Leiomyoma during pregnancy

　　1. Causes of onset

　　The etiology of the formation and growth of leiomyoma is still not very clear at present, and it may involve complex interactions between somatic cell mutation of the normal muscle layer, sex hormones, and local growth factors.

　　Based on a large number of clinical observations and experimental results, it is shown that leiomyoma is a hormone-dependent tumor. Estrogen is the main factor promoting the growth of leiomyoma. Clinically, leiomyoma is more common in women aged 30 to 50, while it is rare before puberty, and the growth of leiomyoma stops and gradually shrinks or even disappears after menopause; during pregnancy, under the condition of exogenous high estrogen, the growth of leiomyoma is faster; treatment to inhibit or reduce estrogen levels can make the leiomyoma shrink; patients with leiomyoma often have endometrial hyperplasia and endometriosis. Experimental studies have shown that the concentration of estradiol in the leiomyoma tissue is higher than that in normal muscle tissue, indicating that there is a high estradiol environment locally. Brandon et al. also found that the concentration of estrogen receptor (ER) and ER-mRNA levels in leiomyoma of the same uterus are significantly higher than those in normal muscle tissue. Recent studies have also found that progesterone is also a factor promoting the growth of leiomyoma. The study shows that the concentration of progesterone receptor (PR) and PR-mRNA content in the leiomyoma tissue are higher than those in the surrounding muscle tissue, and the mitotic phase in the leiomyoma specimens in the secretory phase is significantly higher than that in the proliferative phase. In the cases of leiomyoma treated with progesterone antagonist (MPA), the number of mitotic phases per high-power field is significantly higher than that in the control group. Friedman et al. found that the low estrogen state induced by the growth hormone-releasing hormone agonist (GnRH-a) can make the leiomyoma shrink, but this effect can be inhibited by progesterone, and it can cause the already shrunken leiomyoma to grow rapidly.

　　In addition, some scholars believe that growth hormone (GH) may also be related to the growth of fibroids. GH can synergize with estrogen to promote mitosis and promote the growth of fibroids, and it is speculated that human placental lactogen (HPL) may also synergize with estrogen to promote mitosis. It is believed that the accelerated growth of uterine fibroids during pregnancy is not only related to the high hormone environment during pregnancy but may also involve the action of HPL.

　　Recent research also believes that some growth factors may play an important role in the growth of uterine fibroids, such as insulin-like growth factor I and II (IGF), epidermal growth factor (EGF), platelet-derived growth factor A and B (PDGF-A, B).

　　Recent studies in cytogenetics suggest that chromosomal structural abnormalities are associated with the occurrence and development of uterine fibroids. Uterine fibroids have chromosomal structural abnormalities, such as chromosomal translocation, loss, and rearrangement. It has been reported that abnormal karyotypes in uterine fibroid tissue culture can reach 34.4% to 46.1%, and the karyotype abnormalities are more prominent in histologically special fibroids.

　　Uterine fibroids can also occur in patients with hyperandrogenic adrenal sexual adenopathy, and the pathogenesis is still unclear. In addition, ovarian function and hormone metabolism are controlled and regulated by the higher nervous center, so the activity of the central nervous system may also play an important role in the occurrence of fibroids. As uterine fibroids are more common in women of childbearing age, widows, and those with disharmony in sexual life, long-term sexual dysfunction leading to chronic pelvic congestion may also be one of the causes of uterine fibroids. Chiaffarino believes that the occurrence of uterine fibroids is related to diet. Zhou and others reported that patients with uterine fibroids have immune function changes, mainly low activity of NK cells.

　　In summary, the occurrence and development of uterine fibroids may be the result of the combined effects of multiple factors. The pathogenesis involves various aspects such as changes in estrogen (E2) and progesterone (P) levels locally or globally, local peptide growth factor response, changes in the rate of mitotic cell division, and somatic cell mutation. Among them, E2 regulates the increase of PCNA by increasing the expression of EGF receptor (EGFR) in cells; P, on the other hand, regulates the increase of PCNA by increasing the expression of EGF-like proteins in cells, ultimately leading to the transformation of normal uterine smooth muscle cells into fibroid cells. This pathway provides a new hypothesis for the occurrence of fibroids and may help in the clinical treatment with new methods.

　　The effect of myomas on pregnancy varies depending on the size and location of the tumor. Small myomas, subserous myomas, or myomas near the serous surface have little effect on pregnancy, but multiple myomas or intramural myomas and submucous myomas that protrude into the uterine cavity can hinder conception, causing infertility or miscarriage. The growth of myomas during early pregnancy can accelerate under the action of pregnancy hormones, and the tumor mass can increase. After the middle of pregnancy, due to the relative reduction in blood supply to the myoma, red degeneration or infection is more likely to occur. The enlargement of the pregnant woman's uterus can cause torsion of the pedicle of the subserous myoma. Myomas located at the isthmus or posterior lip of the cervix can block the birth canal, affecting uterine contractions and causing dystocia. The presence of myomas can affect uterine contraction, hinder the spontaneous detachment of the placenta after delivery, and thus lead to postpartum hemorrhage. In addition, the growth of myomas can deform the uterine cavity, thin the endometrium due to compression, impede blood supply, and if the placenta is attached in this area, it can expand around it, causing placenta previa.

　　Secondly, pathogenesis

　　1. Macroscopic myomas can be single but are often multiple. They vary in size, with some as small as millet seeds, even invisible to the naked eye and only identifiable under a microscope, while some can reach the size of a full-term pregnant uterus, with reports of even more than 45kg (100 pounds).

　　Myomas can occur at any part of the uterus, but they grow most frequently in the uterine body, accounting for 90% to 96% of all myomas, with those growing in the uterine cervix accounting for only 2.2% to 8%. In addition, they are occasionally seen growing in the round ligament, broad ligament, and uterine sacral ligament.

　　(1) Intramural myoma: This type of myoma is the most common, accounting for 60% to 70% of all cases. The myoma is located within the uterine muscular layer, surrounded by normal muscular layers, with clear boundaries between the myoma and the muscular wall. The fibrous tissue bundles compressed around the myoma form a 'pseudo-capsule'. Myomas can be single or multiple, and vary in size. Small myomas do not significantly change the shape of the uterus, while large myomas can enlarge the uterus or deform it into an irregular shape, and the uterine cavity also deforms accordingly.

　　(2) Subserous myoma: A myoma protrudes outward from the uterine surface, and when its surface is only covered by a small amount of muscular wall and serous membrane, it is called a 'subserous myoma'. Sometimes, the myoma has only one pedicle connected to the uterine wall, which is called a pedunculated subserous myoma. Subserous myomas with pedicles can undergo torsion of the pedicle, necrosis and shedding of the tumor, and adhesion to adjacent organs, thus obtaining blood supply and growing, known as parasitic myoma. When a myoma grows on the lateral wall of the uterus and grows into the broad ligament, it is called an intraligamentary myoma. Subserous myomas account for 20% to 30% of all myomas.

　　(3) Submucous myoma: A myoma located between the muscular walls near the uterine cavity, growing towards the uterine cavity, and its surface covered by endometrium, is called a submucous myoma. Because it protrudes into the uterine cavity, it can deform the uterine cavity, and sometimes it has a pedicle, with a long pedicle myoma even protruding outside the cervical os. The endometrium on the surface of the myoma may have bleeding, necrosis, and secondary infection.

　　The above types of leiomyomas can occur singly or simultaneously. When two or more leiomyomas occur in the same uterus, they are called multiple uterine leiomyomas.

　　Typical leiomyomas are solid spherical masses with smooth surfaces and distinct boundaries with the surrounding muscle tissue. Although the leiomyoma has no capsule, it forms a pseudocapsule due to the compression of the uterine muscle layer around the leiomyoma, with a loose reticulated area between the pseudocapsule and the leiomyoma. When the capsule is incised, the leiomyoma will jump out, making it easy to remove. Blood vessels enter the pseudocapsule from the outside to supply nutrition to the leiomyoma. The larger the leiomyoma, the thicker the blood vessels, and the blood vessels in the pseudocapsule are arranged in a radial pattern. The tumor wall lacks an outer membrane and is prone to cause circulatory disorders, leading to various degenerative changes in the leiomyoma. Generally, leiomyomas are white, hard, and have grayish white whorl-like lines in the section, slightly uneven. The more fibrous tissue the leiomyoma contains, the whiter and harder it becomes.

　　2. Microscopic examination shows that the leiomyoma is composed of smooth muscle. The cytoplasm contains myofibrils, and the cell bundles are arranged in different directions, forming a whorl-like pattern. In the longitudinal section, the cells are fusiform and relatively uniform in size. The cytoplasm is eosinophilic, and the nucleus is rod-shaped with blunt ends. If it is a cross-section, the cells are round or polygonal, with rich cytoplasm and a round nucleus located in the center. The leiomyoma contains an unequal number of collagen fibers.

　　3. Special tissue types

　　(1) Cellular leiomyoma: The tumor contains a large number of smooth muscle cells, arranged closely, with consistent cell size and shape, only a few cells are atypical, and occasionally there are 1-4 mitotic figures per 10 high-power fields.

　　(2) Bizarre leiomyoma (bizarre leiomyoma): The tumor is mainly composed of round or polygonal cells, with eosinophilic cytoplasm and clear spaces around the nuclei. Its characteristics are cell polymorphism, nuclear atypia, and even the appearance of giant cells. No mitotic figures can be seen. Clinically, it presents a benign appearance.

　　(3) Angiomyoma: Leiomyomas are rich in blood vessels, and tumor cells are arranged around the blood vessels, closely connected with vascular smooth muscle. The tumor section is reddish in color.

　　(4) Epithelioid leiomyoma (epithelioid leiomyoma): Leiomyomas are composed of round or polymorphic cells, often arranged in epithelioid strands or nests. The leiomyoma is yellow or gray. Attention should be paid to whether there is muscle layer infiltration at the edge part; if there is infiltration, it should be considered malignant.

　　(5) Neurofibromatous leiomyoma: The nuclei of tumor cells are arranged in a lattice-like pattern, resembling neurofibromas.

　　4. Several special growth patterns of leiomyomas

　　(1) Intravascular leiomyomatosis: The smooth muscle tissue of the uterus can enter the veins or lymphatic vessels, known as intravascular leiomyomatosis. It is more common to enter the venous vessels. Intravascular leiomyomatosis is benign in histological morphology, but in clinical practice, leiomyomas can grow into the inferior vena cava in a worm-like manner, which can cause death. There have been reports in foreign literature of leiomyomas growing into the inferior vena cava and entering the right atrium, causing heart failure.

　　The tumor tissue within the veins presents as grayish-white polypoid, tufted, or worm-like strands. This intravascular leiomyoma can be pulled out from the blood vessel, can exist freely, or can be connected with the muscular wall. Microscopic examination shows that the tumor is composed of benign smooth muscle and grows within the vascular lumen lined with endothelial cells. Some scholars believe that the origin of the tissue is the smooth muscle tissue of the blood vessel wall itself, while some believe it is the myoma tissue infiltrating into the blood vessels within the muscular layer. The tumor cells are rich in estrogen receptors, and endogenous estrogen plays a certain role in recurrence, so it is not advisable to retain the ovaries for some cases that cannot be completely resected.

　　(2) Peritoneal disseminated leiomyomatosis (leiomyomatosis peritonealis disseminata): It is more common during pregnancy and is related to the stimulation of sex hormones. Tumors can occur in the ovary, round ligament, serosal surface of the internal genitalia, omentum, mesentery, and gastrointestinal wall, resembling the implantation and metastasis of malignant tumors. Grossly, the morphology is similar to that of myomas, presenting nodular, hard texture, and smooth surface. Histologically, it is benign leiomyoma, with rare mitotic figures and non-invasive growth. The origin of the tissue is unknown; some believe that subperitoneal mesenchymal tissue can be metaplastic into smooth muscle tissue, with hormones promoting its nodular growth, while some scholars believe it is the development of homologous multicentric leiomyoma. After the removal of the uterus and both adnexa, the peritoneal lesions can often regress. Disseminated peritoneal leiomyoma during pregnancy can also partially or completely regress naturally after pregnancy.

　　(3) Benign metastatic leiomyoma (benign metastasizing leiomyoma): It is relatively rare. In addition to uterine myoma, it can also be associated with metastasis to the lung, kidney, striated muscles of the limbs, lymph nodes, and other places. Clinically, various symptoms corresponding to the affected site are presented, and patients often have a history of hysterectomy due to uterine myoma many years ago. Histologically, it shows the same tissue changes as benign leiomyoma. When clinical dissemination and metastasis occur, it is necessary to exclude the possibility of malignancy before it can be confirmed as benign metastatic leiomyoma.

　　5. Degeneration: When the myoma grows rapidly or a pedicle is formed, it is prone to insufficient blood supply and nutrient deficiency, causing the myoma to lose its original typical structure and appearance, known as degeneration (degeneration). Degeneration can be divided into benign degeneration and malignant degeneration.

　　(1) Benign degeneration:

　　① Hyaline degeneration: Due to insufficient blood supply to the myoma, some tissue swells and softens, loses the spiral texture, and presents a smooth grayish-white transparent appearance. Microscopic examination shows broad band-like transparent connective tissue, occasionally with shadows of muscle cells. This type of degeneration is most common, generally progresses slowly, and does not cause clinical symptoms.

　　Cystic degeneration: The further development of hyaline degeneration leads to tissue liquefaction, forming cystic cavities containing mucinous or transparent fluid. If the cyst cavity is large, it can make the entire myoma soft like a cyst. Microscopic examination shows irregular cavities, with cystic cavities composed of hyaline degenerated myoma tissue, without an epithelial lining, different from true cysts.

　　③ Red degeneration: Common during pregnancy and puerperium. The fibroid volume rapidly increases, showing symptoms of ischemia, infarction, congestion, thrombosis, and hemolysis. Blood leaks into the tumor, causing the fibroid to become red, resembling raw beef, and losing its original whorl-like structure. Under the microscope, there are thromboses in the large veins within the pseudocapsule and small veins in the tumor, along with hemolysis, a decrease in muscle cells, and a large number of fat globules deposited.

　　④ Fat degeneration: Common in fibroids in postmenopausal women, showing a yellow section with the disappearance of the whorl-like structure. Under special staining, the degenerated area can be seen as a uniform acellular structure with fat tissue deposition and cavities formed by fat dissolution.

　　⑤ Calcification: Common in subserosal fibroids with narrow pedicles and insufficient blood supply. After the fat degenerates into triglycerides, they combine with calcium salts to form calcium carbonate stones, which can form a calcified shell around the fibroid or spread throughout the tumor, making the uterus hard as a stone, forming what is known as a uterine stone. Under the microscope, the calcified area is layered deposition, showing circular or irregular shapes, with fine granules infiltrating into the hematoxylin stain.

　　(2) Malignant degeneration: The malignant degeneration of uterine fibroids is sarcomatous transformation, with a low incidence rate of about 0.5% of uterine fibroids, more common in older women. It is often overlooked due to the lack of obvious symptoms. The tissue in the lesion area is grayish yellow and soft like raw fish meat. The tumor grows rapidly, so if a fibroid rapidly increases in size or is accompanied by irregular vaginal bleeding, it should be considered as a possible sarcomatous transformation. If there is a tendency for fibroids in postmenopausal women to increase in size, they should be more vigilant about the possibility of malignant transformation.

　　1. Infection

　　Fibroid infection is mostly a consequence of pedicle torsion or acute endometritis, with a few cases due to pelvic infection foci affecting uterine fibroids, and blood-borne infection is very rare. Submucosal fibroids are most susceptible to infection, especially those that protrude into the vagina, which are prone to necrosis and subsequent infection. Clinical manifestations are often irregular vaginal bleeding, large amounts of bloody discharge, accompanied by fever.

　　2. Twisting

　　Subserosal fibroids can twist at the pedicle, causing acute abdominal pain. If the twisting is severe and surgery or repositioning is not performed in time, free fibroids can form due to the rupture of the pedicle.

　　1. Symptoms

　　Most patients are asymptomatic and are occasionally discovered during pelvic examination or ultrasound. If symptoms are present, they are closely related to the location, speed of growth, whether there is degeneration, and whether there are complications, rather than the size or number of fibroids. Patients with multiple subserosal fibroids may not have symptoms, while a small submucosal fibroid can often cause irregular vaginal bleeding or menorrhagia. Common clinical symptoms include:

　　1. Uterine bleeding

　　The most common symptom of uterine fibroids, occurring in more than half of patients, is cyclic bleeding, which can manifest as increased menstrual volume, prolonged menstrual periods, or shortened menstrual cycles. It can also manifest as irregular vaginal bleeding without a regular menstrual cycle. The cause of uterine bleeding is related to the following factors:

　　As the uterus grows larger, the area of the uterine cavity内膜 also increases. The area of endometrial shedding during menstruation is large, and the repair time is long, leading to increased menstrual blood volume and prolonged menstrual periods.

　　Interstitial fibroids affect uterine contraction, leading to increased menstrual blood volume.

　　As fibroids grow larger, the veins near the fibroids are compressed, causing dilation and congestion of the venous plexus in the endometrium and myometrium, thereby causing increased menstrual blood volume.

　　Fibroid patients often have hyperplasia of the endometrium; ⑤ the surface of submucosal fibroids often ulcerates and becomes necrotic, leading to irregular uterine bleeding.

　　Uterine bleeding is more common with submucosal and interstitial fibroids, while subserosal fibroids rarely cause uterine bleeding.

　　2. Abdominal mass and compression symptoms

　　As fibroids gradually grow, when they cause the uterus to enlarge beyond the size of a 3-month pregnant uterus or when they are located at the fundus as a large subserosal fibroid, they can often be palpated in the abdomen, more明显 when the bladder is full in the morning. The mass is solid, movable, and painless. When fibroids grow to a certain size, they can cause compression symptoms of surrounding organs. A fibroid on the anterior uterine wall close to the bladder can cause frequent urination and urgency; a large cervical fibroid pressing on the bladder can cause incomplete urination or even urinary retention. A fibroid on the posterior uterine wall, especially at the isthmus or posterior cervix, can compress the rectum, causing incomplete defecation and discomfort after defecation. A large broad ligament fibroid can compress the ureter, even causing renal pelvis hydrops.

　　3. Pain

　　Generally, uterine fibroids do not cause pain, but many patients may complain of a sense of lower abdominal坠胀 and back pain. Acute abdominal pain may occur when the pedicle of a subserosal fibroid twists or when a fibroid undergoes red degeneration. Patients with fibroids complicated with endometriosis or adenomyosis have dysmenorrhea.

　　4. Increased leukorrhea

　　An enlarged uterine cavity, an increase in endometrial glands, and pelvic congestion can cause an increase in leukorrhea. When submucosal fibroids in the uterus or cervix ulcerate, become infected, or necrotize, bloody or purulent leukorrhea may occur.

　　5. Infertility and abortion

　　Some patients with uterine fibroids may be infertile or prone to abortion. The impact on pregnancy and pregnancy outcomes may be related to the growth location, size, and number of fibroids. Large uterine fibroids can cause uterine cavity deformation, hinder the implantation of the gestational sac, and affect the growth and development of the embryo; fibroids pressing on the fallopian tubes can lead to incomplete patency of the tubes; submucosal fibroids can hinder the implantation of the gestational sac or affect sperm entering the uterine cavity. The spontaneous abortion rate in fibroid patients is higher than that in the general population, with a ratio of about 4:1.

　　6. Anemia

　　Due to prolonged menstrual bleeding or irregular vaginal bleeding, anemia can occur, and severe anemia is more common in patients with submucosal fibroids.

　　7. Others

　　A very small number of uterine fibroid patients can produce polycythemia, hypoglycemia, which is generally believed to be related to the production of ectopic hormones by the tumor.

　　2. Signs

　　1. Abdominal examination

　　An enlarged uterus larger than 3 months of pregnancy or a larger subserosal uterine fibroid at the fundus can be palpated above or below the pubic symphysis or in the midline of the lower abdomen. It is solid, painless, and irregular in shape if it is a multiple fibroid.

　　2. Pelvic examination

　　Gynecological bimanual examination, three-part examination, the uterus is enlarged to varying degrees, irregular, with irregular protuberances on the surface, appearing solid. If there is degeneration, the texture is softer. The signs of uterine fibroids during gynecological examination vary according to their different types. Pedunculated subserosal myomas, if the pedicle is long, can be palpated as a solid mass around the uterus, which is freely movable and can be easily confused with ovarian tumors. Submucosal myomas descend to the cervical canal orifice, the cervix is relaxed, and the examiner's fingers can feel a smooth spherical mass inside the cervical canal orifice. If it has prolapsed outside the cervical canal orifice, the tumor can be seen, with a dark red surface, sometimes with ulcers, necrosis. Larger cervical fibroids can cause the cervix to shift and deform, and the cervix can be flattened or moved upwards to the posterior side of the pubic symphysis.

　　The application of minimally invasive technology in gynecological uterine fibroid surgery is another major breakthrough in medicine. It is widely used in developed countries at present and is the preferred surgical method for uterine fibroids, achieving very good results. BBT coagulation and laparoscopic minimally invasive surgery have significant therapeutic effects.

　　Uterine fibroids are the most common benign gynecological tumor of the female reproductive organs. They are most common in women aged 30-50, with the highest incidence rate between 40-50 years old, accounting for 51.2%-60%; it is estimated that about 20%-25% of women aged 35-50 have uterine fibroids.

　　The treatment of uterine fibroids should be decided after comprehensive consideration of the patient's age, symptoms, size of the fibroids, fertility status, and overall health.

　　1. Expectant management

　　Generally, myomas are less than 8 weeks of gestational age, have no obvious symptoms, no complications, no myoma degeneration, or the uterus of a woman near menopause is less than 12 weeks of gestational size, with normal menstruation and no symptoms of compression. In such cases, expectant management can be adopted, with temporary observation. It is recommended to have a follow-up examination every 3-6 months, that is, to carry out regular follow-up observation in terms of clinical and imaging aspects. Generally, myomas can gradually shrink after menopause. However, it should be noted that in a small number of patients, myomas do not shrink but instead increase after menopause, so close follow-up is required. If the myoma grows rapidly, submucosal myoma, or suspected myoma degeneration, or obvious symptoms and anemia are found during the follow-up period, surgical treatment should be considered.

　　2. Myomectomy

　　It is mainly suitable for patients under 45 years old, especially those under 40 years old, who wish to preserve their fertility. Myomectomy can be performed for subserosal, intramural, and even submucosal myomas, and the uterus can be preserved. Submucosal myomas can be removed through hysteroscopy surgery, which causes less pain to the patient and has a faster postoperative recovery, and can even be performed on an outpatient basis. Pedunculated submucosal myomas that have prolapsed into the vagina can be removed vaginally. Subserosal and intramural myomas can be removed through minimally invasive laparoscopic myomectomy.

　　3. Total hysterectomy

　　For patients with myoma of the uterus, who are older, have obvious symptoms, and have no desire for further childbearing, total hysterectomy should be performed. For patients around 50 years old, one or both normal ovaries can be preserved to maintain their endocrine function. Total hysterectomy surgery can be performed via laparoscopy, transvaginal or laparotomy. Laparoscopic or transvaginal surgery causes less trauma to the patient, has a faster recovery, almost no scars, a short hospital stay, and is the current trend in gynecological surgery development.

　　1, Ultrasound examination

　　It is currently a commonly used auxiliary diagnostic method. It can show the enlargement of the uterus, irregular shape, the number, location, size of fibroids, and whether the internal fibroids are uniform or liquefied, cystic degeneration, etc. Ultrasound examination is not only helpful for the diagnosis of fibroids but also provides reference for distinguishing whether fibroids have degenerated, and it is also helpful for distinguishing fibroids from ovarian tumors or other pelvic masses.

　　2, Diagnostic curettage

　　By using a uterine sound, the size and direction of the uterine cavity can be detected, the uterine cavity shape can be felt, and whether there are masses in the uterine cavity and their location can be understood. At the same time, endometrial tissue is scraped for pathological examination to exclude endometrial hyperplasia or other endometrial lesions.

　　3, Hysteroscopy

　　Under hysteroscopy, the uterine cavity shape can be directly observed, whether there are any hyperplastic tissues, which is helpful for the diagnosis of submucosal fibroids.

　　4, Laparoscopic examination

　　When it is necessary to distinguish between fibroids and ovarian tumors or other pelvic masses, laparoscopic examination can be performed to directly observe the size, shape, growth site, and nature of the uterus.

　　5, Radiological examination

　　Uterine salpingography with iodine oil can assist in the diagnosis of submucosal uterine fibroids. In patients with fibroids, the contrast film shows a filling defect in the uterine cavity. CT and MRI are also helpful for the diagnosis of fibroids, but generally it is not necessary to use these two examinations.

　　First, dietary treatment for pregnancy with uterine fibroids

　　4, Silver ear lotus root starch soup, silver ear 25 grams, lotus root starch 10 grams, an appropriate amount of rock sugar, boil the silver ear with an appropriate amount of rock sugar until it is soft, add lotus root starch and serve. Take after the silver ear is soaked, add an appropriate amount of rock sugar and simmer until soft, then add lotus root starch and serve.

　　5, Motherwort 50-100 grams, Chenpi 9 grams, 2 eggs, boil with an appropriate amount of water, remove the shell after the eggs are cooked, and boil for a moment more, eat the eggs and drink the soup. Take once a day before the menstrual period, and take several times consecutively.

　　6, Yuanhu, Aiye, Danggui each 9 grams, lean pork 60 grams, a little salt. Boil the first three ingredients in 3 bowls of water, then remove the dregs, add pork and cook, season with salt, and take it. Take one dose a day before the menstrual period, and take 5-6 doses consecutively.

　　Second, what is good for the body to eat when pregnant with uterine fibroids

　　1, Eat more five-grain and杂粮 such as corn, beans, etc.

　　2, Often eat nutritious dried fruit foods, such as peanuts, sesame seeds, melon seeds, etc.

　　3, Maintain low-fat diet, eat more lean meat, chicken, eggs, quail eggs, crucian carp, turtle, white fish, cabbage, asparagus, celery, spinach, cucumber, winter melon, mushrooms, tofu, kelp, seaweed, fruits, and other cool vegetables and fruits.

　　4, Patients after hysteromyoma surgery should eat nutritious and easily digestible foods for the uterine muscle. For the elderly and weak, the time to consume liquid and semi-liquid foods should be appropriately extended to facilitate digestion, such as lotus root starch, orange juice, etc., or choose lean meat or fresh fish soup, which can ensure nutrition and enhance appetite, and the patient will recover quickly.

　　5. Uterine fibroid patients can eat more sea vegetables such as nori, kelp, sea lettuce, and wakame, as sea vegetables contain the most minerals such as calcium, iron, sodium, magnesium, phosphorus, and iodine. Modern science believes that eating sea vegetables regularly can effectively regulate the acid-base balance of the blood, and avoid excessive consumption of alkaline elements (calcium, zinc) in the body due to acid neutralization.

　　3. Foods to avoid for gestational myoma of the uterus

　　1. The diet should be light, avoid eating foods that generate heat such as mutton, dog meat, shrimp, crab, eel, salted fish, and black fish.

　　2. Avoid spicy foods and drinks such as chili, Sichuan pepper, green onions, garlic, alcohol, and frozen foods.

　　3. Avoid eating hot, coagulating, and hormone-containing foods such as longan, red dates, ejiao, and royal jelly.

　　1. Before Treatment

　　It is necessary to have a detailed understanding of the symptoms and related contraindications of the disease.

　　Traditional Chinese Medicine treatment methods for gestational myoma of the uterus.

　　2. Traditional Chinese Medicine Treatment

　　1. Food Therapy 1

　　①Leonurus heterophyllus 50-100 grams, Citrus reticulata 9 grams, eggs 2 pieces, boil together with an appropriate amount of water, remove the shell after the eggs are cooked, boil for a while longer, eat the eggs and drink the soup. Once a day before the menstrual period, take for several times consecutively.

　　②Yuanhu, mugwort, Angelica sinensis each 9 grams, lean pork 60 grams, a little salt. Add water to the first three ingredients in 3 bowls, decoct to 1 bowl, remove the medicinal residue, then add pork and cook until done, season with salt and take it. One dose per day before the menstrual period, take for 5-6 doses.

　　2. Food Therapy 2

　　①Unhatched feathered chicken (duck) eggs 4 pieces, ginger 15 grams, 50 milliliters of yellow wine. First, remove the shell, feathers, and internal organs of the feathered chicken (duck) eggs, add yellow wine and ginger to cook together, season after cooking, and take it. One dose per day before the menstrual period, take for several days consecutively.

　　②Loofah seeds 9 grams, brown sugar to taste, a little yellow wine. Dry the loofah seeds, decoct the juice, add yellow wine and brown sugar for administration. Take once a day before the menstrual period, for 3-5 consecutive days.

　　3. Food Therapy 3

　　①Atractylodes macrocephala 250 grams, Atractylodes 250 grams, Poria 250 grams, ginger 150 grams, jujube 100 pieces. The first three ingredients are washed, dried, and finely ground and sieved, the kernel of the jujube is removed, and the ginger is ground into a paste and the ginger渣 is discarded. The ginger and jujube paste is mixed with the medicinal powder to make a paste, preserved and stored for later use. Take 30 grams in the morning and evening, with rice wine for administration.

　　②Coix seed 30 grams, old loofah (fresh) 30 grams, decocted to extract the juice, add a little brown sugar for seasoning and take it, one dose per day, take for 5 consecutive days.

　　2. Acupuncture Treatment

　　1. Body Acupuncture (one of them)

　　Acupoint selection

　　Main Points: Uterus, Qugu, Yongqu.

　　Auxiliary Points: Subcortex (ear acupoint), Sanyinjiao, Xuehai, Shenshu, Fuliu.

　　Treatment Method: Main acupoints are taken 1-2 times each time, which can be alternated and supplemented with auxiliary points. The uterus acupoint is obliquely inserted 0.8-1.0 cun, the Qugu and Yongqu points are perpendicularly inserted 0.6-0.8 cun, with the degree of qi as the criterion, applying the method of balanced supplementation and drainage. For auxiliary points, except for ear acupoints using needle insertion or magnetic bead application, the techniques for the rest of the points are the same as the main points. Body points are taken bilaterally, and ear points are alternated unilaterally. The needle is retained for 15-20 minutes. Acupuncture is performed every other day, with 10 sessions as one course. Ear acupoints are needle inserted or applied with magnetic beads twice a week, with 15 sessions as one course.

　　Efficacy evaluation: Criteria for efficacy evaluation: Cure: Ultrasound examination shows that the uterine fibroids have completely disappeared; Basic cure: The volume of the uterine fibroids has decreased by more than 2/3; Effective: The volume of the uterine fibroids has decreased by less than 2/3; Ineffective: There is no decrease in volume before and after treatment.

　　A total of 346 cases were treated, with 288 cases cured (83.2%), 39 cases with basic cure (11.3%), and 19 cases effective (5.5%), with an overall effective rate of 100%. Among the treated uterine fibroids, the largest was as big as a child's head, and the smallest was as big as an egg yolk.

　　2. Body needle (second part)

　　Acupoint selection

　　Main acupoints: Ashi point, Neiguan, and Zhaohai.

　　Location of Ashi point: Tumor mass.

　　Treatment method: All the above acupoints are taken, and body acupoints are selected bilaterally. First, let the patient empty their urine, needle the Ashi point with 3-4 needles, directly inserted 0.6-0.8 inches; Neiguan and Zhaohai are treated with routine needle techniques, using the method of balancing supplementation and draining, needles retained for 15-30 minutes, once every other day, with 7 sessions as one course. Rest for 5 days between courses.

　　Efficacy evaluation: A total of 20 cases were treated, resulting in 15 cases cured, 3 cases showing significant improvement, and 2 cases effective, with an overall effective rate of 100%.

　　3. Electroacupuncture

　　Acupoint selection

　　Main acupoints: Guanyuan, Uterus, and Zhibian.

　　Auxiliary acupoints: Qihai, Xuehai, Yanglingquan, and San Yin Jiao.

　　Treatment method: Local disinfection of the acupoint, inserting a 2-inch 32-gauge filiform needle directly into the acupoint. After obtaining the Qi, connect the electric acupoint instrument, continuous wave, output frequency of 70Hz, stimulating for 10 minutes each time, once a day, with 15 sessions as one course. Rest for 7 days between courses.

　　Efficacy evaluation: A total of 42 cases were treated using the above method, resulting in 33 cases cured, 9 cases effective, with an efficacy rate of 100%.

　　4. Fire needle

　　Acupoint selection

　　Main acupoints: Zhongji, Guanyuan, Shuidao, Guilai, and Pishen.

　　Auxiliary acupoints: Quchi, Hegu, Zusanli, and Ren俞.

　　Treatment method: Ren俞 acupoint and auxiliary acupoints are treated with fire needles, while the rest are treated with filiform needles. The main acupoints are always taken, and the auxiliary acupoints are added appropriately. Fire needles are 2 inches long and 0.8mm in diameter, made of tungsten-manganese alloy. The needle tip is heated for about 5 seconds at a distance of 1cm from the flame of an alcohol lamp, with the front 3cm of the needle body showing bright red. The needle is quickly inserted into the acupoint and quickly withdrawn, and the entire process should be completed within 1 second. The needle insertion depth: abdominal acupoints are 3cm, Ren俞 and Pishen are 1.5cm. Abdominal acupoints can be supplemented with warm moxibustion for 15 minutes. The auxiliary acupoints of Zhaohai and Zusanli are treated with lifting-thrusting and twisting supplementation, while the rest are treated with draining, needles retained for 15-20 minutes. Treatment is given 3 times a week, with 12 sessions as one course, usually requiring three courses.

　　Efficacy evaluation: A total of 50 cases were treated, with 7 cases cured, 18 cases showing significant improvement, 17 cases effective, and 8 cases ineffective, with an overall effective rate of 84%. Western medical treatment methods for uterine fibroids during pregnancy

　　3. Treatment methods for uterine fibroids

　　The treatment must take into account the patient's age, reproductive requirements, symptoms, the size and location of the myoma, and growth rate, among other factors. The treatment can be summarized as follows:

　　1. Follow-up observation

　　For fibroids that are small, asymptomatic, without complications, and without degeneration, there is no impact on health. For perimenopausal patients without clinical symptoms, considering the decline in ovarian function after menopause, fibroids will stop growing. In these cases, expectant management can be adopted, with regular follow-up observations generally once every 3 to 6 months, and the treatment will be decided based on the findings of the re-examination.

　　2. Drug therapy

　　Fibroids are hormone-dependent tumors, and estrogen and progesterone can promote the growth of fibroids. Based on this theory, by applying a mechanism that inhibits the secretion or action of ovarian steroid hormones, fibroids can be shrunk, achieving the goal of alleviating symptoms. However, this therapeutic effect is temporary and cannot cure uterine fibroids, so it cannot be used as the main method of treating uterine fibroids. The main indications for drug treatment of uterine fibroids are: ① Young patients who need to retain the uterus but have large fibroids, where the fibroids can be reduced after taking the drug, facilitating myomectomy surgery. ② Patients with infertility caused by uterine fibroids, where the fibroids can be reduced after taking the drug, delaying surgery, improving fertility conditions, and increasing the chance of pregnancy. ③ Patients with large uterine fibroids and severe anemia who are not suitable for surgery temporarily, where preoperative medication can improve symptoms and correct severe anemia, reducing blood loss during surgery. ④ Patients with high-risk factors or those with significant risks for surgery.

　　Currently, commonly used drugs include:

　　(1) Gonadotropin-releasing hormone agonists (GnRH-a): Currently, commonly used GnRH-a in clinical practice includes leuprolide acetate (Intron-A), goserelin (Zoladex), and triptorelin (Degan).

　　The continuous and high-dose application of this class of drugs can inhibit the function of the gonadotropin axis, rapidly decrease the levels of serum urinary gonadotropin (follicle-stimulating hormone) (FSH), luteinizing hormone (LH), and estrogen (E2) through down-regulation, with E2 reaching the level of postmenopausal women, causing amenorrhea, thereby inhibiting the growth of uterine fibroids and making them shrink, achieving the therapeutic goal. This class of drugs is a long-acting preparation, with leuprolide acetate (Intron-A) 3.75mg/ampoule, administered subcutaneously once every 4 weeks; goserelin (Zoladex) 3.6mg/ampoule, implanted subcutaneously once every 4 weeks; and degarelin (Degan) 3.75mg/ampoule, administered subcutaneously once every 4 weeks. After 3 to 6 months of treatment, the volume of uterine fibroids can be reduced by more than 50%. After stopping the drug for about 4 months, the fibroids may grow again as the level of sex hormones in the body recovers. Currently, such drugs are mainly used for: ① Using the drug before surgery to alleviate symptoms and improve anemia; ② Using the drug to shrink fibroids before surgery to facilitate surgical resection or vaginal surgery or endoscopic surgery; ③ For patients with infertility caused by uterine fibroids, using the drug before pregnancy to shrink the fibroids and facilitate natural pregnancy; ④ For near-menopausal patients with symptoms who do not want to undergo surgery.

　　After the use of GnRH-a, symptoms similar to menopausal syndrome such as hot flashes and night sweats may occur due to the decrease in estrogen levels, as well as a decrease in bone mineral content. Therefore, GnRH-a should not be used for a long time, generally for 3 to 6 months. Some scholars propose that adding a small dose of estrogen (or progesterone) after 3 months of using GnRH-a (i.e., reverse add-back therapy) can effectively control symptoms and reduce such side effects.

　　(2) Mifepristone: It is a derivative of 19-demethyldihydrotestosterone, with strong antipregesterone and antiglucocorticoid effects. It is an anti-early pregnancy drug. In recent years, it has been clinically tested for the treatment of fibroids, and its possible mechanism of action may be:

　　① Antipregnancy hormone (P) action, so that the level of P in the body decreases, inhibiting the growth of fibroids.

　　② Inhibit the transcription and translation process of PR gene, so that the content of PR in the target tissue decreases, causing the fibroid to shrink.

　　③ Inhibit the expression of mRNA of the epidermal growth factor of fibroid cells. The common method is to start taking mifepristone from the second day of the menstrual cycle, 10-25mg/d, for 6 months continuously. After taking the medicine, FSH, LH, E2, and P are all lower than before taking the medicine, causing amenorrhea, and a few patients may have irregular vaginal bleeding. After taking the medicine continuously for 6 months, the volume of the fibroid can be significantly reduced, and the menstrual period can be restored after discontinuation of the medicine for 1 month. After a certain period of time, the fibroid may grow larger again. At present, the mechanism of action, dosage, and efficacy of this drug in the treatment of fibroids are still under exploration.

　　(3) Danazol: Danazol is a derivative of 17α-ethynyltestosterone, which directly acts on the hypothalamus and pituitary through receptors, inhibits the release of GnRH and gonadotropins, and has weak androgenic, anti-E, and anti-P effects, causing fibroids to shrink and thus alleviate clinical symptoms. The usual dose is 400-800mg/d, for 3-6 months as one course of treatment. It can be used for preoperative medication or treatment of fibroids that are not suitable for surgery. Similarly, fibroids may grow larger after discontinuation of medication. Some patients may have irregular vaginal bleeding during the course of treatment. Danazol can cause liver function damage, and if liver function is not normal, the medication should be discontinued. In addition, there may be side effects caused by androgens (weight gain, acne, hoarse voice, etc.).

　　(4) Tamoxifen (Triphenoxamine): Tamoxifen (Triphenoxamine) is a non-steroidal anti-estrogen drug that competitively binds to ER in the cytoplasm of target cells, interferes with cell biological metabolism, inhibits tumor cell growth, significantly reduces serum E concentration, and inhibits the growth of fibroids. However, tamoxifen (Triphenoxamine) also has a weak estrogenic effect, and prolonged use may cause fibroids to increase in some patients, even induce endometriosis and endometrial cancer, which should be noted. The usual dose is 10mg, twice daily orally, for 3 months as one course of treatment.

　　(5) Androgenic drugs: Common androgenic drugs include methyltestosterone (methyltestosterone) and testosterone propionate (testosterone propionate). These drugs can counteract the effect of E, causing the endometrium to atrophy, and can also directly act on the uterus to cause the contraction of the myometrium and vascular smooth muscle, thereby reducing uterine bleeding and stopping the growth of fibroids. The usual dose is methyltestosterone (methyltestosterone) 10mg/d, sublingual administration, for 3 months continuously; testosterone propionate 25mg, injected intramuscularly once every 5 days, a total of 4 times, 1 time/d during the menstrual period, a total of 3 times, not exceeding 300mg per month, and can be used for 3 to 6 months. Generally, masculinization will not occur.

　　During the bleeding period in patients with fibroids, if there is a large amount of bleeding, uterine contractility agents (such as oxytocin, ergot) and hemostatic drugs (such as aminocaproic acid, tranexamic acid (tranexamic acid), Lepidium meyenii, and Sanqi tablets, etc.) can also be used. It should be noted that fibroid patients may have associated endometrial lesions, which should be excluded.

　　4. Surgical treatment

　　The surgical treatment of fibroids includes fibroid resection and hysterectomy, which can be performed via laparotomy, vaginal approach, or endoscopic surgery (hysteroscopy or laparoscopy). With the development of endoscopic technology, many laparotomy fibroid resections and hysterectomies have gradually been replaced by laparoscopic surgery. The choice of surgical method and approach depends on factors such as the patient's age, whether there is a desire for childbearing, the size and growth location of the fibroid, and technical conditions.

　　1. Fibroid resection

　　It is a surgical procedure to remove fibroids while preserving the uterus, mainly used for young women under 40 years old who wish to preserve their fertility. It is suitable for large fibroids; excessive menstrual bleeding that is not responsive to medication; symptoms of compression; infertility caused by fibroids; submucosal fibroids; fibroids that grow rapidly but do not show malignancy. According to literature reports, the pregnancy rate after fibroid resection is 30% to 60%. Contraception for 1 to 2 years after surgery can allow for conception.

　　2. Laparoscopic fibroid resection

　　It is suitable for subserosal fibroids, single or multiple intramural fibroids, but it is better not to preserve the uterus to prevent postoperative recurrence when there are too many fibroids. To prevent postoperative adhesions in the abdominal cavity, the incision on the uterus should be on the anterior wall as much as possible, and the uterus should be incised as little as possible. In each incision, as much fibroid as possible should be removed, and it should also be avoided to penetrate the endometrium. Carefully examine the resected fibroids and send them for frozen section examination to rule out malignancy. Hemostasis should be thorough, leaving no dead space, and avoid injury to the interstitial part of the fallopian tube, striving to achieve peritonealization of the uterine incision.

　　The main risk of fibroid resection is bleeding, and subsequent pregnancy requires caution for uterine rupture and placenta accreta. Elective cesarean section is recommended at term pregnancy.

　　3. Vaginal fibroid resection

　　Submucosal fibroids that have prolapsed through the cervical os can be removed vaginally. Submucosal fibroids located within the uterine cavity can be removed through hysteroscopic surgery.

　　4. Hysterectomy

　　Multiple fibroids, larger than 2.5 months of pregnancy, with obvious symptoms that are not responsive to medication, fibroids with a possibility of malignancy, no desire for childbearing, should undergo hysterectomy. Hysterectomy can be chosen between total hysterectomy or vaginal supracervical hysterectomy. For older patients, especially those with severe cervical hypertrophy, laceration, or erosion, total hysterectomy is recommended. Before performing a supracervical hysterectomy, the possibility of cervical malignant disease must be ruled out. Hysterectomy can be performed via laparotomy, vaginal approach, or laparoscopy, depending on the size of the fibroid and technical conditions. Broad ligament fibroids, cervical fibroids, and retroperitoneal fibroids are closely related to the ureter, and surgery can be challenging, with laparotomy being preferable.

　　The age for ovarian preservation is generally considered to be 50 years, and those under 50 years of age who can preserve their ovaries should be preserved as much as possible. If both ovaries can be preserved, it is better to preserve both sides than to preserve only one side.

　　5. Uterine Artery Embolization

　　In 1995, Ravina of France first reported the use of uterine artery embolization (uterine arterialembolization, UAE) to treat uterine fibroids. Since then, there have been successive reports on this. In recent years, many units in China have also begun to explore the use of UAE to treat uterine fibroids. By means of interventional radiology, the artery catheter is directly inserted into the uterine artery, and permanent embolic particles are injected to block the blood supply of the uterine fibroids, thereby achieving the shrinkage or even disappearance of the fibroids. It is reported that the recent effective rate can reach 80% to 90%, and the average reduction in fibroid volume is about 50%. UAE for the treatment of uterine fibroids is currently still in the exploration stage, and the long-term efficacy and its impact on ovarian function still need to be observed through a large amount of clinical follow-up. Therefore, caution should be exercised when choosing interventional treatment for uterine fibroids, especially for those with uncontrolled pelvic inflammation, those who hope to preserve fertility, patients with arteriosclerosis, and those with contraindications to angiography, who should be listed as contraindications to this treatment.

　　6. Cesarean Section

　　For uterine fibroids associated with the following one or more conditions, cesarean section should be considered.

　　(1) The placenta is implanted on the surface of the fibroid, which may cause postpartum hemorrhage.

　　(2) Uterine fibroids below the lower segment of the uterus or the cervix can block the birth canal or be accompanied by placenta previa and malpresentation.

　　(3) Had undergone a myomectomy or had a long history of infertility and eagerly desired a child.

　　For conditions other than the above, vaginal delivery can be tried. During the delivery period, it is necessary to closely observe uterine contractions and the progress of labor, especially to be vigilant about placental accreta and postpartum hemorrhage caused by poor uterine contractions.