Dr. med. Eduarda Jurševiča Estētiskās medicīnas klīnika
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Myomas: in what cases is a surgery needed?

Myomas: in what cases is a surgery needed?

Myomas can be considered one of the most pressing gynecological problems. But the problem is that each case of this disease is practically unique: symptoms can vary from none to very serious, tactics of treatment - from regular monitoring to urgent surgical intervention. What is a myoma, and why does it take so many different guises? Gynecologist, specialist at the “Lipex” clinic, Anton Babushkin clarifies.

What is a myoma?

Myoma has many names - fibromyoma, leiomyoma or uterine fibroid, and is the most common pelvic tumor in women. Although myoma is a completely benign tumor, it can cause great trouble if its treatment is not given proper attention.

The uterus consists of several layers. The thickest layer of the uterus, which consists exclusively of muscle tissue, is called "myometrium." This is the layer that is affected in the context of myomas - the tumor begins to develop from the muscles of the uterus. The muscle layer is the middle layer between the mucous membrane that is “growing” inward, into the uterine cavity - the endometrium - and the external layer that is “growing outward”, towards the bladder and colon.

Why do myomas form?

As with most other kinds of tumors, no one can truly say what causes myomas to form. In the same way, it is impossible to explain why in one patient tumor that is one centimeter large is asymptomatic in the uterus for life, but in another patient, it grows so rapidly in six months’ time, so that it necessitates an operation. This is most often associated with a genetic predisposition, with external factors such as stress, alcohol and nicotine.

Although it is impossible to name the causes of the problem, the fact remains that myoma is a hormone-dependent tumor. It is estrogen and progesterone that affect the growth of these tumors. Therefore, most often, myoma is a problem faced by women of reproductive age - a period when hormones are actively and successfully produced. This also explains why hormone replacement therapy - for example, after menopause, can provoke the growth of a small myoma that has been “dormant” for a long time.

What are the symptoms?

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Before describing the symptoms, first we need to understand how different myomas can be.

If the myoma grows in the direction of the uterine cavity, then it is called “submucous” or “submucosal”. It is these formations that most often cause symptoms: severe menstrual pain and heavy bleeding, and as a result - anemia, weakness. If the myoma is large, it “occupies” the territory where the embryo potentially wants to attach, deforms the endometrium: submucous myoma can be the cause of infertility, problems with completing a pregnancy. An important symptomatic difference between polyps and myomas: in the case of the first, the patient complains of spotting bleeding, but in the case of submucosal myomas, there is heavy menstrual bleeding.

Another variant of myomas is the one that grows "outward" – subserous myomas. The symptoms - a feeling of pressure, constantly full bladder, frequent urination, constipation, chronic pelvic or even lumbar pain. If the myoma is small, there may be no symptoms.

There is another type of myomas that develop in the muscle layer of the uterus - intramural. Such a node can also bleed and cause a miscarriage or infertility. But, as a rule, this tumor does not cause complaints and does not interfere with the overall quality of life. This type of myoma is most common one.

There is also pedunculated fibroids. There is a danger that the “stalk” it is attached to will twist - the blood supply to the fibroid will stop, the fibroid cells will begin to die, which can cause intolerable pain. This is a direct indication that an emergency surgery is necessary! Depending on the location of the fibroid, it can be squeezed out, directly into the cavity of the cervix or even into the vagina – it is the so-called "fibroid expulsion”. This situation is also very painful: the cervical canal opens, later there is spotting from the genital tract.

How to diagnose a myoma?

If the myoma is large, then it can be "felt", palpated during a gynecological examination. But, in the case, for example, of a submucous node growing inward, alas - it is impossible. That is why the gold standard for diagnosing myomas is ultrasonography.

During the ultrasonography, the myoma looks dark, the edges are very clearly visible, the shape is round, it has a bright shadow, called the “comet tail artifact”. The result of the ultrasonography depends on how the patient will be treated. It is necessary to understand the size of the tumor, where and how deep it is in the tissues of the uterus.

In order to make the picture clearer, sonohysterography can also be performed - this will help to distinguish a myoma from, for example, a polyp (see the article "Polyps").

With an accuracy of 90-95%, suspicious myomas can be seen during the ultrasonography. For example, myomas that have begun to “die” – the tissues have started to break up, the tumor has cavities with liquid inside, the contour of it is changing. In this case, it is vital to make sure that it is not a malignant tumor. Therefore, after ultrasonography, the patient is sent to magnetic resonance to clarify the situation.

There is no point in taking an aspirate — that is, fluid from the uterine cavity — for analysis. With such an analysis, the state of the myometrium cannot be checked.

How to treat myomas?

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Treatment of myomas is necessary only if there are symptoms or the fibroid is too large. If not, it is necessary to do an ultrasonography scan every six months to control the size of the myoma. A small fibroid is not a hindrance to either pregnancy or bearing a fetus.

There are several treatment options. The first is hormonal treatment. It works partially. Myoma grows under the influence of hormones, and if the medicine blocks their production or effect they have on the tumor, it is a way to reduce it, weaken its blood circulation and save the patient from symptomatic bleeding. The prescription of hormonal drugs is often the solution before surgery to make the tumor easier to remove, but, alas, medications work only in 35-40 percent of the cases. Sometimes the tumor does not respond to medication at all, or may even begin to grow.

To date, there are two types of drugs that can be used to treat myomas. The first (an analogue of gonadotropin-releasing hormones, such as buserelin acetate (Zoladex, Dipherelin)) acts at the level of the brain and dramatically changes the hormonal background. The drug causes an artificial menopause with all the ensuing consequences - osteoporosis, sweating, weight gain, and so on. Therefore, no more than 2-3 courses of the drug are recommended before surgery.

The second is ulipristal acetate (“Esmya”), a newer and less aggressive drug that acts exclusively on the myoma, allowing the hormones to continue to affect the body, and no symptoms of menopause are observed. This drug that is prescribed by specialists today. The medicine can be taken in courses.

However, the medication has contraindications. Firstly, according to new recommendations, it should not be prescribed to patients with liver problems: before it can be prescribed, it is necessary for the patient to take liver tests. And secondly, it should not be forgotten that “Esmya” relieves the patient from symptoms exactly as long as the drug is taken, and after it is no longer taken, the myomas increase in size again and become the cause of complaints once more.

Also: if surgery is necessary, the first group of medicines is more suitable, because ulipristal acetate softens the myoma too much, complicating the surgery.

Doctors sometimes suggest an intrauterine hormonal device (“Mirena”) as a treatment. Although it can reduce symptoms, the bleeding and pain can reoccur with time. The spiral affects the endometrium more than it affects the myoma.

The main treatment method is surgery

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If the patient is close to menopause and does not plan a pregnancy, and the myoma is large enough, or if there are several, in these cases, it is suggested removing the entire uterus. Doctors say that for a woman of reproductive age who does not want to have children anymore, only the ovaries are of importance (to produce hormones and maintain a normal hormonal background). They, if there is no pathology, are left intact, but in the case of a correct removal of the uterus, health is not affected in any way.

The second option is to remove only the myomas - this is usually the preferred method for those planning a pregnancy. And here the type of the operation matters: 

  • Hysteroresectoscopy, when under the visual control of the camera, the myoma is removed from the inside of the uterine cavity, without cuts in the abdomen (read more in the article "Polyps"). The doctor will most likely choose this method if the myoma is submucous and small (for example, up to 2-3 cm).


  • Laparoscopy, in which, under general anesthesia, the patient undergoes 3-4 incisions in the abdomen, not more than 10 mm in diameter, through which a camera and instruments are inserted into the cavity;


  • Laparotomy - an open operation with an incision on the frontal wall of the abdomen. This method is the best if the myoma is very large (more than 6-7 cm) or located in an “unfortunate” and poorly visible place.

Which of these three methods the gynecologist chooses depends on where the myoma is located, its size and, of course, the doctor’s practice in the particular method - the most important part of the operation is the suturing to successfully restore the integrity of the uterus.

Another treatment option is uterine artery embolization. The essence of this procedure is that the blood flow of the fymomas is blocked by a special substance that is injected into the uterine artery through a thin catheter that is inserted through the groin. This is a minimally invasive procedure that does not require general anesthesia, and is performed not by gynecologists, but invasive radiologists. When the nutrition of the myomas is blocked, they begin to die on their own. But, if the myoma is large, such a "half-dead" tumor can become infected, causing severe pain. Moreover, embolization is currently not recommended for women planning a pregnancy.

What to expect after the treatment?

If a fibroid is only treated with medications, one needs to understand that this is a temporary therapy, and as soon as the patient stops taking the medication, the myoma will grow back and the symptoms will appear again.

In the case of surgical treatment, there is a fundamental difference for women planning a pregnancy. After hysteroresectoscopy, you can already become pregnant in the next cycle. And with laparoscopy and laparotomy, if the myoma was found in the muscle and if there had to be incisions in the uterus, the patient will need to wait at least six months (to form a scar), and preferably 12 months, so that the scar is covered with elastic tissues that are necessary for pregnancy. In case of pedunculated or subserous fibroids that are growing towards the organs, the patient can already become pregnant in the next cycle after the surgery.

It should be noted that if there have been multiple myomas, and if there has been a large incision in the uterus, a caesarean section should be considered to avoid the rupture of the uterus that can be caused by the stress during childbirth. But everything is very individual – such questions should be discussed with an obstetrician-gynecologist, based on the operation that has been performed in order to treat myomas.

The most important thing is that getting rid of the unpleasant symptoms of myomas is not only possible, but necessary. The doctor will select the treatment tactics individually, based on the case of each patient.


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