What Is a Myoma? Why Does It Occur and What Are Its Types?

Myomas are benign masses that develop in the muscular layer of the uterus, with well-defined borders and a round or irregular shape. Their size can range from a few millimeters to sizes large enough to fill the abdominal cavity (20-25 cm or more). There may be a single myoma, or the uterus may contain numerous myomas.

Causes and Risk Factors: Although the exact cause of myomas is not fully known, the female hormones estrogen and progesterone are thought to play an important role in their development. For this reason, they are more common during the reproductive years and tend to shrink after menopause, when hormone levels decline. Other risk factors include:

• Age: Incidence increases throughout the reproductive years (especially between ages 30-50).
• Race: They tend to occur more frequently and at a younger age in Black women compared to white women.
• Genetic Predisposition: The risk is higher in those with a family history of myomas (mother, sister).
• Early Age at First Menstruation: Starting menstruation at an early age may increase the risk.
• Nulliparity: The risk may be slightly higher in women who have never given birth.
• Obesity: A high body mass index may increase the risk.
• Dietary Habits: A diet heavy in red meat is thought to increase the risk, while a diet rich in green vegetables may be protective. Vitamin D deficiency may also be a risk factor.

Types of Myomas (By Location): The location of myomas within the uterus directly affects the symptoms they cause and the treatment options:

• Submucosal Myomas: These are myomas that grow toward the inner cavity of the uterus (beneath the endometrial layer). Although this is the least common type, it is generally the type that causes the most symptoms (severe and irregular bleeding, menstrual pain, infertility, recurrent miscarriages). They are classified according to how far they protrude into the uterine cavity (Type 0, 1, 2).
• Intramural Myomas: These myomas are located within the muscular wall of the uterus. This is the most common type. When small, they usually cause no symptoms, but as they grow, they can lead to increased menstrual bleeding, pain, and a sensation of pressure. If they press on the uterine cavity, they can cause infertility or miscarriage.
• Subserosal Myomas: These are myomas that grow toward the outermost surface of the uterus (beneath the serosal layer). They usually do not affect menstrual bleeding and may remain asymptomatic for a long time. When they become very large, they can press on surrounding organs (bladder, bowel), causing complaints such as frequent urination, constipation, or a feeling of abdominal fullness. They may sometimes be attached to the uterus by a thin stalk (pedunculated/stalked subserosal myoma); if this stalk twists on itself (torsion), it can cause sudden, severe pain.
• Cervical Myomas: These are rare myomas located in the cervix (neck of the uterus).

What Are the Symptoms of Myomas? When Should You See a Doctor?

A significant proportion of women with myomas (50-80%) experience no symptoms at all, and the myomas are discovered incidentally during a routine gynecological examination or an ultrasound performed for another reason. In myomas that do cause symptoms, the most common complaints are as follows:

• Abnormal Uterine Bleeding:
  
  • Heavy Menstrual Bleeding (Menorrhagia): Bleeding that is much heavier than normal and/or contains clots. The need to change pads or tampons frequently.
  • Prolonged Menstrual Bleeding (Hypermenorrhea): Menstrual periods lasting longer than 7 days.
  • Intermenstrual Bleeding/Spotting (Metrorrhagia): Irregular bleeding or spotting between two menstrual periods.
  • Anemia: Iron-deficiency anemia may develop due to heavy and prolonged bleeding. It leads to symptoms such as weakness, fatigue, paleness, and palpitations.
• Pelvic Pain and Pressure Sensation:
  
  • A sensation of fullness, heaviness, or pressure in the lower abdomen or groin.
  • Dull pelvic pain that can become chronic.
  • Severe cramping during menstrual periods (dysmenorrhea).
  • Back or leg pain (due to the myoma pressing on nerves).
• Symptoms of Pressure on Neighboring Organs:
  
  • Pressure on the Bladder: Frequent urination, a sensation of incomplete bladder emptying, sudden urinary urgency, or, rarely, inability to urinate.
  • Pressure on the Bowel: Constipation, straining, or pain during bowel movements.
• Painful Intercourse (Dyspareunia): This can occur, particularly with myomas located in the lower part of the uterus or with large myomas.
• Abdominal Swelling or a Palpable Mass: With myomas that reach very large sizes, visible abdominal enlargement or a palpable firmness may be noticed.
• Infertility and Pregnancy Complications:
  
  • Submucosal or large intramural myomas that press on the uterine cavity in particular can cause infertility by preventing the embryo from implanting in the uterus or by disrupting sperm passage.
  • Myomas can increase the risk of miscarriage, preterm birth, abnormal fetal positioning (breech presentation, etc.), placental abruption, difficulties during delivery, and excessive postpartum bleeding.

If you are experiencing one or more of the symptoms listed above, or if a myoma was detected during your routine checkup, you should be sure to consult a Gynecology and Obstetrics Specialist to have your condition evaluated and to have a personalized follow-up/treatment plan created for you.

How Is a Myoma Diagnosed? Diagnostic Methods Used in Ankara

Myomas can generally be diagnosed easily. The main diagnostic methods used by Prof. Dr. Nuray Bozkurt in Ankara are as follows:

• Gynecological Examination: During a manual examination (bimanual examination), the doctor may detect an increase in uterine size, irregularity in shape, or firmness. However, small myomas may not be detectable on examination.
• Ultrasonography (USG): This is the most commonly used and most valuable method for diagnosing myomas.
  
  • Transvaginal Ultrasonography (TVUS): This ultrasound, performed through the vagina, images the uterus and ovaries much more closely and clearly, determining the location, size, number, and type (submucosal, intramural, subserosal) of myomas with a high degree of accuracy.
  • Abdominal Ultrasonography: Performed over the abdomen, this is used particularly to assess the overall size and abdominal location of very large myomas, or in patients who are virgins.
• Saline Infusion Sonohysterography (SIS) or Fluid Ultrasound: Sterile saline solution is introduced into the uterus under ultrasound guidance to expand the uterine cavity, and the ultrasound performed at the same time allows submucosal myomas and polyps in particular to be distinguished more clearly. It is useful when investigating infertility or abnormal bleeding.
• Magnetic Resonance Imaging (MRI): In cases where ultrasound is insufficient, this provides very detailed information about the exact location, number, and size of myomas. It is used particularly in patients with large and numerous myomas prior to surgical planning, or to distinguish myomas from other pelvic masses (adenomyosis, suspected sarcoma, etc.).
• Hysteroscopy: This involves direct visualization of the inside of the uterus by inserting a thin camera through the cervix. It provides a definitive diagnosis of submucosal myomas and allows for their removal (hysteroscopic myomectomy) in the same session. It is particularly important in patients with abnormal bleeding or infertility complaints.
• Blood Tests: A complete blood count (hemogram) is generally not performed to diagnose myomas, but rather to assess anemia resulting from the excessive bleeding they cause.

Myoma Treatment: When and How Is It Performed? Current Options in Ankara

Not every myoma requires treatment. The treatment decision is entirely individualized and depends on the following factors:

• Presence and Severity of Symptoms: This is the most important indication for treatment.
• Size, Number, and Location of Myomas: Myomas that are particularly large, numerous, or that distort the uterine cavity may require treatment.
• Patient’s Age: In women approaching menopause, follow-up alone may be sufficient if symptoms are mild.
• Desire for Children: The choice of treatment varies considerably depending on whether the patient is planning a pregnancy in the future.
• Growth Rate of Myomas: Rapidly growing myomas may require closer follow-up or treatment.

The treatment options offered or referred by Prof. Dr. Nuray Bozkurt in Ankara are as follows:

1. Follow-up and Observation (Watch and Wait):

• This is the most commonly applied approach.
• It is suitable for small myomas that are asymptomatic or cause only very mild symptoms.
• It may also be preferred in patients approaching menopause.
• Changes in the size of the myomas and the emergence of any new symptoms are typically monitored through regular gynecological examinations and ultrasonography at 6-month or 1-year intervals.

2. Medical (Drug) Treatment:

• Drug treatments do not permanently eliminate myomas, but they can help control the symptoms they cause (particularly excessive bleeding and pain). When the drugs are discontinued, the myomas usually return to their previous size and the symptoms may recur.
• Hormonal Medications:
  
  • Birth Control Pills (Combined Oral Contraceptives): These can reduce menstrual bleeding and regulate the menstrual cycle. They do not affect myoma size.
  • Progestins: These can be used in the form of progesterone-only pills, injections, or a hormonal intrauterine device (IUD). They are particularly effective in controlling excessive bleeding.
  • GnRH Analogs (Monthly or 3-Monthly Injections): These create a temporary menopausal state by suppressing estrogen production in the body. This achieves a reduction in myoma size of up to 30-50% and a marked decrease in bleeding. However, they have menopausal side effects such as hot flashes and a risk of bone loss, and are generally used for a maximum of 3-6 months to shrink myomas before surgery to facilitate the operation, or to correct severe anemia.
• Non-Hormonal Medications:
  
  • Tranexamic Acid: This is a non-hormonal medication that helps reduce the amount of menstrual bleeding. It is used only on menstrual days.
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Pain relievers such as ibuprofen and naproxen are used to relieve myoma-related menstrual pain (dysmenorrhea).

3. Surgical Treatment:

• Surgical treatment is the definitive solution for myomas that cause severe symptoms, do not respond to drug therapy, are very large or rapidly growing, or are thought to be causing infertility or recurrent miscarriages. The choice of surgical method is determined by whether the patient wishes to have children.
• Myomectomy (Removal of the Myomas Only, Preserving the Uterus):
  
  • Purpose: To remove only the myomas while preserving the uterus. This is a suitable option for women who wish to have children or do not want to lose their uterus.
  • Methods: Different techniques are used depending on the location, size, and number of the myomas:
    
    • Hysteroscopic Myomectomy: A camera is inserted into the uterus to remove submucosal myomas (those growing into the uterine cavity) without any abdominal incision. This is the least invasive method, with very rapid recovery. It is suitable only for submucosal myomas of an appropriate size.
    • Laparoscopic Myomectomy (Minimally Invasive Surgery): A camera and surgical instruments are inserted through small incisions in the abdomen to remove myomas, usually those within the uterine wall (intramural) or on the outside of the uterus (subserosal). Compared to open surgery, this offers less pain, a shorter hospital stay, faster recovery, and better cosmetic results. However, it may not be suitable for very large or numerous myomas, and the surgeon’s experience is important.
    • Robotic Myomectomy: This is laparoscopic surgery performed with the assistance of robotic arms. It can offer the surgeon better visualization and maneuverability, but it is more costly and not available at every center.
    • Laparotomic (Open) Myomectomy: This involves removing the myomas through a larger incision in the abdominal wall (similar to a cesarean incision, or vertical). It is preferred particularly for very large (giant) myomas, numerous myomas, or myomas located in hard-to-reach areas of the uterus. Recovery time is longer than with other methods.
  • Risks: There is a risk of myomas recurring after myomectomy. The risk of bleeding during surgery may be higher than with hysterectomy. Rarely, adhesions may form in the uterus. In patients planning a pregnancy, the mode of delivery (vaginal/cesarean) is determined according to the type of surgery performed.
• Hysterectomy (Complete Removal of the Uterus):
  
  • Purpose: This is a definitive and permanent treatment method for women who have severe myoma-related complaints and no longer wish to have children. The possibility of myoma recurrence is eliminated.
  • Methods: Hysterectomy, too, can be performed in different ways:
    
    • Vaginal Hysterectomy: The uterus is removed through the vagina. There is no abdominal incision, and recovery is rapid. However, it may not be suitable for every patient (particularly if the uterus is very large or the patient has previously had abdominal surgery).
    • Laparoscopic Hysterectomy: The uterus is removed using a minimally invasive method, through small incisions in the abdomen. Recovery is faster than with open surgery.
    • Robotic Hysterectomy: This is laparoscopic hysterectomy performed with robotic assistance.
    • Abdominal (Open) Hysterectomy: The uterus is removed through an abdominal incision. This is generally preferred when the uterus is very large or when adhesions are present.
  • Note: During hysterectomy, the ovaries are generally left in place. Since the ovaries continue to produce hormones, the patient does not enter menopause immediately (unless she is already at the age of menopause).

4. Other Interventional Treatment Methods: These methods are used less frequently and are suitable for specific patient groups:

• Uterine Artery Embolization (UAE): This procedure involves entering through a groin blood vessel under angiographic guidance to block the uterine arteries that feed the myomas with small particles. It causes the myomas to shrink and symptoms to decrease. It is performed by interventional radiologists. It is generally not recommended for patients wishing to have children, as it may affect blood flow to the uterus and ovaries.
• Magnetic Resonance-guided Focused Ultrasound (MRgFUS): This method uses high-intensity ultrasound waves delivered from outside the body, focused on the myoma tissue with the help of MR imaging, to destroy it with heat. It does not require an incision or anesthesia. However, it is not suitable for every type or location of myoma, and more data is needed on its long-term outcomes and effects on pregnancy.

Recovery and Follow-up After Myoma Treatment

The post-treatment process varies depending on the method used:

• Follow-up and Observation: Regular checkups (every 6 months to 1 year) continue to see whether there are any changes in symptoms or a rapid increase in myoma size.
• Medical Treatment: The effectiveness of the medications and any possible side effects are regularly monitored. It should be kept in mind that symptoms may return after the medications are discontinued.
• Surgical Treatment:
  
  • After Myomectomy: Recovery time varies depending on the type of surgery performed (hysteroscopic, laparoscopic, open). Pain control, wound care, and the timing of return to normal activities are determined by the doctor. Women planning a pregnancy are advised to wait a certain period of time after surgery (usually 3-6 months). Whether delivery needs to be by cesarean section is decided by the doctor based on the extent of the surgery and the condition of the uterus. Since myomas can recur, annual gynecological checkups are important.
  • After Hysterectomy: Recovery time again depends on the type of surgery. Since the uterus has been removed, menstruation no longer occurs and pregnancy is no longer possible. If the ovaries have been preserved, no menopausal symptoms occur. Sexual life is generally not affected, or in some cases may improve as pain decreases. Counseling may be helpful for concerns related to hormonal changes and body image.

Myoma Treatment in Ankara: Safe and Effective Solutions with Prof. Dr. Nuray Bozkurt

Prof. Dr. Nuray Bozkurt offers her patients in Ankara comprehensive care, drawing on her up-to-date knowledge and experience in the diagnosis and treatment of myomas:

• Accurate and Detailed Diagnosis: She accurately determines the location, size, number, and type of myomas using advanced ultrasonography and, when necessary, other imaging methods.
• Personalized Treatment Plan: Taking into account factors such as the patient’s age, symptoms, myoma characteristics, desire to have children, and personal preferences, she decides on the most appropriate treatment option (follow-up, drug therapy, surgery) together with the patient.
• Minimally Invasive Surgical Expertise: When surgery is required and appropriate for the patient, she is experienced in performing minimally invasive methods such as laparoscopic and hysteroscopic surgery, which provide faster recovery (or refers the patient to teams experienced in this area).
• Safe Surgical Practice: When open surgery (myomectomy or hysterectomy) is required, she performs the operation in fully equipped hospital facilities in Ankara, prioritizing patient safety.
• Uterus-Preserving Approach: In patients who wish to have children or want to preserve their uterus, she prioritizes the myomectomy option and takes care to preserve the uterus.
• Comprehensive Information and Follow-up: She explains the risks and benefits of treatment options in detail, informs the patient about the pre- and post-operative process, and provides close follow-up.
• Patient-Centered Approach and Communication: She offers accessible communication throughout the treatment process, understanding her patients’ concerns, patiently answering their questions, and remaining easily reachable (0538 983 18 78)(0312 284 00 12).

If you are experiencing symptoms related to myomas, have been diagnosed with a myoma, or would like a second opinion regarding your current condition and treatment options, you can meet with Prof. Dr. Nuray Bozkurt at our clinic in Ankara to determine the most suitable approach for your situation. To create a personalized treatment plan tailored to your health, comfort, and future plans, please call us at 0538 983 18 78 to schedule an appointment.