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

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

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

In what cases it is possible to observe myoma and not to operate?

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 (the desire to have children in the future), a decrease in the quality of life, the size, location of myomatous nodes, etc. The decision is made jointly with the woman on the basis of a thorough discussion and consideration of possible alternatives. You can resort to conservative methods of treatment. True, today they are not effective enough. Hormonal drugs of the new generation can stop the growth of fibroids if the tumor consists mainly 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. Some people will benefit from this therapy, some won't. Treatment with non-steroidal anti-inflammatory drugs somewhat reduces pain and bleeding.

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

Uterine fibroids: indications for surgery

Absolute indications for surgical treatment of uterine fibroids, regardless of the age of the patient, are:

the size of the fibroids, exceeding 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 gestation);

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

pronounced pain syndrome;

secondary changes in the node (necrosis, infection);

the presence of submucosal or subserous nodes of any size on long legs, with a high probability of twisting;

cervical, interligamentous, "born" node;

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

pronounced violations of the functions of neighboring organs (frequent urination, prolonged constipation). Due to pressure on the back wall Bladder reflux occurs (reflux of urine into the ureter), the risk of inflammatory diseases increases (for example, exacerbation chronic pyelonephritis), expansion of the ureters and renal pelvis up to secondary hydronephrosis.

Surgical treatment of uterine fibroids

The choice of volume and access of surgical intervention depends on the size and localization of the myomatous node, the age of the patient, her desire to preserve the reproductive and menstrual functions. In any case, in the treatment of young women, we are guided by the principle: "Remove myoma - 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 a second operation.

The EMC Clinic of Gynecology and Oncogynecology performs laparoscopic myomectomy, which has practically no restrictions on the size of uterine fibroids, hysteroresectoscopic removal of submucosal uterine myomas, combined laparoscopic-hysteroscopic myomectomy. The issue of hormonal preoperative preparation of patients is decided individually. With multiple myomatous nodes, the wall of the uterus is incised above the surface of each of them, the nodes are fixed with special tools and removed. The vessels in the node bed are coagulated (turn 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 start preparing for pregnancy 6-12 months after the operation (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 supplying myoma, as a result of which the growth of the node stops, and it “shrinks”. It is also possible to target the node with focused high-energy ultrasound. Women in pre- and postmenopause are shown uterine artery embolization, extirpation (complete removal) of the uterus with or without appendages. If the fibroid does not grow and does not cause discomfort, in this case, treatment is not recommended.

Content

Myoma is a benign neoplasm of a hormone-dependent nature, localized in the muscular layer of the uterus. Pathology is typical for women from 30 to 45 years old, but can develop in more young age. If you start when the formation is small, you can avoid surgery, as well as more serious indications in the form of removal of the organ.

The feasibility of surgical treatment

Uterine fibroids form and develop in a muscular layer called the myometrium. Upon reaching a significant size, the formation can migrate and be diagnosed:

• in the body of a muscular organ;
• in the neck part.

Specialists distinguish the following options for fibroids regarding its localization in the uterus:

• subserous, located under the serous membrane;
• submucosal or submucosal, is located under the mucous membrane;
• intramural or interstitial, grows in the thickness of the myometrium;
• intraligamentary, progresses between the leaves of the broad ligament;
• retroperitoneal, grows from the cervical part.

Uterine fibroids usually have the form of nodes, which are characterized by a different number and size:

• multiple and single tumor;
• neoplasm of small, medium or large sizes.

Large nodules are often an indication for surgery or removal of the uterus. Myomatous nodes are attached to the tissue of the uterine wall through a wide base or thin stem. The growth rate of neoplasms depends on the structure.

1. Simple fibroids grow slowly and reach significant volumes within five years.
2. Proliferating tumor characterized by rapid progression.
3. Presarcoma contains altered cells, characterized by the presence of several large nuclei.

Histological composition may differ. If the formation contains predominantly smooth muscle cells in the structure, leiomyoma is diagnosed. Fibrous tissue in the composition of the tumor characterizes fibromyoma.

Myoma has a hormone-dependent etiology and pathogenesis. Congenital disorders occurring in the muscular tissue of the uterus under the influence of internal and external adverse factors are also considered as the cause of the formation of a neoplasm.

Before treating the disease, it is necessary, if possible, to eliminate the factors that provoke the progression of the nodes. Otherwise, the treatment may be useless, which will lead to tumor growth and an indication for its surgical removal.

The severity of the clinical picture is essential when choosing treatment tactics. Often, the disease proceeds latently, which contributes to its rapid progression and detection at an advanced stage. This explains why doctors often have to remove nodes surgically.

Features of the clinical picture are often an indication for surgery.

There are certain indications for both the removal of fibroids and the body of the uterus.

Doctors distinguish the following indications for the removal of fibroids:

• leiomyoma size at least 12 weeks;
• combination of fibroids with endometriosis or cancer;
• torsion of the legs of fibromyoma, its necrosis;
• violations of the functioning of internal organs;
• severe pain;
• oncological alertness;
• reproductive disorders;
• lack of effect from the use of drugs that stop acyclic.

The following sizes of nodes are called, which correspond to the weeks of pregnancy:

• a small fibroid corresponds to five weeks of pregnancy and two centimeters;
• secondary education, equivalent to a pregnancy for a period of eleven weeks and having a size of up to six centimeters;
• a large tumor looks like a 15-week pregnancy with nodes that have a volume of more than six centimeters;
• with a giant neoplasm an increase in the uterine cavity reaches 16 weeks or more.

A large or giant fibroid is an indication for removal. Sometimes doctors have to remove small fibromyomas, in particular, with torsion of the leg, necrosis of the formation, infertility. A few decades ago, gynecologists believed that with fibroids, the uterus should be removed.

V last years indications for removal of the uterus were minimized. In modern gynecology, large fibroids and the onset of menopause are no longer indications for removal of fibroids.

It is necessary to remove the uterus with myoma in the following cases:

• suspicion of oncology;
• concomitant prolapse of the uterine body and cervix;
• active progression of endometriosis.

When a woman's uterus is removed, she not only loses her reproductive function. Removal of the uterus will necessarily entail serious consequences for health. In this connection, organ-preserving operations are carried out in modern gynecology. Removal of the uterus is necessary only for certain indications.

Operation methods

If indicated, uterine fibroids should be removed. Before removing the neoplasm, the doctor must conduct an examination to determine the exact location and type of leiomyoma.

When indications for surgical treatment of fibromyomas are carried out using:

• organ-preserving treatment;
• radical operations.

For small fibroids, the indication is treatment with sparing tactics, for example, uterine artery embolization, myomectomy, FUS ablation. During such operations, the myomatous node is removed, and the reproductive function is preserved.

Embolization of the uterine arteries consists in removing the node by blocking the vessels that feed it. Such removal of fibroids refers to an effective technique with a relatively low percentage of relapses.

Organ-preserving removal is carried out by several techniques.

1. Laparoscopic and laparotomic myomectomy. Indications for removal are single and multiple tumors of the interstitial or subserous variety. Laparotomy removal is used quite rarely due to trauma and the risk of surgical complications. Among the indications for the isolation of large leiomyomas, uterine deformities.
2. . Removal must be carried out using a hysteroscope with a submucosal location of the tumor. During this manipulation, gynecologists have to both diagnose and remove leiomyomas. The operation is also performed at the birth of the submucosal node. Removal must be performed in the first days of the cycle during a planned operation. You can remove fibroids in a hospital and outpatient setting.

When using surgical methods of treatment, it is necessary to take into account that the removal of uterine fibroids is often accompanied by a risk of complications and relapses.

In gynecological practice, sometimes doctors have to remove uterine fibroids using a radical method. Radical surgery requires removal of the uterus. Radical surgeries include:

• hysterectomy;
• extirpation.

After the surgical treatment The patient is undergoing medical examination. As a rule, a woman also has to take hormonal drugs to prevent relapse.

Hysterectomy

A uterus with fibroids can be removed with an operation called a hysterectomy. This intervention ranks second in frequency in women. Experts note that this is one of the most common ways to remove fibroids.

Absolute indications, in which it is necessary to remove the uterus in case of myoma, are the processes of its descent or prolapse, as well as the suspicion of cancer. Hysterectomy is often necessary for women to remove a uterus with advanced tumor after menopause.

With fibroids, the removal of the uterus can be carried out in different ways. There are several types of hysterectomy, with which you can remove the body:

• subtotal, consisting in the removal of the uterus while preserving its cervical part;
• total, meaning the removal of both the uterus and its cervix;
• hysterosalpingo-oophorectomy, implying the removal of the uterine body, ovaries, and tubes.

Before removing the affected organ, the doctor must warn about the complications that may arise during and after the hysterectomy. Complications after a hysterectomy include:

• allergic reactions to anesthesia, leading to death;
• damage to organs located in the pelvis, as well as nerve bundles;
• postoperative bleeding;
• intestinal obstruction;
• development of the adhesive process;
• peritonitis.

After removal, the patient needs to carefully monitor her well-being. In the absence of complications, recovery after a hysterectomy will take about two months.

Hysterectomy has a number of distant ones that adversely affect a woman's life. The long-term consequences after removal by the hysterectomy method include:

• posthysterectomy syndrome;
• exacerbation of diseases of the cardiovascular system;
• the risk of developing a tumor in the mammary glands;
• the development of manifestations of menopause, for example, depression and sweating, hot flashes, osteoporosis;
• problems in intimate life due to the occurrence of vaginal dryness, decreased libido;
• prolapse of the vaginal walls;
• urinary incontinence;
• bacterial vaginosis;
• hypertension;
• obesity.

The patient after the removal of the uterus, which implies a hysterectomy, must take hormonal drugs. After a hysterectomy, a woman loses her reproductive function, which is especially important for women of childbearing age.

Many modern gynecologists say that it is not always worth removing an organ through a hysterectomy. In some cases, an organ-preserving intervention is required. Before deciding on a hysterectomy and removing an organ, one must think about the consequences that may appear in the long term.

When diagnosing a tumor, the first thing the patient asks the doctor is whether it is necessary to remove the fibroid.

Causes of the appearance of pathology

Doctors identify several main causes of the appearance of such a tumor, these are:

1. Hormonal disbalance.
2. Low immunity.
3. genetic predisposition.

Tumor types

There are three types of fibroids:

• Submucosal - means that the pathology grows inside the uterus.
• Subserous - try to get out of the organ.
• Interconnective.

On average, pathologies are diagnosed with a size of about fifty millimeters, although it can grow up to one hundred millimeters. But large tumors are a rarity.

Symptoms of the disease

It should be noted that on early stages, the disease does not show any symptoms, so it is very difficult to diagnose it. Although this can happen if a woman undergoes a preventive examination by a gynecologist.

But if the disease is running, the tumor has already reached a sufficiently large size, then certain symptoms appear, namely:

• Profuse and prolonged menstruation.
• Pain in the lower abdomen.
• Infertility (spontaneous miscarriage or premature birth in which the child does not survive).

If fibroids do not pose any danger to a woman's health, doctors recommend treatment medications. However, it rarely gives a positive result and ultimately, the tumor has to be removed surgically.

Is it possible to cancel the operation

Speaking specifically about the removal of the uterus, then such an operation is recommended to be carried out when a woman has crossed the line of forty years. At this age, women already have children, they no longer plan to give birth, so they no longer “need” the uterus.

If a woman agreed to such an operation, then before performing it, the doctor should observe the development of the pathology for some time. Find out how fast it grows and only after that make a decision about removal.

For the operation to take place, certain indications are necessary:

1. The patient is over forty years old.
2. The size of the pathology is more than twelve weeks of pregnancy.
3. The development of fibroids for more than four weeks a year.
4. The degeneration of a neoplasm into a cancerous tumor. The age of the patient will not be taken into account, as well as the presence of children. Because the focus will be on her life.

In medicine, there are cases when fibroids resolve themselves, during the period when a woman reaches menopause. At this time, the body stops producing estrogen, which feeds the pathology, and over time, the tumor disappears. It doesn't happen in one month, it can take years. If everything goes well, then the operation can not be carried out.

If the patient is diagnosed with many fibroids, then she is sent for examination. Having studied its results, the doctor will be able to clearly understand the whole picture of the pathology, and only after that will make a decision about the removal.

If the disease is found in a woman who is under forty years of age, then the decision to remove will be made in order to save the organ and remove only the tumor.

The question of whether it is necessary to remove uterine fibroids can be answered as follows: if the woman's age has crossed the forty-year limit, then the entire organ must be removed. Thus, doctors will save a woman from possible relapses and cancerous pathologies.

The main indications for surgery

So, there are certain indications that indicate the need to remove the pathology, regardless of the age of the woman:

• The size of the neoplasm is more than twelve weeks.
• The rapid growth of pathology.
• With the appearance of heavy bleeding, not only during menstruation, but also between it.
• development of anemia.
• The appearance of fainting.
• At painful sensations, which arise due to the fact that the neoplasm begins to compress neighboring organs or nerve endings.
• Negative changes in the structure of pathology.
• With a formation growing on a thin, long base, by which it is connected to the uterus. In this case, the leg may twist and bleeding will occur.
• The location of the tumor in the cervix.
• Infertility due to this pathology.

Any disturbances in the functioning of the organs located near the neoplasm can affect the removal:

1. Violation of the emptying of the bladder. Because of this, urine can accumulate in it, and this leads to inflammation, sand and stones.
2. The ingress of urine into the ureter, which causes inflammation and pyelonephritis.
3. Due to the clamping of the rectum, defecation is not going well. The consequence of this is constant constipation, and then poisoning of the body.
4. Squeezing of the nerve endings near the rectum, because of this there is pain in the heart, lower back and legs.

Surgical removal of fibroids

Before determining which method will be used to remove the pathology, it is necessary to consider the following factors:

If the patient is not yet forty years old, then only the neoplasm is removed, without touching the uterus. After forty, the removal of an organ is possible because it has already completed its leading role in a woman's life.

• Tumor size twelve weeks.
• The location of the neoplasm, if it is found on the back wall of the uterus.

If the removal is directed only at the tumor itself, then the pathology may occur again, after some time.

With a small tumor, it is necessary to monitor its further development. If it does not increase and does not cause discomfort to the patient, then surgery is not required. A woman needs to regularly undergo preventive examinations in order to see the changes in time and make the right decision.

Varieties of operations

There are several types of surgical treatment:

• Laparotomy. To excise the tumor in this way, you will have to make an incision in the patient's abdomen. The main indications of this method are a large or multiple neoplasm that deforms the organ itself. A good prevention would be a woman's pregnancy two years after the operation.
• Laparoscopy. To do this, you do not need to cut the stomach, only its piercing is required, which subsequently does not leave scars. The most appropriate indication would be a small tumor size, about nine weeks. If this method is applied to a large pathology, then bleeding from the uterus may occur.
• Hysteroscopy. No incisions or punctures are required during this process. The operation is performed through the vagina. Indications are small neoplasms, a pathology on the basis, a pathology that degenerates into a cancerous tumor.
• Hysterectomy. Excision of not only neoplasms, but also of the uterus, which can be carried out through an incision in the abdomen or vagina. This method is used if the tumor is critical and can threaten the woman's life. Such removal is carried out mainly by women after forty years of age, but if the situation is critical, then it can be prescribed to patients who have not reached this age.
• Embolization. In this case, the blood vessels are clogged and the neoplasm, due to lack of nutrition, slowly dies off.

Condition of a woman after removal of the uterus

After the removal of the organ, the following consequences may occur:

1. Depressive states of a woman.
2. Mental disorders.
3. Pain syndrome in the pelvis.
4. Violations in the work of the genitourinary system.
5. Lack of orgasm.
6. Loss of interest in sexual activity.
7. Early menopause (if ovaries remain).

The main thing is that doctors remember that there are no “extra” organs in the body, so you should think about it before completely removing the uterus.

When is it necessary to remove uterine fibroids?

Uterine fibroids is a neoplasm that has grown in the myometrium (muscle layer) and consists of connective tissue and veins. A woman who has been diagnosed with one or more myoma nodes, first of all asks the attending physician about whether it is necessary to remove the organ.

The main causes of fibroids are:

• hormonal imbalance;
• failures in immunity;
• heredity.

There are three types of myomatous nodes:

• sumbucose (growing inside the organ);
• subserous ("get out" in the peritoneum);
• interconnective.

The average size of the node is 5 cm, sometimes it reaches 10 cm, large fibroids are rare.

The main symptoms of fibroids (especially multiple or large) fall into three categories:

• disruption of menstrual bleeding;
• pain in the lower abdomen;
• infertility (sometimes miscarriage or premature birth, due to which the child rarely survives).

For non-dangerous fibroids, conservative treatment is indicated. But, unfortunately, in most cases it turns out to be ineffective and the patient is recommended surgery.

Is it possible to do without surgery?

Basically, it is necessary to remove the uterus after the age of 40, when the woman does not plan to give birth to children anymore, and the organ is no longer needed. In this case, doctors are obliged to observe the condition of the tumor (tumors) in advance, find out how much they progress, and whether it is worth intervening surgically. The main indication for the operation is the age of the patient after 40 years and the size of the myoma nodes, which exceeds the gestational age of 12 weeks and grows rapidly over time (more than 4 weeks per year). It is also necessary to remove the organ in the case when doctors suspect that the uterine fibroids have begun to degenerate into a malignant cancerous tumor (sarcoma). Then a hysterectomy is allowed in young women (up to 40 years old) who have not had children in order to save their lives.

If one or more myomatous nodes are found, a complete examination is necessary so that the doctor, having a complete picture of the patient's health status, decides on the advisability of performing a surgical operation. In women under the age of 40, surgeons try to remove fibroids while preserving the organ or most of it.

After the age of 40, doctors agree that the best option during menopause is the complete removal of the uterus in order to avoid recurrence (reappearance of fibroids) and cancer.

Indications for surgical intervention

Below are situations when it is worth performing an operation to remove a fibroid or an organ as a whole (regardless of how old a woman is):

• If the size of the myomatous node corresponds to the gestational age after the 12th week;
• If uterine fibroids catastrophically increase rapidly (for 4 or more weeks of pregnancy);
• When myoma nodes manifest themselves as frequent and heavy bleeding (both menstrual and intermenstrual), the patient develops general anemia against the background of blood loss, accompanied by pallor of the skin, poor health and fainting;
• If the fibroid causes severe pain (severe cramps during menstrual bleeding, abdominal pain due to tumor compression of adjacent organs and nerve endings in the spine);
• If an ultrasound examination revealed irreversible changes in the myomatous node (its necrosis, rupture, infection);
• When the patient has a uterine fibroid of a subserous or sumbucous type, growing on a long stalk, through which it is connected to the organ. There is a high probability of torsion of the leg, as a result of which severe uterine bleeding (if the fibroid is submucosal) or peritonitis (if the peritoneal node) may begin;
• If the fibroid is located in the neck area;
• If the myomatous node is located submucosally on a thin long stalk and is visible in the lumen of the cervix, begins to "be born", it can be removed surgically by twisting the stalk;
• In preparation for IVF;
• If the patient is diagnosed with infertility associated with the myomatous node, its size or location;
• When fibroids cause miscarriages or pregnancy fading.

If violations in the functioning of neighboring vital organs are diagnosed:

• Urination is disturbed, urine stagnates in the bladder, due to which its inflammation may develop or sand with stones may form;
• The back wall of the bladder is compressed, urine is thrown back into the ureter, which can provoke pyelonephritis and other inflammatory diseases, cause an expansion of the renal pelvis (hydronephrosis);
• The process of defecation is disturbed (the rectum is clamped), because of which the patient has prolonged constipation, which threatens to poison the body;
• There is compression of the nerve endings near the rectum, which causes sciatica (severe back pain) and pain in the heart, lower extremities.

Surgical treatment of myoma nodes

The choice of method and volume of surgical intervention directly depends on several factors:

• At a young age, they try to save the uterus; only the myomatous node can be removed;
• After 40 years, the uterus can be removed - it has fulfilled its main function in female body. In this case, menstrual and reproductive functions will be depressed;

The size of the neoplasm (more than 12 weeks - surgery is indicated).

Localization of the tumor (myoma, located on the back wall, can provoke miscarriages).

An important nuance of myomectomy is that in a certain percentage of cases there is a relapse of the disease (tumors return, reappear in other areas).

Types of operations

1. Laparotomy of fibroids is performed through an incision in the abdominal cavity. The main indications for its implementation are the large size of the tumor or a large number of them, as a result of which the uterus is severely deformed. Before the operation it is necessary to undergo special training, after it it is necessary to avoid physical activity about 2-3 months and monitor the condition of the seam. Ideally, a couple of years after laparotomy myomectomy, you can start planning a baby;
2. Laparoscopic removal of myomatous nodes - removal of neoplasms through pinholes in the peritoneum (there are no scars after the operation). The optimal indications for laparoscopy of fibroids is its average size (the value is approximately 8-9 weeks), with laparoscopy of large tumors, uterine bleeding is frequent;
3. Hysteroscopy of fibroids is a procedure performed without punctures and incisions in the abdominal cavity. All manipulations are carried out through the cervix and vagina. Indications: small nodes, submucosal pedunculated fibroids, sumbucose neoplasms, accompanied by severe bleeding, myoma degenerating into a cancerous tumor;
4. Hysterectomy is the removal of an organ along with tumors, either through incisions in the peritoneum or through the vagina. Hysterectomy can be performed in extreme cases for women over 40 years old according to additional indications with the permission of the attending physician (cancer, necrosis of the myomatous node, huge neoplasms that compress neighboring organs);
5. Embolization of the veins of the tumor (blockage of the main vessels), as a result of which it dies and decreases in size.

Post-castration syndrome or consequences of hysterectomy

The consequences of removing the uterus can be:

S. B. Golubchin, MD professor, obstetrician-gynecologist, 1958.

Obviously, there are no women who would gladly accept the news that they are about to have an operation to remove the uterus. 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 surgery to remove the uterus, and in most cases, the indication for this is uterine fibroids. The average age of women undergoing this operation is 41; by modern standards, this is the most active and rich age of a woman. It is amazing that in 90% of cases these women could be cured without removal of the uterus. In other words, they had an extra operation.

And the most shocking thing: from Vladivostok to Kaliningrad, year after year, like a spell, the same words of gynecologists who send women to remove the uterus sound: “Why do you need a uterus that you grabbed onto it so much. You have 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 but relief. You have no choice: other treatments are ineffective! You can, of course, try, but you will still return to us - and we will cut it out for you. These words, alas, produce an effect, and as a result, according to statistics, we have about a million removed queens a year ...

Or maybe they are right? And removal of the uterus is actually a reasonable treatment for this disease and there are no consequences from such treatment? So many gynecologists can't be wrong! 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 seemed to be a benign, but 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, in this list, the uterus is almost in the first place.

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

A person can exist without one kidney, lung, part of the intestine, but everyone understands that this existence is no longer a fully-fledged person, so why is a woman without a uterus in the minds of a number of doctors perceived from a healthy position? Indeed, it has been known for many years that the removal of the uterus entails the development of the so-called post-hysterectomy syndrome - a symptom complex of disorders of the endocrine, nervous, cardiovascular and other systems that occurs after the removal of the uterus and is associated with this removal by a direct causal relationship. A separate place is occupied by psychological consequences - the presence of the uterus is a subconscious element of femininity, involvement in the female sex. The presence of a uterus gives a woman a constant inner confidence that she can give birth to a child. And even if she definitely does not want to have more children, the permanent deprivation of this function may be emotionally unacceptable for her.

Consequences of removal of the uterus

From a medical point of view, the removal of the uterus can have a number of rather serious consequences.

According to a large study performed in Sweden (for several decades, a rigorous analysis of the case histories of more than 800 thousand (!) women who underwent hysterectomy was carried out), a significant increase in the risk of developing cardiovascular diseases (heart attacks and strokes) was noted if the uterus retired before age 50. This study was very large-scale, as the analysis of the consequences over more than a 30-year period was carried out.

In other words, the removal of 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 the operation, 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 cancers increases. See details.
• There is depression, irritability, insomnia, memory impairment, flushes of heat to the face.
• There is increased fatigue.
• Urination disorders (frequent urination, urinary incontinence) may occur.
• Some women report pain in the joints.
• The risk of fractures increases due to the possible development of osteoporosis.
• The frequency of problems in sexual life is increasing (decreased libido, pain during sexual activity, disappearance of vaginal orgasm, decreased intensity of orgasm, vaginal dryness).
• More likely to occur prolapse of the walls of the vagina.
• Weight gain is possible (development of metabolic syndrome, development of endocrine diseases).
• Hair loss may occur.

Operational risks

In addition to the long-term consequences of the removal of the uterus, it is necessary to know about the possible consequences of the surgical intervention itself:

• drug 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 - a second operation 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 the “simple surgery” to remove the uterus really looks like, so easily offered by doctors to women with uterine fibroids.

Many patients whose friends or relatives have undergone hysterectomy usually do not need to be explained. They themselves often say the following phrase: “I will categorically 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 that they had their uterus removed. Most often, these are women who had significant problems before the removal of the uterus (abundant prolonged bleeding, pain, frequent urination, etc.). After the removal of the uterus, 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 associate them with the removal of the uterus.

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

Remove the uterus and save the ovaries?

Here it is necessary to point out one more cunning of gynecologists who propose to remove the uterus as soon as possible. Often they emphasize the fact that the ovaries after the operation will remain and continue to work fully, only the uterus is removed - "no longer the necessary bag for bearing children, stuffed with knots." It is not true! In the process of removing the uterus, in any case, the blood supply to the ovaries is disturbed, since one of the important pathways for the blood supply to the ovary, the branch of the uterine artery, is crossed.

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

On the whole, one can continue to argue indefinitely in favor of preserving the uterus, but I would like to express the main idea: the doctor has no right to decide for the patient which organs she needs, and without which, in principle, she 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 shortcoming, from which his patients suffer, while concealing or knowingly falsely 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 the removal of the uterus, in all other cases it is not necessary 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 striving to preserve an organ, we proceed from the physiological teachings of IP Pavlov that a violation of the function of any one organ cannot but affect the whole organism as a whole, causing various changes and disturbances in it. Thus, the premature cessation of the ovarian-menstrual function in young and middle-aged women adversely affects the metabolism, inevitably causes precipitation and premature aging of the body. K. Petrova proved 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 the premature, and even more so the artificial cessation of menstruation in connection with the removal of the uterus, has a very serious effect on the woman's body as a whole and on her nervous system in particular.

No less important for a woman and childbearing function. Many examples can be given when a woman suffering from primary or secondary infertility is ready to undergo any operation to restore her childbearing function. Infertility often brings discord into family life.

Unfortunately, we must state 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 position is based on assumptions about the possibility of degeneration of a benign tumor into a malignant neoplasm and about the independent occurrence of a malignant tumor in the remaining part of the organ. Therefore, some surgeons, even at present, when removing cystic ovarian tumors, do not take enough care of the ovarian tissue, excising the latter as much as possible, and sometimes even remove 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 fibromyomas, it is usually customary to remove the uterus, regardless of the age of the operated person, which deprives the woman of ovarian-menstrual and childbearing functions. Unfortunately, only some obstetrician-gynecologists recognize the expediency of using conservative operations.

The etiology of cancer has not yet been elucidated, and we believe that the radicalism of the operation performed cannot protect organs that have not been completely changed before from subsequent damage to cancer. 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 it is not, and we see no reason to operate on benign tumors only radically and thereby deprive women of their physiological functions, dooming them to subsequent suffering. This is especially true for young and middle-aged women.

We can state with full responsibility that during operations for benign tumors they should be removed radically, and in terms of preserving the organ itself, it is necessary to exercise maximum conservatism.

We believe that one of the main provisions of modern gynecology should be reconstructive 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 clarification of indications and contraindications for surgical treatment, the development of methods of reconstructive surgery in gynecology” (A. B. Gillyarson).

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

We emphasize once again that this text was written fifty years ago, and, as you understand, comprehended even earlier. It is sad to admit that during this time practically nothing has changed, that the same huge army of gynecologists obsessed with surgical radicalism remains, and the voices of doctors who insist on preserving the organ are practically not heard or are forgotten just as quickly as it happened with the work of M. And Alexandrova. And this despite the fact that right now in our arsenal there are 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 very slowly. Sad, isn't it?

29.04.2017

Uterine fibroids is a pathology that consists of blood vessels and connective tissue. It grows from the muscular layer of the organ, and may look like a single or multiple node.

When diagnosing a tumor, the first thing the patient asks the doctor is whether it is necessary to remove the fibroid.

Causes of the appearance of pathology

Doctors identify several main causes of the appearance of such a tumor, these are:

1. Hormonal disbalance.
2. Low immunity.
3. genetic predisposition.

Tumor types

There are three types of fibroids:

• Submucosal - means that the pathology grows inside the uterus.
• Subserous - try to get out of the organ.
• Interconnective.

On average, pathologies are diagnosed with a size of about fifty millimeters, although it can grow up to one hundred millimeters. But large tumors are a rarity.

Symptoms of the disease

It should be noted that in the early stages, the disease does not show any symptoms, so it is very difficult to diagnose it. Although this can happen if a woman undergoes a preventive examination by a gynecologist.

But if the disease is running, the tumor has already reached a sufficiently large size, then certain symptoms appear, namely:

• Profuse and prolonged menstruation.
• Pain in the lower abdomen.
• Infertility (spontaneous miscarriage or premature birth in which the child does not survive).

If fibroids do not pose any danger to a woman's health, doctors recommend treatment with medications. However, it rarely gives a positive result and ultimately, the tumor has to be removed surgically.

Is it possible to cancel the operation

Speaking specifically about the removal of the uterus, then such an operation is recommended to be carried out when a woman has crossed the line of forty years. At this age, women already have children, they no longer plan to give birth, so they no longer “need” the uterus.

If a woman agreed to such an operation, then before performing it, the doctor should observe the development of the pathology for some time. Find out how fast it grows and only after that make a decision about removal.

For the operation to take place, certain indications are necessary:

1. The patient is over forty years old.
2. The size of the pathology is more than twelve weeks of pregnancy.
3. The development of fibroids for more than four weeks a year.
4. The degeneration of a neoplasm into a cancerous tumor. The age of the patient will not be taken into account, as well as the presence of children. Because the focus will be on her life.

In medicine, there are cases when fibroids resolve themselves, during the period when a woman reaches menopause. At this time, the body stops producing estrogen, which feeds the pathology, and over time, the tumor disappears. It doesn't happen in one month, it can take years. If everything goes well, then the operation can not be carried out.

If the patient is diagnosed with many fibroids, then she is sent for examination. Having studied its results, the doctor will be able to clearly understand the whole picture of the pathology, and only after that will make a decision about the removal.

If the disease is found in a woman who is under forty years of age, then the decision to remove will be made in order to save the organ and remove only the tumor.

The question of whether it is necessary to remove uterine fibroids can be answered as follows: if the woman's age has crossed the forty-year limit, then the entire organ must be removed. Thus, doctors will save a woman from possible relapses and cancerous pathologies.

The main indications for surgery

So, there are certain indications that indicate the need to remove the pathology, regardless of the age of the woman:

• The size of the neoplasm is more than twelve weeks.
• The rapid growth of pathology.
• With the appearance of heavy bleeding, not only during menstruation, but also between it.
• development of anemia.
• The appearance of fainting.
• With pain that occurs due to the fact that the neoplasm begins to compress neighboring organs or nerve endings.
• Negative changes in the structure of pathology.
• With a formation growing on a thin, long base, by which it is connected to the uterus. In this case, the leg may twist and bleeding will occur.
• The location of the tumor in the cervix.
• Infertility due to this pathology.

Any disturbances in the functioning of the organs located near the neoplasm can affect the removal:

1. Violation of the emptying of the bladder. Because of this, urine can accumulate in it, and this leads to inflammation, sand and stones.
2. The ingress of urine into the ureter, which causes inflammation and pyelonephritis.
3. Due to the clamping of the rectum, defecation is not going well. The consequence of this is constant constipation, and then poisoning of the body.
4. Squeezing of the nerve endings near the rectum, because of this there is pain in the heart, lower back and legs.

Surgical removal of fibroids

Before determining which method will be used to remove the pathology, it is necessary to consider the following factors:

• The age of the woman.

If the patient is not yet forty years old, then only the neoplasm is removed, without touching the uterus. After forty, the removal of an organ is possible because it has already fulfilled its main role in a woman's life.

• Tumor size twelve weeks.
• The location of the neoplasm, if it is found on the back wall of the uterus.

If the removal is directed only at the tumor itself, then the pathology may occur again, after some time.

With a small tumor, it is necessary to monitor its further development. If it does not increase and does not cause discomfort to the patient, then surgery is not required. A woman needs to regularly undergo preventive examinations in order to see the changes in time and make the right decision.

Varieties of operations

There are several types of surgical treatment:

• Laparotomy. To excise the tumor in this way, you will have to make an incision in the patient's abdomen. The main indications of this method are a large or multiple neoplasm that deforms the organ itself. A good prevention would be a woman's pregnancy two years after the operation.
• Laparoscopy. To do this, you do not need to cut the stomach, only its piercing is required, which subsequently does not leave scars. The most appropriate indication would be a small tumor size, about nine weeks. If this method is applied to a large pathology, then bleeding from the uterus may occur.
• Hysteroscopy. No incisions or punctures are required during this process. The operation is performed through the vagina. Indications are small neoplasms, a pathology on the basis, a pathology that degenerates into a cancerous tumor.
• Hysterectomy. Excision of not only neoplasms, but also of the uterus, which can be carried out through an incision in the abdomen or vagina. This method is used if the tumor is critical and can threaten the woman's life. Such removal is carried out mainly by women after forty years of age, but if the situation is critical, then it can be prescribed to patients who have not reached this age.
• Embolization. In this case, the blood vessels are clogged and the neoplasm, due to lack of nutrition, slowly dies off.

Condition of a woman after removal of the uterus

After the removal of the organ, the following consequences may occur:

1. Depressive states of a woman.
2. Mental disorders.
3. Pain syndrome in the pelvis.
4. Violations in the work of the genitourinary system.
5. Lack of orgasm.
6. Loss of interest in sexual activity.
7. Early menopause (if ovaries remain).

The main thing is that doctors remember that there are no “extra” organs in the body, so you should think about it before completely removing the uterus.