Smooth muscle growths in the uterus and cervix are called myomas. Myoma is a benign smooth muscle tumor that develops from the smooth muscle of the uterus and can occur outside the endometrium, muscle layer or uterus. Uterine myomas are tumors that are sensitive to estrogen, known as the female hormone. Therefore, they develop more frequently during the reproductive years when women have high estrogen levels, and the frequency and size of myomas decrease in postmenopause when estrogen levels are low.
Myomas occur as a result of stimulation of the cells in the muscle layer of the uterus under the influence of hormones, and myomas are particularly sensitive to the hormone estrogen. Myomas may occur in women of childbearing age because the level of the female hormone estrogen is at a certain level. During menopause, myomas begin to shrink due to the decrease in estrogen hormone levels. As the myoma shrinks during menopause, the symptoms of myomas decrease.
Age of First Menstruation
Those who see their first menstruation earlier are more likely to develop myomas. This is because a woman is exposed to estrogen for a long time.
Genetic abnormalities are found in approximately 50% of myomas. Patients whose mother or sister has myomas are more likely to develop myomas.
Myomas are 2-3 times more common in black women than white women.
Number of Births
Women who have given birth have fewer myomas than women who have never given birth.
Obesity and Diet
Since the increase in body mass index increases the incidence of uterine myomas, more uterine myomas are seen in obese women. In addition, myomas are seen more frequently in women who are fed with a diet rich in red meat than in women who eat mainly green vegetables. Alcohol consumption also increases the incidence of uterine myomas.
Increased Estrogen Level
Myomas contain more estrogen receptors than the normal muscle layer of the uterus. As the estrogen hormone decreases during menopause, myomas may also shrink or even disappear. Progesterone, another female hormone, can play both a suppressive and stimulating role in myomas.
Although they are formed in the inner or outer layer of the uterus, the layer where all myomas form is the myometrium, which grows from here and affects other layers.
• Myomas formed in the muscle layer are called ‘intramural myomas’.
• Myomas in the inner lining of the uterus are called ‘submucous myomas’. These submucous myomas can grow from the cervix to the vagina and are called ‘vaginal myomas’.
• Myomas that appear on the outermost part of the uterus and grow outward from the uterus surface are also called ‘subserous myomas’.
• Some myomas appear as a thin stalk attached to the uterus and these myomas are called ‘stem subserosal myomas’. When subserosal myomas grow outside the uterus and cause an irregular appearance outside the uterus, they are called “exophytic-looking myomas.”
• Myomas can affect all of these layers depending on their size, and these myomas are called ‘transmural myomas’.
• Sometimes, a myoma may leave the uterus and continue to grow somewhere in the abdomen, and these myomas are called ‘parasitic myomas’.
• If a myoma originates from the anterior wall of the uterus, it is called a ‘corpus anterior myoma’ if it originates from its posterior wall, it is called a ‘corpus posterior myoma’.
• If the myoma originates from the top of the uterus, it is called ‘fundus-derived myoma’.
• Myomas can originate from the right or left side wall of the uterus and grow towards the ligaments that support the uterus, and these myomas are called intragamental myomas.
• Myomas can also rarely be seen in the cervix. These myomas are also called ‘cervical myomas’.
Myomas are often discovered incidentally on ultrasound during routine gynecological follow-up. Some myomas that do not cause complaints may be large enough to be detected by abdominal examination and are called giant myomas.
• Excessive and heavy menstrual bleeding
• Pain in the abdomen and groin area
• Recurrent miscarriages
• Frequent urination or difficulty urinating due to pressure on the bladder
• Difficulty making defecation due to pressure on the anus area, constipation
Symptoms of myomas in women vary according to the location of the myomas in the uterus;
• Myomas located near the uterine cavity (submucous myomas); it can lead to more infertility, excessive menstrual bleeding and miscarriage.
• Myomasin the uterine wall (intramural myomas); It can often cause excessive menstrual bleeding. Large myomas cause groin pain and pressure in the lower abdomen.
• Adjacent myomas (subserous myomas) on the outer wall of the uterus may not cause any symptoms, but these types of myomas, especially large ones, may cause groin pain, abdominal pain and pressure.
Even small ones can cause heavy menstrual bleeding and menstrual irregularities. Submucosal myomas; since they are myomas that negatively affect the endometrium, they prevent the embryo from attaching to the endometrium. Therefore, they can cause infertility. Although women with submucosal myomas can become pregnant, their risk of miscarriage is significantly higher than for other women.
Momas that develop from the middle layer of the uterine wall are called intramural (intrauterine myomas) and especially large intrauterine myomas can push the uterine wall and cause menstrual irregularities, infertility and miscarriage. In addition, myoma pain occurs in the abdomen and groin area, especially in myomas of 5 cm and larger.
Myomas that arise from the outer layer of the uterus are called subserous myomas. Subserosal myomas often do not cause myoma symptoms. However, when 9 cm myomas grow to 10 cm or more, they can cause serious pain problems. Especially 7 cm myomas and myomas located in the anterior or upper part of the uterus can be felt by pressing on the abdomen with the hand.
This means a myoma, like a parasite, that feeds on another part of the body, not from where it originated. In particular, stem cell subserosal myomas grow over time and cannot be fed from the uterine region. Since they cannot be fed, they leave the uterus and fall into the abdomen. They can continue to grow there by feeding as parasites on adjacent organs in the area where they fell. Sometimes, myoma fragments remaining in the abdominal cavity after myoma surgery may enlarge and cause parasitic myomas.
Myoma Born in the Vagina
The myoma begins to push towards the cervix with the effect of gravity. Depending on the size of the myoma and the opening of the cervix, these submucosal myomas rarely extend from the cervix to the vagina. These myomas are called vaginal myomas. The most feared feature of these myomas is infection. When vaginal myomas become infected, they cause foul-smelling discharge, high fever, malaise, and high levels of infection in the blood. Vaginal myomas must be treated before they cause this condition.
Stem (Pedicle) Myoma
Some myomas rarely grow and are attached to the uterus by a thin stalk. This growth of myomas is called peduncle myomas. If these myomas are subserous, they grow out of the uterus. The main feature of these myomas is that they regrow and cause enough pain to force the patient to emergency surgery.
Pelvic ultrasound is the first method to be performed in the diagnosis of uterine myomas and is the most frequently used method. Ultrasound is an inexpensive diagnostic method that can be easily applied. It can be administered through the abdominal wall and vagina. Although transabdominal ultrasound can diagnose large myomas, small myomas may be missed and may not be able to clearly distinguish the location of myomas.
Vaginal ultrasound, on the other hand, shows millimeter myomas and shows exactly where the myomas originate in the uterus. Transvaginal ultrasound diagnoses myoma with 95-100% specificity in patients with a uterus less than 10 weeks gestation. Myomas are well-defined, hypoechoic (darker than normal uterine tissue) masses that are usually hidden on ultrasound.
Saline Infusion Sonography
Sometimes submucous myomas growing in the lining of the uterus cannot be clearly differentiated by ultrasound. In this case, the cannula is inserted into the uterus before the ultrasound examination. After the vaginal ultrasound probe is inserted into the vagina, the inside of the uterus is filled by injecting fluid into the uterus through a previously inserted cannula. This procedure is called saline infusion sonography. This method can easily detect and diagnose uterine submucosal myomas and intramural myomas or endometrial polyps that disturb the uterus.
Uterine Film (HSG)
Hysteroscopy (HSG) is not a method used to diagnose uterine myomas. HSG is often used to test for infertility. In this method, a cannula is inserted into the uterus and a radioactive opaque substance is injected into the uterus, filling the uterus and spreading it through the uterus tubes into the abdomen. During this process, simultaneous radiological images are taken and the distribution of the radioactive material in the stomach is monitored through tubes. Fallopian tube adhesions,myomas and polyps that cause infertility can be visualized with this method.
Hysteroscopy is done by inserting a system containing a camera into the uterus through the vagina. Before the procedure, the cervix is opened enough for this system to pass. A system containing optics and a cannula is then inserted into the uterus that allows fluid to pass through. The uterus is filled with fluid given through this cannula. The camera detects whether there is a space-occupying lesion in the uterus. In particular, submucosal myomas, intramural myomas that compress the endometrial cavity or endometrial polyps are clearly seen with this procedure.
One advantage of this system is that myomas seen with the attachments of the system can be removed immediately. At the same time, it is assessed whether there is an obstruction in the tubal inlets and whether the tubes are open. However, myomas under the serosa and myomas in the muscle layer cannot be detected by hysteroscopy.
MRI (Magnetic Resonance)
MRI is a method that is successfully used in the diagnosis of many diseases today. MRI is not a very common method for gynecological problems, as many diseases can be diagnosed with ultrasound. In cases where the masses cannot be diagnosed with ultrasound, MRI can be a guide. It is quite successful in showing where these masses come from, whether they are benign or malignant, their size and probability. Similarly, if the myomas has grown, degenerated, and disfigured outside of the uterus, an MRI may be helpful. In the presence of giant myomas, it clearly shows us the boundaries of the mass, its size and its relationship with neighboring organs. If sarcomatous degeneration is present, which is a sign of malignant transformation of the myomas, an MRI may show that the myoma may be malignant. Which occurs in about 1 in 500 women with myomas.