Nebojša Zečević


Date 13.10.2018 09:39 Author: Asst. Nebojša Zečević, MD, PhD

About 1/3 of all gynecological hospitalizations are due to uterine fibroids (myomas). In most cases, they are noncancerous growths and can easily be removed

The patients often have a family history of uterine fibroids, which indicates the genetic basis and inheritance of myomas. Although 40 to 50 per cent of myomas are said to be inherited, the true genetic basis for the occurrence of miomas is not fully defined. There is an increased risk of myomas in women who are obese, have never given birth or have never breastfed.
A negative finding does not mean that there is no myoma!
The existence of a myoma is determined by examination. However, a negative finding does not mean that there is no myoma. In one study in 48 „clear“ findings, 27 small tumors were later found. Therefore, it is considered that there is a significantly higher number of myomas than officially recorded and that it is never possible to remove all myomas - that is why relapses are very common even after extensive surgeries.

Why are myomas growing?
The growth of a myoma depends on the production of the estrogen hormone, so myomas most often appear during the reproductive period. This implies that nulliparity and not breastfeeding are risk factors for myoma formation - relative risk decreases with each pregnancy and breastfeeding.
Paradoxically - lower risk for myoma occurrence for female smokers!
Older women who did not give birth and obese women are at greater risk.
Recent research indicate that both the hormones, estrogen and progesterone are responsible for the growth of the uterine myoma.

Where myoma develops

Where myoma develops

One, two or more, where they are most often found, how many are they?
Miomi can be individual, but are usually multiples.
They all begin in the uterine wall (intramural), but further expansion and growth can develop on the surface of the uterus (subserosal) or to the uterine cavity (cavity), submucous.
There can be miomi on a socket or a wider base, as well as parasitic, for example, on the omentum (a tumor of the abdominal tissue).
The size of the myoma varies from a few millimeters to several tens of kilograms. In 1888 a tumor of 65 kg was documented. Although a 4-5 kg mycosis is not a rare occurrence, they are usually much smaller.
Can they become cancerous?
Miomi can become malignant, and then we talk about sarcoma.
Sarcomatosis (malignant change) is more common in submucosal myoma and is the most serious myocome degeneration. Fortunately, this malignant transformation is very rare being found in just 0.04% to 0.7% of cases.

Symptoms of uterine myoma depend on their number, localization and size, as well as the possible existence of degenerative changes. They can include:
- Unhealthy bleeding
- Swelling in the lower abdomen and small pelvis
- Large belly
-Supont abortions and other pregnancy-related symptoms
- Sterility
However, many women do not feel any symptoms.
Are all myomas the same?
Myomas are not identical, using the older classification:
1. Symptomatic, asymptomatic
2. Submucosal, intramural, subserotic
3. Cervical, corporal, intraligamentary, nascent (one that "is born" through the cervix)...

Uterine fibroids new classification

There is now a new classification:
Here all myomas are categorised according to their position in the womb and are divided into 8 groups.
Treatment methods
The therapy for each patient with myomas requires a special approach and assessment, taking into account the following factors:
- Patient"s age
- Parity (whether she gave birth) and her wishes for motherhood
- Position and velvet myoma, problems that she feels
- Desires and affinities of the patient towards a certain type of treatment.

1. Myoma monitoring
Expectative approach - no specific therapy, monitoring for 6 months.
This approach is suitable for all patients who do not have severe problems and in whom the size and position of the myomas do not disturb their usual quality of life. It is also recommended for menopausal women who are without or with minimal problems and who do not expect further myoma growth due to cessation of ovarian function. In patients in this group, the risk of complications during the operation itself, as each operation carries a risk, is greater than the risk of malignant myoma degeneration or any complication related to the myomas.

2. Hormone therapy
This is a recent type of therapy and is administered with drugs that lead to a change in the level of myoma cell receptors, which leads to the cessation of growth, withdrawal and reduction in their size. It is especially suitable for patients who have minimal problems or want to postpone surgical treatment for a limited time. For now it is quite expensive, and these medicines cannot be obtained on a prescription.

3. Radiological methods of treatment (HIFU, Uterine fibroid embisation)
At the moment these are performed very rarely in our country with variable success. They are used far more frequently in more developed countries.

4. Myomectomy - operative myoma removal laparoscopic or open surgery.
Depending on the type of myoma, it is most often proposed for:
Miome type 0 and 1 - hysteroscopic solution
Miom type 2 - hysteroscopic solution with the possibility of recurrence
Miom type 7 - laparoscopic surgery
Miom type 5 and 6 - laparoscopic resolution, more complicated
Miom type 4 - most often do not need to be operated
Miom type 3 - if it causes discomfort, it should be operated on with a laparoscopic surgery or MINILAP technique
Miome type 2 - 5, Hybrid myoma - most commonly by open operation, MINILAP technique

5. Removal of the uterus - Hysterectomia.
This method is applied in women who: have completed reproductive function, do not intend to give birth or in whom the uterus is changed, if the intervention required the reconstruction of the uterus with an increased risk of complications.
Removal of the uterus due to myoma can be by laparoscopic, open-ended surgery or vaginal surgery.
Vaginal surgery has advantages such as faster recovery, non-irritation of the abdomen and fewer postoperative outcomes. A patient is a good candidate for vaginal hysterectomy (vaginal removal of the uterus) due to myoma, if she gave birth through the vaginal route, if myomas and the uterus are not over-sized and if the patient is accepting of this type of treatment.

How are operations performed?
1. Vaginal surgery is performed in the operating theatre in gynecological position with the possibility of spinal anesthesia. The stay in the hospital after surgery is about 3 days, if there are no complications. If necessary, one or both ovaries (for women over the age of 46 years) can be removed during the same procedure, thereby preventing possible problems with ovarian tumor pathology in later life.
2. Laparoscopic hysterectomy (total laparoscopic hysterectomy - TLH) due to uterine myoma is particularly beneficial for women with small and medium-size myomas who have not had previous surgery in the abdomen and small pelvis (virgin abdomen), regardless of whether they gave birth or not. This operation is performed in an operating theatre, under general anesthesia, without the possibility of regional (spinal anesthesia) and lasts an hour or less. It requires specific laparoscopic equipment and a well trained team of doctors. During this operation, one or both ovaries can be removed in agreement with the patient, based on the assessment of the gynecologist. Recovery in these patients is very fast if everything goes without complications. The patient may be released from hospital the day after surgery, with antibiotic therapy only.
3) Open hysterectomy is the removal of the uterus with or without the removal of the ovaries by a conventional route through a low, most commonly transverse abdominal, cut. It is performed in an operation theatre under general or regional anesthesia and lasts about an hour.
It can be used for women who have had previous abdominal and small pelvic surgery (a number of adhesions are expected), in patients with large myomas and elderly who have cardiorespiratory complications that make laparoscopic surgery contraindicated. Recovery is slower and more painful due to the existence of an operative cut, and the patient must remain in hospital for at least 4 days after surgery.


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Ass. prof.  Nebojša Zečević, MD, PhD, a specialist in Gynecology and Obstetrics and doctors of other medical specialties, advise on how to protect health, deal with medical problems and diseases and have healthy offspring.



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