Myoma!

Fibroids are benign tumoral structures that develop from the smooth muscle tissue of the uterus (womb). It can be in more than one number or in different sizes, it may or may not give symptoms depending on this.
It is most common in women aged 30-45 years. It is rarely seen during adolescence. Its regression or even disappearance after menopause, its tendency to grow during pregnancy, the more intense presence of estrogen receptors in myoma, its shrinkage when GnRH agonists are used show that estrogen has a role in its pathogenesis.
Myomas are named as subserosal, intramural, submucous myoma, intraligamentary, cervical myoma according to their location in the uterus. Intramural fibroids are the most common.
Fibroids can vary in size from 2-3 mm to 25-30 cm in diameter. It can be a single tumor or it can be multiple. Especially in large fibroids, sometimes degenerative changes are seen. These are: hyaline degeneration (most common), carneous degeneration (mostly in pregnancy), cystic (5-10%), calcific (postmenopausal), fatty (rare), septic, necrotic, malignant degeneration (0.1-0.5%).

Since fibroids do not usually cause symptoms, they are often noticed during general gynecological examination and ultrasonography. However, menstrual irregularity, excessive menstrual bleeding, anemia, pain during sexual intercourse, frequent urination, enlargement and swelling in the abdomen, pain, infertility and miscarriage due to its location close to the tubes or in the uterus, pain in the coccyx due to pressure on the intestines, Constipation, torsion due to large and pedunculated myoma turning around itself may cause complaints.

Diagnosis The best method is gynecological examination and ultrasonography. On examination, the uterus is palpated as larger and harder than normal, when the number of fibroids is high, the normal uterus shape is distorted, myoma born into the vagina is seen as a mass extending from the cervix to the vagina. If there are degenerative changes in myoma, fibroid nodules are felt as soft. The dimensions and localization of myoma are easily recognized by ultrasonography, especially in the diagnosis of small submucous myomas, vaginal USG gives better results. In addition, Hysteroscopy, Hysterosalpingography, Laparoscopy, CT and MR can be used in differential diagnosis. However, Dialation and Curettage are performed to rule out other pathologies associated with bleeding fibroids.
In differential diagnosis: Pregnancy, Adenomyosis, Adnexal mass, Ectopic pregnancy, Endometrial polyp, Endometrial cancer, Congenital uterine anomalies should be considered.
The probability of fibroids turning into cancer is around 2 in 1000, usually seen in menopausal women. If myoma is growing rapidly, it should be investigated in terms of cancer risk.
If fibroids are small and do not cause complaints, they usually do not require treatment. Routine gynecological examination and ultrasound follow-up every 6 months is sufficient.
GnRH analogs and some drugs can reduce fibroids with the effect of temporary menopause by suppressing the ovaries. The purpose of its use is to make the operation easier and reduce bleeding by shrinking the fibroid before surgery. However, this effect is temporary, as soon as the drug treatment is stopped, the fibroid returns to its former size. In addition, it can cause existing small fibroids to shrink even more, causing them to be overlooked during surgery. In addition, if these drugs are used for a long time, they cause complaints such as osteoporosis and hot flashes.
If myoma is large and in number to cause significant complaints, is located to cause infertility or miscarriage, if it is the cause of excessive menstrual bleeding and anemia, and if it cannot be clearly differentiated from malignant tumors such as cancer surgical treatment is necessary. Since myomas located close to the ovaries can be confused with ovarian tumors in women older than 40 years of age, they should definitely be taken.
The surgical method to be chosen in the treatment of fibroids varies depending on the patient’s age, social status and child desire. In addition, the number, size and location of myomas determine the type of surgery. Removal of only fibroids according to these factors (myomectomy)or complete removal of the uterus (hysterectomy) preferable. Usually open surgery (laparotomy)in the form of, in recent years, appropriate cases laparoscopyis also preferred.
In myomectomy surgery, it is aimed to strip the fibroids from their capsule and remove them. It is an approach that generally protects the uterus in women who want a child. However, the risk of developing myomas again in women whose fibroids were removed by myomectomy is 50-60% within 5 years. Because it can be thought that all fibroids are removed in the surgery, but fibroids that are too small to be noticed with the naked eye may enlarge and become noticeable over time after the operation and may require reoperation. Pregnancy is allowed 1 year after myoma is removed. Since the risk of thinning and rupture in the region of myoma operation will increase during labor, cesarean section should be preferred as the delivery method.
Hysterectomy should be preferred in women with rapidly growing fibroids and who do not plan to become pregnant in the future. The uterus is completely removed, but the ovaries can be left in order to prevent the patient from entering menopause. After this operation, the person will not be able to have a period again and have a baby. However, since the vagina is not touched, the vagina does not lose its shape and length. After about 1 month, the patient can easily return to his normal sexual life.
Myoma and Pregnancy : In 5% of pregnancies, uterine fibroids are found, most of them do not affect the course of pregnancy. However, the incidence of abortion (miscarriage) has increased by 2 times, it may cause early pregnancy bleeding. 30% of fibroids grow during pregnancy, this growth occurs most in the first 10 weeks of pregnancy, carneous degeneration is common during pregnancy. This degeneration creates a picture similar to acute abdomen, it is usually controlled with rest and analgesics. If unsuccessful, surgery is resorted to and myomectomy is performed. However, this is not used much because it causes both excessive blood loss and fetal loss.
In pregnancies with fibroids, placement of the placenta and anomalies of the baby’s posture have increased, especially cervical fibroids may obstruct the birth canal, intramural fibroids may prevent the coordinated contractions of the uterus. The probability of preterm birth, premature rupture of membranes, malpresentation, ablatio placentae, placental retention and postpartum hemorrhage increases. The incidence of birth by cesarean section is high. As a general rule, myomectomy is not performed in the pregnant uterus, but hysterectomy during cesarean section is a good treatment option for women with multiple myomas and who no longer want children.

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