MYOMA (Myoma)

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Myoma is the name given to the most common benign tumors that originate from the smooth muscles of the uterus and are seen in female organs. It is seen in 40-50% of women, most commonly between the ages of 30-40. It is not seen before puberty.

It causes a wide variety of complaints and symptoms depending on the region where it develops and its size. For example, while a very large myoma located outside the uterus may not cause any complaints, a very small myoma located inside the uterus may cause life-threatening bleeding. Excessive menstrual bleeding is the most common complaint in fibroids. It can also cause painful menstruation, frequent urination by putting pressure on neighboring organs, kidney enlargement (hydronephrosis) by putting pressure on the lower urinary tract (ureters), constipation, lower abdominal and waist pain, pain during sexual intercourse, infertility, recurrent pregnancy losses and abdominal bloating. Giant fibroids that grow to fill the entire lower abdomen can block bilateral urinary tracts and cause kidney decay. Fibroids can grow rapidly during pregnancy.

Myomas are given various names depending on their location in the uterus. Myomas that grow towards the outer wall of the uterus are called "subserous myomas". These do not cause bleeding, and even if they reach very large sizes, they do not cause any significant complaints. Myomas located in the uterine wall are called "intramural myomas" and most often cause excessive menstrual bleeding and painful menstrual complaints. Those located in the uterine cavity are called "intracavitary myomas", and those located just under the inner lining of the uterus are called "submucous myomas". Although the fibroids in this last group are large in size, they can cause very severe complaints (painful menstruation and excessive menstrual bleeding). Sometimes myomas originating from the uterine cavity can come out of the cervix over time.

sex hormones

Myomas grow under the influence of sex hormones. The proof of this is that they do not appear before puberty, they shrink after menopause, they carry sex hormone receptors (estrogen and progesterone receptors), and they usually grow during pregnancy, when sex hormones are very high. There are also genetic effects in the appearance of myomas. Approximately 40% of the first-degree female relatives of women with myomas have myomas.

Myomas can have a negative impact on fertility. Myomas, especially those located in the uterine cavity and under the uterine membrane, can disrupt the implantation of the embryo and cause infertility. In addition, some myomas cause blockage and enlargement of the ducts, causing infertility. These types of myomas must be removed by surgery. It is located on the uterine wall and is 4-5 cm long. Myomas larger than XNUMX cm can also negatively affect pregnancy. If there is no other underlying cause affecting pregnancy, such fibroids should be removed, especially if there is more than one. Myomas that grow outside the uterine wall do not affect pregnancy. Therefore, any surgery is not recommended.

The presence of myoma is very important during pregnancy. The risk of miscarriage is increased in women with myomas. Fibroids can grow rapidly during pregnancy and can cause premature separation of the baby's partner (placental abruption). Again, large myomas located close to the cervix can block the birth path and prevent normal birth. Sometimes they can even cover the cesarean section, making the cesarean section very difficult. Myomas that grow during pregnancy shrink rapidly after pregnancy. Removal of fibroids during cesarean section can lead to very dangerous bleeding. Therefore it is not recommended.

The delivery method of patients whose myomas located in the uterine wall were removed before pregnancy should be by cesarean section. Because there is a risk of uterine rupture in the normal birth of these patients. However, patients whose myomas located in the uterine cavity have been removed can have normal birth.

Does myoma become cancerous?

Approximately 60% of patients aged 70-1 who undergo surgery for myoma are diagnosed with cancer (leiomyosarcoma). Here, cancer of the myoma is out of the question. In the post-menopausal years, the sudden growth of previously known myomas should alert the physician.

How is myoma diagnosed?

It is not difficult to diagnose myoma. During gynecological examination, feeling that the uterus is larger than normal, has irregular borders, and has a hard structure raises suspicion. Very large myomas can even be felt through the abdominal wall. Myoma diagnosis is made by vaginal examination in married women and by abdominal ultrasonographic examination in virgins with a rate of 90%. In the diagnosis of myomas located in the uterus, ultrasonographic examination by injecting fluid into the uterus (sonohysterography), medicated film of the uterus (hysterosalpingography), and in the diagnosis of abnormally located myomas, computerized tomography and MRI can be used.

How is myoma treated?

In the treatment of patients whose complaints are not severe, medications can be tried first. Painkillers that inhibit prostaglandin synthesis and birth control pills containing low hormones can be used for this purpose.

Myomas that have reached large sizes or cause very severe complaints will need to be removed. The operation to be chosen here is determined by the patient's age and pregnancy expectation. While it is preferred to remove myomas in young patients, those who have completed their fertility and menopause Hysterectomy may be recommended for pregnant women. The patient's preferences determine the type of operation.

Main types of myoma removal:

1- With open surgery method: Classically, by opening the abdomen, all myomas in the uterus can be cleaned. No matter how many fibroids are in the uterus, these fibroids can be removed if desired, preserving the uterus.

Regardless of the patient's age and the number of myomas, every patient who requires surgery for myomas should be offered the option of removing the myomas without removing the uterus. Technically this is possible. Below are pictures of a surgery in which we preserved the fertility of a 39-year-old woman who had not given birth after removing 24 myomas.

a- Appearance of the uterus before surgery;

b- Picture of 10 myomas, the largest of which was 24 cm, removed by surgery;

c- Appearance of the uterus after surgery;

In such surgeries, some special techniques must be applied to prevent blood loss and excessive bleeding must be prevented during the operation.

2- Laparoscopy With the help of: Small myomas in the uterine cavity and the uterine wall cannot be removed with this method. It is generally preferred for stalked myomas that have grown outside the uterus. The safety of this method in women considering pregnancy is not clear.

3- With hysteroscopic resection: 4 cm in the uterine cavity. Myomas up to size can be removed this way.

4- Vaginal myoma removal: Myomas visible and hanging from the cervix can be removed without cutting the abdomen. For patients who prefer to have their uterus removed, this procedure can be done in three ways;

a- With open surgery method: The uterus is completely or partially removed.

b- With laparoscopic method: It can be applied by surgeons experienced in laparoscopy.

c- Vaginal hysterectomy surgery: In appropriate cases, it is the most traumatic surgery method for the patient.

Do myomas recur after removal?

After fibroids are removed, there is a 30% risk of recurrence until menopause. The recurrence rate in patients who have multiple myomas removed is higher than those who have a single myoma removed. This should be explained very clearly to patients.

Are there any non-surgical myoma shrinking methods?

Yes there is. These;

1- When we want to shrink the myoma temporarily (such as before the operation), drugs that cause pseudo-menopause (GnRH analogues) can be used. In this way, myoma sizes can be temporarily reduced by 40-50%.

2- Myomas can be reduced in size by blocking the vessels that supply blood to the uterus (uterine artery embolization).

3- Destruction of myoma (myolysis) by freezing or electric current.

4- The most recently developed method is the method of destroying myoma with high-intensity ultrasound waves accompanied by MRI.

The last two methods are not suitable for women who have not completed their fertility and want to have children.

Intrauterine devices (spirals) that secrete hormones (progesterone) have an important place in the non-surgical treatment of patients with small myomas and complaints of bleeding and painful menstruation. Because these types of intrauterine devices both correct bleeding problems and treat painful menstruation.