MINISTRY OF PUBLIC HEALTH OF UKRAINENATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSYA

CHAIR OF OBSTETRICS AND GYNECOLOGY №1

METHODICAL INSTRUCTIONS for practical lesson

«Gynaecological aspects of diseases of the mammary gland. Benign tumours of the female genital organs.»

MODULE 3: Diseases of the Female Reproductive system. Family planning.CONTEXT MODULE 5: Principles of oncogynecology.

Topic: Benign tumours of the female reproductive organs. Gynecological aspect of diseases

of the mammary gland.

1. Topicality: Early and active detection of benign tumours and precancer disorders of the

female reproductive organs and mammary glands, their timely and correct treatment –are the

guarantee to solve the problem of malignant diseases. Annumerated causes make this topic

rather important.

2. Number of hours: 4

3. Educational objectives: to acquaint the students with frequency, structure, risk factors of

development of benign formations of the female reproductive organs and mammary gland.

Discuss clinical manifestation, methods of diagnostics and treatment of benign tumours of the

external genitals, ovaries, uterus and mammary gland.

To know: a=II

1. Pathogenetical variants of development of uterine myoma.

2. Classification of uterine myoma.

3. The main clinical symptoms peculiar for uterine fibromyoma.

4. Examination methods to diagnose uterine myoma.

5. Conservative methods of treatment.

6. Indications for surgical treatment of myoma.

7. Methods of surgical treatment of myoma.

8. Classification of benign ovarian tumours.

9. Complications of ovarian tumours.

10. Peculiarities of examination and treatment of ovarian cystoma.

11. Gynecological preconditions of diseases of the mammary gland.

3.2 To be able to:

1. Diagnose benign tumours of the external genitals, uterine and adnexa.

2. Make up a proper plan of examination to diagnose benign uterine tumours.

3. Make up a proper plan of examination to diagnose benign ovarian tumours.

4. Prepare a set of instruments to perform diagnostic scrapping of the uterine wall.

5. Make a target biopsy of the uterine cervix.

6. Perform speculum examination, vaginal examination, make the initial diagnostics.

8. Make up an individual plan of treatment.

3.3 Master the practical skills = a III.

1. Speculum examination of the uterine cervix.

2. Take smears for the cytological examination.

3. Bimanual gynecological examination.

4. Perform differentation diagnostics of intramural band submucous uterine myoma, cyst and

cystoma.

5. Determine indications for surgical treatment in patients with ovarian tumours and their

complications (torture of tumour peduncle, rupture and malignization).

III. Recommendations to the student

BENIGN OVARIAN TUMORS

Ovarian tumors are very common among all gynecologic diseases The mortality rate is high

because no effective screening devices are available for early detection.

According to pathogenic theory of ovarian tumors, gonadotropic ovarian hyperstimulation is

the leading factor in the development of ovarian tumors. This theory should be recommended

for pathogenetical explainatum of malignant ovarian tumors diagnosis and treatment.

The risk factors associated with ovarian carcinoma are:

women with impairment of ovarian function

women with postmenopausal bleeding

women that have been monitored for a long period of time with the diagnosis of uterine

fibromyoma, chronic inflammatory processes of uterine adnexa, benign ovarian tumors

women that have had surgical intervention in pre- or postmenopause with keeping ovaries (or

their resection)

All ovarian tumors should be divided into two main groups:

blastomatic unprohferative tumors (ovarian cysts)

blastomatic proliferative tumors (ovarian cystadenomas)

Clinical manifestations of ovarian tumors are various and usually uncertain. It depends on

tumor's type and character, and also on the spread of the process in the case of malignant

tumor.

OVARIAN TUMORS CLASSIFICATION

Only histologic signs can give a possibility to distinguish benign and malignant ovarian

tumor. From the prognostic or survival standpoint, however tumor grade remains the most

important factor for all the ovarian tumors.

Histologic classification of ovarian tumors is presented below.

I. Epithelial tumors:

A. Serous

B. Mucinous

C. Endometriod

D.Clear cell

E. Brenner

F. Mixed epithelial

G.Undifferentiated

H. Unclassified.

There are benign and malignant tumors in each of these groups of neoplasms.

II. Sex cord stromal tumors:

A. Granulosastromal cell

B. Androblastoma

C. Gynandroblastoma

D. Unclassified

III. Lipid cell tumors

IV. Germ cell tumors:

A. Dysgerminoma

B. Endodermal sinus tumor

C. Embryonal carcinoma

D. Polyembryoma

E. Choriocarcinoma

F. Teratoma

G. Mixed forms

V. Gonadoblastoma:

A. Only blastoma (without any forms);

B. Mixed with disgerminoma and other forms of germ cell tumors.

VI. Soft tissue tumors not specific to the ovary.

VII. Unclassified tumors.

VIII. Secondary (metabolic) tumors.

VIII. Tumor-like conditions:

A. Pregnancy luteoma

B. Ovarian stroma hyperplasia and hyperkeratosis

C. Considerable ovarian edema

D. Functional follicle cyst and luteal cyst

E. Multiple luteal follicle cysts and (or) luteal cysts

F. Endometriosis

G. Superficial epithelial cysts-inclusions

H. Simple cysts

I. Inflammatory processes

J. Paraovarian cysts

UNBLASTOMATIC UNPROLIFERATIVE OVARIAN TUMORS (ovarian cysts)

Follicle cyst

Follicle ovarian cyst is a single tumor with a thin membrane of mobile consistency with a

straw-colored fluid. Its formation is a result of fluid retention in atretic follicles. Follicle cyst

may be found in women of any age more often after inflammatory processes. True ovarian

blastopmatic process is absent in such tumor. Cyst membrane is not a new created tissue, it’s

a result of the excessive extension of follicle membrane. Although these cysts may attain a

size from 8 to 10 cm in diameter, spontaneous resolution usually occurs within the weeks. It

has been growing inside of abdominal cavity.

Clinic. The main symptom is the low abdominal pain, rarely menstrual cycle impairment or

uterine bleeding as a result of hyperstimulation from exogenous gonadotropins is observed.

Signs of acute abdomen are present in the case of ovarian cyst torsion. Bimanual examination

reveals ovarian enlargement up to 10 cm. It is mobile, cystic unilateral mass. Sometimes

inflammatory processes in uterine adnexa are present. Follicle cysts rarely produce any

symptoms and diagnosis is often made during monitoring.

Tratment. Observation for 2-3 menstrual cycles is necessary. If a spontaneous resolution

doesn’t occur, surgical intervention-ovarian resection or oophorectomy – should be

recommended. It is very necessary because before surgical intervention it is difficult to make

a differential diagnosis of ovarian cyst and serous cystadenoma. Total hysterectomy should be

performed in climacteric and postmenopausal women.

Corpus luteum cyst

Corpus luteum cyst is an unilateral cyclic enlargement which exceeds 8 cm in diameter.

Grossly, the cyst protrudes from the contour of the ovary and the wall appears convoluted and

thick. The cyst is filled with yellow fluid or blood.

Clinic. Symptoms are related to large size or complications of torsion, rupture or hemorrhage.

The main complaint of the patient is abdominal pain as a result of concomitant inflammatory

processes of uterine adnexa. Special clinical signs are absent. Treatment More commonly

luteum cysts produce no symptoms and undergo absorption or regression. It is necessary to

make observation for 2-3 reproductive cycles. Surgical intervention should be recommended

in the case if corpus luteum cyst regression doesn't occur.

Theca lutein cysts belong to retential ovarian cysts.

Parovarian cyst. Parovarian cyst is formed as a result of fluid retention in ovarian adnexa

which has been situated in the broad ligament. It arises at the age of 20-40 years old because

only in reproductive period ovarian epoephoron is well developed and it undergoes atrophic

changes in climacteric women.

Clinic. Pain in the lower abdomen and sacral region may be present. Symptoms of adjacent

organs compression are present if the tumor reaches large sizes. Symptoms of acute abdomen

are common in the case of parovarian pedicle cyst torsion. At bimanual examination pelvic

mass with smooth surface and elastic consistency which is palpated near uterus is found. It is

painless and immobile.

Treatment. Surgical removal of parovarian cyst. It is very necessary to store the ovarian

function. Puncture of the cyst should be indicated in some cases.

BLASTOMATIC PROLIFERATIVE OVARIAN TUMORS

(ovarian cystadenomas)

Serous cystadenoma. Serous cystadenoma is unilocular unilateral benign cystic neoplasm

derived from the surface epithelium of the ovary and lined by epithelium that resembles the

mucosa of the oviduct. It contains clear yellow fluid. The benign serous cystadenoma is

usually between 5-15 cm in diameter. The symptoms of peritoneal irritation are present in the

case of pedicle torsion. These tumors are revealed during monitoring.

Pelvic examination reveals mobile, painless and unilateral tumor with smooth external

surface. Ultrasonography and laparoscopy may confirm the diagnosis.

Treatment is surgical because of the relatively high rate of malignancy. In the patients after

the childbearing age (after 40 years old) treatment should consist of bilateral

salpingoophorectomy and hysterectomy not only because of chance of future malignancy, but

because of the increased risk of similar occurrence in the contralateral ovary. In the younger

patients with smaller tumors an attempt can be made to perform an ovarian cystectomy to try

to minimize the amount of ovarian tissue removed.

Papillary serous cystadenomas. The papillary projections of ovarian cystadenomas may

grow inside and outside of the tumor capsule. There are also mixed tumors when these

projections are placed into internal and external surfaces of the tumor. No characteristic

symptoms are specific for this tumor. Frequently, it is revealed during monitoring. The

diagnosis is based on the results of bimanual examination, ultrasonography and laparoscopy.

Bimanual examination reveals immobile painless lobulated tumor which is situated near

uterus. Frequently it resembles the subserosal uterine fibroid. These tumors have high

frequency of malignant change.

Treatment is surgical and it is the same as in case of serous cystadenomas.

Mucinous cystadenoma

Mucinous cystadenoma is a benign epithelial tumor which may be present in women of

different age. It may reach large sizes, sometimes it is multilocular, with round or oval form.

The cut surface shows the individual cysts or lobules of various sizes that contain sticky slimy

or viscid material of yellow or brown color.

Clinic. No symptoms are specific for this tumor even in case of large sizes Pain in the lower

part of the abdomen and back region may be present in case of intraligamentous location.

Symptoms of adjacent organs compression are present if a tumor is huge. Ascites is rare.

Bimanual research reveals elastic tumor with lobular surface in the adnexal region.

Laparoscopy and ultrasonography can be used for diagnostics.

The usual treatment for the obviously benign mucinous cystadenoma is unilateral

oophorectomy.

Pseudomyxoma. Pseudomyxoma is one of the kinds of mucinous cystadenoma. The

incidence of these tumors is low. The tumor is multilocular and has a thm wall It can be

ruptured spontaneously or during the pelvic exam. Pseudomyxoma peritoneal is the

complication that may result if the contents of mucinous cyst is spilled into the peritoneal

cavity by rupture, extension or at surgery.

Clinic. Pain is the main characteristic sign of pseudomyxoma The clinical course is usually

progressive malnutrition and emaciation. The palpation of the abdomen is painful.

Pelvic exam reveals elastic tumor, frequently of large sizes which is situated near uterus The

diagnosis is proved during operation.

Treatment is surgical. The fluid is difficult to remove because of its viscosity. Repeated

chemotherapy may be required in postoperative period

Cystadenofibroma. Cystadenofibroma is a benign tumor which is developed from ovarian

stroma. It has round or oval form, it is firm and unilateral and may reach the sizes of fetal

head. The age distribution is 40-50 years old It has asymptomatic duration or sometimes it is

accompanied by ascitis. Hydrothorax and anemia may be present in rare cases (Meigs

Syndrome)

The treatment is surgical — removal of the tumor.

SPECIAL FORMS OF OVARIAN TUMORS

Androblastoma (arrhenoblastoma). Androblastoma which is usually masculinizing tumor is

reported to produce masculinization. It occurs very rarely and its duration is also malignant.

Androblastoma is unilateral tumor with smooth or lobular surface. It has small sizes and

pedicle and it is mobile.

Clinic. Breast, uterine and female external genitalia atrophy are the characteristic signs.

Uterine and ovarian hyporplasia, endometrial atrophy are common. Amenorrhea and all

masculinizing features are present. The combination of masculinizing and feminizing

symptoms is possible.

Diagnosis. Ultrasonography, laparoscopy and ovarian biopsy play an important role at

confirmation of diagnosis.

Treatment is surgical — removal of the tumor.

In the majority of cases prognosis is favorable.

Thecoma (Theca cell tumor). Thecoma belongs to the feminizing tumors. It occurs at all ages

but is common after 40 years old and later. The evidence indicates that thecomas arise from

the ovarian cortical stroma. Theca cell tumors are unilateral and in most cases they are not

malignant. Their sizes may vary from small to those of fetal head. The external surface is

firm, ovoid or round, smooth, and gray, occasionally streaked with yellow. Symptoms are

related to estrogen production. When the granulosa cell tumor occurs in the pediatric age

group, it may contribute to signs and symptoms of precocious puberty and vaginal bleeding.

In women of reproductive age group such symptoms as impairment of menstrual function,

infertility and pregnancy loss are common. Menopause bleeding, enlarged sizes of uterus and

breasts, increasing libido are present in these patients.

Diagnosis is based on clinic, bimanual research, ultrasonography, laparoscopy and

hysteroscopy.

Treatment is surgical.

Folliculoma. Folliculoma is a hormonal active tumor which produces estrogenic components

and may be manifested in patients through feminizing characteristics. It varies from

microscopic inclusions to 40-50 cm in diameters, they are yellow-colored.

Clinic. Symptoms depend on the level of hyperestrogenemia and on the women age. The girls

have the signs of precocious puberty. In reproductive age group women amenorrhea, acyclic

bleeding, and later menopausal uterine bleeding may be present.

Diagnosis is based on the ultrasonography results, laparoscopy, histologic examination of

tissue.

Treatment is surgical In malignant duration of the disease total hysterectomy with omentum

major incision should be performed. Chemotherapy is prescribed in III-IV stages of cancer.

Benign cystic teratoma (Dermoid cyst)

Dermoid cysts are almost always ovarian tumors. The tumors may occur at any age Dermoids

are bilateral and have 5-10 cm in diameter. At operation, the tumors are found to be round

with smooth, glistening, grey surface. At body temperature, they have the consistency of other

tensely cystic tumors. Outside the body, they have a soft pultaceous consistency.

Clinic. No symptoms are common for small sizes tumors. Pain is present in case of large

tumors. Ultrasonography, laparoscopy are used for diagnosis.

Treatment is surgical. It consists of excision of the cyst, conserving the remaining portion of

the ovary.

Brenner tumor.

The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to those of

fibroma. It constitutes approximately l%-2% of all the ovarian tumors and is rarely malignant.

Brenner tumors have been reported in patients older than 50. Frequently a tumor is unilateral,

its shape, sizes and consistency are similar to fibroma.

Clinic. A few Brenner tumors are associated with postmenopausal bleeding, and it is

suggested that some may contain hormonally active stroma. Bimanual examination,

ultrasonography and laparoscopy are diagnostics.

Treatment consists in simple excision or oophorectomy.

Diagnosis of benign ovarian tumors.

General and pelvic examination should be performed. Differential diagnosis should be made

with uterine fibromyoma, endometriosis, inflammatory tuboovarian tumors and moving

kidney.

Additional methods of investigation such as uterine probbing, culdoscopy, cystoscopy,

urography, X-ray examination, ultrasonography and laparoscopy should be performed.

Thus, benign ovarian tumors have some common peculiarities of clinical course, such as:

for a long period of time they are asymptomatic, they are growing into direction of abdominal

cavity. Pain is a common symptom in case when the tumor is growing intraligamentously

in the majority of cases cysts and cystadenomas are mobile as a result of pedicle presence.

The anatomical and surgical pedicles are distinguished. The anatomical pedicle is composed

of the infundibulopelvic ligament, the ovarian ligament and mesoovarium. Surgical ligament

composes of all of these structures and fallopian tube with its nerves vessels. During tumor

removal the clamps should be put on the surgical pedicle below the place of torsion

the signs of adjacent organs compression are present during tumor' growing

the tumors are palpated as a rule in the lateral sides of the uterus

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 estrogen production. In the majority

of cases these patients have an hormonal dysfunction 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 endometrium 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 myomet-

rium. 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 subcuta-

neous 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 examination

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