Uterine myomas are benign tumors originating from the muscular and connective tissues of the uterus. It can also be called fibromioma, leiomyoma, fibroid, considering its histological structure. It is the most common pelvic tumor. Uterine fibroids develop in 20-25% of women.
It has been observed that it takes about 3 years for a fibroid nucleus to reach its orange size. It is known that myoma shrinks in menopause; however, about 10% of the fibroids continue to grow.
Sometimes it appears that the muscle and connective tissue in the wall of the uterus grows with the entire uterus due to diffuse hyperplasia. This condition is called “myometrial hypertrophy” or chronic subinvolution. No fibroid nuclei are found here. It usually occurs in multipara (women who have given more than one birth); however, it is rarely seen in nulliparas (also in women who have not given birth).
Although the exact cause is not known, it is thought to develop as a result of exposure of myomas to excessive estrogen. Pathological conditions known to be estrogen-dependent, such as endometrial hyperplasia, endometriosis and endometrial cancer, are known to occur more frequently in women with myomas. Growth trends during pregnancy and reduction of fibroids by GnRH antagonists also suggest the effect of estrogen. However, a direct and precise relationship has not been established between fibroids and estrogen.
Myomas are usually massive (multiple), distinct, spherical or irregular masses. A structure consisting of intertwined smooth muscle bundles of different size and developing in different directions is observed by microscopic examination. Connective tissue is among the smooth muscle fibers. A false capsule formed by myometrium fibers is observed around the tumor. Myom is separated from the surrounding tissues with a sharp border with this capsule. Tumor feeding occurs through small veins that go through the capsule and penetrate into the myoma through the fibers, penetrating in places. These veins originate from 1-2 large veins located in the pedicle (stem) of the fibroids.
Myomas take different names according to their settlements.
- Submucous Myoma
- Intramural (interstitial) fibroids
- Subserous Myoma
Submucous Myoma: Immediately (the inner lining of the uterus) emerges from the muscle tissue under the endometrium and grow into the inner cavity of the uterus. They can even come out of the cervical (cervical) canal by forming a pedicle (stem) (fibroid born vagina). Such stem myomas can turn around themselves and become torsioned, and infection can easily develop. Since these types of fibroids make pregnancy difficult or even prevent it, they are myomas that must be removed.
Intramural myomas: They develop in the middle layer within the wall of the uterus. They can be of various sizes. It can enlarge the uterus by making small and large humps (potato sack view) and subserosal myomas may be added (uterine myomatosis). Sometimes one or more myomas enlarge the uterus properly and completely. In the German literature, this is called "Kugel myom."
Subserosal myomas: These are myomas that come out just below the serosa, the outer layer of the uterus. (Abdominal) They grow on the outer surface of the uterus towards the abdominal cavity. They may be seated with a handle or a wide base. Myomas with stems can fall into the abdominal cavity by turning the stem around itself and torsioning. If they can stick to the omentum and feed them, they continue to develop here and are called parasitic myoma. Sometimes these fibroids in the abdominal cavity are replaced. Subseous myoma is called intraligamentary myoma if the ligamentum has grown between the two leaves of the latum.
How does myoma manifest?
Most fibroids do not produce symptoms. Myomas without symptoms are small ones. Sometimes, subserous myomas do not show any symptoms even though they grow to an advanced degree. In such myomas, patients realize that their abdomen is growing and apply to the physician.
Generally, patients present with complaints such as vaginal bleeding, pain, frequent urination, feeling of pressure in the lower abdomen and meteorism (excessive intestinal gas) or complaints such as infertility (infertility).
The most important symptom in myomas is bleeding. Its characteristic feature is its menorrhagia (excessive amount of menstrual bleeding). However, metroragy (irregular bleeding) can also be seen. In submucous myomas, fibroids hanging in the inner cavity of the uterus are perceived as foreign bodies, causing irregular uterus contractions, bleeding and pain occur. In submucous fibroids, they cause more bleeding in the form of menometroragy, i.e. irregular and abundant bleeding, while intramural fibroids cause more bleeding in the form of menorrhagia, hypermenorrhea (the amount of bleeding and day increased). Anemia may develop due to chronic blood loss.
Causes of bleeding in fibroids:
- Enlargement of the endometrial cavity and increased bleeding surface,
- Increased vascularity of the uterus,
- Endometrial hyperplasia accompanied frequently (can be found at a rate of 50%),
- Myoma prevents the contraction of the uterus and the vessels can not be closed,
- Submucous myoma causing ulcers in the adjacent endometrium,
- It is because of the shape changes that occur as a result of compression of the adjacent endometrium, this region endometrium is not able to adapt to menstrual cyclic changes and causes irregular bleeding.
When investigating the cause of bleeding in women with myoma, endometrium biopsy must be performed.
Pain in myomas is not very common. If myoma (pedicled) is stems and submucous, they cause uterine contractions and cause pain. This pain is usually in the form of cramps during menstruation. In addition, if the pedicle is torsioned or the fibroids are infected, pain will occur, similar to labor or a sudden knife can cause stinging pain. There may be occasional pain independent of menstrual bleeding, but this is extremely rare.
Highly enlarged fibroids can put pressure on the pelvic nerves, causing pain on the waist and legs. Sometimes the cause of pain is other lesions that accompany myoma (eg endometriosis).
3. Abdominal distention and pressure related findings;
The person feels fullness in the pelvis (groin). Sometimes large fibroids cause urine complaints by pressing the bladder. They can lead to constipation, gas and painful deformation (defecation) by pressing on the rectum (the last part of the intestine), and hydroureteronephrosis as a result of the urinary incompletion of urine by pressing the urinary tract.
Myomas can prevent sperm transmission and thus conception (fertilization) by pressing the tubes. If fertilization has taken place, it may also prevent implantation (adhesion of the embryo) by disrupting the surface of the endometrium. As myomas grow, they may cause abortion (miscarriage) by making shape and circulation disorders in the uterus. In the absence of room for the baby due to fibroids, it can lead to preterm labor and placental adhesion abnormalities may occur. It may affect the fetus's entry into the birth tract during pregnancy and cause difficult births. In the presence of fibroids obstructing the birth canal, cesarean is the only form of delivery. Following birth, it can prevent the uterus from contracting and recovering regularly.
During the gynecological examination, information about the number, size and localization (location) of fibroids is obtained. Today, ultrasonography is the most widely used method in the diagnosis of fibroids. Anesthesia examination is recommended in obese patients with difficulty in diagnosis and virgo (virgin) women. Diagnostic hysteroscopy is the most reliable method especially in the diagnosis of submucous myomas. It can be performed without the need for anesthesia, even without the need for instruments used for examination. Laparoscopy is the most reliable method in the definitive diagnosis of myomas.
Ovarian tumors and subserosal fibroids can be mixed by inexperienced individuals. In addition, initial ovarian cancers stuck in the uterus can be mistakenly diagnosed as fibroids. Normal pregnancy, adnexal mass, adenomyosis, uterine anomalies, adjacent organ tumors, pelvic kidney, myometrial hypertrophy and other causes that cause vaginal bleeding should be distinguished from myomas.
- Torsion: Myomas with stems turn around and get stuck and the bleeding is impaired. When fibroids are torsioned, blood circulation is blocked and leaks out of the vein. Peritoneal irritation occurs. Sometimes fibroids fall into the omentum and feed from there (parasitic fibroids).
- Infection: Submucous fibroids can ulcerate and become infected.
- Maling change (cancer formation): Less than 0.5% of cases return to leiomyosarcoma. If the fibroid is growing rapidly, pain and fever occur, malignancy should be suspected.
- Degeneration: Disruption of cell structure in fibroids, the cause of degeneration is nutritional deficiency of fibroids. Degenerate becomes myomageous, delicate soft and larger. Degenerative changes can be listed as follows;
- Atrophy: Myoma shrinks after menopause or sometimes after pregnancy. Microscopic fibroid appearance disappears. It disappears in parallel with the clinical symptoms.
- Hyaline degeneration: It is the most common fibroid degeneration. Yellow-white areas are seen in myoma.
- Cystic degeneration: Cystic cavities occur in fibroids.
- Calcification: Occurs especially in subseous myoma. The reason is again malnutrition.
- Calcium carbonate and calcium phosphate settle in the tissue.
- Septic degeneration: As a result of nutritional deficiency, necrosis and infection subsequently develop in the middle of fibroids. Pain is fever and tenderness.
- Red degeneration (carcinous degeneration): This type of degeneration is specific to pregnancy and postpartum period. In the second trimester, fibroids grow acutely and become painful. There is vomiting, weakness and fever. The reason is subacute necrosis, which develops as a result of nutritional deficiency. Venous thromboses, interstitial bleeding and hemolysis hemoglobin, which give the tissue red color. It is self-limiting and does not require special intervention. Rest and analgesics are sufficient.
- Acid (Pseudo Meigs syndrome): It is rare, it usually develops as a pedicular subseous myoma performs peritoneal irritation.
- Bleeding, Mixomatous (oily) degeneration, Inversion are rare complications.
Pregnancy And Myoma
It is accepted that the fibroids grow during pregnancy. The edema that occurs in the fibroid tissue that causes the growth of fibroids in pregnancy is congestion and bleeding of the fibroid in degenerate. The most common degeneration in pregnant women is red degeneration. Degeneration in pregnant usually occurs in the 2nd and 3rd trimesters. Severe pains and tenderness in the uterus occur. It is treated by giving bed rest and analgesics.
Surgical treatment is not preferred; because myomectomy in pregnant women can lead to excessive bleeding. If myomectomy is to be performed in a pregnant woman, it is recommended to do it 3 months after birth, so that the vascularity of the uterus decreases and its dimensions decrease, the risk of complications decreases.
Myomas can be the cause of infertility. However, in order to say that fibroids are the cause of infertility, other causes of infertility must be investigated and found to be completely normal.
After myomectomy in women with myomas, 40% pregnancy can be achieved. Miscarriages, premature birth, intrauterine fetal death, premature rupture of membranes (early water intake), extremity anomalies and anomalies of the baby's birth canal are more common. The causes of miscarriages are impaired uterine blood flow, uterine contractions, insufficient embryo adhesion area and decreased widening feature of the uterus. The relationship between the localization of the myoma and the adhesion of the embryo is important. If the conception is on myoma, the complication rate increases to 75%.
In addition, if the placenta is above the submucous myoma, it may be difficult to separate it, which may require manual placenta removal or a hysterectomy. The risk of postpartum hemorrhage also increases due to placental adhesion anomalies and fibroids impair the ability of the uterus to contract. If there is no other problem to prevent normal birth in women with myoma, spontaneous vaginal delivery should be preferred. In pregnant women who had undergone myomectomy, it would be more appropriate to have a cesarean section due to the weakness and tear of the uterus wall, the location of the fibroid in the uterine cavity during the operation. it is decisive in the cesarean decision.
The form of myoma treatment is affected by factors such as the patient's age and child expectation, socioeconomic status, general health status, anemia due to chronic blood loss, localization and size of fibroids. In treatment, first of all, the general health of the patient should be improved and if necessary, treatment of anemia, which develops due to chronic blood loss, with blood transfusions.
In the treatment, the following methods are applied:
1. Follow-up with periodic examinations:
Very small (hazelnut-sized) fibroids of reproductive age are followed up every 3-6 months without any intervention until the age of 40. The aim is to avoid attempts that may damage the uterus in terms of fertility if small fibroids do not grow. Myomas, which are slightly larger in the premenopausal period, may be followed up with periodic examinations, considering that they will disappear spontaneously when they enter menopause. No surgical intervention is performed in fibroids that do not grow during follow-up or whose size has not reached 10-12 weeks of gestation or do not complain.
2. Medical treatment:
Danazol and progestins can be used in the medical treatment of myoma, but its benefits should be discussed. These drugs are present in endometrial hyperplasia, endometriosis, functional cyste etc. A palliative treatment is provided by controlling fibroid growth in patients with complaints such as. However, when GnRH antagonists, which have been used in recent years, are used for a period of 6-12 months, it reduces the fibroid mass as well as complaints and an effective treatment can be provided. There are also those who prefer to decrease the tumor volume by using it for a while before the operation in large fibroids and then do the operation. However, it is an expensive treatment method and in myomectomies following the use of GnRH anatagonists, surgical removal (enucleation) of the fibroid nuclei is more difficult due to the deterioration of the pseudo capsule of the fibroid. Any use of estrogen-containing preparations should be avoided.
3. Surgical treatment:
- Curettage: It is necessary to make a differential diagnosis of bleeding in the patient with complaints, it should be kept in mind that endometrial cancer and precancerous lesions of the endometrium are more common in women with myoma.
- Myomectomy-hysterectomy: Surgical treatment should be performed in myomas, which have been found to grow rapidly during periodic follow-up, cause bleeding that does not respond to medical treatment, have reached the size of 10 gestational weeks or were born in a vagina with a pedicle. Myocectomy should be performed when it reaches 3-4 cm in cervical fibroids, and it may be difficult to remove when it grows larger. Myomectomy is recommended for healthy women under the age of 40 and with an expectation of children. Total hysterectomy (removal of the uterus) is recommended in women over 40 years of age. Considering that the average age of menopause is around 46.5 in our country, it will be correct to remove the ovaries in women over 45. Myomas born into the vagina can be easily removed by twisting the pedicles through the vaginal route. In cases of uterine fibroids and uterine prolapse, vaginally hysterectomy can be performed. Thus, it is performed in the plastic surgery of the vagina in the same session. It is possible to remove submucous myomas with the help of hysteroscopy, which has been widely used in recent years.
- Radiotherapy: It is a very rarely used treatment method today. External beam therapy is applied with cobalt. Its purpose is to eliminate ovarian function and put it into menopause especially in patients who have bleeding complaints and cannot be operated due to the high risk of surgery. With this treatment, hemorrhage is stopped first and then there is a shrinkage with atrophy in fibroids.
- Dyspnea peritoneal leiomyomatosis: It is a rare condition in nonneoplastic characters originating from smooth muscle cells in the peritoneal connective tissue and developing multifocal. It is common in pregnancy. It is accepted that the decidual reaction occurring in the peritoneum during pregnancy stimulates metaplasia in myofibroblasts. It regresses spontaneously after birth.
- Intravenous leiomyomatosis: It is a tumor that grows in venous vessels and develops from smooth muscle cells. It is considered to originate directly from smooth muscle cells in the vascular wall or to spread the uterine fibroid through the vein. Its treatment is surgery.
- Benign metastasis fibroids: It is considered as metastasis of uterine fibroids. It is very rare and is considered to be dependent on estrogen. It may regress spontaneously after pregnancy.
- Lymphangioleiomyomatosis: It is a fibroid that develops from smooth muscle cells along the lymph vessels. It is dependent on estrogen. Its treatment is surgery.