What are fibroids (uterine fibroids) and why does they occur?


Fibroids are the most common uterine tumor found in women. Myoma occurs in almost a quarter of women of childbearing age. According to one version, it is believed that it is formed in the smooth muscles of the uterus. Although the cause of fibroids (the mechanism that triggers its formation) is not exactly known, its appearance in childbearing age and the subsequent decrease in volume during menopause indicates that it is associated with the hormone estrogen. Its formation during periods of increased estrogen, such as pregnancy, confirms this point of view.

Where exactly do fibroids form in the uterus?


Fibroids can occur and develop in different places. For example, they can grow on the wall of the uterus (intramural), just under the outer lining of the uterus (subserous), into the uterus itself (submucous), and also be located outside it, while attaching to the uterus with a pedicle (pedunculated fibroids).

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If myoma surgery is not necessary during cesarean section, it is not recommended to be performed. Because both fibroids that grow during pregnancy shrink after delivery and fibroid surgeries during cesarean section are more bleeding.
Fibroids occur in about a quarter of women of childbearing age.

Are fibroids harmful? What kind of problems do they cause?


Fibroids are usually benign tumor, and cases of detection of fibroids with malignant (cancerous) cells are extremely rare. However, in cases of detection of fast-growing fibroids during routine observations, risks of cancer cell development should not be neglected. Fibroids, depending on their size and location in the uterus, can cause many problems. For example, while fibroids that grow into the uterus cause problems such as irregular bleeding, difficulty conceiving, and miscarriage (loss of pregnancy), fibroids that grow outward without being noticed for a long time can be detected by accident. Fibroids located in the front of the uterus press on the bladder, which causes frequent urination and a feeling of pressure in the front of the uterus. Fibroids pressing against the back of the intestine can cause complaints such as difficulty defecating, constipation, and pain during sexual intercourse.

Do fibroids affect pregnancy?


Fibroids, depending on the location, can cause problems such as difficulty conceiving or not being able to conceive (infertility), difficulty continuing pregnancy (miscarriage, termination of pregnancy). Thus, the formation of fibroids under the placenta leads to insufficient provision of the fetus with nutrients, as well as to a delay in fetal growth. Fibroids begin to grow during pregnancy due to hormonal changes and can increase in size by two or more times compared to the period before pregnancy. Besides, the process of fibroids degradation (cell death occurring inside the fibroids) can cause pain. Even in cases of successful onset and course of pregnancy, depending on the location, fibroids can also cause additional problems, such as difficult labor, an increase in the likelihood of cesarean section, and an increase in the number of postpartum bleeding.

Opening the uterus (Womb), localizing the fibroid and carefully removing it from the uterus.

How is fibroids treatment done?


Treatment of fibroids is usually carried out individually, depending on the patient’s problems. Small-volume fibroids that are detected randomly and do not cause the patient complaints or problems can be tracked without any treatment. Large fibroids that cause complaints in patients (inability to conceive, miscarriage, pain, irregular bleeding, etc.) require potential treatment, and treatment planning is carried out depending on the condition of the patients, as well as the location and type of fibroids.

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Postoperative view of multiple fibroids removed from our patient. The presence of bad cells in the myoma, the largest dark color at the bottom, was detected by pathology.

Miyom tedavi seçenekleri nelerdir?

Miyomlar için çok farklı tedavi seçenekleri mevcuttur. Bazı ilaçlar miyomların küçülmesini sağlayabilmektedir. Ancak ilaçların kesilmesinden sonra kişi menopoza girmeyecekse miyomların yeniden büyürler. O nedenle miyomlar için ilaç tedavisi yaygın uygulanılan ve etkili bir tedavi yöntemi değildir. Miyomların çıkarılması (myomektomi) miyomlar için kalıcı tedavi fırsatı sağlamaktadır. Miyom alma ameliyatları (myomektomi) açık ameliyatla (laparotomi ile myomektomi), kapalı (laparoskopik myomektomi), vajinal yoldan (vajinal myomektomi) ya da histeroskopi ile (histeroskopik myomektomi) gibi pek çok yoldan ve çok sayıda teknik ile gerçekleştirilebilir. Tedavi planlaması ve hangi tedavinin uygulandığı hususu hastanın ve miyomların durumu ile ilgili olarak hasta ile istişare edilerek ve hasta aydınlatılarak verilmektedir. Farklı tedavilerin birbirine göre üstünlükleri ya da dezavantajları karar verirken göz önünde bulundurulmalı ve tartışmalıdır. Örneğin rahmin iç tabakasına (endometriuma) bası yapan ve bu nedenle gebe kalamayan bir hanımefendide miyomun açık ameliyatla çıkartılmasının endometriuma daha az zarar vermesi beklenirken, laparoskopik miyom ameliyatı yapılacak olursa kanama kontrolü için termal enerji ihtiyacı olduğundan daha fazla endometrial hasar oluşturabilecektir. Yine laparoskopik miyom ameliyatında miyomun çıkarılması için parçalama operasyonu (morselasyon) gerekecektir ki morselatör (miyom parçalama sistemi) kullanımının miyom hücrelerinin ve hatta kanser var ise bu kanser hücrelerinin karın içine yayılmasına neden olduğuna dair olgu sunumları mevcuttur. Miyom tedavisinin bir başka şekli de miyomları besleyen damarların anjiyografi ile kapatılmasıdır (embolizasyon). Bu yöntemde miyom olduğu düşünülen tümör hakkında patolojik inceleme yapılamaması ve miyomların tamamen ortadan kalkmaması dezavantaj olarak görülmektedir. Sonuç olarak opere edilecek miyomlarda da hangi operasyonun tercih edileceği hususu da çok önemli olup, bizim tedavi beklentimizi potansiyel olarak en iyi ve güvenli sağlayacak tedavi tipi seçilmelidir.

Sezaryen sırasında miyom alma ameliyatı yapılır mı?

Sezaryen sırasında görülen miyomların çıkarılması konusu her zaman tartışma konusu olmuştur. Bazı otoriteler rahime giden kan akımının gebelikte çok fazla olduğu ve bu nedenle myomektomi sırasında daha fazla kanama beklendiği ayrıca doğumdan sonra miyomların hacimlerinin küçüleceği düşüncesi ile sezaryen sırasında miyom alma işleminin (myomektomi) yapılmasını önermemektedirler. Bazı otoriteler ise çıkarılması kolay olan ya da myomektomi yapılması zorunlu sayılabilecek miyomların çıkarılması uygun görmektedirler. Burada belirleyici olan hususun hastanın ve miyomun özellikleri ile birlikte, hekimin tecrübesi, hastane koşullarının ve kan ihtiyaçlarının karşılanabilme potansiyeli olduğu düşünülebilir ve tedavinin tüm bunlar göz önüne alınarak planlanması uygun olacaktır.

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Preoperative view of the patient with multiple fibroids.

What are the existing methods of treating fibroids?

There are many different treatments for fibroids. Some medications may allow reducing the size of the fibroids. However, if the patient does not go through menopause after stopping taking medications, the fibroids will start to grow again. Therefore, medical therapy of fibroids is not a common method of treatment. Removal of fibroids (myomectomy) makes it possible to provide a long-term cure for fibroids. Fibroids removal (myomectomy) can be performed by open surgery (laparoscopic myomectomy), closed surgery (laparoscopic myomectomy), vaginal surgery (vaginal myomectomy), or by hysteroscopy (hysteroscopic myomectomy). Treatment planning and how it will take place is coordinated with the patient after taking into consideration personal and fibroids condition. When making a decision, both advantages and disadvantages of different treatments should be considered and discussed by comparing them with each other. Another form of treatment for fibroids is selective occlusion (clogging) of the blood vessels that feed the fibroids, using angiography (embolization of the uterine arteries). The disadvantages of this method are the lack of a pathological study of the tumor, which is considered a myoma, as well as the fact that the complete removal of the myoma does not occur, and it remains in the patient’s body.

 

Can the fibroids removal surgery be performed during a caesarean section?


The question of removing fibroids during a cesarean section has always been a subject of discussion. Some experts do not recommend performing a myomectomy during a cesarean section. They argue that during myomectomy heavy bleeding can occur since the blood flow in the uterus is too strong during pregnancy. While other specialists consider it appropriate to remove fibroids in cases where they are small in size or in situations in which myomectomy may be required for health reasons. The characteristics of the patient and fibroids, the experience of the doctor, the hospital conditions as well as the ability to meet the need for blood can be considered decisive factors in making decisions and planning treatment.

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Figure 1. Regions and types where fibroids can be seen in the uterus