Features of the Uterine Cavity in Patients with Myoma

Was carried out a comparison of the thickness and volume of the endometrium in healthy women and patients with uterine myoma.According to the age composition allgroups were similar and consisted of patients of reproductive age and of premenopausal age.Was revealed a significant (p<0.05) excess of the volume of the uterine cavity in both phases of the menstrual cycle in women suffering from uterine fibroids, in comparison with the control group.Among patients with fibroids along with the growth of the volume of the uterus was detected a significant (p<0.05) increase in endometrium, while the thickness of the median complex was not changed.

The problem of ultrasound diagnosis of uterine fibroids is a subject of many scientific papers,and currently it is generally accepted that sonography is a leading instrumental method of identifying the disease.In the scientific literature arediscussed the issues of localization, size, structure and blood supply of the myomatous nodes (Demidov, Zykin, 1990;Zykin, Medvedev, 2000;Fedorova, Lipman, 2002;Ozerskaya, 2013;Fascilla, Cramarossa, Cannone, 2016).Data were presented regarding the ultrasonic criteria of the complications of fibroids and principles of differential diagnosis with benign and malignant diseases (Chekalova, Zuev, 2004;Ozerskaya, Ageyeva, 2009;Medvedev, Rud'ko, 2010;Bulanov, 2014;Takeda, Nakamura, 2016).However, it was not given enough attention for the condition of the uterus in patients with fibroids.The purpose of the present study was to change this situation.

METHODS
Were examined 72 patients with uterine fibroids in reproductive and premenopausal periods, whose average age was 42 + 7.9 years (ranging from 23 to 56 years).The control group consisted of 73 women with a mean age of 39+6.8 years (from 26 to 54 years),with no gynecological pathology.The distribution of patients by age and phases of the menstrual cycle are presented in table 1.
Ultrasound examination was carried out on the apparatus Voluson 730 Expert (GE, Austria) by the multifrequency transducers with the transabdominal and transvaginal access in a traditional method.When measuring the volume of the uterus and endometrium was used a software, with the corresponding function of the device with the inherent formula of ovoid: V=ÀõÂõÑõ0,523, where A, B and C -are the three mutually perpendicular linear dimensions (figure 1, 2).In connection with a high measurement error of the endometriumvolumein patients with submucosal location of the node, such patients were not includedin the study.
The obtained results were processed by standard statistical methods.All quantitative data were obeying to a normal distribution, presented as M±s.In those cases, when data did not obey a normal distribution, they were presented as the median (med) and as 5 and 95 percentiles.To identify differences in quantitative traits between the groups we used univariate analysis of variance and bilateral Student t-test.Differences were considered significant at p < 0.05.The results of the study At the studying of a control group the volume of the uterine body was in the range of 22.7-72.6cm 3 with an average value of 44.2+13,9 cm 3 .Any significant differences between phases of the menstrual cycle were not obtained (p>0.05).
The thickness of the endometrium in the early proliferative phase ranged from 2 to 10 mm (4.9+2.3 mm), in the late proliferative phase -from 2 to 11 mm or 6.3+2.6 mm), increasing in the secretory phase from 7 to 15 mm (10,1+2.3mm).Differences between phases were significant (p<0.05).
The volume of the endometrium in the early proliferative phase ranged from 0.4 to 4.6 cm 3 (med 1,7 cm 3 ) and in the late proliferative -from 0.8 to 7.0 CC (med 2,3 cm 3 ) without significant differences in the rate (p>0.05).In the secretory phase of the cycle the endometrial volume increased from 1.7 to 9.1 cm 3 (med 4,2 cm 3 ) (p<0,5).Volume changes of endometrial thickness and endometrial volume, depending on the phase of the cycle, are presented in table 2.
Pathology of the myometrium, endometrium and (or) ovaries of patients of a control group was not revealed.
The volume of the uterus affected by fibroids, ranged from 25,2 to 450,0 cm 3 , it was met among women in the early proliferative phase (med 87,0 cm 3 ).In the late proliferative and secretory phase fluctuations between the minimum and maximum values of the volume of the uterus were less significant and amounted to 49.5-203,4 cm 3 and 42.5-242,4 cm 3 , respectively (med 102,2 and 98,1 cm 3 ).Any significant differences between the cycle phases were not obtained (p>0.05).
A single myomatous node was detected in 27 (37,5%) women, two nodes -in 10 (13.9%) and multiple in 35 (48.6 percent).Isolated lesions of posterior wall were observed in 20 (27.8 percent) cases,the front -12 (16,7%), the bottom -7 (9,7%), the nodes at both walls -33 (45,8%).The combination of myoma in the body of the uterus and cervical-isthmical region were observed in 8 (11,1%) patients.Interstitial and (or) interstitial- Among patients with myoma the uterine endometrial thickness in the I phase of the cycle ranged from 2 to 14 mm, from 4-th to 9-th day of cycle the median was 5 mm, andfrom 10-th to 14-th day-6 mm (p>0.05).In the second phase the endometrial thickness ranged from 2 to 17 mm (måd 7 mm) (p>0.05).Any significant difference in endometrial volume trough the different phases of the cycle were not obtained.So, in the early proliferative phase the fluctuations were between 0.8 and 12.2 cm 3 (m∑d of 3.9 cm 3 ), in late -from 1.9 to 9.4 cm 3 (måd of 6.6 cm 3 ) and secretory -between 1.7 and 16.7 cm 3 (måd of 7.9 cm 3 ).The structure and echogenicity of the endometrium in 47 (65,3%) patients was consistentwith the phase of the menstrual cycle,while in 19 (26,4%) cases was observed lag of a secretory transformation as in I and the II phases of the cycle, and in 6 (8.3%) was observed hyperechogenic endometrium in the first phase.Thebasallayerin 38 (27,4%) women was indistinct and uneven.
The volume of the body of the uterus, the thickness and volume of the endometrium in patients with myoma with accuracy rates compared to the control group are presented in table 3.
The thicknesses of the endometrium among patients with fibroids did not depend on the volume of the uterus,while the volume of the endometrium in thesepatientsincreased with the increasing of a size of the uterus affected by fibroids.
Was made an analysis of the distribution of patients undergoing curettage of the uterus because of the uterine bleeding,depending on the volume of the uterus.It was found that among women with uterine volume of up to 75 cm 3 there were no intrauterine interventions on this occasion.Among 17 patients in whom the uterus was from 75 to 100 cm 3 , 3 patients (17,6%) underwent the curettage of the uterus.In 18 patients with uterine volume from 100 to 150 cm 3 anuterine bleeding was observed in 6 (33,5%) cases.Women with uterine volume of more than 150 cm 3 were 14 people, among them 2 patients t (14,3%) -underwent dilatation and curettage of the cavity.
Any structural pathology of the ovaries in patients with uterine myoma was not detected.

DISCUSSION
Uterine fibroids are the most common benign tumor of the myometrium, which affects about 20% of women older than 30-35 years (Vikhlyaeva, 2004;Tikhomirov, Lubnin, 2006;Borgfeldt, Andolf, 2000).In younger women fibroids are found much less frequently, and in children and adolescents -it is an exclusive disease (Borgfeldt, Andolf, 2000;Moroni, Vieira, Ferriani, et al., 2015).A. L. Tikhomirov and D. M. Lubnin (2006) noted that in patients at the age of 22-23 years are diagnosed predominantly interstitialsubserous fibroids.In the current study these data are confirmed.Thus, among the 8 women whose age was from 23 to 30 years, subserous and interstitial-subserous site location was noted in 6 cases, and interstitial -only in two.Asymptomatic fibroids are observed in approximately one third of patients with uterine myoma (Vikhlyaeva, 2004; Ishchenko, Botwin, Leninskiy, 2010).Menstrual cycle for the majority of domestic and foreign researchers is the most frequent clinical symptom.
Hypermenstrual syndrome may be associated not only with submucous location of the node, but also with the violation of the contractile activity of the uterus, dilation of the cavity and, consequently, with an increase in the area of the endometrial rejection (Ishchenko, Botwin, Lenchinskiy, 2010; Savitsky, Savitsky, 2003).
The results of the study showed that in the control group, the thickening of the endometriumis synchronouswith an increase of the endometrial volume from the early proliferative to the secretory phase of the menstrual cycle (figure 3).
In patients with uterine myoma the endometrial thickness in the I phase did not differ from the values of healthy women of similar age,but beginning from the late proliferative phasethe increase in thickness significantly (p<0.05)slows down.At the same time, the volume of the endometrium continues to grow (figure 4).
When comparing the values of thickness of the endometrium in patients with myoma and control groups was revealed a significant (p<0.05)reduction only in the secretory phase, whereas in phase I the performance is virtually identical (figure 5).
The volume of the endometrium in patients with myoma in both phases of the cycle was almost in 2 times more than in women in the control group (figure 6).
In addition, noteworthy is the steady increase in the absence of changes in the thickness of the endometrium as the growth of myoma of the uterus (figure 7).
Both facts prove the increase of the uterine cavity.In the work of G. A. Savitsky and A. G. Savitsky (2003) is indicated that the area of the endometrium in women with fibroids, consistent with 8-9 weeks of pregnancy increases by more than 1.5 times, consistent with 12 weeks -by more than 3.5 times, and 16 weeks -by more than 5.5 times.However, the visual changes of the thickness of the endometrium with hysteroscopy were not detected (Bacsko G. et al., 1997) (Bacsko, Major, Csiszár, Borsos, 1997).
Among clinicians there is no consensus about the tone of the affected uterine myometrium in the mechanism of uterine bleeding.So, A. I. Ischenko et al. (2010) believe that the trigger of menorrhagia and metrorrhagia is a hypotension of the myometrium,and G. A. Savitsky and A. G. Savitsky (2003) -a hypertension.According to I. S. Sidorova (2003) the presence of simple fibroids is much less likely to cause uterine bleeding than proliferating fibroids.Often a combination of fibroids and endometrial hyperplasia can also be the cause of hyperpolymenorrhea (Tikhomirov, Lubnin, 2006;Sidorova, 2003;Lalonde, 1994;Galen, Isaacson, Lee, 2013).Despite the fact that among the surveyed patients with myoma the hyperplastic processes of the endometrium were absent, the combination of these hormone-dependent diseasesdoes not exclude.
In this study is marked a dependence of the frequency of curettage of the uterine cavity due to bleedings on the uterus volume.So, in the group of patients with the uterus, which volume do not exceed 75 cm 3 , there were no intrauterine interventions on this occasion.With the increase in the uterus of up to 100 cm 3 , the curettage was done in 17.6% of women, in the uterus of up to 150 cm 3 -in 33,5%.It was probably associated with the increased area of desquamation.Among women with uterine volume of more than 150 cm 3 a frequency of operative hemostasis was 14.3%, which can be associated with a greater frequency of operative treatment of myoma in the early stages and if patients had such enlarged uterus, reaching in the work in maximum of up to 450 cm 3 ,at the same time the clinical manifestations of the disease were not so significant.In addition, a shown increase in a volume of the endometrium according to the growth of myoma of theanda reducing in the frequency of curettage of the cavity in patients with uterus of more than 150 cm 3 , confirms polyetiological nature of hypermenstrual syndrome.

CONCLUSION
According to the conducted research we can draw the following conclusions 1.
The thickness of the endometrium in patients with uterine myoma in the I phase of the cycle does not differ from the healthy women.2.
In the second phase of the cycle in patients with uterine fibroids the processes of secretory transformationare slowing.This contributes to the reducing of thickness of the endometrium.

3.
The volume of the endometrium in patients with myoma is more in both phases of the cycle compared with the control group and it increases at the growth of the uterus.
Thus, not only determining the thickness but also the volume of the endometrium allows usbetter define the condition of the uterine cavity.This method allowsto assess endometrial pathology such as diffuse hyperplasia and polyp, and to conduct differential diagnostics between benign and malignant processes.

Fig. 1 .Fig. 2 .Fig. 4 .Fig. 3 .
Fig. 1.The measurement of the length and anteroposterior size of the uterus and endometrium in the sagittal plane scanning

Fig. 5 .Fig. 6 .Fig. 7 .
Fig. 5. Comparison of the thickness of the endometrium in women of the control group and patients with uterine myoma

Table 3 .
The volume of the body of the uterus, the thickness and volume of the endometrium in patients with hysteromyoma

Table 2 .
The volume of the body of the uterus, the thickness and volume of the endometrium in patients of the control group Note: *-reliability of differences of indicators between the cycle phases >0,05; **-reliability of differences of indicators between cycle phases <0,05.

Table 1 .
The distribution of patients by age and phases of the menstrual cycle