Myomas !

Uterine fibroids are benign tumors arising from the muscle and connective tissues of the uterus. It can also be called fibromyoma, leiomyoma, fibroid, considering its histological structures. 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 myoma seed to reach the size of an orange. It is known that fibroids shrink in menopause; However, in 10% of the cases, myoma continues to grow.
Sometimes it is seen that the uterus enlarges as a whole due to diffuse hyperplasia of the muscle and connective tissue in the uterine wall. This condition is called “myometrial hypertrophy” or chronic subinvolution. Myoma nuclei are not found here. It usually occurs in multiparous women (women who have given birth more than once); however, it can rarely be seen in nulliparous women (also in women who have not given birth).
Although the exact cause is unknown, it is claimed that fibroids develop as a result of exposure to excessive estrogen. It is known that pathological conditions known to be estrogen dependent, such as endometrial hyperplasia, endometriosis and endometrial cancer, are more common in women with fibroids. The shrinkage of fibroids due to the effect of estrogen, which disappears in menopause, their absence before puberty, their tendency to grow during pregnancy, and the shrinkage of fibroids by GnRH antagonists also suggest the effect of estrogen. However, a direct and definite relationship between fibroids and estrogen has not been established.
Fibroids are usually multiple (multiple), discrete, spherical or irregularly lobulated masses. In microscopic examination, a structure consisting of intertwined smooth muscle bundles developing in different sizes and in different directions is observed. Between smooth muscle fibers is connective tissue. A pseudo-capsule formed by myometrial fibers is observed around the tumor. Myoma is separated from the surrounding tissues by a sharp border with this capsule. Tumor nutrition is via small vessels that run along the capsule and occasionally puncture the capsule and enter the myoma along the fibers. These vessels originate from 1-2 large vessels located in the pedicle (stem) of the fibroid.
Myomas have different names according to their localities:
-Submucous Myoma
-Intramural (interstitial) Myoma
-Subserous Myoma
Submucous fibroids: They emerge from the muscle tissue just below the endometrium (the inner layer of the uterus) and grow into the inner cavity of the uterus. They can even come out of the cervical (cervix) canal by forming a pedicle (handle) (myoma born into the vagina). Such pedunculated fibroids can turn around and torsion and infection can develop easily. Since these types of fibroids make it difficult and even prevent pregnancy, they are myomas that must be removed.
Intramural fibroids: They develop in the middle layer of the uterine wall. They can be of various sizes. It can enlarge the uterus by making large and small mounds (potato sack view), and subserosal myomas may also join them (uterus myomatosis). Sometimes one or more fibroids enlarge the uterus properly and completely. In German literature, this is called “Kugel myoma”.
Subserosal fibroids: They are fibroids that arise 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 stalked (pediculated) or seated with a broad base (sessile). Stem fibroids can fall into the abdominal cavity when the stem rotates around itself and is torsioned. If they can attach to the omentum and feed, they continue to develop there and are called parasitic fibroids. Sometimes these fibroids in the abdominal cavity are displaced (Wanderingmyoma) (Wandering fibroid). If the subserous fibroids have grown between the two leaves of the ligamentum latum, this type of fibroid is called intraligamentary fibroid.
Most fibroids do not cause symptoms. Asymptomatic fibroids are small ones. Sometimes, subserous fibroids do not give any symptoms even though they grow to a great extent. In this type of fibroids, patients notice that their abdomen is enlarged and apply to the physician.
Generally, patients present with complaints such as vaginal bleeding, pain, cystitis (urinary complaints) and meteorism (excessive intestinal gas) due to pressure, and with complaints such as infertility.
1.Vaginal bleeding: The most important symptom of fibroids is bleeding. Its characteristic feature is menorrhagia (excessive bleeding). However, metrorrhagia (irregular bleeding) may also be seen. In submucous fibroids, the fibroids protruding into the inner cavity of the uterus are perceived as a foreign body, causing irregular uterine contractions, bleeding and pain occur. Submucous fibroids cause more menometrorrhagia, that is, irregular and copious bleeding, while intramural fibroids cause more menorrhagia and hypermenorrhea (the amount and day of bleeding have increased). Anemia develops due to chronic blood loss.
Causes of bleeding in myoma:
a) Enlargement of the endometrial cavity and increased bleeding surface,
b) Increased vascularity of the uterus,
c) Endometrial hyperplasia, which often accompanies it (it can be encountered at a rate of 50%),
d) Myoma prevents the uterus from contracting and the vascular openings cannot be closed,
e) Submucous fibroids causing ulcers in the adjacent endometrium,
f) Due to the shape changes that occur as a result of compression in the adjacent endometrium glands, the endometrium of this region cannot comply with menstrual cyclic changes and causes irregular bleeding.
There is an indirect relationship between endometrial cancer and fibroids. When investigating the cause of bleeding in women with fibroids, endometrial biopsy must be performed.
2.Pain: Pain in myoma is not very common. If the fibroids (pediculated) are pedunculated 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 fibroid becomes infected, pain occurs, it can cause pain similar to labor pain or sudden stabbing pain. Occasionally, pain independent of menstrual bleeding may occur, but this is extremely rare.
Severely enlarged fibroids can press on the pelvic nerves and cause pain in the lower back and legs. Sometimes the cause of the pain is other lesions (eg, endometriosis) accompanying myoma.
3. Abdominal swelling and compression-related findings; The person feels fullness in the pelvis (groin). Sometimes, large fibroids cause urinary complaints by pressing on the bladder. They can cause constipation, gas and painful defecation (defecation) by pressing on the rectum (the last part of the intestine), and hydroureteronephrosis as a result of incomplete excretion of urine by compressing the urinary tract.
4. Infertility (Infertility):
Fibroids can compress the tubes and prevent sperm passage and thus conception (fertilization). If fertilization has occurred, it may also disrupt the endometrial surface and prevent implantation (adhesion of the embryo). As myomas grow, they can cause abortion (miscarriage) by making shape and circulation disorders in the uterus. If there is no room for the baby due to myoma, it may lead to preterm labor and placental adhesion abnormalities may occur. During pregnancy, it can affect the position of the fetus in the birth canal and cause difficult delivery. In the presence of uterine fibroids that block the birth canal, cesarean section is the only method of delivery. It can prevent regular contractions and recovery of the uterus following delivery.
In the gynecological examination, information is obtained about the number, size and localization (location) of myomas. Today, ultrasonography is the most widely used method in the diagnosis of fibroids. Examination under anesthesia is recommended in obese patients and virgo (virgin) women who have difficulty in diagnosis. Hysterosalpingography (HSG) is especially helpful in the diagnosis of submucous fibroids. Urography and cystography provide the relationship of myoma with the ureter and differential diagnosis with the pelvic kidney. Computerized tomography is not always a definitive and detailed diagnostic tool in the diagnosis of fibroids. Laparoscopy is the most reliable method in the definitive diagnosis of fibroids.
Ovarian tumors and subserosal fibroids can be confused with inexperienced people. In addition, incipient ovarian cancers that adhere to the uterus may be mistakenly diagnosed as fibroids. Normal pregnancy, Adnexal mass, Adenomyosis, Uterine (uterus) anomalies, Neighboring organ tumors, Pelvic kidney, Myometrial hypertrophy and other causes leading to vaginal bleeding should be differentiated from myoma.
1-Torsion: It is the disruption of blood supply by squeezing fibroids around themselves. When myoma is torsioned, first the blood circulation is blocked and extravascular leakage occurs. Peritoneal irritation occurs. Sometimes the fibroid falls into the omentum and feeds from there (parasitic fibroid).

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