Myomas, Diagnosis and Treatment
The most common tumours seen in women are benign myomas and are found in 20-30% of women. It is defined as estrogen dependent tumours in women of reproductive age. It takes its origin from the smooth muscle cell fibres of the uterus (uterus) and can grow either oval or round. They give symptoms according to the fact in which direction they grow after taking origin from the smooth muscles of the uterus, but often they may not show any signs.
Location of Myomas
If they grow under the endometrium (intrauterine tissue that we expel with menstruation) as the location, they are called submucosal myomas, which is the subgroup that causes the most bleeding complaint. Submucosal myomas spring down the endometrium by pressing the endometrium from below and may cause increased bleeding due to compression and necrosis. If they grow inside the uterus wall, they are called intramural myomas and may not cause symptoms and may cause bleeding. If they grow too big, they can press on the bladder from the front wall and press on the rectum frequently from the back wall and lead to constipation. If they tend to grow beneath the outer membrane (serosa) of the uterus, they are called subserosal myomas. Rarely, the cause of bleeding, subserosal myomas, especially if they are stalked, may cause pain by turning from their stems (torsion).
We can say that all these complaints can occur in only 10% of women with myomas, and 90% will be detected randomly during examination and ultrasonography without any complaints.
Complaints and Findings of Myomas
2/3 of women with myoma often talk about mild pain, but the most common cause of pronounced pain is degeneration. Necrosis areas begin within the fibroid tissue, which has a very vascularization (vascularization) and causes severe pain. We can see this a lot in red degeneration, which is frequently observed in the second half of pregnancy. The second most common cause of pain is torsion in stem myomas. When submucosal myomas try to rise from the uterine cavity to the vagina (myoma instatus nascendi), pain appears as a complaint.
Bleeding is one of the major reasons for application. Especially in submucosal myomas or relatively large intramural and subserosal myomas, hemorrhage may develop with enlargement to the endometrial area or necrosis and secondary infection. The estrogen hormone myomas, which temporarily rise in the pre-menopausal period, can suddenly grow between 40-45 years of age and thus reveal the bleeding problem. Bleeding occurs with the prolongation of menstruation in terms of quantity and day (menometrorrhagia). From time to time, it may be expressed as intermittent bleeding or frequent menstruation. Along with bleeding, the patient can also apply with problems such as anaemia, extreme weakness, palpitations, and impaired concentration.
Depending on the size and localization of myoma, constipation may occur if the urine is frequently pressed from the front wall and the rectum is pressed from the back wall.
Very rarely, if the female myoma grows too much, she can apply by stating that it is in the abdomen. In this case, when the abdomen is palpated (in physical examination), the uterus with myoma will be easily felt during manual examination.
The Probability of Myomas to return to cancer
The possibility of cancer transformation of fibroids is extremely rare and the conversion to leiomyosarcoma, an average of 0.5% uterine smooth muscle malignant (malignant) tumour, is reported. Leiomyoma feels homogeneous and soft by hand. The diagnosis can only be made after pathological examination. It is very important not to be confused with atypical cell rich fibroids in diagnosis because it may increase the frequency of unnecessary hysterectomy and other treatments.
Diagnosis in Myomas
Diagnosis can be made easily by bimanual examination of the womb that has grown up with primary examination. Here, gold standard ultrasonography is used in radiological auxiliary methods. Around the fibroids, a border separating the fibroids from the normal uterine muscle is clearly monitored, and it can be distinguished more hypoechogenically as the fibroid density takes less than smooth muscle tissue. Except for very specific conditions such as differentiation of intraligamenter myomas from ovarian tumours, MR and CT have no special place in the diagnosis of myoma and leiomyosarcomas are not used in the differential diagnosis from fibroids. In cases where intramural fibroids are to be taken laparoscopically, MRI can be useful for good mapping.
Myoma Treatment: Myomectomy and Hysterectomy
Perhaps the first thing to say in myoma treatment is that drug treatment is never an issue. Aromatase inhibitors and GnRH analogues have been tried in treatment and it has been understood that aromatase inhibitors are not useful. This group is normally used in the treatment of breast cancer with its anti-estrogenic effect. With GnRH analogues, it reduces estrogen and temporarily shrinks fibroids with temporary menopause effect during usage periods. It is possible to use it to shrink myomas and reduce bleeding before surgery without treatment, but there are a few important drawbacks here. Since GnRH analogues shrink myomas too much, we may miss myomas that we need to take during surgery and we may encounter them in USG after a few months. Since the surgical boundaries of myoma will be erased, surgical technique may be difficult and surgical bleeding may be exaggerated especially after the use of analogue in hysteroscopic myomectomies. When there are many other techniques to reduce surgical bleeding, it is necessary to avoid time loss and high cost of GnRH analogues.
Briefly, fibroid therapy is surgery.
The surgical decision should be completely customized according to the severity of the patient’s complaint, how much the complaint affects his physical and social life, the presence of cancer suspicion, the physical, psychological and social structure of the patient. If the uterus is larger than 12 weeks of gestation, surgery can be considered even if the patient has no complaints, but this is completely case-dependent. Bleeding, pain, pressure or mass finding will affect the surgical decision more objectively. Because, in premenopausal women who have a 12-week uterus but have no complaints, surgery may not be made considering that myomas will get smaller after menopause. The important thing here is to follow up the physician with a USG every 4-6 months. Surgery should be considered if cancer is suspected in fast-growing myomas, if the kidneys are damaged by bladder or ureter pressure, or if degenerate myomas growing in localizations that can be confused with ovarian tumors cannot be distinguished from ovarian tumours.
The main goal here is also the main goal of medicine:
‘Don’t hurt first’
After the surgery decision is made, the type of surgery should be decided by discussing the conditions with the physician and the patient together.
1) Myomectomy: Many women are rightly concerned about the possibility of taking the uterus when they make a surgical decision. The conditions of the changing era brought along being a later mother, which revealed the need to protect the uterus and fertility with increased gynecological problems. Many women also consider the uterus as a symbol of ‘femininity’ outside of fertility and keep hysterectomy equivalent to ‘castration’. Instead of discussing this idea, I think it is necessary to respect only and I share it with my patients. Basically, the uterus is only a bed for the development of the baby, and its presence is necessary only for childbearing. In cases where the uterus is removed, the ovaries continue their functions and the patient who does not have menstruation maintains the hormone active process until the age of his or her natural menopause. However, we see that taking the uterus negatively affects female sexuality in the expression of many women.
In women who have not completed the child process under the age of 40 or who want to protect their uterus even if they are over 40, only fibroids or fibroids are taken and the uterus is protected. Here, myomas are easily separated from the uterine muscle tissue and the natural space that emerges after myoma is repaired by bringing the muscle tissue closer together. The possibility of hysterectomy is extremely rare when natural cleavages of bleeding control and myomectomy are well done. Nevertheless, consent should be given to the physician about the necessity of leaving the decision of the possibility of hysterectomy to the myomas and in the case of severe surgical bleeding in localizations that are too large or dangerous from the patient. If she wants to conceive, the woman may be given a pregnancy leave 6 months after myomectomy
2) Hysterectomy: In women over the age of 40, but to be fair, 45 years of age and women who do not want to have fertility, hysterectomy (removal of the uterus) can be performed due to myomas. Here, taking the ovaries (ovaries) is a decision that can be made completely according to age and menopause. While it may not be meaningful to protect ovaries in women with pre-menopause or menopause, ovaries should be left in women who have not yet entered menopause and the natural hormone pattern should be preserved. It has been understood that ovaries (ovaries) in women beyond the age of 45 secrete androgenic hormones after menopause and have many benefits, especially cardiovascular health, skin health, and sexual health. Whenever there are clear indications personally in the surgical decision, I always favour an organ-preserving attitude.
In severe vaginal bleeding that reduces haemoglobin level below 7 due to myomas,
If the uterus is greater than 12 weeks of gestation,
If pressure findings (especially to urinary tract) threaten environmental organs,
If fibroids are growing fast or growing after menopause
If degenerated myomas on the side wall are mixed with ovary tumors, there is an indication for hysterectomy.
Creating a road map for surgery
This should be done by completely considering the localization of fibroids or fibroids, the size of the uterus and fibroids, the patient’s physical condition and personal decision.
Both myomectomy and hysterectomy can be performed by laparotomy (open surgery) or by laparoscopy (myomectomy and hysterectomy) and hysteroscopy (in myomas with a submucosal component predominance).
While laparoscopy (open surgery) is performed by opening the abdomen of the patient, laparoscopy involves entering the abdomen of the patient through three or four holes, and surgical operation is performed without opening the abdomen with the help of trocars.
Here, the rule that must be followed carefully is the same:
‘Don’t hurt first’
Because, especially in laparoscopic myomectomy, more physician experience is required than many laparoscopic procedures and the necessity of serial and rapid suturing should be kept in mind laparoscopically. The best group of patients selected here are myomas sitting on the uterus with a subserosal and thin base, and when the sutured area is small and shallow, surgical bleeding and other long-term complications are reduced. How professionally repaired the remaining space after removal of the fibroids that sit in the uterus with a large and wide base, with intramural and especially submucosal components, difficult in laparoscopic technique in large myomas. Because tissue openness is increased by stitching these layers in open surgery, but mostly single layer sutures are used in laparoscopy. It is not enough to ensure bleeding control during the procedure. The number and effectiveness of the applied suture provides the strength of the uterine tissue. Therefore, insufficient stitches may bring the possibility of tearing the uterus while the uterus grows during pregnancy. Operative laparoscopy is a difficult, long and painful process to settle in our country’s conditions as a technique and experience. The biggest advantage of laparoscopy is that the abdomen is not opened directly, it is more comfortable for the patient, requires a short hospital stay, and allows to return to work and daily life more quickly. However, it may be much more rational to prefer laparotomy in difficult surgical possibilities that may be complicated. Every condition should be clearly shared with the patient and decision should be made by making profit and loss calculations together.
Hysteroscopic surgery in submucosal myomas is particularly successful in selected cases and reduces laparoromy rates. Because with a hysteroscopic procedure to be performed in 15 minutes, the patient who can go home that day is saved from an open abdominal surgery and afterwards a long recovery period. The important point here is patient selection. If fibroid is completely submucosal and below 2 cm, that is type 0, it is the best group of patients for hysteroscopic myomectomy. If more than 50% of myoma is submucosal and 2-5 cm, hysteroscopy becomes difficult and a second operation session may be required to remove the myoma completely. Finally, if less than 50% of myomas are submucosal and above 5 cm, it is not appropriate to perform hysteroscopy outside of highly experienced hands.
The first of the two main complications in hysteroscopy is entirely related to the logic of the surgical technique. In order to inflate the cavity of the uterus called cavum during surgery and take myoma or polyp there, we deliver the fluid we call resectosol into the cavum with a higher pressure than blood pressure. When we make a surgical incision, the vascular ends are exposed, and since the resectosol pressure is higher, the resectosol goes into the vein and enters the systemic circulation. When this cycle lasts, the balance of electrolytes such as sodium potassium may be disturbed, and the amount of circulating fluid may increase beyond the load that the heart can bear. Therefore, patient selection should be made very well in every way and risks and critical issues should be shared with the patient in detail.
New technologies such as myosure, which can be done with saline solution in hysteroscopy and can be done by minimizing the risk of myoma tissue damage and adhesion in intrauterine tissue, provides great comfort to the patient and physician.
If surgery is a preference hysterectomy, laparoscopy actually increases the surgical comfort of the woman. If the operative devices used in laparoscopy are sufficiently equipped, it is a very suitable option in selected patients since it does not require surgical sutures. Hysterectomy can be completed fully by laparoscopy and laparoscopic vaginal dome sutures can be applied, or if the patient has previously delivered vaginally and if the vagina is relaxed, vaginal dome repair can also be performed. It is a more open form of surgery to modification. Physician experience in every way is also very important in laparoscopic hysterectomy.