries in women, the production of ovarian hormones decreases, osteoporosis and urogenital disorders develop. Women remain premenopausal until natural menopause, which occurs 3 years earlier. These consequences do not occur after uterine artery embolization.

How to remove fibroids using myomectomy

When surgically treating women under 40 years of age, surgeons focus their efforts on preserving the uterus and specific functions of the female body. How is surgery to remove uterine fibroids performed? At the present stage, conservative or organ-preserving operations have become widespread. Conservative myomectomy is also performed in women with unrealized generative function or who wish to preserve menstrual function.

An abdominal myomectomy is an open abdominal procedure performed through an incision in the anterior abdominal wall. This operation has an important advantage. It allows you to preserve the uterus and reproductive function of a woman. Abdominal surgery to remove uterine fibroids has the following disadvantages:

• • • more than six recovery period;
    • the formation of adhesions in the pelvis, which leads to infertility;
    • frequent re-growth of myomatous nodes from myoma rudiments that were not removed for technical reasons;
    • allergic complications;
    • development of uterine necrosis.

These complications are never observed after uterine artery embolization. A promising and gentle method for treating uterine fibroids is laparoscopic myomectomy. This method of removing uterine fibroids is used in the treatment of pedunculated myomatous nodes, small interstitial and subserous nodes. The rehabilitation period for laparoscopic myomectomy is much shorter than for abdominal surgery. Undesirable aspects of laparoscopic myomectomy are the long duration of the operation, the impossibility of palpation and removal of all small nodes located between the muscles of the myometrium, which becomes the reason for the survival and growth of the tumor. Doctors are currently successfully solving this problem using intraoperative ultrasound of the uterus. Laparoscopic myomectomy

In recent years, surgery to remove fibroid nodes in many foreign clinics is performed using the da Vinci robot system. The technology provides a three-dimensional surgical field and allows surgeons to achieve High Quality surgical suture.

Hysteroscopic surgery to remove fibroids is the method of choice for treatment for submucosal nodes. The doctor inserts a hysteroscope into the uterine cavity, performs resection of the submucosal myomatous node, curettage of the uterine mucosa and burning it to create amenorrhea. When a conservative transcervical myomectomy is performed, a woman’s fertility (ability to bear children) is restored and menstrual function is normalized.

Hysteroscopy is performed in the presence of a submucosal node with a diameter of no more than 5 cm in patients who do not have concomitant pathology of the pelvic organs. Embolization of the uterine arteries is performed in the presence of myomatous formations of any size. If there are concomitant diseases, our doctors decide on the possibility of performing the procedure individually.

Uterine artery embolization surgery

Uterine artery embolization is an organ-preserving method of treating uterine fibroids, which leads to a reduction in the size of myomatous nodes and cupping clinical manifestations diseases. The essence of the method is the introduction of embolic particles (non-reabsorbable polyvinyl alcohol particles) into the uterine arteries through a catheter. They are delivered by the bloodstream to the final sections of the arterial bed. Foci of massive necrosis and vascular thrombosis form in the tissues of the myomatous node.

Uterine artery embolization in our clinics is performed by an endovascular surgeon. Embolization surgery does not require general anesthesia. The process of inserting a vascular catheter into the femoral artery is painless. The doctor administers local anesthesia at the puncture site.

Through a puncture in the groin area, the surgeon inserts a thin catheter into the femoral artery, which is then inserted into both uterine arteries. First, the doctor injects an iodine-based contrast agent through the catheter and the patient undergoes an X-ray. This allows the endovascular surgeon to ensure that the catheter has reached the desired location. At this moment, patients sometimes feel warmth in the lower abdomen. Next, a suspension with emboli is injected through the catheter. The operation is completed with control angiography. After making sure that the fibroid is drained of blood, the endovascular surgeon removes the catheter from the artery. The puncture site is covered with a sterile pressure bandage.

The total duration of the procedure is from 10 to 15 minutes. Next, the patient is transferred to a ward, where she is given pain relief therapy. Already 2.5 hours after the procedure, doctors allow you to bend your legs, after 6-7 hours the patient can get out of bed and eat.

The following complications occur extremely rarely after uterine artery embolization:

• thrombosis of the punctured artery;
• bruising in the area where the catheter was inserted,
• amenorrhea;
• damage to the pelvic artery by the catheter.

The experience of the doctors at our clinics and an individual approach to the management of each patient allows us to avoid these complications. The only “complication” that may occur is a bruise at the puncture site. In order to prevent complications after uterine artery embolization, our gynecologists conduct a comprehensive preoperative examination of the patient, which includes the following types of research:

• bacterioscopic examination of the vaginal microflora (if inflammatory changes are detected, antibacterial therapy is carried out);
• oncocytological examination of the endocervix and exocervix;
• ultrasound examination of the pelvic organs and vessels with determination of the speed of blood flow in the uterine, ovarian arteries and their branches (assessment of blood flow parameters in the vessels of the uterus is carried out using ultrasound triplex scanning of blood vessels in B-mode, Doppler sonography and color Doppler mapping of blood flow;
• hysteroscopy and separate diagnostic curettage, followed by pathohistological examination (in case of dysfunction of the ovaries, an increase in the median echo, which does not correspond to the day of the menstrual cycle).

If a neoplasm of the ovary or one of the nodes is detected with multiple growth patterns of the subserous type on a thin base, surgeons perform surgical laparoscopy - removal of the ovarian mass before embolization of the uterine arteries, followed by pathohistological examination. Then, embolization of the uterine arteries is performed, and after reducing the size of the uterine tumor, laparoscopic removal of the myomatous node is performed. This tactic allows you to reduce the amount of blood loss and the risk of “unlacing” the myomatous node into the abdominal cavity.

Most patients experience complete recovery after embolization of the uterine arteries, and myomatous nodes are significantly reduced in size. A year after the procedure, the size of the uterus approaches normal.

• changes in mental balance;
• autonomic disorders;
• arterial hypertension;
• development of obesity.

The threat of thyroid and breast cancer increases, interest in sexual activity disappears, and, as a result, problems in relationships with a spouse or partner. Sometimes removal of the uterus is a forced decision when fibroids do not respond to alternative treatment. In this case, we recommend that you first consult our gynecologists.

After myomectomy, the uterus is restored and after six months the woman can theoretically plan a pregnancy. But postoperative scars remain on the uterus. They can cause complications during pregnancy and cause uterine rupture during childbirth. After embolization of the uterine arteries, no scars remain on the uterus, the structure of the organ is restored, and there are no complications during pregnancy and childbirth associated with the UAE procedure.

2 years after surgery for conservative removal of fibroids, 14% of patients experience a relapse of the disease. After 5 years, new myomatous nodes appear in almost all patients. Repeated removal operations leave new scars on the uterus, which threatens problems when bearing a child. Due to the fact that after embolization of the uterine arteries, the blood supply is lost not only to the dominant myomatous node, but also to small formations, the rudiments of fibroids, the risk of relapse is negligible. For this reason, our gynecologists perform uterine artery embolization in the presence of uterine fibroids.

Bibliography

• Savitsky G. A., Ivanova R. D., Svechnikova F. A. The role of local hyperhormonemia in the pathogenesis of the growth rate of tumor nodes in uterine fibroids // Obstetrics and Gynecology. – 1983. – T. 4. – P. 13-16.
• Sidorova I.S. Uterine fibroids (modern aspects of etiology, pathogenesis, classification and prevention). In the book: Uterine fibroids. Ed. I.S. Sidorova. M: MIA 2003; 5-66.
• Meriakri A.V. Epidemiology and pathogenesis of uterine fibroids. Sib Med Journal 1998; 2:8-13.