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Myoma, Diagnosis and Treatment

Aug 5, 2021 | Gynecology - IVF | 0 comments

What is myoma?

  • Fibroids are benign (benign, non-cancerous) tumoral structures that can be seen in the uterus and cervix and develop from smooth muscle tissue.
  • It is often described as a tumour.
  • They are defined by different names in the literature:
    • Leiomyoma, fibro myoma, myoma, leiomyofibroma, fibroleiomyoma and fibroid. It is most often called leiomyoma.
  • They vary in size from a pinhead to the size of a watermelon. They usually grow very slowly.
  • It could be just one, or it could be too many to count.
  • Each fibroid mass is called a fibroid nucleus. It usually tends to be more than one. Sometimes a single fibroid core can enlarge significantly and reach very large sizes. In such patients, there are probably other fibroid nuclei, even a few millimeters in diameter.
  • Its most important feature is that it is almost always benign and the probability of it turning into cancer is negligibly low.
  • 75% of patients are unaware that they even have fibroids. Its incidence is 20-25%.
  • It is known that this rate does not reflect the truth since their size is very variable, and if a careful examination is made, the incidence of uterine fibroids is higher.
  • Fibroids often occur between the ages of 30-40 and shrink after menopause in those who do not receive hormone therapy. It is extremely rare to be seen before puberty.

What are the Types of Fibroids?

Fibroids create different types of complaints depending on the region (localization) where they are located. For this reason, they are classified according to their location in the womb. A woman may have one or all of these four types of fibroids. It is common for women to have more than one type of fibroid, and it can be difficult to tell which fibroid is causing the symptoms. It would be appropriate for a woman with only one visible fibroid to consider having more than one fibroid when discussing treatment.

If you think you have fibroids or are experiencing any signs or symptoms of fibroids, please consult your doctor or an obstetrician as soon as possible to prevent any further complications causing your symptoms. Knowing the types of fibroids and understanding the symptoms will help you choose the right fibroid treatment.

1 – Submucosal Fibroids (in the inner layer of the uterus):

  • Fibroids are the least common type of fibroids. These types of fibroids form and develop in the layer just below the uterine cavity. Large submucosal fibroids can cause enlargement of the uterine cavity, causing obstruction of the cord tubes, and may cause some pregnancy-related complications.
  • Some Fibroids do not cause any symptoms, while others can be very severely symptomatic. Symptoms associated with submucosal fibroids include very heavy or excessive bleeding and prolonged menstrual cycles. These symptoms can cause a clotting problem and continuous bleeding, which can cause discomfort in daily life. Untreated, prolonged, or excessive bleeding can lead to larger and more complicated problems, such as fatigue or anemia, which may even require a blood transfusion later on.
  • Submucosal fibroids are the most common causes of problems such as bleeding and infertility.
  • Submucosal fibroids can sometimes grow further and hang from the cervix into the vagina, which are called vaginal fibroids. In these fibroids, ulceration (tissue loss) and discharge complaints occur and infection tendencies are higher. Sometimes they can cause very heavy bleeding.

2 – Intramural Fibroids (in the middle layer of the uterus):

  • Intramural Fibroids typically develop within the uterine wall and grow from that point.
  • These fibroids are among the most common among other types of fibroids.
  • When an intramural fibroid enlarges, it feels like the uterus is larger than normal, which can sometimes be confused with weight gain or pregnancy. Such fibroids can also lead to “multiple symptoms.”
  • Some of the symptoms that appear with intramural fibroids can lead to excessive menstrual bleeding leading to prolongation of menstrual cycles and pelvic pain resulting from additional pressure on surrounding organs due to coagulation problems and fibroid enlargement, resulting in frequent urination and pressure.

3 – Subserosal Fibroids (in the outer layer of the uterus):

  • They develop on the outside of the uterus and above the uterine wall. These types of fibroids continue to develop and grow outward. It is usually detected incidentally during examination.
  • The enlargement of the subserosal fibroid places additional pressure on the surrounding organs. Therefore, its symptoms are not usually in the form of excessive menstrual bleeding or interference with a woman’s typical menstrual discharge. However, these types of tumors cause pelvic pain and pressure.
  • Depending on the stiffness and severity of the fibroids and their location, other complications may appear in addition to pain and pressure. They usually appear as a separate mass from the uterus, attached to the uterus by a thin or thick stalk.

4 – Fibroids with Stems:

  • Among the different types of fibroids, including submucosal, intramural and subserosal fibroids, pedunculated fibroids are also included.
  • Peculiar Fibroids grow on a stem and eventually develop into pedunculated submucosal fibroids or pedunculated subserosal fibroids. These fibroids grow inside the uterus and also tend to grow outside the uterine wall.
  • Symptoms associated with pedunculated fibroids can sometimes cause pain and pressure as the fibroid rotates on the stem.
  • If the fibroid rotates around itself, the stem, that is, the blood connection, is also disrupted and “degeneration” occurs in the fibroid core. If the stem of the fibroid sits on a wide base, it is called “sessile type fibroid”.

Fibroid Symptoms

  • Women between the ages of 35 and 54 have a potentially higher risk of developing fibroids.
  • When it comes to fibroids, understanding what they are and what their symptoms are is important to deciding on the most appropriate treatment option.
  • There are many different symptoms that women with fibroids may experience. In some cases, there may be no symptoms at all.
  • Depending on the size and location of the fibroid, the symptoms can be severe enough to affect a person’s ability to carry on with their daily activities. However, many women with fibroids are still able to carry on with their daily work without any change in their standard of living.
  • Because fibroids are sensitive to hormonal influence, fibroid symptoms are usually periodic, similar to menstruation.
  • Elevated estrogen levels cause most fibroids to enlarge and also increase symptoms.

Below is a list of the most common symptoms associated with fibroids.

Bleeding

  • Menstrual cycles of women usually last 4-5 days and occur every 28 days and do not interfere with the daily activities of the person. Even if the periods are irregular or uncomfortable, they usually affect the daily life of the woman.
  • Excessive menstrual bleeding is one of the most common symptoms of fibroids.
  • It is common in intramural and submucosal fibroids, and submucosal fibroids cause the most bleeding.
  • The amount of bleeding increases as the place gets closer to the inner part of the uterus.
  • Problems such as clotting problem caused by symptoms, severe, painful and long menstrual periods occur.
  • Long-lasting abnormal uterine bleeding can lead to serious side effects such as anemia and weakness, dizziness, shortness of breath, palpitations, headaches over time. However, if a woman experiences excessive menstrual bleeding, it can potentially cause more serious problems.
  • Fibroids include irregular menstrual bleeding (metrorrhagia), amenorrhea (amenorrhoea), infrequent periods (oligomenorrhea), frequent periods (polymenorrhea), excessive bleeding or prolonged periods (hypermenorrhea or menorrhagia), and little bleeding or short periods of menstruation (hypomenorrhoea). ) may also cause symptoms such as

pain

  • Pain in myoma is not very common. It usually occurs due to fibroid degenerations.
  • If the fibroids are stalked, they cause uterine contractions and cause pain. In addition, if the stem turns around itself or if the fibroid becomes infected, pain occurs.
  • Severely enlarged fibroids can press on the pelvic nerves and cause pain in the lower back and legs. Sometimes the cause of pain is other lesions accompanying myoma (such as Adenomyosis, Endometriosis).
  • Adenomyosis occurs as a result of the growth of the tissue that makes up the outer uterine wall (endometrium), the middle layer of the uterine wall and supporting vascular tissue (myometrium).
  • The outer uterine layer prevents adhesion formation. However, adhesion occurs when the fibroid develops and begins to grow, which can sometimes cause a lot of pain.
  • Endometriosis occurs when endometrial tissue is found on the outside of the uterus, which can be another painful and uncomfortable symptom of fibroids. In this case, a full gynecological examination is necessary to accurately diagnose the fibroid and to identify the symptoms in question.

Pressure Symptoms

  • Compression symptoms may result from pressure on adjacent internal organs such as the rectum and bladder.
  • Fibroids located on the cervix cause serosanguinosis (consisting of serum and blood), vaginal discharge, bleeding and dyspareunia (painful or difficult sexual contact).
  • The frequency and urgency of urination increases as fibroids that press on the bladder (urinary bag) create additional pressure on this organ. This not only causes a lot of pain and discomfort, but also prevents the person from continuing their daily activities.
  • If fibroids are close to the urethra (urinary tract) and bladder neck, they can cause acute urinary retention (inability to urinate) and overflow incontinence (incontinence).
  • As long as there is no permanent damage to the kidney, the anatomical integrity is restored by removing the compressing mass and the symptoms disappear.
  • Another possible effect of the growth of fibroids is that it puts extra pressure on the intestines. In this case, bowel movements become difficult, hemorrhoids (hemorrhoids), constipation and / or abdominal tension may occur.

Fibroid Complications

While many fibroids do not show any symptoms, in some cases, they are diagnosed through complications. Rotation on the stem (Torsion): As a result of the rotation of the stem fibroids around the stem and compression of the stem, the blood supply is impaired. First, the venous and then the arterial circulation is blocked and extravascular leakage occurs. This causes pain.

Infection:

  • It is a rare condition. It can ulcerate and become infected. It causes pain and bleeding.
  • Transformation into cancer: The thing that worries women with fibroids the most is whether the fibroids will turn into cancer. 0% of women with fibroids. In 5 of them, a type of cancer called leiomyosarcoma is seen in the advanced stages. However, many researchers argue that it does not originate from existing fibroids, but develops on its own and independently of others.
  • If a known fibroid starts to grow rapidly, if pain and fever are observed, it should be examined in detail.
  • Fibroids that grow after menopause can be risky in this regard.

Fluid accumulation in the abdomen Ascites (Pseudo Meigs syndrome):

Fluid accumulation occurs in the abdominal cavity, especially when pedunculated subserosal fibroids disturb the peritoneum. It is rarely seen.

Intra-abdominal bleeding:

  • It is rarely seen.
  • Bleeding as a result of rupture of one of the vessels on the fibroid.

Inversion of the uterus (Inversion):

  • It is the fact that the uterus is turned inside out like a glove finger due to the pedunculated submucosal fibroid pulling the uterus downwards.
  • It is very severe pain.
  • However, it should not be forgotten that the patient may have severe bleeding complaints before this situation develops.
  • It is a dangerous but rare condition.

Deterioration by change (Degeneration):

  • It is a change in the normal cell structure of a fibroid.
  • The cause of degeneration is the nutritional deficiency of the fibroid.
  • Degenerating fibroids become painful, tender, soft and larger.

Degenerative changes can be listed as follows;

  • Atrophy degeneration:
    • After menopause or sometimes pregnancy, the fibroid shrinks.
    • Microscopic fibroid appearance disappears. The clinical symptoms also disappear in parallel.
    • Hyaline degeneration: It is the most common fibroid degeneration.
    • The change first occurs in the fibrous tissue.
    • Macroscopically, yellow-white areas are seen.
    • Microscopically, eosinophilic substance accumulates in the tissue.
  • Cystic degeneration:
    • If the hyalinized fibroids liquefy, cystic spaces occur in these areas.
  • Calcification:
    • It occurs especially in subserous fibroids. The reason is nutritional deficiency.
    • Calcium carbonate and calcium phosphate precipitate in the tissue.
  • Septic degeneration:
    • As a result of nutritional deficiency, necrosis and subsequent infection develops in the middle of myoma.
    • There is pain, fever and tenderness.
  • Red degeneration (carneous degeneration):
    • This type of degeneration is specific to pregnancy and puerperium.
    • In the second trimester (trimester), the fibroid grows acutely and becomes painful.
    • Vomiting, weakness and fever occur. Its cause is subacute necrosis, which develops as a result of nutritional deficiency.
    • Venous thromboses, interstitial hemorrhages, and hemoglabin that give the tissue its red color are.
    • The cause of hemolysis is lipod factor formed during necrosis.
    • It is self-limiting and requires no special intervention.
    • Rest and analgesics are sufficient.
  • Myxomaous (fatty) degeneration:
    • It is rare.
    • It is asymptomatic and usually follows hyaline degeneration.

Fibroids and Infertility

Many ideas have been put forward about how fibroids can lead to infertility;

  • Fibroids prevent the development of the lining of the uterus.
  • Failure of the endometrial tissue to develop may prevent pregnancy by making it difficult for the embryo to attach to the uterus and may cause miscarriage.
  • When the fibroids reach very large sizes, it may cause an ectopic pregnancy by making it difficult to move inside the ovary.
  • It can prevent pregnancy by disrupting the position of the cervix, preventing the progression of sperm and fertilization.
  • It can prevent fertilization by causing deformities in the uterus.
  • Increased estrogen levels during pregnancy can cause small fibroids to grow, leading to miscarriage and premature birth.
  • In the etiology of infertility, fibroids affect 5-10% of all cases. However, when other concomitant infertility causes are excluded, fibroids alone are responsible for only 2-3% of infertility cases.

Fibroids and Pregnancy

  • The incidence of uterine fibroids during pregnancy varies between 0.3% and 7.2%, although it varies according to the centers. There are effects of both pregnancy on myoma and myoma on pregnancy.
  • Studies show that undesirable conditions such as miscarriage, premature birth, premature separation of the placenta, abnormal position of the baby in the uterus, premature separation of the placenta are slightly more common in pregnant women with fibroids. The size, number and location of fibroids determine whether these undesirable conditions are seen or not.
  • In the presence of multiple fibroids and submucosal fibroids, these adverse events are most likely to occur.
  • A problem that fibroids can cause during pregnancy is localized severe pain that can be seen between 16-20 weeks of pregnancy. These pains can usually be controlled with painkillers.
  • In most pregnant women, fibroids do not adversely affect the course of pregnancy.
  • In the past, it was thought that fibroids grow rapidly during pregnancy, but recent studies show that this is not true.
  • Most fibroids stay the same size throughout pregnancy, while the few fibroids that can grow usually show this growth in the first trimester of pregnancy.

What are the Risk Factors and Causes?

It is estimated in the clinical literature that approximately 20-40% of the entire female population has fibroids. The high rate in question reveals the importance of all women being informed about fibroids, possible symptoms and fibroid treatment options.

Fibroids are the most common tumors in the female reproductive system and all women have these tumors.
there is a risk of getting caught. The most important risk factors are;

  • black race
  • Nulliparity (never giving birth)
  • genetic affinity
  • Obesity

It is not known why fibroids occur. There are different theories;

  • Genetic changes:
    • When the cells in many fibroids are examined, some coding changes are observed in the genes related to the uterine smooth muscle.
  • Other factors:
    • Some substances, such as insulin-like growth factor, can affect fibroid growth.
  • Hormones:
    • Estrogen and progesterone are two female hormones that prepare the uterus for pregnancy.
    • When the fibroid tissue is examined, it is determined that estrogen receptors are more abundant in the cells of the fibroid tissue than in the normal uterine muscle cells.

However, there is evidence to suggest that hormones are associated with fibroid development;

  • The development of fibroids before puberty is very rare.
  • The most common period is the 40s before menopause, when ovulation is disrupted and estrogen production is not met.
  • After menopause, fibroids stop growing or regress.
  • Fibroids are accompanied by other diseases that develop due to excess estrogen, namely ovulation disorders, hyperplasia (thickening of the inner wall of the uterus) and polyps.
  • Fibroids grow rapidly during pregnancy when progesterone, one of the female hormones, is high.
  • Drugs that suppress female hormones and create a situation similar to menopause shrink fibroids.

What are the Diagnostic Methods?

  • Gynecological Examination
  • The best method for the diagnosis of fibroids other than small subserosal fibroids is gynecological examination.

Display Methods

  • Ultrasonography:
    • This method, which is painless and painless, is a diagnostic tool that works by using sound waves called echo with the help of an apparatus (device) inserted over the abdomen or into the vagina.
    • Myoma nodule is easily recognized as a lesion that echoes different from the myometrium.
    • Vaginal ultrasound examination can provide more detailed information.
    • As a result of the examinations, fibroids are displayed, their location and size are determined. However, if the fibroids are smaller than 1 cm or very large, ultrasound examination may not give a healthy result.
  • Computed Tomography (CT) & Magnetic Resonance (MR):
    • A three-dimensional view of the uterus can be obtained with CT, and the size and location of the myoma can be determined with MR.
    • They are rarely used because of their high cost.
  • Hysterosalpingography(HSG-Uterine Film):
    • It is an X-ray examination taken during the introduction of a drug that does not pass X-ray rays into the uterus.
    • With this method, which allows the diagnosis of abnormalities in the uterus and tubes, fibroids are also diagnosed.

Special Reviews

  • Hysteroscopy:
    • In this examination, which is used in the diagnosis and treatment of submucosal fibroids, a telescopic device called a hysteroscope is passed through the vagina and cervix and inserted into the uterus for evaluation.
    • With this method, which can be applied under local anesthesia, fibroids can be removed at the same time.
  • Laparoscopy:
    • It can be used for differential diagnosis of fibroids.
    • It is based on the examination of pecvic structures by entering with a device called telescopic through a small incision made from the abdomen with a device called laparoscope.
    • It can be applied in hysteroscopy during the procedure performed under general anesthesia.
  • FOG (Saline Infusion Sonography):
    • It is a method that can be used in the diagnosis of submucosal fibroids, based on the principle of injecting fluid into the uterine cavity and providing swelling.
    • Saline is an excellent agent for demonstrating the uterine cavity.
  • Dilatation curettage (D&C):
    • “Dilation” is used to mean the widening of the cervix.
    • The dilation of the cervix is necessary to insert the necessary instruments (curette or aspirator) into the uterus for curettage. Especially in bleeding fibroids.

Treatment Methods

Observation

Medical Treatment

  • GnRH Analogs
  • Androgens
  • Progestins

Surgical treatment

  • myomectomy
  • Abdominal Myomectomy
  • Laparoscopic Myomectomy
  • Hysterescopic Myomectomy
  • hysterectomy

Focused Ultrasound Surgery

  • Uterine Fibroid Embolization

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