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06_Benign_tumors_uterus

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					Approved
on the conference of the Department
of Obstetrics and Gynecology with the Course
of Infant and Adolescent Gynecology
“____” _____________200 p.
protocol No
T.a.The Head of the department, Professor
O.A.Andriiets’___________



                     Methodological instruction
           on the themes singled out for independent study
                   “Benign tumors of uterus”




                                 Subject-gynecology
                                 For 5 year students of
                                 medical faculty
                                 2 academic hours
                                 Developed by assistant, PhD
                                 Oksana Bakun




                       Chernivtsi, 2008
I. Scientific and methodical grounds of the theme
  Early and active diagnosis of benign tumors and precancerous diseases of female
genitalia, their timely and correct treatment are the pledge for solution of cancer
problems.
II. Aim:
A student must know:
   1. Classification of uterine myoma.
   2. Methods of examination for diagnosis of uterine myoma.
   3. Conservative methods of treatment.
   4. Methods of myoma surgery.
   5. Classification of uterine myoma.
   6. What additional methods of investigation are used for confirmation of the
      diagnosis?.
A student should be able to:
   1. Diagnose benign tumors of uterus.
   2. Diagnose precancerous diseases of uterine cervix.
   3. Carry out a vaginal speculum-examination, vaginal examination, put up
       primary diagnosis.
III. Recommendations to the student
UTERINE MYOMA
Uterine myoma (fibromyoma, leiomyoma) — is a benign tumor which contains
varying amounts of muscle and fibrous elements.
Concerning gynecologic diseases benign tumors are found in 10-25% of all the
cases, although during the last years the tendency of increasing the quantity of
these tumors is observed. The myoma arises seldom in young women. The risk of
disease grows after 35-40 years, at the age which is close to climacterium. Later
beginning of menstrual function, irregular menstrual cycle, high frequency of
induced abortions are present in the past history of the patients. Therefore, 35-40
years women are patients at risk for uterine fibromyoma.
Tumor histogenesis and structure. Uterine myoma belongs to tumors, which are
growing from mesenchyma. It has three consecutive stages in its morphogenesis.
They are:
    active region of growth formation
    growing of tumor without differentiation
    growing of tumor with differentiation and maturation
The areas of growth are formed mainly around the vessels. These regions are
characterized by a high level of metabolism and increased capilary and tissual
permeability which stimulate the tumor growing. Uterine fibroid has in its
development parenchymal-stromal features of that layer, from which it has been
educed, therefore the parenchyma and stroma ratio in a tumor is different.
Leiomyoma is developed at predominance of muscle elements, in the structure of
fibromyoma fibrous tissue is predominant. The consistency of tumor depends on
fibrous and muscle tissue ratio: the more there are muscle fibers, the more the
tumor is mild at palpation.
Myomas are classified according to histologic structure as myoma, fibromyoma,
angiomyoma and adenomyoma. According to the speed of growing there are the
tumors which are growing slowly and quickly. According to histogenesis
peculiarities there are distinguished simple and proliferative myomas. Proliferative
myomas contain much more atypical muscle elements, where is a great number of
plasmatic and lymphoid cells and increased mitotic activity. The incidence of
proliferative myomas happen twice more often in the patients with fast growing
tumors.
Very often uterine fibroids arise in places of complex interlacing of muscle fibers
of uterus — near tubal angles, on uterine center line. The myoma is characterized
by the effusive growing. As compared with cancer fibroids they move apart tissue
without destroying it. Tumor is growing simultaneously with tissue mass
surrounding it. Uterine fibroids have few veins, basic amount of vessels is situated
in pseudo-capsule. Uterine fibroids' lymphatic system is atypical without absorbent
vessels. Uterine fibroids are deprived of nervous terminals, choline and adrenergic
nervous frames.
According to their location in the uterus myomas are classified into:
    subserosal — subperitoneal uterine fibroids, which are growing under the
      outer serosal layer of the uterus, may have a wide or thin pedicle.
    interstitial (intramural, intraparietal) — uterine fibroids, which are growing
      within the muscular wall of the uterus
    submucosal — uterine fibroids which are growing under the uterine mucous
      into the uterine cavity
    atypical forms of uterine fibroids location: retrocervical myoma grows from
      the posterior surface of the uterine cervix, it is situated within a retrocervical
      fat; paracervical myoma grows from the lateral part of uterine cervix, it is
      situated in the paracervical fat; intraligamentary myoma grows from the
      uterine body or cervix within the broad ligaments.
The fibromyoma can have one fibroid (nodulosus fibromyoma), many fibroids
(multiple fibromyoma) and diffuse growth (diffuse fibromyoma).
Hormonal status of the patients with fibromyoma. They are considered
hormonally depend tumors because the growth of these tumors is related to estro-
gen production. In the majority of cases these patients have an hormonal dys-
function of ovaries which is characterised by anovulatory cycles, corpus luteum
insufficiency. It leads to hyperestrogenemia and lowering of progesterone level.
Small cystic changes in ovaries occur due to hormonal disordes. Uterine endo-
metrium and myometrium are under the influence of estrogenic hormones. Their
excessive amount in blood can lead to endometrial hyperplastic processes and
cystic changes in myometrium. Such local hyperhormonemia leads to pathological
hypertrophy of myometrium. Not only sexual hormones synthesis, metabolism and
interaction impairment, but also the state of the myometrial receptors especially
large activity of the estrogen receptors as compared with progesterones receptors,
take part in a pathogenesis of uterine fibromyoma.
Fibromyoma grows slowly without any proliferative changes at presence of small
cystic changes in ovaries with nonsignificant hyperestrogenemia. Fibromyoma
growing depends on its type, location, blood supply and patient's age. Fibromyoma
grows quickly in young patients, particularly during pregnancy, as the
fetoplacental complex synthesizes large amount of estrogenic hormones, which are
tumor stimulating growing factor. Quite often fibromyoma accelerates its growing
in climacterium, when there is a rearrangement of woman's hormonal system.
Ovaries undergo polycystic degeneration at that time.
Clinic. Clinical manifestation of fibromyomas depends on uterine fibroid's
location, size of tumour, rate of its growing, and also presence of complications.
Of the most myomas there are not any symptoms at the initial stages. The main
symptoms are pain, bleeding, sensation of pelvic heaviness in the lower part of the
abdomen, progressive increase in pelvic pressure, infertility, frequent urination,
pressure on the rectum. These symptoms most commonly occur during the
excessive growth of tumor, and sometimes they testify development of secondary
degenerative or inflammatory changes in fibromyoma tissue.
Menstrual function in the patients does not variate in case if tumor is sub-serosal
because attached to the uterus by only a stalk or on a wide basis under a peritoneal
integument and it is practically outside of uterine borders. Another spectrum
presentation includes patients with atypical (subperitoneal) location of uterine
fibroids: the tumors from the anterior wall of the uterus and antecervical location
can press upon urinary bladder and cause dysuric signs; pressure on the ureters (as
they traverse the pelvic brim) leads to hydroureter and sometimes to
hydronephrosis. Retrocervical location of uterine fibroid due to intensive growing
can spread in all small pelvic, compressing rectum and provoking constipation.
Intraligamentary tumor during its growing moves apart the broad ligament of the
uterus. As the ureters are passing in the lower areas of parametrium, the tumor
results in pressure upon ureters leading to hydroureters or hydronephrosis.
Cyclic menstruation is present but it is painful (algomenorrhea).
Submucosal location of uterine fibroid is characterized by cramping cyclic
menorrhagia which has been changed into acyclic bleeding.
Monthly appreciable bleeding leads to the secondary iron deficiency anemia.
Characteristic dystrophical myocardial changes called "myom' heart" result from
the secondary anemia and chronic hypoxia and are often found in patients with
fibromyoma. Liver function is frequently broken in these patients. Probably, these
changes are the result of steroid hormones metabolism dysfunction. Hypertrophy
of the left ventricle, myocardial dystrophy, ischemic heart disease, idiopathic
arterial hypertension are also present in these patients. In most of the patients after
fibromyoma removal the arterial pressure is reduced to the normal level. This fact
confirms the idea of pathogenetic connection of fibromyoma with changes in
myocardium and rising of arterial pressure.
Diagnosis. History of the patients includes hereditary predilection (myoma in
mother and other reproductive organs tumors in close relatives); menstrual
dysfunction, late beginning of menarche and metabolism infringement (obesity,
diabetes mellitus). Reproductive dysfunction (infertility, pregnancy loss), induced
abortions (mucous and myometrium trauma should lead to endometrial receptor
device changes),extragenital diseases, which caused endocrine and ovarian
disordes, in particular can be present in these patients.
Bimanual examination in uterine fibromyoma has characteristic signs. It includes
the presence of a large midline mobile pelvic mass with the regular contour. The
mass usually has a characteristic "hard" feel or solid quantity.
Additional methods of investigation are used for confirmation of the diagnosis.
    uterine sounding
    curettage of uterine cavity
    Hysterography
    Hysteroscopy
    Laparoscopy
Pelvic ultrasonography is the most common method to confirm the uterine myomas
presence. The ultrasonographer may suggest location, quantity, size of uterine
fibroids, their sructure, presence of destructive changes. Dynamic observation
enables to supervise efficiency of the conservative therapy, tumor growing, or, on
the contrary, its reduction under the influence of treatment.
Uterine fibroids' complications
Prolapse of submucous fibroid (cervical protruding myoma)
Submucous fibromyoma is accepted by uterus as an ectogenic body. Fibroid
descent to the inferior portion of uterus, irritating the isthmus receptors. It results in
myometrial contractions, cervical dilation and uterus pushes out fibroid into
vagina. Pedunculated tumor is connected with uterus. If pedicle is short, it can
result in difficult complication — oncogenetic inversion due to prolapse of the
submucous fibroid. Speculum examination should be performed for confirmation
of this diagnosis: cervical protruding myoma is visible.
Treatment Submucous tumor can be easily removed by the incision of long
pedicle by clamping the base through the cervix. The pedicle is then ligated. Such
removal of fibroid can lead to uterine perforation when the pedicle is short and
wide. These patients need hysterectomy.
Torsion of uterine fibroid
Torsion of uterine fibfoid is a very common in subserous location. Clinically it is
characterized by crarfiping pain, signs of peritoneal irritation, fever, urinary
frequency and symptoms of rectal pressure. In this situation necrosis and infection
are common.
Surgical treatment Myomectomy is more commonly done when abdominal
myoma location. Myomectomy should be the operation of choice in case of single
subserous pedunculated tumor
Uterine fibroid' necrosis
Necrosis of uterine fibroid results from blood supply disorder of the tumor,
occuring    due to rapid       growing, pregnancy,        mechanical     accident,    and
postmenopausal atrophy. It leads to tumor edema and pseudocapsule hemorrhages
Clinically it is characterized by cramping pain which enforces during palpation.
Signs of peritoneal irritation are found. Fever and leukocytosis accompany severe
degeneration.
Treatment is surgical removal.
Uterine fibroid' suppuration
Uterine fibroid's suppuration arises primarily very seldom. Sometimes it is a result
of necrosis. Submucous and interstitial uterine fibroids may be suppurated. The
serious septic state demands supracervical hysterectomy (subtotal) or total
hysterectomy.
Pseudocapsule' and uterine fibroid' vessels rupture
Pseudocapsule' and uterine fibroid' vessels rupture happens very seldom. It is
accompanied by severe pain, signs of intraabdominal hemorrhage (hemorrhagic
shock).
Uterine myoma and pregnancy
Pregnancy at fibromyoma of uterus comes mainly at subserous and interstitial
location of uterine fibroids. Submucous fibroids manifest with pregnancy
progressing.
Diagnosis of pregnancy in such patients represents appreciable difficulties. During
the pregnancy there is a threat of its interrupting as the result of fibroid blood
supply disorder (its necrosis, pseudocapsule hemorrhage). The function of urinary
bladder and rectum is broken. Fetal position is frequently incorrect — oblique or
transversal one. Breach presentation is common if the myoma does not let the fetal
head get into pelvic inlet. Preterm rupture of amniotic fluid, primary and secondary
dystocia of labor are common.
Cesarean section should be pcrfoimed if the nodes are placed behind the course of
the genital canal and block the plane of pelvic inlet. Vaginal delivery is
recommended in all other cases of labor. Postpartum hemorrhage happens in the
third period of labor. Uterine fibroid should undergo involution until their
complete regress in women with high-grade lactation during the further duration of
puerperium.
TREATMENT OF UTERINE MYOMA
Treatment of fibromyoma should be operative and conservative.
Indications to operative treatment are: myomatous uterus larger than 12-week of
pregnancy, acceleretion of tumor growing, presence of such symptoms as pam,
bleeding, secondary anemia; myoma's complications; suspicion on malignant
degeneration and combining with endometriosis and endometrial hyperplasia.
Operative treatment is performed in case when the patients have contraindication
to hormonal treatment. These contraindications are: thromboembolism and
thrombophlebitis, varicose phlebectasia, hypertension, operation concerning
malignant tumors m the past, no effect from hormones.
Surgical interventions are divided into radical and conservative — plastic ones.
Radical operations are in uterine removal — total hysterectomy or supracervical
hysterectomy
Hysterectomy should be performed in 45-year-old women and older during tumor
growing in menopause, presence of cervical and endometrial pathological changes
(dysplasia, erosion, polyps, scars), combination of fibromyoma with precanserous
lesions of uterine cervix and uterus, endometriosis, cervical and isthmic myoma
Supracervical hysterectomy is performed in all other cases
Conservative-plastic operations are carried out for reduction or preserving of
female menstrual and reproductive functions. Their using is justified in young
women for anatomo-functional safety of uterus, fallopian tubes, ovaries and
ligaments.
Conservative treatment of uterine fibromyoma has been confirmed patho-
genetically and is directed on correction of hormonal state, treatment of anemia
and metabolic dysorder, inhibition of tumor growing.
Indications. Conservative treatment is recommended at any age, lr case of myoma
duration with poor symptoms or without any symptoms, at presence of
contraindications to operative treatment.
Conservative therapy includes a diet with the usage of products, which contain
A,E,K,C vitamins, such microelements as copper, zincum, lodum, iron, antianemic
therapy, vitamin therapy, uterotomc drugs for decreasing of menstrual hemorrhage,
lodium drugs should provoke inhibition of estrogenic secretion at ovaries 0,25%
solution of potassium iodide should be taken in a dose of 15 ml once or twice per
day continuously during 6-10 months. It is nessesary to combine lodium drugs
with phytotherapy — 60 ml of potato juice per day .Electrophoresis of 1-2%
solution of potassium iodide is commonly used 40-60 procedures are needed for
the treatment course.
Hormonal therapy. Gyfotocyn is given intramusculary in the dose of 1 ml during
12-15 days since 5-7 day of menstrual cycle during 6-8 cycles. This medicine is
recommended at menorrhagia of the patient at any age.
Androgens could be applied at uterine myoma in the period of penmeno-pause Its
effect can be achieved by pituitary gland suppresion Androgens can result in
reduction of uterine size, endomenal atrophy, ovaries follicular depressing.
Methylandrostendiolum is prescribed 50 mg per day during 15 days in the
follicular phase of reproductive cycle for 3 to 4 months. Methyltestosterone is
administrated in 2 pills under the tongue three times per day during 20 days with
10-day time-out for at least 3 months.
Hestagens have been used in uterine fibromyoma because of its antiestrogenic
effect. First line progestines are Progesterone in a dose of 5-10 mg intramusculary
once per day for 10-12 days in luteal phase of a reproductive cycle or 2 ml 12,5 %
solution of 17- Hydroxyprogesterone Capronate intramusculary on 12-14 day of a
cycle for at least 3 months are prescribed.
Pharmacologic removal of the ovarian estrogen source can be achieved by
suppresion of the hypothalamic-pituitary ovarian axis by the use of gonadotropin-
releasing hormone (GnRH) agonists. Buzerelinum, gozerelinum and gestrmol
belong to the essentially new medicines that are a gonadotropin-releasing luteal
hormone agonists. Buzerelinum in a dose of 200 mg is administrated subcutane-
ously for the first 14 days of reproductive cycle, then endonasal prescription in the
dose of 400 mkg per day for 6 months. Zoladex-Depo is applied subcutaneous in a
dose of 3,6 mg once a month for at least 6 months. This treatment is commonly
used for 3 to 6 months before the planned hysterectomy, but it can also be used as
a temporizing medical therapy until the natural menopause comes. GnRH agonists
can not only result in reduction of uterine size, but also lead to a technically easier
surgery with significantly diminished blood loss.
HYDATIDIFORM MOLE (Molar pregnancy)
Hydatidiform mole is one of the forms of trophoblastic disease (pathology of
conceptus) which is characterised by abnormal proliferation of syncytiotro-
phoblast and replacement of normal placental trophoblastic tissue by hydropic
placental villi. Hydropic villi are up to 3 cm in diameter and look like a mass of
grape-like vesicles.
The ethiology and pathogenesis of trophoblastic disease is unknown. Molar
pregnancy may be divided into complete mole and incomplete (partial)
hydatidiform mole. Complete hydatidiform mole is identified macroscopically by
edema and swelling of virtually all chorionic villi with a lack of fetus or amniotic
membranes. It is developed during the first weeks of pregnancy. Incomplete
(partial) hydatidiform mole is often associated with the identifiable fetus or with
amniotic membranes. Grossly, placenta has a mixture of normal and hydropic villi
that look like mosaic.
The diagnosis of invasive mole (also called chorioidcarcinoma detruens) rests on
the demonstration of complete hydatidiform mole. Hydropic villi invade into the
myometrium on different distances destroying muscle elements and vessels. It is
similar to tumor growing.
Clinic. Hydatidiform mole is characterised by such main symptoms as:
    uterine size/dates discrepancy (uterine enlargement greater than expected for
      gestational dates)
    tigh-elastic uterine consistancy
    numerous painless spotting with the fragments of edematous trophoblast
      (absolute sign)
    other signs and symptoms, including visual disturbances, severe nausea,
      vomiting,     marked   pregnancy-induced      hypertension     (preeclampsia),
      proteinuria
    absence of positive signs of pregnancy (fetus is not found by ultrasound and
      physical examination, heart tones of the fetus are absent)
    "snowstorm" appearance of hydatidiform mole during the ultrasound exami-
      nation
    great increasing of hormones in urine
    presence of large adnexal masses (theca lutein cysts) as the result of high
      levels of ChGT
Treatment. In most cases of molar pregnancy the definite treatment is removal of
intrauterine contents. Uterine curettage is do by dilation of the cervix followed by
suction curettage (large danger for perforation), vacuum aspiration, digital removal
of mole (in the case if cervical canal passes 1-2 fingers) with the following
curettage.
With cases involving 24 weeks' gestational size, an alternative to suction
evacuation is induction of labor by prostaglandin and Oxytocin. Hysterectomy
should be performed in case of excessive bleeding. All removed tissues should
undergo histologic examination.
After reception of histological research results, that confirm the diagnosis, the
woman is sent to oncologist's consultation where they will decide whether
chemotherapy (Methotrexatum) is necessary.
IV. Control questions and tasks
   1. Clinic of uterus fibromyoma.
   2. Diagnostics and differential diagnosis of uterus fibromyoma.
   3. Indication to surgery of uterus myoma.
   4. Pathogenesis of uterus myoma.
   5. Classifications of uterus myoma.
   6. What is a hormonal status of the patients with fibromyoma?.
   17. Methods of treatment of uterus myoma.
V. List of recommended literature
   1. Danforth’s Obstetric and gynaecology.-Seventh edition.-1994.-P.1023-1055
   2. Gynecology.-Stephan Khmil, Zina Kuchma, Lesya Romanchuk.-2003.-
P.251-263
   3.Gynaecology illustrated. David McKay Hart, Jane Norman.-Fifth Edition.-
2000.-P.269-271




   Approved on Session of Department of Obstetrics and Gynecology with course
of Infant and Adolescent Gynecology_________________ protocol No________


       T.a.The Head of Department:_______________ O.A.Andriiets’

				
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