Myoma is a benign tumor of the smooth muscle layer of the uterus, seen in one out of every 5 women. Although fibroids are called tumors, they are actually benign uterine tumors.
In this article, you can find answers to all the questions about the causes, symptoms, treatment for fibroids where genetic predisposition plays an important role. The article also contains the information about potential surgery options.
Fibroids are tumors that originate from benign, smooth muscle cells of the uterus. Although the incidence varies from society to society, an average of 15-25% of women havefibroids.
While most women with fibroids have no symptoms, 10-20% of women require their fibroid to be removed surgically.
Since fibroids are estrogen-dependent tumors, they are mostly seen in women of reproductive age. During pregnancy, fibroids may grow as the estrogen level in blood increases, and in menopause, fibroids may shrink as the estrogen level in blood decreases.
Although it is not known exactly why myomas occur, scientific studies point to some factors that cause myoma.
When these factors are considered, it is known that the most important risk factor is familial, in other words genetic predisposition. Apart from genetic factors, the following reasons are among the risk factors of fibroids.
Race: The prevalence of fibroids is higher in blacks than in the white race. Studies have shown that the risk of fibroids in the black race is 9 times higher.
Hormones: It is now a known fact that fibroids are an estrogen-dependent disease. All the reasons that increase estrogen in the body cause myoma if there is a genetic predisposition. Hormones stimulate growth factors in myoma tissue, causing myoma to grow and even reach dangerous dimensions.
For example, as estrogen hormone increases during pregnancy, existing fibroids may grow. Or, because the body estrogen level decreases during menopause, the existing fibroids shrink.
Environmental factors: All environmental factors that increase estrogen levels can cause myoma. These factors include obesity, birth control pills, vitamin D deficiency, and unbalanced diet.
Especially consuming too much red meat, consuming less vegetables, fruits and dairy products as well as excessive alcohol consumption can cause myoma.
Most fibroids are detected during routine gynecological examinations without any symptoms. However, the most common symptoms of fibroids in women are:
Abnormal menstrual bleeding: One of the most common complaints among the symptoms of myoma is excessive menstrual bleeding (menorrhagia) or non-menstrual bleeding. 30% of women with fibroids have menstrual irregularity, excessive bleeding or post-intercourse bleeding. The amount of bleeding changes according to the type of myoma, its location, size and pressure on the uterine wall.
Pain: Myoma may cause pain depending on the size of the myoma, the location and the degeneration (decay that occurs due to the malnutrition of the myoma). Myoma pain mostly felt around the groin and leg. It can rarely cause back pain.
Complaints due to the compression of myoma: The symptoms of myoma vary according to the organ that the myoma is compressing. For example, if myoma is a type of fibroid that grows forward, that is, towards the bladder, if it is pressing on the bladder (urine bag); it is common for woman to experience some discomfort such as frequent urination, inability to empty urine completely.
If the fibroids enlarged towards the back, it causes intestinal compression, which may cause constipation, frequent bowel movements, and painful bowel movements.
Very large varieties of fibroids may rarely compress the ureters, which can cause enlargement of the kidneys and,subsequently can cause further kidney pain and flank pain.
Infertility: Although it is not scientifically clear that myomas cause inability to conceive, if there is no other factor that causes infertility, myoma may be responsible for inability to conceive. Fibroids, especially those that are close to the uterine wall or tubes or that cause compression, can cause infertility.
Recurrent miscarriages: Fibroids that are close to the endometrium (inner layer of the uterus) where the baby will settle, may cause miscarriage in the early weeks of pregnancy. Large fibroids that are not close to the uterine wall may cause premature birth in later weeks of pregnancy.
Myoma is diagnosed during a gynecological examination. Depending on the location and size of the myoma, it can be diagnosed during palpation. Especially fibroids in the frontwall of the uterus are more easily understood.
Myoma is diagnosed mainly by ultrasound. Even 1-2 cm very small fibroids can be easily diagnosed by ultrasonography. If there are many fibroids, MRI is required to find out the location and size of myomas.
Based on the results of the MRI, myoma surgery method (open myoma surgery or closed/ laparoscopic myoma surgery) is decided.
In order to clearly understand the relationship between myoma and the cavity (endometrium),saline infusion sonography (SIS) should be performed. Based on the result of SIS, the relationship of myoma with the uterine wall and the type of surgery is decided (Hysteroscopic myoma surgery or Laparoscopic myoma removal).
Although medicated uterine film (HSG) is not used in common for the diagnosis of myoma, compression of the myoma into the uterus can be seen in the medicated uterine film taken for another reason. Ultrasonography or MRI is required for definitive diagnosis.
Fibroids can be either single or multiple. There are 4 types of myomas according to the location.
Intramural myoma (myoma embedded in the uterus): The most common type of myoma. Intramural myoma is the type of myoma that is embedded in the uterine muscle layer (myometrium). Intramural fibroids usually do not show symptoms until they reach very large sizes however after that stage, it may cause bleeding, menstrual delay or irregularity by pressing on the uterine wall. Or, it grows out of the uterus and puts pressure on the surrounding organs, causing symptoms such as groin pain, frequent urination, constipation.
Submucous myoma (Myoma in the inner wall of the uterus): This type of myoma located in the endometrium, which is the inner layer of the uterus. Even if the submucous fibroid is very small in size, it causes more bleeding as it expands the uterine wall.
It is a type of myoma that prevents the embryo from attachingto the uterine wall (implantation) as well as the continuation of pregnancy. It is the type of fibroids that must be removed before assisted reproductive techniques such as IVF.
Subserous myoma (Myoma growing out of the uterus): Subserous myomas are a type of myoma located under the membrane layer surrounding the outside of the uterus. Subserous fibroids usually do not bleed, they mostly cause pressure complaints such as groin pain, frequent urination, constipation, kidney pain. However, myoma must reach large dimensions in order to cause these complaints.
Parasitic myomas: Those are the fibroids that occur as a result of subserous fibroids growing over time until they lost their blood supply from uterus then detaches from the uterus and continues feeding and growing from the organ in the abdomen where they fall nearby.
Myoma born in the vagina: This type of myoma, which occurs as a result of submucous fibroids growing and coming out of the cervix due to the effect of gravity, is very rare.
Myoma treatment should be individually tailored and provided based on the individual patient’s health needs. In the decision of myoma treatment in Ankara, we draw a treatment plan according to the following criteria.
There are 3 methods for myoma treatment in Turkey.
The most suitable candidates for non-drug and non-surgical follow-up in the treatment of fibroids are; It is a group of patients whose fibroids are small in size and who do not have complaints such as bleeding, pain, compression on surrounding organs. Patients with no myoma symptoms and no serious changes in the size of their myoma within 3-months can be followed up without medication and surgery.
The answer to the question of whether every myoma should be surgically removed is NO. If every uterine fibroids had been removed, approximately half of the women should have undergone myoma operation. However, only 10% of women with fibroids undergo surgical procedures due to myoma.
Because if there is no complaint of compression on any organor bleeding due to myoma and if there are no findings that suggest cancer (malignant smooth muscle tumor, sarcoma),there is no need for surgery.
However, patients with one or more of the following complaints should consider having myoma surgery.
In our clinic in Ankara, we prefer one of the 2 methods.
Closed fibroid surgery;
Open fibroid surgery
The location and size of myomas are determined by ultrasound examination before myoma surgery. In multiple myomas, the location and size of myomas can be determinedprecisely via MRI scanning around the groin area.
In particular, MRI to be performed before closed myoma surgery increases the safety of the surgery and shortens the operation time. Before myoma surgery, blood supply must be in place against blood loss that may occur during surgery.
The age of the patient is very important in choosing the method of myoma surgery to be performed. If the patient at ages close to menopause, surgery may be postponed considering the possibility that the growth of myoma will stop and shrink in menopause.
Laparoscopic myomectomy (closed myoma surgery) or hysteroscopic myomectomy (hysteroscopic myoma removal) method can be used to protect the uterus at a young age.
It is very important that the gynecologist who will apply thosemethods in these surgeries has experience in advanced endoscopic surgery.
It is also very important to request video images of the operation performed and to question the number of the surgeon's previous laparoscopic myoma surgeries.
Routine administration of GNRH analogues to the patient before myoma surgery should be avoided. Although these agents are recommended by some surgeons to reduce bleeding, they obscure the line where the myoma attaches to the uterus and makes it difficult for the fibroid to separate from the uterus.
In rare cases, the GNRH drug can be used to stop the patient's bleeding before surgery and raise the patient’s blood level ready for surgery.
One of the most important risks of myoma surgery is bleeding. In some cases, even the uterus can be lost due to bleeding. For this reason, vasoconstrictor (vasoconstrictor) agents or temporary compression of the arteries are recommended methods in laparoscopic myomectomy to reduce bleeding.
The use of these agents will reduce the need for bleeding control alongside with electrical cauterization (burning) and provide stronger wound healing. Strong wound healing is important in terms of the tensile strength of the uterine muscle and the healthy continuity of pregnancy in patients who want to conceive.
The laparoscopic hysterectomy method (which means removing the entire uterus with a closed surgical technique) is an alternative treatment, for women near the end of their reproductive age with multiple fibroids.
If the patient is young, wants a child or does not want the uterus to be removed, we recommend that only fibroids be removed regardless of the number and size of myoma.
Because even if the patient is not young and will not give birth to another child, the uterus removal may negatively impact on the patient’s psychology. In fact, recent scientific studies recommend organ-sparing surgery where possible in patients with fibroids, that is, removing only the fibroids whilst keeping the uterus.
As a myoma surgery method, we mostly use myomectomy (removal of myoma) instead of hysterectomy (uterine removal) in our clinic in Turkey.
Myoma surgery can be done open or closed. Open myoma surgery is performed by making an incision in the abdomen like a cesarean section. Closed/keyhole myoma surgery is performed by laparoscopy or hysteroscopy method.
