What is Myoma?

The myomas are benign, non-cancerous tumors originating from the myometrium (the uterine muscle layer).

What is Myoma?

The myomas are benign, non-cancerous tumors originating from the myometrium (the uterine muscle layer). The myomas are also called fibroids, leiomyoma, leiomyomata, or fibromyoma. They may vary from 1 cm to 20 cm in size, and this is a disease observed in about 25-50% of all women and every third woman above 35 years of age. Rarely, it can also be observed beginning from 15 years of age. The patient may have only one myoma or numerous myomas large and small in different regions of the uterus. It is difficult to predict whether the myomas are scattered individually or in clumps. They can be very small for a very long time, grow rapidly and suddenly, or slowly for years.

 

What are the Causes of Myoma?

Although the myomas occur rather frequently, very little is known about what causes them. Estrogen, known as the female sex hormone, causes the myomas to grow. Therefore, the myomas grow 2-3-fold generally in the reproductive age and pregnancy. In the menopause age, on the other hand, the myomas generally shrink due to decreasing estrogen hormone.

 

How Many Types of Myomas are there?

The myomas are divided into 3 groups based on their locations in the uterine tissue:

Submucosal Myomas

 

These are the myomas that grow toward the uterine cavity. Although they are the least encountered myoma type, they are the myomas that cause the most bleeding. They damage the endometrium by pressing on it. They cause the complaints such as increase in the amount of menstrual bleeding, extended menstrual bleeding, bleeding with clots, bleeding out of menstrual periods, and serious anemia connected to these bleedings. Sometimes, they may grow from cervix into the vagina. In such cases, the complaints of pain and bleeding during sexual intercourse may be observed.

Intramural Myomas

 

They are the myomas located in the middle of the uterine wall, i.e. in the muscular tissue. They are the most frequently encountered myoma type. Like submucosal myomas, they may cause increased menstrual bleeding, extended menstrual period, and anemia connected to it. Besides, such myomas create pain and fullness sensation in the abdomen by causing the uterus to enlarge. Additionally, the big myoma and the uterus enlarged due to it press on the surrounding organs. Such pressure on the intestines causes inability to defecate and chronic constipation complaints. Pressure on the urinary bladder may cause problems such as difficulty in urinating or, on the contrary, frequent urination.        

Subserous Myomas

 

They are the myomas that grow from the external side of the uterus toward the abdominal cavity. Typically, they do not cause bleeding problems. Depending on the size of the myoma, the pressure problems stand out more. They mostly cause the pressure symptoms such as abdominal pain, abdominal cramps, back pain, fullness sensation, difficulty in urinating or frequent urinating, and constipation.

What are the Symptoms of Myoma?

Most of the myomas do not cause any complaint, and thus they do not require treatment. However, 10-20% of all myomas may cause certain complaints depending on their locations.

Changes in menstrual cycle and menstrual bleeding (the most frequently encountered complaints)

Pain

• Longer or more frequent menstrual periods
• Vaginal bleeding out of menstrual periods
• More than normal vaginal bleeding
• Abundant vaginal bleeding with clots
• Menstrual cramps
• Anemia caused by heavy bleeding
• Abdominal painand fullness sensation
• Abdominal cramps
• Pains in back, waist, anus, and legs (frequently a blunt, heavy, and stinging pain)
• Pain during sexual intercourse

Pressure

• Difficulty in urinating or frequent urinating (as a result of the pressure applied on the urinary bladder by myomas)
• Inability to defecate and chronic constipation (as a result of the pressure applied on the intestinal system by myomas)

Infertility: Particularly, the (submucosal) myomas that grow toward the uterine cavity prevent placement of the pregnancy in the uterus.

Uterine and abdominal distention

Although most of the myomas do not cause any problem, complications may occur rarely. The myomas connected to the uterine surface with stems may cause torsion (the condition in which the myoma swivels and prevents blood flow). In such cases, pain, nausea, or fever may be observed. The myomas may be infected (inflamed). In very rare cases, transformation into cancer may be observed together with fast growth of the myoma and the other symptoms.

Myomas and Pregnancy

Some of the pregnant women may have myomas, and they usually do not cause any problem.

The myomas increase in size together with the increase in the amount of blood coming to the uterus and the increase in estrogen during pregnancy. Together with the growth of myomas, pressure sensation and pain may arise. In the most of the patients, the myomas shrink after the pregnancy.

The myomas can increase the risks of the following:

• Miscarriage (the condition in which the pregnancy ends before the week 20)
• Premature birth
• Breech birth (the condition in which the baby comes in a position other than head-first)
• More blood loss during and/or after the delivery

Rarely, a big myoma may block the cervix or prevent the baby's passage through the birth canal. In such cases, the delivery is performed by cesarean section. Mostly, it is not necessary to treat myomas during pregnancy. Very rarely, a pregnant woman may undergo myomectomy operation, or myomectomy may be necessary during cesarean section. Sometimes, a pregnant woman who has myomas may need to rest or be hospitalized due to the threat of pain, bleeding, or premature birth.

How are They Diagnosed?

Most of the myomas can be detected with gynecological examination and ultrasonography. Sometimes, the following additional diagnosis methods can also be used.

• Hysteroscopy: A thin device equipped with a camera at the end and called hysteroscope is used to see the uterine. This device is inserted into the uterus vaginally through the cervix. In this way, the myomas inside the uterine cavity are viewed.
• Hysterosalpingography (HSG): It is a special radiography allowing to detect the abnormal changes in the shapes and sizes of uterus and tubes.
• Saline Infusion Sonography (SIS): It is ultrasonographic examination of the uterus by injecting physiological saline solution into the uterus. In this way, the myomas and polyps inside the uterus can be distinguished from each other.
• Laparoscopy: The myomas on the external side of the uterus can be detected with a camera inserted into the abdomen through a small skin incision opened in the navel, above the navel, or immediately below the navel.
• Magnetic Resonance Imaging (MRI) and Computed Tomography (CT): They are needed rarely. Sometimes, when they are used to examine another medical problem or symptoms, the myomas can be detected by chance.

What are the Treatment Options for Myomas?

The small myomas that do not cause any complaints and the myomas seen in a woman near her menopause age usually do not require treatment. Unless the myomas cause pain during sexual intercourse, there is no need to limit sexual activity.

In case of myomas that require treatment, the treatment options vary by the factors such as the patient's age, desire to have a child, and the location, number, size, and growth speed of the myomas. The myomas can be treated with medicine or surgical operation.

1. Medicines

The medicines such as gonadotropin-releasing hormone (GnRH) agonists can be used to shrink the myoma temporarily to prepare the myomas for operation, and to control bleeding. 

2. Surgical Operations

Myomectomy

 Myomectomy is surgical removal of only the myomas while still leaving the uterus intact. Since the patient's uterus is preserved with this operation method, the patient has the chance to have a child. If the patients who have had myomectomy become pregnant after the operation, they can perform normal vaginal delivery; but the need for cesarean section is also probable. While removing the myomas, it is particularly necessary to pay attention to remove the myomas without damaging the endometrium layer that covers the uterine wall and without destroying the uterine integrity in the patients who want to have child. 

It is necessary to remember that myomas may develop again in future after the operation. Myomectomy can be performed by using several different techniques. The surgical technique used depends on location, number, and size of the myomas.

• Laparotomy (open surgery)
• Laparoscopy (closed surgery)
• Hysteroscopy

 

The submucosal myomas that grow toward the uterine cavity can be removed with hysteroscopic surgery performed vaginally without making any incision in the abdomen. In this method, although the myomas on the uterine wall and deeper parts of the uterine cannot be removed, the bleedings caused by myomas frequently can be brought under control. It is mostly unnecessary to stay in hospital overnight after hysteroscopy. The myomas growing on the uterine wall or toward outside the uterus may be removed with laparoscopy (closed surgery) or laparotomy (open surgery). An incision is performed in the abdomen for laparotomy. Then the myomas are removed through this incision. The myomas can also be removed by using the laparoscope used to see inside the abdomen.

The virgin patients can also have myoma operation. When the laparoscopic (closed surgery) or laparotomic (open surgery) surgery is applied, the hymen is not damaged.

Hysterectomy

Hysterectomy is treatment of the patient by removal of the whole uterus together with the myoma through laparoscopy (closed surgery) or laparotomy (open surgery) or through the vagina. The operation method to be applied is determined on the basis of the size of the uterus, and the sizes, number, and locations of the myomas. After the hysterectomy, the patient can no longer have a child.

Uterine Artery Embolization

In this method, the blood vessels that go to the uterus are occluded in a controlled manner. The blood flow that allows the myomas to grow is stopped. In this way, it is ensured that the myoma shrinks.