Symptoms scar tissue pain after hysterectomy: Physical Therapy for Hysterectomy Scars and Adhesions
After your surgery – UNC Department of Obstetrics & Gynecology
Pain after hysterectomy
About 2-3% of women who have had hysterectomy develop a new pain problem after surgery. Because we specialize in the evaluation and treatment of pain, we often see women with this problem.In some instances, the pain comes from scar tissue that has formed during the healing process of the original hysterectomy surgery. When this scar involves one or both ovaries, the pain may occur in monthly cycles, in a pattern similar to menstrual discomforts a person may have had before hysterectomy. Pain during sexual intercourse is common in this situation as well.
In other instances, the ovaries may be innocent, but the pain can come from the healed tissue at the very top end of the vagina, where sutures were placed. In this problem, when the doctor puts a speculum in the vagina to see the upper end, it may look perfectly normal. If he/she then touches the tissue at the upper end with a cotton-tipped applicator, even gentle touch may be felt as pain. This means that there is neuropathic pain, or pain that comes from nerve endings that are sending out pain signals when they shouldn’t be. There often is no evidence of a lump or tissue damage or anything else that is different from the expected.
It is important to recognize this, because if this problem isn’t detected, then the ovaries may be suspected as the cause of the pain, and may be removed for no good reason! Pain of this type can be treated by a variety of techniques aimed at quieting the abnormal nerve signals. These include putting local anesthetics high in the vagina, injections, medications aimed at decreasing abnormal pain signals, and sometimes, surgical revision of the top end of the vagina. We have had good success performing this surgery laparoscopically when it is needed.
Q: What if I can’t move my bowels after surgery?
A: Begin stool softener (Colace or generic docusate sodium) as soon as you come home. Take a 100mg capsule three times daily. Chew Gum. Recent research has demonstrated that gum chewing makes bowel contents travel through faster. A high fiber diet will also help speed the return of normal bowel function. Adding an over the counter fiber laxative (Benefiber, Metamucil, Citrucel, etc.) twice daily should be sufficient. If you go 3-4 days and still haven’t moved your bowels, take a mild laxative like Milk of Magnesia or Senokot. Repeat every 12 hours till you get results
Q: How should I care for my incisions?
A: Incisions are closed with a suture material that dissolved in approximately two weeks so you may see some threads there. They do not need to be removed; they will dissolve and fall out on their own. The paper “Steri-strips” should be removed 10 days after surgery.
Incisions that do have sutures and/or steri-strips can be cleaned with soap and water in a shower immediately. If an incision looks at all open or is oozing it is a good idea to apply ½ strength hydrogen peroxide (mixed half and half with tap water). After the peroxide stops bubbling, blow the skin dry with a hair dryer on the warm setting. Then apply Neosporin or triple antibiotic ointment. This regimen should be repeated twice daily until incisions appear closed and dry.
Q: “I have a heavy pressure sensation in my lower pelvis. It hurts to sit a long time and I feel as though all my pelvic organs are trying to fall out.”
A: Many women experience a reactive muscle spasm in the muscles of the pelvic floor. These muscles attach at the pubic bone in the front and the tail bone in the back. The vagina and rectum are between them. When they go into spasm, women experience a downward pressure feeling that may increase when standing for prolonged periods, sitting on those muscles, or passing a bowel movement. The best recommendations are to consciously relax those muscles, ie “Let it fall!” Apply a heating pad to the front and/or back, and take ibuprofen. This should improve after a few days of employing these measures.
Q: I feel like I need to urinate all the time and when I do go, it burns and not very much comes out.
A: You probably have a bladder infection. Drink a lot of water, avoid caffeine, and please call the office (919-966-7764).
Q: I don’t have pain at the beginning of urination, but do have intense pain as I finish emptying my bladder. What’s wrong?
A: You are probably experiencing bladder spasms which are most common after a hysterectomy. This usually shows a gradual improvement over the first several weeks after surgery. As long as you don’t have frequency, urgency or burning, this is not a problem. However, if the discomfort is bothersome to you, you may try AZO-standard over the counter. If this does not offer enough relief, medications may be prescribed temporarily.
Q: I’m exhausted and just don’t feel well after my surgery. Is this normal?
A: To some extent, your fatigue is related to your general condition before your surgery and the length of time you were under anesthesia. After resting for a couple of days post-op, some muscle wasting is to be expected and you will need to rebuild your activity gradually. However, if you are short of breath going up stairs, feel generally ill (rather than just sore), or are running a fever over 100.5 degrees for more than 24 hours, please call the office. Each day, you should feel a little better. If this is not the case, please let us know.
Q: I’m having my first period after my laparoscopy and my flow is unusually heavy and my cramping is worse than usual. Is this normal?
A: During a laparoscopy, an instrument is placed inside the uterus which allows your surgeon to manipulate the uterus so he or she can see behind it. This instrumentation and manipulation often increases the flow of the first menstrual period after surgery and may also make the cramping more severe. This does not predict how you will do in the future.
Q: I had a hysterectomy within the last month and am now experiencing vaginal bleeding. Is this normal?
A: Light spotting is normal for up to six weeks while the suture line heals. Some women experience a gush of blood followed by spotting for several hours. This is usually due to a clot or hematoma forcing its’ way through the suture line at the top of the vagina. If you experience this gush, sit down, put your feet up and see if the bleeding lessens and stops. If it does, do not worry about this. If you have bleeding that requires pad changes every 2 hours or less that persists, please come in to the emergency room.
Q: How can I make my incisions scarless?
A: As a scar “matures” over the months after surgery, it shortens and tends to become attached to the layers of tissue underneath. One of the best things we’ve found for incisions, both small incisions from laparoscopic surgery and larger incisions from open laparotomy surgery, is to have a person massage the scar once it has healed for about three weeks. Place your 2nd and 3rd fingers over the scar and apply gentle pressure while moving your hand in a circular motion. Do this for a few minutes each day, and keep it up for the first few months after surgery. This may both make the scar feel more comfortable and keep it from developing an indentation or “puckered” look.
Adhesions – Better Health Channel
An adhesion is a band of scar tissue that joins two internal body surfaces that are not usually connected. Organs or tissues within the body stick (adhere) to other internal surfaces.
Adhesions develop as the body attempts to repair itself. This normal response can occur after surgery, infection, injury (trauma) or radiation. Adhesions may appear as thin sheets of tissue similar to plastic wrap, or as thick fibrous bands.
Adhesions can affect the female reproductive organs (ovaries, fallopian tubes), the bowel, the area around the heart, the spine and the hand. They can cause a range of problems including infertility, dyspareunia (painful intercourse), pelvic pain and bowel obstruction or blockage. Adhesions can also lead to a complex set of problems called adhesion-related disorder (ARD).
Adhesions are a widespread problem. Up to 93 per cent of people who have abdominal surgery go on to develop adhesions. Abdominal adhesions also occur in 10 per cent of people who have never had surgery.
Risks of adhesions
- develop after any kind of pelvic or abdominal surgery – people who have major or multiple procedures are even more at risk
- cause significantly higher post-operative complications (leaks, wound infections, haemorrhages) in people with adhesion-related perforations. This may also lead to a longer stay in hospital
- lead to other risks and complications, including small bowel obstructions, infertility and chronic pelvic pain
- cause increased risk, complexity and complications during subsequent surgery.
The incidence of adhesions has increased with the rise in gynaecological procedures. Up to 90 per cent of women suffer post-operative adhesions following major gynaecological surgery.
Development of adhesions
Adhesions develop as the body attempts to repair itself. This is the body’s normal response after:
- surgery, particularly abdominal surgery
- injury (trauma)
- radiation treatment.
Adhesions can also form after inflammation in the abdomen or pelvis.
Symptoms of adhesions
Although most adhesions are painless and do not cause complications, adhesions cause 60 to 70 per cent of small bowel obstructions in adults and are believed to contribute to the development of chronic pelvic pain.
Adhesion-related disorder (ARD) is a group of symptoms that may occur as a result of adhesions. A person with ARD will usually experience chronic abdominal pain.
Typical adhesions form within the first few days after surgery, but symptoms can last for months or even years. Symptoms may be mostly in one area of the abdomen, but are often generalised, vague, ‘crampy’ and difficult to define. This means ARD can be difficult to diagnose.
Symptoms of ARD may include:
- chronic pain
- bowel obstruction and an inability to pass gas
- urinary bladder dysfunction
- pain and difficulty having a bowel movement
- pain on movement such as walking, sitting or lying in certain positions
- emotional disorders such as depression, thoughts of suicide or hopelessness.
Other intestinal problems may include constipation, obstruction, or alternating constipation with diarrhoea from partial obstruction.
Women may experience gynaecological problems, which can add to the anxiety and self-esteem problems that may already be experienced by women who suffer with this disorder.
Symptoms of ARD can be mistaken as a sign of another condition. These can include a whole host of other possible diagnoses such as chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, depression and anxiety.
Diagnosis of adhesions
It is very difficult to diagnose the chronic pain of adhesions correctly. Diagnostic tests such as blood tests, x-ray procedures, CT scans, MRIs and ultrasound will not diagnose adhesions. Hysterosalpingography (an x-ray that views the inside of the uterus and fallopian tubes) may help diagnose adhesions inside the uterus or fallopian tubes.
According to your symptoms, your doctor will order the appropriate diagnostic tests to rule out other medical conditions that may have similar symptoms.
If the results of these tests are normal or negative for abnormal pathology, a diagnostic laparoscopy may be appropriate. This is the only test that can confirm the presence of adhesions. If adhesions are found, you doctor can usually release them during the same surgery.
Treatment of adhesions
Adhesions can be treated either with open or laparoscopic (keyhole) surgery, known as adhesiolysis. The adhesions are cut by scalpel or electrical current.
As adhesions are likely to form after certain surgical procedures, open adhesiolysis may not be worthwhile, except to remedy serious problems such as bowel obstruction.
In around 70 per cent of cases, the operation to remove the original adhesions will cause more adhesions to develop. Discuss the risks, benefits and alternatives to surgery thoroughly with your doctor before you make a decision.
People with symptoms of adhesions may consider laparoscopic surgery. The advantage of this procedure is that only a small incision (cut) is required, which is why it is also known as ‘keyhole surgery’. Laparoscopy is the preferred method for performing infertility surgery as there is a decreased risk of new adhesions forming.
Laparoscopic adhesiolysis can significantly improve quality of life among women with chronic pelvic pain due to adhesions. This procedure shows similar results to more invasive forms of surgery when it comes to managing extensive adhesions. However, it can be time-consuming (the procedure may take two to four hours), technically difficult and involves some risk. Adhesion barriers (commercially made) that are placed at the time of surgery may reduce adhesion formations.
Adjuvant treatment (using commercially available product such as intercoat) after adhesiolysis is beneficial in preventing the development of intrauterine adhesions.
Most women who choose to have laparoscopic adhesiolysis:
- are discharged on the same day of the procedure
- don’t need to have major abdominal cuts (incisions)
- experience minimal complications
- return to full activity within one week of the procedure.
Non-surgical treatments for adhesions
Alternatives to surgery include:
- medication – this is often the first treatment choice for acute pain and forms part of the treatment for chronic pain
- physical therapy
- lifestyle changes
- soft tissue mobilisation (Wasserman et al 2019)
Although they can be helpful, medications are not a cure-all. They can cause side effects or may be ineffective, and are often costly. A pain specialist can advise you on the non-surgical treatment options most suited to your situation.
Where to get help
- Your GP (doctor)
- Nurse-on-Call Tel. 1300 60 60 24 – for expert health information and advice (24 hours, 7 days)
Hysterectomy (removal of the uterus) at Medica International Clinic24
Hysterectomy is a surgical procedure during which the uterus is removed. In some cases, this operation is supplemented with the removal of the ovaries and cervix. Indications for hysterectomy are different, most often it is oncological diseases.
Our expert in this field:
Alimardonov Murad Bekmurotovich
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Removal of the uterus is a major surgical procedure. The recovery period after such an operation is quite long, but at present there are minimally invasive techniques that help to shorten it and reduce the risk of complications.
Medica24 international clinic employs highly qualified gynecological surgeons. They perform hysterectomy and other gynecological interventions in an operating room equipped with the latest equipment. Our doctors are fluent in modern surgical techniques that provide minimal trauma to the operation and the fastest possible recovery.
Indications for removal of the uterus
First of all, it is important to understand that hysterectomy is not a non-alternative method of treatment. It is absolutely indicated only for malignant tumors of the female reproductive organs, because in this case it is the only way to achieve remission and save a woman’s life. In the case of other pathologies, it is often possible to save the uterus. And only if none of the organ-preserving methods of treatment helps, the doctor decides to perform a hysterectomy.
Main indications for hysterectomy:
- Cancer of the body, cervix or ovaries.
- Uterine fibroids, which grow rapidly, reach a large size, cause severe pain, bleeding, interfere with the onset of pregnancy. Previously, hysterectomy was the main treatment for uterine fibroids. Currently, almost exclusively organ-preserving techniques are used. Removal of the uterus with fibroids is an extreme measure.
- Uterine prolapse is a condition in which the uterus slips into the vagina. In this case, a woman may experience urinary incontinence, impaired defecation.
- Severe forms of endometriosis – a disease in which the tissue of the lining of the uterus (endometrium) grows in places where it should not be, for example, on the surface of the peritoneum, ovaries.
- Abnormal vaginal bleeding.
- Chronic pelvic pain.
- Adenomyosis is a disease that develops as a result of a number of endocrine and immune disorders. At the same time, the endometrium grows strongly, and the wall of the uterus thickens.
If you are suffering from a benign uterine disease and your doctor has told you that you need a hysterectomy, you should talk to him, ask why this decision was made, if you can still try other alternatives to save the organ. It makes sense to get a second medical opinion from another specialist: perhaps he will offer organ-preserving methods of treatment. You can always consult an experienced gynecologist at Medica24 International Clinic. In difficult cases, we have the opportunity to convene a medical consultation, where various specialist doctors will assess your situation and find the best solution.
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Types of hysterectomy
Depending on the nature of the disease, the amount of surgical intervention may vary. There are four types of hysterectomy. The most radical ones are used for malignant neoplasms – this is necessary in order to completely remove the tumor tissue and prevent recurrence:
- Subtotal hysterectomy (supravaginal amputation of the uterus) involves the removal of only the body of the uterus, leaving the cervix intact.
- Total hysterectomy (extirpation of the uterus) – removal of the body and cervix.
- Total hysterectomy with bilateral salpingo-oophorectomy – removal of the body and cervix, fallopian tubes and ovaries.
- Radical hysterectomy – removal of the body and cervix, surrounding tissues and the upper part of the vagina. This operation can also be supplemented with salpingo-oophorectomy. Such surgical interventions are performed only for malignant tumors.
Removal of the uterus can be done in a variety of ways: open through an incision or using minimally invasive techniques. The choice of hysterectomy technique primarily depends on the nature of the disease, the general condition of the woman, comorbidities, experience, skill level of the surgeon and the availability of the necessary equipment in the clinic. The qualifications of surgeons and the equipment of the international clinic Medica24 allow performing various types of surgical interventions, of any level of complexity.
Open surgery is the most common way to remove the uterus. The surgeon makes an incision 12-17 cm long from the bottom up or in the transverse direction above the pubis and removes the organ through it. After the operation, the woman stays in the hospital for 2-3 days, then she is discharged.
Minimally invasive surgery
There are four hysterectomy techniques that can be classified as minimally invasive:
- Laparoscopic. The operation is performed with the help of special instruments through punctures in the abdominal wall. In this case, the image from the abdominal cavity is displayed on a special screen.
- Vaginal (vaginal). The uterus is removed through an incision made inside the vagina. At the same time, no scars remain on the skin of the abdominal wall.
- Laparoscopic vaginal. It is a combination of the two previous methods. The surgeon simultaneously makes an incision inside the vagina and punctures on the abdominal wall.
- Robot-assisted. Laparoscopic surgery, during which the surgeon controls the “arms” of the robot using a special remote control and monitors the progress of the operation on the screen.
Comparison of open and minimally invasive surgery: advantages and disadvantages
Minimally invasive hysterectomy methods have some advantages over open surgery. They are characterized by a shorter recovery period, a woman is discharged from the hospital faster, complications such as pain, infection, postoperative hernias occur less frequently. With the help of these techniques, minimal tissue injury is achieved, the volume of blood loss is reduced, and there are no large noticeable scars on the skin.
Minimally invasive surgery is economically less expensive. Only robot-assisted operations cost more than open surgery.
However, minimally invasive hysterectomy is not suitable for all patients. Some conditions make such operations difficult or even impossible:
- a large amount of scar tissue from previous surgical interventions;
- dimensions of the uterus;
- woman’s general health.
A woman who is about to have a hysterectomy should talk to her doctor about what types of surgery are possible in her case.
Preparation for surgery
Hysterectomy – elective intervention. The woman is assigned a hospitalization date in advance: the operation will be performed on the same or the next day. It is imperative to tell the doctor about the existing allergic reactions to drugs and latex, chronic diseases, and the medications the patient is taking. Drugs that reduce blood clotting may have to be discontinued for a while, as otherwise the operation will be accompanied by the risk of large blood loss.
Before a hysterectomy, a woman undergoes a preoperative examination, which includes:
- General and biochemical blood tests.
- Study of blood coagulability, coagulogram.
- Ultrasound of the pelvic organs.
- Tests for infections: HIV, syphilis, viral hepatitis, smear for flora, trichomoniasis, gonorrhea, PCR for chlamydia.
- Cytological smear from the cervix.
- Consultation of a general practitioner and, if necessary, other specialists.
The list of studies and analyzes can be expanded if a woman suffers from cardiovascular pathologies, respiratory diseases, diabetes mellitus. If you plan to remove the uterus by vaginal access, it is first important to identify and eliminate foci of infection in the vagina.
The day before, you need to shave off the hair in the pubic area, perineum. A hysterectomy is performed under general anesthesia, so you should not eat or drink anything 8-10 hours before the operation. In addition to the surgeon, the patient is consulted by an anesthesiologist beforehand. In some cases, spinal anesthesia may be used. An anesthetic is injected into the spinal canal under the membranes of the spinal cord in the lumbar region, while the lower half of the body loses sensitivity, and the woman remains conscious.
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Possible complications of hysterectomy
In most cases, hysterectomy is not accompanied by any problems, especially if it is performed by an experienced doctor using modern equipment. However, as with any surgical intervention, there is a small risk of some complications:
- severe bleeding;
- formation of blood clots in the vessels of the lower extremities – compression underwear is used to prevent this complication;
- accidental injury to urinary tract, intestines;
- reactions to anesthetic drugs;
- urinary incontinence;
- prolapse, prolapse of the vagina;
- chronic pelvic pain;
- formation of a fistula (pathological communication) between the vagina and the bladder or rectum.
After a hysterectomy, a woman will still be able to have sex because the vagina remains, but pregnancy becomes impossible. If a woman still wants to have a child in the future, and it is impossible to save the uterus, modern reproductive medicine can offer a solution in the form of surrogacy.
If the ovaries are removed along with the uterus, the woman goes through menopause. Therefore, if the operation was performed on a young patient, the doctor will suggest hormone replacement therapy. Menstruation will disappear in any case, since the uterus is no more.
After the removal of the ovaries, the service of surrogate motherhood will no longer be possible. A woman will in no way be able to become the biological mother of a child, because eggs will not be produced in her body. This situation is also resolvable. You can pre-extract germ cells from the ovaries and store them in a cryobank. Discuss this possibility with your doctor if it is relevant to you.
If a woman has her uterus removed, but one or both ovaries are left, then there is a high probability that, regardless of age, she will go through menopause in 5 years.
The uterus should not be taken as an organ dedicated exclusively to carrying a pregnancy. It plays an important role in the body, and after its removal, the so-called post-hysterectomy syndrome may develop. It manifests itself with various symptoms:
- Vegetative-vascular disorders: attacks of increased heart rate, poor tolerance to high and low temperatures, numbness and “crawling” in different parts of the body, chills, periodic increases in blood pressure, excessive sweating.
- Psycho-emotional disorders: fatigue, depression, decreased performance, lethargy, weakness.
- Metabolic disorders: increased blood pressure, impaired lipid and carbohydrate metabolism, obesity.
After minimally invasive interventions, the recovery period usually lasts 3-4 weeks, after open interventions – 4-6 weeks. The stitches are removed after about a week.
Recommendations in the postoperative period:
- Sex and intense physical activity are contraindicated for 6 weeks.
- Pain may disturb for several days. They can be removed with ordinary painkillers from the home first aid kit.
- You can return to driving after about 2 weeks.
- Air travel and long distance travel are allowed after 3 weeks.
- Do not douche the vagina, use vaginal suppositories, tampons for four weeks.
During the year after a subtotal hysterectomy, small periods may occur – they are due to a small amount of mucous membrane that remains in the cervix.
Seek immediate medical attention if symptoms such as severe vaginal bleeding, fever over 38 degrees, severe nausea, vomiting, frequent, difficult, burning urination, severe pelvic pain, redness, and pain in the suture area.
Gynecologists at the Medica24 International Clinic always try to adhere to organ-preserving tactics. They try to save the uterus whenever possible. If a hysterectomy is still unavoidable, our doctors perform it as carefully as possible, take all measures to avoid possible complications and minimize the negative consequences for the woman. We take care of women’s health.
The material was prepared by a gynecologist, oncologist of the international clinic Medica24, candidate of medical sciences Alimardonov Murad Bekmurotovich.
Condition of the mammary glands in women after laparoscopic hysterectomy
To date, worldwide, hysterectomy remains the most common operation on the pelvic organs in women. In this case, the main indication for surgery is uterine fibroids with clinical manifestations. In recent years, there has been a clear upward trend in the number of hysterectomies in women of reproductive age . Considering the high frequency of the combination of pathological changes in the mammary glands with uterine myoma, which, according to the literature, reaches 90% [2, 3], of particular interest is the study of the state of the mammary glands before and after surgical treatment of uterine fibroids.
As is known, benign diseases of the mammary glands in women are considered, on the one hand, as a possible background for the development of cancer, on the other hand, as a group of diseases that significantly reduce the quality of life. A number of studies have shown that most often uterine fibroids are combined with proliferative forms of fibrocystic mastopathy, in which the relative risk of developing breast cancer is increased [4–6]. It should be recognized that in the literature there are only a few works on the state of the mammary glands in patients operated on for uterine fibroids. This was the reason for conducting scientific and practical research.
The aim of this study was to evaluate the dynamics of the state of the mammary glands in patients with uterine myoma before and after laparoscopic hysterectomy (LH), depending on the age of the patient and the amount of surgery performed.
Material and methods
The study included 103 patients aged 39-50 years who underwent HT for uterine fibroids with clinical manifestations. All patients were divided into 2 groups: the 1st group consisted of patients (n=41) operated on in the amount of supravaginal amputation of the uterus without appendages at reproductive age (36—44 years). The 2nd group included 62 women who underwent hysterectomy in the amount of supravaginal amputation of the uterus or extirpation of the uterus in premenopause (45-47 years). Of these women, 24 (38.71%) underwent bilateral adnexectomy during HT for benign ovarian neoplasms, respectively, in 38 (61.29%), the uterine appendages on both sides were preserved. Indications for surgical treatment of the examined patients are presented in the table.
According to the presented data, among the indications for PH in patients of the 1st group, large uterine fibroids with dysfunction of the pelvic organs prevailed. The average size of the removed uterus corresponded to that at 14-15 weeks of pregnancy. In patients of the 2nd group, the most common indication for surgery was various menstrual disorders leading to anemia. The average size of removed queens in this group corresponded to that at 9-10 weeks pregnant. Indications for removal of the cervix were represented by dysplasia, leukoplakia, ectopia in combination with cicatricial deformity.
All patients with menstrual disorders in order to clarify the state of the endometrium at the first stage underwent hysteroscopy with separate diagnostic curettage of the uterine walls. The rest of the patients underwent aspiration biopsy from the uterine cavity.
Operative laparoscopy was performed using a standard set of endoscopic equipment from Karl Storz (Germany). Laparoscopic operations were performed under endotracheal anesthesia with the imposition of pneumoperitoneum with the patient in the Trendelenburg position.
The follow-up period in both groups was 3 years.
In order to assess the dynamics of the state of the mammary glands, all patients underwent palpation examination of the mammary glands, ultrasound scanning of the mammary glands and mammography before and after surgical treatment. According to the indications (when detecting nodular forms of mastopathy, including solitary cysts and to clarify the diagnosis), a puncture or aspiration biopsy of the mammary glands was performed under ultrasound control with a cytological examination of the biopsy.
Examination before surgery revealed pathological changes in the mammary glands in 74 (71.8%) of 103 women.
Changes in the mammary glands before performing HT in patients of the 1st group were represented by diffuse fibrocystic mastopathy (DFCM), noted in 28 (68.3%) cases. Of these, DFCM with a predominance of the glandular component was diagnosed in 7 (25.0%) patients, the cystic component in 8 (28.6%), and the fibrous component in 4 (14.3%). Accordingly, 9(32.1%) of patients a mixed form of DFCM was detected. It should be noted that earlier the diagnosis of fibrocystic mastopathy (FCM) was established only in 10 (35.7%) of the 28 examined women. At the same time, 17 (60.7%) patients complained of mastalgia of varying intensity. Of these, about 50% of women did not attach much importance to complaints and did not go to the doctor. In addition, 4 (9.8%) patients had a sectoral resection of the mammary gland for fibroadenoma in their anamnesis.
The structure of breast diseases in patients of the 1st group before the LH is shown in fig. 1, a. Figure 1. The structure of breast diseases in patients of the 1st group (a) and 2nd group (b) before HT. DFCM – diffuse fibrocystic mastopathy; DUFCM – diffuse nodular fibrocystic mastopathy.
Among patients of the 2nd group, various diseases of the mammary glands at the time of admission for HT were detected in 46 (74.2%) out of 62. The structure of diseases of the mammary glands in patients of the 2nd group before surgery at the time of admission and in the history is shown in Fig. . 1b.
Pathological changes in the mammary glands at the time of hospitalization for surgical treatment were presented by DFCM in 42 (67.7%) patients of the 2nd group. At the same time, the predominance of the glandular component was found in 13 (30. 9%) of 42 women, cystic — in 10 (23.8%), fibrous — in 3 (7.1%). A mixed form of DFCM was observed in 16 (38.1%) of 42 patients. Diffuse-nodular form of FCM was detected in 4 (6.5%) patients who underwent PH in premenopause. In 15 (24.2%) women, a history of surgical interventions on the mammary glands for fibroadenoma and solitary cysts of the mammary glands was noted.
Three years after PH, mammological examination revealed various diseases of the mammary glands in 40 (97.6%) patients of the 1st group. Among the pathological changes in the mammary glands, as before the operation, DFCM prevailed, detected in 33 (82.5%) of 40 patients. At the same time, in 3 (7.5%) patients who underwent PH at reproductive age, the nodular form of FCM was diagnosed after surgery, and in 4 (10.0%) – a mixed diffuse-nodular form of FCM.
In the 2nd group, in patients who underwent hysterectomy without appendages, various diseases of the mammary glands were diagnosed in 35 (92.1%) out of 38 in the long-term period. FCM form — in 5 (14.3%), nodular FCM — in 4 (11.4%). In addition, 2 (5.7%) patients had a recurrence of solitary cysts of the mammary glands. At the same time, there were no significant differences in the state of the mammary glands after supravaginal amputation of the uterus or hysterectomy.
Among 24 patients who had uterine appendages removed during hysterectomy, fibrofatty involution dominated in the mammary glands, moderate manifestations of DFCM persisted only in one (4.2%) patient.
The dynamics of the state of the mammary glands in the examined patients before and after the LH is shown in fig. 2. Figure 2. Dynamics of the state of the mammary glands in the examined patients before and after LH. At the same time, group 2A reflects information about premenopausal patients who underwent HT with preservation of the uterine appendages. Accordingly, group 2B presents data on patients who underwent LH with the removal of the uterine appendages.
In view of the fact that from a functional point of view, the mammary glands and genital organs are one in the reproductive system, the need to assess the condition of the mammary glands in patients with dyshormonal gynecological diseases is quite obvious. When studying the frequency of a combination of diseases of the mammary glands and genital organs, it was found that the most common pathology of the mammary glands is detected in patients with uterine myoma, and, according to various data, is 69—90% [2, 3, 6, 7]. Until now, the main method of treatment of uterine fibroids remains surgical, and the most commonly performed operation is hysterectomy. The state of the mammary glands as target organs after hysterectomy is of undoubted interest, especially in patients operated on at reproductive age.
In the present study, the incidence of non-cancer breast diseases (NBC) in patients with uterine myoma before surgical treatment was 71.8%. According to the literature, the highest risk of developing NVMJ is observed at the age of 45 years . According to our data, before surgical treatment, dyshormonal pathological changes in the mammary glands at the time of admission in patients of reproductive age and in premenopause occurred almost equally often: in 68. 3 and 74.2% of cases, respectively. However, in patients of the 2nd group, a history of surgical interventions for fibroadenomas and solitary cysts of the mammary glands occurred 2.5 times more often. In addition, patients who underwent hysterectomy at reproductive age did not have diffuse nodular forms of FCM before surgical treatment.
Until now, when performing a hysterectomy, the question of the volume of the operation remains unresolved, i.e. remove or save uterine appendages. This problem is discussed in connection with the possibility of various benign and malignant changes in the left uterine appendages and in the mammary glands (as target organs). A number of studies have shown that bilateral oophorectomy in patients with uterine myoma with proliferative forms of FCM leads to regression of proliferative changes in the breast tissue [4, 8]. The results obtained in this study are consistent with the literature data that surgical treatment with the removal of uterine appendages has a positive effect on pathological changes in the mammary glands and reduces the risk of their diseases. Thus, among 24 premenopausal patients in whom the uterine appendages were removed during hysterectomy, moderate manifestations of DFCM persisted only in one (4.2%). At the same time, over a three-year follow-up period after hysterectomy with preservation of the uterine appendages, the results of the study made it possible to state an increase in the number of diseases of the mammary glands in reproductive age by 29.3%, in premenopause – by 17.9%. In addition, these patients were characterized by the progression of the diffuse forms of the disease that were present before the operation into more severe localized forms. The data obtained are consistent with the results of the study by M.I. Piddubny et al. on the state of target organs in patients operated on for uterine fibroids . However, the currently generally accepted tactic for choosing the volume of surgery in patients of reproductive age in the absence of ovarian masses involves the preservation of the uterine appendages. As is known, post-ovariectomy syndrome develops in patients with hysterectomy with removal of both ovaries due to a sharp shift in hormonal balance and secondary involvement of hypothalamic structures in the pathological process. According to E.M. Vikhlyaeva, the clinical picture of the disease after an acute shutdown of ovarian function is characterized by the greatest severity during the first 2 years after surgery and is expressed in various manifestations of vegetative-vascular disorders. According to the author, it is expedient to preserve intact ovaries in all women undergoing surgical treatment up to the period of perimenopause . It should be noted that we share this opinion: the removal of the uterine appendages in the present study was performed only in the presence of benign ovarian masses.
Thus, patients with uterine fibroids who are expected to undergo hysterectomy with preservation of the uterine appendages are at increased risk for the development and progression of mammary dysplasia in the postoperative period. This makes it necessary to consider the common pathogenetic mechanisms of development of uterine fibroids and dyshormonal diseases of the mammary glands and to implement an integrated approach when choosing a method of treatment in these patients.