Clinical and morphological features of submucosal uterine myoma in women of reproductive age

The research is dedicated to the clinical and morphological study of submucous uterine myoma in women of reproductive age. The relevance of the work is due to the high prevalence of uterine myoma and the trend towards its development in young patients, which necessitates the preservation of reproductive and menstrual function. The work analyzes the pathogenic mechanisms of the disease, clinical features of the course of submucous myoma, risk factors, and methods of organ-preserving surgical treatment. Special attention is paid to the morphological and immunohistochemical study of myomatous nodes and the endometrium, as well as the evaluation of the effectiveness of myomectomy from the perspective of restoring reproductive health.

Within the framework of the dissertation, the tactics for managing patients of reproductive age with submucous uterine myoma are optimized, taking into account the clinical and morphological features of the disease. The molecular and biological state of the endometrium and myometrium in normal conditions and in pathological processes is studied, as well as the remote results of conservative myomectomy from the perspective of preserving the reproductive function of a woman.

Uterine myoma is the most common tumor in the structure of diseases of the female reproductive sphere and occupies a significant place among the pathology of the reproductive system. About 25% of women over 30 years old suffer from this disease. Research conducted in recent years indicate a clear trend towards the development of uterine myoma in young and even juvenile patients, which makes the question of preserving reproductive and menstrual function in this group of women quite acute. This problem acquires not only medical but also social significance, as uterine myoma contributes to the formation of primary and secondary infertility, and, as the sole cause of reproductive failures, is found in 12-20% of patients with impaired fertility [14,35,63,90].

The submucous location of a myomatous node is an unfavorable variety of myoma localization, as it practically always requires surgical treatment, leaving no chances for conservative therapy. With this location of myomatous nodes, the infertility rate reaches 30-35%, and during pregnancy, miscarriage, the occurrence of complications both during gestation and during childbirth and in the postpartum period are possible [16,26,37,101].

The prevalence of the combination of uterine myoma and endometrial hyperplasia reaches 30-76%, which indicates systemic damage to the uterus in hyperplastic diseases of the endometrium and myometrium [56, 65,148].

According to data from morphological studies, uterine myoma represents a monoclonal tumor whose development occurs from growth zones located around a thin-walled vessel [20,32]. Initial myoma cells differentiate into myofibroblasts, which then transform into myoblasts and fibroblasts [22]. Their growth continues for many years against the background of pronounced ovarian activity under the influence of both estrogens and progesterone. Along with traditional views on the leading role of estrogens in the pathogenesis of hormone-dependent diseases, the relationship to progesterone as a stimulator of tumor growth is being reconsidered in recent years [70,130]. Estrogens stimulate the hyperplasia of smooth muscle cells, progesterone increases the mitotic activity of cells, initiates the production of growth factors and their receptors, and participates in the process of differentiation of smooth muscle cells. In the literature, great importance in the development of hormone-dependent hyperplastic diseases of the uterus is attributed to the role of tissue receptors of steroid hormones [146]. The synthesis of receptors in the uterus is hormone-dependent in nature and occurs under the influence of many factors: the amount and ratio of sex hormones and growth factors, the phase of the menstrual cycle, the degree of damage to the target organ by the pathological process, metabolic disorders, and the imbalance of other hormones [31,33,70,104,105,128].

The approach to the treatment of uterine myoma at the current stage consists of improving and implementing organ-preserving methods into practice. Timely diagnosis and the use of such surgical treatment methods as hysteroscopy and laparoscopy have made it possible to expand the opportunities for performing myomectomy, increase its effectiveness, reduce the risk of postoperative complications, shorten the duration of hospital stay, and, most importantly, give patients of reproductive age a chance to realize their childbearing function [1,27,35,59,79].

However, the recurrence of myoma or the continued growth of small myomatous nodes ranges from 9 to 55%, which is especially relevant for patients who have no children [69].

Thus, today the questions of the interaction of steroid hormones and their receptors in the process of development and growth of uterine myoma, the restoration of reproductive health after organ-preserving surgery, which largely depends on the adequacy of subsequent hormone disorder therapy, and the development of preventive and therapeutic measures to reduce the frequency of this pathology remain relevant [35,75,84,98,132].

Research objective

Optimization of the tactics for managing patients of reproductive age with submucous uterine myoma, taking into account the clinical and morphological features of the disease.

Research tasks

1. To analyze risk factors and clinical manifestations of submucous uterine myoma in women of reproductive age.

2. To determine diagnostic criteria for choosing a surgical approach during myomectomy.

3. To study the molecular and biological state of the endometrium and myometrium in normal conditions and in combination with submucous uterine myoma and hyperplastic process of the endometrium.

4. To evaluate remote results of myomectomy from the perspective of preserving the reproductive function of a woman.

5. To improve the tactics for managing patients of reproductive age with submucous uterine myoma.

Scientific novelty

For the first time in a major city, an analysis of the clinical course of submucous uterine myoma was conducted, and diagnostic criteria for performing operative interventions using various surgical approaches were determined.

For the first time, the features of the biomolecular state of the endometrium and myometrium in normal conditions and in combination with submucous uterine myoma and hyperplastic process of the endometrium were studied. Remote results of myomectomy were analyzed, taking into account the conducted pathogenetic hormone therapy.

Practical significance

The work revealed a positive influence of myomectomy on the restoration of menstrual and reproductive functions, which confirms the necessity of performing organ-preserving operations on the uterus. Based on ultrasound and hysteroscopy data, indications for performing myomectomy using various surgical approaches and techniques were clarified. Conducting immunohistochemical study of removed myomatous nodes and endometrial tissue with determination of receptors to sex steroids, proliferative activity of cells, and the area of the vascular bed allows for conducting reasoned hormone therapy in the postoperative period. The effectiveness of myomectomy with subsequent hormone therapy for the restoration of menstrual and childbearing function of women of reproductive age has been demonstrated.

Theses for defense

1. In patients of reproductive age with true submucous uterine myoma, the procedure of choice is hysteroscopic myomectomy.

2. Determination of receptors to sex steroids, proliferative activity of cells, and the area of the vascular bed in removed myomas and endometrial tissue allows for conducting reasoned hormone therapy, which contributes to the restoration of the reproductive function of a woman.

Presentation of dissertation materials

The materials of the scientific research were reported and discussed at a joint conference of the departments of obstetrics and gynecology of the faculty for advanced training and professional retraining of specialists, obstetrics and gynecology with a course of prenatal diagnosis, obstetrics and gynecology of the pediatric and dental faculties of GBOU VPO SGMA Minsocrazvitia Russia, the commission on motherhood and childhood of the Smolensk State Medical Academy (2011), the international congress "Outpatient-gynecology - at the epicenter of women's health", 2012.

Based on the results of the conducted research, 5 scientific papers were published, of which 2 are in the central press and 3 are in local press.

Implementation of the results of the work into practice

The results of the research have been implemented into the clinical practice of the gynecology department of "NUZ Branch Hospital named after K.E. Tsiolkovsky, Kaluga, OJSC RZD", the gynecology department, the women's consultation of MLPU "Clinical Hospital No. 1" in Smolensk, and are used in the educational process at the department of obstetrics and gynecology of the faculty for advanced training and professional retraining of specialists at SGMA.

Volume and structure of the dissertation

The dissertation is built in the traditional manner and consists of 5 chapters: a literature review, materials and research methods, 3 chapters of original research, discussion of the obtained results, conclusions, practical recommendations, and a list of references. The work is presented on 137 pages of computer text, contains 19 tables, and 57 figures. The list of references consists of 147 sources, of which 75 are in Russian and 72 are in foreign languages.