hysteromyoma
hysteromyoma
A tumor consisting of smooth muscle and fibrous tissue of the uterine wall. The most common benign tumor of female reproductive organs. It is generally believed that long-term and sustained estrogen stimulation is the main cause of this disease. Most of them occur at reproductive age, and the tumor will shrink after menopause. According to the growth site, it can be divided into uterine body myoma and cervical myoma, the former is more common. Myoma can be single or multiple. According to the relationship between myoma and muscle wall, it can be divided into the following categories: ① subserous myoma. Myoma protrudes from the uterine surface. ② Intermuscular myoma. Myoma grows in the myometrium of uterus, which is the most common. ③ Submucosal myoma. Myoma is located in the submucosa of the endometrium, which grows into the uterine cavity and sometimes protrudes from the cervix, which is the cause of menorrhagia and irregular bleeding. Due to the disorder of blood circulation, fibroids can be denatured, such as vitreous degeneration, cystic degeneration, red degeneration, calcification and so on. A very small number of fibroids will also become sarcomas, which are more common in the elderly and people with fast growth of fibroids.
Treatment measures
The treatment of hysteromyoma depends on the patient's age, symptoms, location, size, growth rate and number of hysteromyoma, uterine deformation, whether fertility function is preserved and the patient's wishes. There are several ways to deal with it.
1. Expectant therapy has the advantages of small fibroids, no symptoms, no complications and degeneration, and no impact on health. Perimenopausal patients have no clinical symptoms. Considering ovarian dysfunction, myoma may shrink or shrink. Expectant therapy can be used in all the above cases, that is, regular follow-up observation (3 ~ 6 months 1 time) in clinical and imaging aspects. According to the review, we will decide how to deal with it.
Usually, postmenopausal fibroids shrink naturally and do not need surgical treatment. However, patients with fibroids are over 40 years old, and it may be several years before menopause. Surgery can also be considered. However, conservative treatment can be given before operation, and those who are effective can not be operated for the time being. It should also be noted that the fibroids of postmenopausal women, a small number of patients with fibroids do not shrink but increase, so follow-up should be strengthened.
Second, drug therapy There have been many new developments in drug therapy.
(1) indications for drug therapy
1. Young people who want to keep their fertility. Childbearing age is infertility or abortion caused by fibroids. After drug treatment, fibroids shrink and promote pregnancy and fetal survival.
2. In premenopausal women, the fibroids are not very big and the symptoms are mild. After medication, the uterus contracted and menopause, and the fibroids shrank accordingly, thus avoiding surgery.
3. There are indications for surgery, but there are contraindications, which require preoperative treatment.
4. Patients with medical and surgical diseases are incompetent or unwilling to operate.
5. Before choosing drugs for treatment, diagnostic curettage should be used to do endometrial biopsy to rule out malignant transformation, especially those with menstrual disorder or increased menstrual flow. Curettage has both diagnostic and hemostatic effects.
The basis of drug treatment is that hysteromyoma is a sex hormone-dependent tumor, so antagonistic hormone drugs are used for treatment. Recently, drugs that temporarily inhibit ovaries have been used. Danazol and gossypol are commonly used drugs in China. Other androgens, progestins and vitamins are also used. Since 1983, it has been reported that gonadotropin-releasing hormone analogue (GnRHa) has successfully reduced uterine fibroids. Studies have proved that GnRHa indirectly reduces gonadotropin secretion at the pituitary level, thus effectively inhibiting ovarian function, the so-called "down-regulation" phenomenon.
(2) Types and usage of drugs
1.LHRH agonist (LHRH-A): GnRHa is a new anti-gynecological drug that has appeared in recent years. After a large number of continuous application of LHRH, pituitary cell receptors are full of hormones and cannot synthesize and release FSH and LH; In addition, LHRH has extrapituitary effect, which promotes the increase of LHRH receptor in ovary and reduces the ability of ovary to produce estrogen and progesterone. Because drugs significantly inhibit FSH and reduce ovarian hormone secretion, its effect is like "drug-induced ovarian resection", which makes fibroids shrink. LHRH and LHRH-A are heterogeneous bodies with the same work, but the activity of the latter is several times higher than that of the former.
Usage: LHRH-A is commonly used for intramuscular injection, subcutaneous implantation or nasal injection. From the first day of menstruation, intramuscular injection of 100 ~ 200μ g lasted for 3 ~ 4 months. Its effect depends on dosage, route of administration and time of menstrual cycle. After medication, the average size of myoma was reduced by 40 ~ 80%, the symptoms were relieved and anemia was corrected. The decrease of serum E2 is consistent with the decrease of myoma. FSH and LH have no obvious changes, and the myoma grows again soon after stopping the drug, suggesting that the effect of LHRH-A is temporary and reversible. If used in perimenopausal period, it can reach natural menopause in a limited time. For example, it is used to preserve fertility, reduce intraoperative bleeding and narrow the scope of surgery when fibroids shrink and local blood flow decreases; Or that myoma which originally affect the mouth of fallopian tube, after treatment, the myoma shrink, so that the blocked fallopian tube is unobstructed and the pregnancy rate is improved. In order to reduce the regrowth of myoma after drug withdrawal, 200 ~ 500 mg medroxyprogesterone acetate can be used in turn when LHRH-A is used to maintain its curative effect.
Side effects are hot flashes, sweating, vaginal dryness or bleeding disorders. Low estrogen may lead to osteoporosis.
2. Danazol: It has weak androgen effect. Danazol can inhibit the function of thalamus and pituitary and reduce the level of FSH. LH, thus inhibiting the production of ovarian steroids, and can also directly inhibit the enzymes that produce ovarian steroids. As a result, the level of estrogen in the body decreases, the growth of uterus is inhibited, the endometrium shrinks and amenorrhea occurs. At the same time, fibroids also shrink and become smaller. But for young people, stopping taking drugs for 6 weeks can restore menstruation. Therefore, it needs to be applied repeatedly.
Usage: 200mg, 1, taken orally for 3 times, and taken continuously for 6 months from the second day of menstruation.
The side effects were hot flashes, sweating, weight gain, acne and increased SGPT of liver function (liver function was checked before and after medication). You can recover after 2 ~ 6 weeks of drug withdrawal.
3. Gossypol is a dialdehyde naphthalene compound derived from cottonseed, which acts on ovary, but has no inhibitory effect on pituitary gland, and has a specific atrophy effect on endometrium, but also has an inhibitory effect on endometrial receptors, and has a denaturing effect on uterine muscle cells, leading to pseudomenopause and uterine atrophy. The medicine has the laudatory name of China danazol, and the effective rate of improving the symptoms of hysteromyoma is 93.7%, and the myoma is reduced to 62.5%.
Usage: 20mg, once a day/kloc-0, for 2 months. 20mg twice a week, 1 month. 1 week, 1 time, continuous service 1 month, ***4 months. Because the side effect of gossypol is renal potassium excretion, attention should be paid to liver, renal function and hypokalemia. Gossypol usually needs to be supplemented with 10% potassium citrate. Ovarian function recovered after drug withdrawal.
4. Vitamins: Vitamins are used to treat uterine fibroids because they can reduce the sensitivity of uterine fibroids to estrogen, regulate the neuroendocrine system, normalize steroid hormone metabolism, and promote the shrinkage of uterine fibroids. 1980, the Soviet Union reported that vitamin A plus vitamins B, C and E were combined to treat more than 80% of small fibroids without side effects. It has also been tried in China, and the cure rate is 7 1.6%. This method is suitable for small fibroids.
Usage: Vitamin A150,000,000 000IU, taken orally every day on 15-26 days of menstruation. Vit Bco 1 tablet 1 taken orally three times a day on the 5th-14th day of menstruation. Vitc, 0.5, twice a day, taken orally on menstrual day 12-26. Vit E 100mg, 1 time per day, taken orally on14-26th day of menstruation for 6 months.
5. Androgen: antagonizes estrogen, controls uterine bleeding (menorrhagia) and prolongs menstrual cycle.
Usage: methyltestosterone 10mg, taken sublingually,/kloc-0 times a day for 3 months. Or 4 ~ 7 days after menstruation, intramuscular injection of testosterone propionate 1 time, daily 1 time, 25mg each time, for 8 ~ 10 days, can achieve hemostasis effect. Long-acting testosterone is testosterone phenylacetate, which is three times stronger than testosterone propionate. 150mg monthly injection 1 ~ 2 times. Generally, there will be no masculinity, and even if there is, the symptoms will naturally disappear after stopping the drug. Androgen should be used within 6 months. If you need to use it again, you should stop using it after 1 ~ 2 months.
Long-term administration at the above dosage has no side effects. Can make postmenopausal women enter menopause and stop bleeding. Androgen can not only prevent the growth of fibroids, but also make the fibroids of 1/3 ~ 1/2 patients degenerate and shrink. Because androgen causes water and salt retention, patients with heart failure, liver cirrhosis, chronic nephritis and edema should use it with caution or contraindication. Because some scholars think that the occurrence of fibroids may also be related to androgen, and some tend not to use androgen.
6. Progesterone: Progesterone is an antagonist of estrogen to a certain extent, which can inhibit its effect, so some scholars use progesterone to treat uterine fibroids with persistent follicles. Commonly used progestogens are medroxyprogesterone acetate (medroxyprogesterone acetate), Funing tablets (medroxyprogesterone acetate) and Fukang tablets (norethindrone). Pseudopregnancy treatment can be carried out regularly or continuously according to the specific conditions of patients, so as to soften the fibroids. But it is not suitable for long-term application, because it will enlarge the tumor and cause irregular uterine bleeding.
Medroxyprogesterone acetate: the periodic treatment is 4mg orally every day, from the sixth day to the twenty-fifth day of menstruation. Continuous treatment: 4mg in the first week, 1 day 3 times, 8mg in the second week, 1 day 2 times. 10mg, twice a day 1. All patients continued to take drugs for 3 ~ 6 months. It is also useful to take 10mg and 1 three times a day for three months.
Fukang tablets: periodic treatment is 5 ~ 10 mg per day, and the menstrual period is 6 ~ 25th or16 ~ 25th. The continuous treatment was 5mg in the first week, 0 days 1 time, 2 weeks 10 mg, 0 days 1 time. 10mg, twice a day 1. All cases were used for 3 ~ 6 months.
7. Tamoxifen (TMX): TMX is a stilbene derivative and a non-steroidal anti-estrogen drug. It forms TMX-ER complex by competitive binding with ER in cytoplasm, which is transported to the nucleus for long-term preservation. TMX first acts on the pituitary gland, then affects the ovary, and also has a direct impact on the ovary. TMX has a good effect on ER positive.
Usage: 10mg, 1, taken orally, three times a day, with three months as a course of treatment. Side effects include mild hot flashes, nausea, sweating and delayed menstruation.
8. Trienone (R2323): a derivative of nerestrine, 19 nortestosterone, which has a strong anti-estrogen effect. Inhibit the secretion of FSH and LH by pituitary gland, reduce the level of estrogen in the body and contract the uterus. It is mainly used for treating hysteromyoma.
Usage: 5mg, 3 times a week, placed in vagina, suitable for long-term application to prevent uterine rebound. In the first 6 months, the curative effect was good and the uterine contraction was obvious. Side effects are acne, hot flashes and weight gain.
During the bleeding period, patients with fibroids have a large amount of bleeding, so uterine contractions or hemostatic drugs can be used orally or intramuscularly. Such as motherwort liquid extract, motherwort cream, oxytocin and ergonovine. Hemostatic drugs include Fuxuening, Sanqi tablets, Zhixuemin, Zhixuefang acid, Zhixuehuanic acid, 6- aminoacetic acid and so on. Calcium can stimulate uterine muscle tension, increase blood coagulation performance, and can also be tried. Such as 10% calcium gluconate 5 ~ 10 ml intravenous injection, or 5% calcium chloride 30 ~ 35 ml warm liquid enema.
Don't forget that diagnostic curettage is not only helpful for diagnosis, but also can effectively stop bleeding when hemostatic drugs for vaginal bleeding are ineffective.
Anemia should be corrected by taking vitamins, iron or blood transfusion.
Chinese medicine treatment can reduce menstrual flow, see the chapter on menstrual diseases for details.
Those who fail in drug treatment and can't relieve symptoms and aggravate or suspect malignant transformation should be treated surgically.
Third, surgical treatment of patients with uterine fibroids, the age of hysterectomy and appendectomy was previously set at 45 years old or older. Now it seems that from the reality, especially according to the progress of gynecological endocrinology, the age of ovarian preservation is generally 50 years old (the average age of menopause is 49.5 years old), that is to say, all those under 50 years old should be preserved. Or the normal ovaries of premenopausal women after the age of 50 should also be preserved, and age markers should not be used. Because normal postmenopausal ovaries still have certain endocrine function, and they still need to work for 5 ~ 10 years. Preserving ovaries helps to conceal autonomic nerves, regulate metabolism, and is conducive to the transition to old age. The uterus also has its endocrine function. It is the target organ of the ovary and should not be removed casually. Usually, the age of hysterectomy is over 45 years old, and those under 45 years old, especially those under 40 years old, should have myomectomy. If you can keep both sides, it is better to keep both sides than just one side. The incidence of ovarian cancer with preserved ovaries is 0. 15%, which is not higher than the incidence of ovarian cancer without hysterectomy.
(1) Hysteromyomectomy: It is an operation to remove the myoma in the uterus and keep the uterus. Mainly used for people under 45 years old, especially people under 40 years old. This is not only for infertile women who have no children, but also for those who have children, the fibroids are bigger and the diameter is more than 6 cm. Menstruation is excessive, and drugs are conservative and ineffective; Or have symptoms of oppression; Submucosal myoma; Myoma grows faster. For the sake of physical and mental health, enucleation should also be taken. As for the number of fibroids, it is usually limited to 15. No matter how many children are in urgent need, even those above 100 have examples of children being dug up. At most, the 1 16 muscle nucleus was removed in Shandong Provincial Hospital.
If the myoma is malignant, accompanied by severe pelvic adhesion, such as tuberculosis or endometriosis; Or cervical cytology is highly suspicious and malignant.
Before myomectomy, it is best to do pathological examination of endometrium before operation to exclude precancerous lesions or canceration of endometrium. Pay attention to whether the myoma is malignant during the operation, and send a quick biopsy if it is suspicious.
In order to prevent postoperative abdominal adhesion, the incision on the uterus should be in the front wall, with as few incisions as possible, and one incision should remove as many fibroids as possible. You should also try to avoid penetrating the endometrium. The incision should be completely stopped bleeding, and no dead angle should be left in the suture incision. Postoperative uterine incision should be peritonized as much as possible. Submucosal myoma, which has been taken out from the cervix, can be taken out through the vagina. Excessive traction should be avoided when taking out, so as not to damage the uterine wall when taking out. Those who have not slipped out can also be taken out through abdominal uterine incision. Hemostatic drugs and antibiotics should be given after operation; Pregnant women should use contraception for 1 ~ 2 years; Be wary of uterine rupture and placenta implantation in future pregnancy, and choose cesarean section at full term. Myoma may recur after enucleation and should be examined regularly.
(2) Hysterectomy: If expectant therapy and drug therapy can't improve the symptoms of patients, and those who need surgery don't meet the requirements of hysteromyomectomy, hysterectomy should be performed. Hysterectomy can choose total hysterectomy or vaginal hysterectomy. Hysterectomy, mainly through the abdomen, individual tumors are small, the appendix has no inflammatory adhesion, the abdominal wall is too fat, and those with eczema on the abdominal wall can consider transvaginal.
The advantages of transabdominal operation are: the technical operation is simpler than that of transvaginal operation, and there is less bleeding; Myoma is large and adnexal adhesion is easy to deal with. The disadvantage is that if proctoptosis and vaginal wall relaxation occur, more vaginal surgery is needed.
Complex cases such as cervical leiomyoma and leiomyoma of broad ligament cause serious anatomical variation and adhesion of pelvic organs (ureter, bladder, rectum, great vessels, etc.). ), and the operation is not easy to expose, which brings great difficulties to the operation. These problems can be referred to the monograph of gynecological surgery.
Large submucosal myoma causes bleeding and secondary severe anemia, and surgery (simple myomectomy or hysterectomy) is usually performed after blood transfusion to improve physical condition. However, in remote rural areas, sometimes there is insufficient blood source and bleeding, which is not suitable for walking. The cervix is wide open, and the myoma has protruded outside the cervix or near the vaginal opening. Taking out fibroids through the vagina is often more helpful to stop bleeding and correct the general situation.
Excision generally advocates total hysterectomy, especially for patients with cervical hypertrophy, laceration or severe erosion. However, if the patient's general condition is poor and the technical conditions are limited, only subtotal hysterectomy can be performed, and the incidence of stump cancer is only about 1 ~ 4%. However, it is still advisable to check regularly after operation.
Fourth, radiotherapy is ineffective for drug treatment and taboo or refusal of surgical treatment. But there are also some taboos:
(1) Patients under the age of 40 generally avoid using radiotherapy to avoid premature menopausal symptoms.
(2) Submucous myoma (submucosal myoma with wide basement can be treated by X-ray). After radium therapy, necrosis is easy to occur, causing serious intrauterine and pelvic infection.
(3) Pelvic inflammatory disease: Acute and chronic pelvic inflammatory disease, especially those suspected of adnexal abscess, should not be used, because radiotherapy can stimulate inflammation.
(4) If the myoma is pregnant for more than 5 months and the uterus is large, or the uterine cavity is filled with radium, the expected effect is often not achieved.
(5) Uterine fibroids are malignant or suspicious.
(6) Uterine fibroids and ovarian tumors coexist.