The Detergents And Disinfectants For Instruments And Surfaces (Hexanios - Surfanios)

Myoma Uteri (Leiomyoma, Fibromyoma, Fibroid)

• It is the most common benign solid pelvic mass in women and the most common genital tract tumor after the age of 35. It is a benign uterine tumor that does not have a capsule, but is well-defined (pseudocapsulated), composed of smooth muscle and fibrous elements.

• Myomas are the most common cause of laparotomy and hysterectomy in women.

• The incidence varies with age (30-70%). While it is observed in 40% at the age of 35, it is observed in approximately 70% at the age of 50. Most fibroids grow slowly. After the age of 35, the growth rate decreases.

etiology

• Although the etiology has not been clearly determined, its relations with genetic, hormonal and growth factors have been defined.

► Genetic factors: Fibroids are monoclonal tumors of smooth muscle cells of the myometrium. Chromosomal anomalies are observed in 40% of the cases and are the most common.

► Hormonal factors: Myomas are rarely seen before puberty, they are most common in women of reproductive age and regress in the postmenopausal period.

► Growth factors: Local growth factors are secreted from smooth muscle cells and fibroblasts and they stimulate myoma growth. Many growth factors are produced in excess from fibroid tissue; TGF-(3, bFGF, EGF, PDGF, IGF and prolactin

Risk factors

• Age: The incidence increases with age.

• Early menarche

• Family history: The risk increases 2.5 times in women whose first-degree relatives have fibroids.

• Ethnicity: It is 2.9 times more common in black people.

• High BMI and obesity

• Diet: While the incidence increases in a diet rich in red meat, it decreases in a diet rich in green vegetables.

• Polycystic ovary syndrome: The risk increases.

Exercise, multiparity, smoking, late menarche and being in the postmenopausal period reduce the incidence of fibroids.

There is no definite relationship between the use of combined oral contraceptives and the development of new fibroids.

• There is no relationship between the incidence of previous history of STD (HSVI-II, CMV, EBV, chlamydia), history of IUD use or exposure to talcum powder.

Classification

• intramural fibroids: These fibroids located in the myometrium are the most common type. If there is only one fibroid that enlarges the uterus symmetrically, it is called Kugel's fibroid.

• Submucous fibroids: They are located just below the endometrium. As it grows, it can completely fill the endometrial cavity and enlarge the uterus. Sometimes the cervix can expand and come out, which is then called uterine fibroids. Fibroids born in the vagina are usually associated with infection. Abnormal uterine bleeding is common in submucosal fibroids.

• Subserous fibroids: Myoma is located just below the uterine serosa. It usually enlarges the uterus asymmetrically. Sometimes it extends into the abdominal cavity, as it grows, it becomes a fibroid connected by a stalk (stem fibroid). Rarely, this fibroid attaches to a place such as the abdominal wall, omentum, mesocolon, begins to feed from there, and then the stem degenerates and disappears, this is called parasitic fibroid.

• Intraligamentary fibroids: Subserous fibroid If it grows into lig. latum , it gets this name. Surgery is difficult due to their proximity to the ureter and iliac vessels.

• Cervical fibroids: They originate from the cervix. Since they grow towards the parametrium, their surgery is difficult.

• Intravenous leiomyomatosis: It is rare. Fibroid parametrium and in the lig.latum veins  It proceeds in a polypoid fashion .

FIGO Classification of Fibroids by Localization

It is classified as submucous, intramural, subserosal and transmural.

► Type O: It is intracavitary and completely contained in the cavity (stemmed submucosal fibroid)

► Type 1: Submucous fibroids, less than 50% of which is inside the myometrium

► Type 2: Submucous fibroids with 50% or more of them in the myometrium

► Type 3: Myoma without intracavitary component and adjacent to the endometrium

► Type 4: Intramural fibroids that do not cause extension in the endometrium or serosa

► Type 5: Subserosal fibroids with at least 50% intramural

► Type 6: Subserosal fibroids with less than 50% intramural

► Type 7: Stemped subserosal fibroids

► Type 8: Fibroids unrelated to the myometrium; fibroids in the cervical, round or broad ligament, parasitic fibroids

► Transmural fibroids (hybrid fibroids): These are fibroids associated with both the endometrial and serosal surface. The association number is noted first with the endometrium and then with the serosa (sample type 2-5).

degenerations

• Hyaline degeneration: It is the most common and clinically mildest degeneration type. It is characterized by the filling of smooth muscle cells with fibrous connective tissue.

• Cystic degeneration: If the hyaline degeneration continues, cystic areas develop as a result of liquefaction in certain areas of the myoma.

• Fatty degeneration: Rarely, in severe hyaline degeneration, the fibroid may have a yellow, oily appearance.

• Calcific degeneration: It is mostly seen in postmenopausal women and subserous fibroids. Sometimes it can be observed on direct abdominal radiographs.

• Hemorrhagic degeneration

• Necrotic degeneration: It occurs as a result of torsion of pedunculated subserous fibroids. It shows signs of acute abdomen.

• Red (carneous) degeneration: It is a subgroup of necrotic degeneration. It is frequently observed in pregnancy. It is ischemic, necrotic degeneration that develops due to rapid growth of the tumor. It is the fastest growing type of degeneration.

• Malignant (sarcomatous) degeneration: It is the least common degeneration.

Clinic

• Fibroids are mostly asymptomatic. The most common symptoms associated with fibroids are abnormal uterine bleeding, pelvic pain (such as dysmenorrhea), and a feeling of pelvic pressure.

• Abnormal uterine bleeding is common due to myomas, and the most common symptom and the most common surgical indication for fibroids is abnormal uterine bleeding (most commonly menorrhagia).

• Fibroid degeneration can cause pelvic pain and is often described as dysmenorrhea or dyspareunia. Acute pain rarely develops as a result of torsion or infarction of a pedunculated fibroid. Fibroids may also be associated with back pain.

• Increase in uterine volume due to myoma is associated with compression symptoms and can be described as a feeling of pelvic pressure. Frequent urination, nocturia or urgency may occur as a result of the fibroid's pressure on the bladder. Ureteral compression is encountered 3-4 times more on the right because the left ureter is behind the sigmoid colon. Again, as a result of compression on the rectum, the patient may have constipation and tenesm. Thrombophlebitis may be due to pelvic congestion.

• Submucosal fibroids cause distortion in the uterine cavity, reducing fertility, and removing submucosal fibroids increases fertility. However, subserosal fibroids do not affect fertility and removal does not increase fertility. Intramural fibroids slightly reduce fertility, but removal does not increase fertility.

• Polycythemia can also be seen in very large fibroids. The cause of polycythemia is the increase in erythropoietin produced by the fibroids.

Diagnosis

• The diagnosis of clinically significant subserosal and intramural fibroids can usually be made by pelvic examination. The uterus is larger than normal, firm, irregularly circumscribed, and there is no tenderness. However, small submucous fibroids cannot be detected by pelvic examination.

• During curettage, the diagnosis can be made when the curette gives a jumping sensation in the wall of the endometrial cavity or the cavity feels uneven.

• Ultrasonography is the most useful method in the differential diagnosis of fibroids and other pelvic masses. MRI more precisely determines the number, diameter, position of fibroids and their relationship to the endometrial cavity, and submucosal fibroids are best detected with MRI. Hysteroscopy, hysterosalpingography, laparoscopy, CT, direct abdominal radiography, IVP are other auxiliary diagnostic methods.

• Definitive diagnosis of fibroids is made by pathological examination.

Treatment

• Treatment options; observation, medical treatment, myomectomy (hysteroscopic, laparoscopic, abdominal), hysterectomy and uterine artery embolization.

• In the presence of fibroids in asymptomatic women, the decision should be made according to the patient's fertility wishes. Asymptomatic women are followed if there is no desire for fertility. Untreated pregnancy may be permitted in women with uterine fibroids who desire fertility and do not cause cavity distortion. If there is a fibroid causing distortion in the cavity, myomectomy should be performed.

medical treatment

► GnRH agonists reduce uterine size, fibroid size and reduce bleeding. After 8-12 months after discontinuation of treatment, the fibroid returns to its pre-treatment size. For this reason, they are used either in the perimenopausal period or especially in cases with medical complications for surgery, to reduce symptoms until menopause or to facilitate the operation by shrinking myoma in cases where conservative treatment will be applied, that is, myomectomy will be performed.

► GnRH antagonists also reduce myoma size.

► Mifepristone reduces myoma size similar to GnRH agonists.

► Ullipristal is a selective progesterone receptor modulator with mifepristone-like effects.

► LNG -IUD can be used in selected patients with myoma-related menorrhagia. It can be used in patients who do not have a uterus older than 12 weeks and have a normal uterine cavity.

Aromatase inhibitors; Since the aromatase level is high in fibroids, its use in the treatment of fibroids seems reasonable, but more data is needed for clinical use.

Medical treatment indications in myoma uteri
	NSAİ	COC	Depot medroxyprogesterone	LNG-IUD	GnRH agonist	ulipristal
dysmenorrhea	+	+	+	+	+	+
menorrhagia	-	+	+	+	+	+
pelvic pressure	-	-	-	-	+	+
infertility	-	-	-	-	+	-

Surgical treatment

► There is no indication for surgery in asymptomatic patients. surgical options; abdominal myomectomy, laparoscopic myomectomy, hysterescopic myomectomy, endometrial ablation, abdominal hysterectomy, laparoscopic hysterectomy and vaginal hysterectomy.

► Hysterectomy: It can be performed in symptomatic patients who do not desire fertility in the future.

► Myomectomy: Myomectomy is a surgical treatment option for women who want to preserve fertility. Myomectomy can also be done by laparoscopy. Submucous fibroids (type O) can be easily removed by hysteroscopic surgery (N J 2) or vaporized by laser. The recurrence rate after myomectomy is 50% and 1/3 of these patients undergo surgery again.

surgical treatment indications

1. Abnormal uterine bleeding that is resistant to medical treatment and can cause anemia

2. Severe dysmenorrhea, dyspareunia or severe groin pain

3. Acute pains caused by torsion of pedunculated fibroids

4. Myoma born in the vagina and causing a feeling of pressure

5. Ureteral obstruction and formation of hydronephrosis

6. Infertility due to fibroids only

7. Recurrent pregnancy loss as a result of the disorder of the endometrial cavity

8. Reaching large sizes to create pressure findings

9. Rapid increase in uterine size in the postmenopausal period

► Endometrial ablation: It can be used in the treatment of abnormal bleeding due to fibroids in selected patients with no expectation of fertility.

► Uterine artery embolization: Uterine artery embolization may be preferred in selected patients, but it is recommended not to be used in patients with fertility desire.

Fibroids and Pregnancy

• 5% of pregnancies have uterine fibroids. The course of fibroids during pregnancy is variable and unpredictable; however, most fibroids do not increase in diameter during pregnancy. 30% of fibroids grow during pregnancy and this growth is greatest in the first 10 weeks. Fibroids that have grown during pregnancy regress four weeks after birth.

• When they are large, they can cause the following complications:

► Abortion

► Early pregnancy bleeding

► Intrauterine growth retardation

► Preterm action

► Placental settlement anomalies

► Malpresentation

► Premature rupture of membranes

► Placental abruption

► Postpartum atony bleeding

► Rarely, fetal damage due to mechanical compression of myoma can be seen (torticollis, etc.).

• 5% myoma degeneration is seen in pregnancy and the most common type of degeneration during pregnancy is red degeneration and mimics acute abdomen.

The most appropriate treatment is rest and the use of nan-narcotic analgesics (ibuprofen). If the result is not obtained, first narcotic analgesic is used, if still unsuccessful, laparotomy is performed. Myomectomy during pregnancy is not recommended as it will cause both excessive blood loss and fetal loss; but it can still be tried as a last resort. Tocolytic therapy is given to the patient in the postoperative period.

• Caesarean section is commonly preferred in pregnant women with fibroids. It is appropriate not to perform myomectomy in the pregnant uterus during cesarean section, but it can be done in selected patients.

BENIGN ADNEXIAL MASSES

• 60% of adnexal masses are nonneoplastic (functional cysts). In differential diagnosis

case age dp is very important.

• Differential diagnosis in women of childbearing age is many and varied. Both benign and malignant tumors can occur. Pregnancy should be kept in mind during this period.

• In premenarchal and postmenopausal women, an adnexal mass must be met with suspicion and investigations for the diagnosis should be started immediately.

• Less than 2% of ovarian cancers occur in childhood and adolescence. In this age group: 1% of tumors are ovarian tumors. Two-thirds of ovarian neoplasia seen before the age of 20 are germ cell tumors. The most common neoplastic tumor in children and adolescents is mature cystic teratoma.

• Any ovarian enlargement in the postmenopausal period should be considered malignant until proven otherwise.

• Benign-malignant distinction of ovarian kits is made as a result of pathological evaluation. True functional cysts regress spontaneously after 4-6 weeks of follow-up.

Distribution of adnexal masses by age groups
Newborn	prepubertal	adolescent	reproductive	perimenopausal	postmenopausal
functional ovarian cyst	functional ovarian cyst	functional ovarian cyst	functional ovarian cyst	Fibroid
Germ cell ovarian tumor	Germ cell tumor of the ovaries	Pregnancy	Pregnancy	Epithelial ovarian tumor	functional ovarian cyst
		Germ cell tumor of the ovaries	Leiomyomas	functional ovarian cyst	bowel disease
		Obstructed vaginal or uterine anomalies	Epithelial ovarian tumor		Metastasis
		Epithelial ovarian tumor

FUNCTIONAL OVARY CYST

Follicle cyst

► It is the most common functional ovarian cyst. In cases where there is no ovulation, they are cysts filled with clear fluid, with a wall over 3 cm of granulosa cells.

These cysts can reach 8 cm in diameter and often disappear spontaneously within 4-8 weeks.

Corpus Luteum Cyst

► They are unilateral and measure 3-11 cm. They can cause local pain and tenderness.

They usually regress spontaneously within 1-2 months. These cysts can rupture frequently in the 20-26 days of the cycle. and cause intra-abdominal bleeding. Women who use anticoagulants are particularly at risk. It is seen more on the right side and following coitus. Clinical findings of corpus luteum cysts are confused with adnexal torsion. It can be confused clinically with ruptured ectopic pregnancy since it usually causes amenorrhea or delayed menstruation. It is the most frequently ruptured cyst that causes hemoperitoneum.

Functional ovarian cysts tend to rupture more frequently than neoplastic ovarian tumors.

Theca Lutein Cyst (hyperreactio luteinalis)

► They are the rarest of the functional cysts, They are usually bilateral and mostly occur during pregnancy (especially molar pregnancy and multiple pregnancy). These cysts are usually large (30 cm) and multicystic. Since high hCG is a risk factor, it is associated with molar pregnancy, multiple pregnancies, diabetes, Rh isoimmunization, clomiphene citrate, ovulation induction with hMG or FSH, and use of GnRH analogues. They may regress spontaneously.

The most common benign ovarian neoplasia is mature cystic teratoma.

Diagnosis

• A complete pelvic examination (including a rectovaginal examination) should be performed. USG is very valuable in diagnosis and is a primary diagnostic tool especially in adolescents. Transvaginal USG gives more accurate and reliable results in the diagnosis of pelvic masses compared to transabdominal USG.

Ultrasonography criteria of adnexal masses

Benign

- Diameter< 8 cm

- Unilocular cyst

- Smooth surface

- No Ascites

- unilateral

- mobile

- Thin-walled

- No internal echogenicity

- No additional abdominal organ pathologies

- No neovascularization

- Doppler normal

- No internal echogenicity and thick septation

malignant

- Diameter > 8-10 cm

- Multilocular - solid mass

- Uneven surface

- There is Ascites

- bilateral

- Fixed (adhesive with surrounding textures)

- thick walled

- There is internal echogenicity

- There are additional abdominal organ pathologies

- There is neovascularization

- There are Doppler changes

- Internal echogenicity and thick septation

Solid ovarian masses

► Fibroma and fibrothecoma (most common)

► Sex-cord stromal tumors

► Krukenberg tumor

► Ovarian leiomyoma and leiomyosarcoma

► Carcinoid tumor

► Primary lymphoma

► Transitional cell tumor (Brenner)

► Ovarian remnant syndrome

Because of its low sensitivity and specificity, Ca-125 is not used as a diagnostic marker in the presence of adnexal mass, especially in premenarchal and reproductive age women. In the postmenopausal period, it is used because its sensitivity and specificity increase.

Ultrasonographic feature is more helpful than Ca-125 in determining the risk of malignancy in premenopausal women. Findings suggestive of malignancy in ultrasonography; solid component, mural nodule, papillary extension and ascites.

Differential diagnosis

• Uterine Masses: Pregnancy and uterine leiomyomas should be kept in mind.

• Tubal masses: Tubal ectopic pregnancy, tubo-ovarian abscess

• Paraovarian cysts

• Other: Intestinal masses

Management

Adnexal Mass Management in Premenarchal and Adolescent Periods

► The majority of unilocular cysts in premenarchal (prepubertal) girls are benign, and unilocular cysts usually regress within 3-6 months. After cyst aspiration, the probability of recurrence of the cyst is high. Absolute karyotype should be checked in prepubertal multilocular cysts. In contrast, solid, cystic and enlarging masses larger than 8 cm require surgical exploration.

Adnexal Mass Management in Reproductive and Postmenopausal Periods

► Laparotomy should be planned for clinically suspicious lesions (large, solid area weighted, fixed or irregularly circumscribed) in premenopausal patients.

► In postmenopausal patients, complex adnexal masses should be taken to laparotomy regardless of their diameter. However, if the asymptomatic, <5 cm, uniloculated, thin-walled cysts are accompanied by a normal CA-125 level, their malignant potential is quite low and a conservative approach (follow-up with USG every 2-3 months) can be applied.

Management in pregnancy and adnexal mass

► In case of rupture or torsion and causing labor obstruction, it should be taken into surgery.

► According to tumor size; If the diameter is >10 cm, all masses should be surgically removed. If the diameter is < 5 cm, follow-up is sufficient. If the diameter is between 5-10 cm, if it is a simple mass, it is followed by Doppler ultrasonography and MRI, and if it has a complicated appearance, it is taken to surgery. Elective surgeries are preferably in the weeeks 16-20 during pregnancy.

Treatment

• In patients with functional ovarian cysts, there is no difference between suppression therapy with COC and observation (follow-up) in terms of shrinkage or complete disappearance of the cyst. Although COCs are protective for functional ovarian cyst formation, they are not helpful in the treatment of large functional cysts.

• If the mass is thought to be benign in cases undergoing surgery, the primary approach should be laparoscopy. In addition, conservative surgical approaches (cystectomy, cyst capsule coagulation) should be tried first in cases of infertile and reproductive age group. In addition, cyst aspirations performed with ultrasonography, which is another approach, have a high risk of recurrence (50%).

• Surgical exploration is absolutely necessary in cases with suspected torsion or malignancy. In addition, ultrasound-guided aspiration of ovarian cysts with suspected malignancy should be avoided.

• Monitoring of ovarian blood flow in Doppler ultrasonography does not definitively rule out torsion. Today, in the treatment of ovarian torsion, even if it appears necrotic, detorsion and cystectomy with laparoscopy are recommended.