Uterine myomatosis

• Uterine myomatosis refers to the development of multiple uterine fibroids in a woman's uterus.
• For the treatment of uterine myomatosis, medical or surgical treatment can be chosen.
• In cases where uterine myomatosis presents severe symptoms, surgical removal of uterine fibroids is the best option.

Uterine myoma refers to the entity whereby the uterus in women is characterised by the presence of several fibroids within the uterus. The concept of myoma is understood as a benign tumour that forms and develops from one or more of the layers that make up the walls of the uterus in women.

Uterine myomatosis, therefore, encompasses multiple types of uterine fibroids that can be classified according to their typology, their location and the symptoms they cause in the female reproductive system.

Uterine myomatosis as a complex and global entity is found, according to surveys and the latest clinical trials, in at least 20-40% of women of reproductive age. 

This figure does not mean that all women affected by uterine myomatosis have accompanying symptoms, since in at least 75% of them, these alterations in the layers of the uterus are asymptomatic, i.e. they do not affect their daily lives and therefore remain undiagnosed.

However, uterine myoma is a global disease that will affect most women throughout their lives. In a recent study, the presence of fibroids was detected in more than 80% of uterine specimens examined in pathology laboratories when they had to be removed because of fibroids or another cause related to the female reproductive system.

Common symptoms of uterine myomatosis in women are prolonged and sometimes more painful menstruation than usual and episodes of intermenstrual bleeding that can lead to a long-term diagnosis of anaemia.

The relationship between uterine myomatosis and pregnancy problems has been studied at length and has been widely proven. It is currently estimated that 10% of women who suffer or suffer repeated miscarriages suffer from uterine myoma and that 5% of female causes of infertility can be associated with the presence of this entity in the uterus of women.

Sometimes, the removal of uterine fibroids that cause pregnancy problems for women can resolve this situation and improve the probability of carrying a pregnancy to term, avoiding possible miscarriages.

Conception and infertility specialists always recommend a thorough study of this probability in couples who have been trying to conceive for at least one year without the use of contraception, which is considered the definition of infertility by most gynaecological and obstetric societies and consensuses.

However, 11% of couples in which the woman has uterine myomatosis have managed to achieve a normal pregnancy and delivery despite having these abnormalities. This explains how complicated the reproductive process is and how uterine myomatosis may play a role but is not the only necessary cause.

Uterine myomatosis must be suspected in order to reach an accurate diagnosis. In some cases, the gynaecologist will examine the woman for uterine fibroids, but this is not usually the case.

Generally, the patient will consult a gynaecologist alleging the presence of pelvic pain, repeated urinary infections in which a urological process has been ruled out as the cause, increased menstrual bleeding or abnormal uterine bleeding and/or fertility problems. These clinical features already introduce the entity of uterine myomatosis as the main suspected disease in the differential diagnosis.

After the initial suspicion, a gynaecological examination is carried out by palpation of the uterus through the abdomen and vagina, which should reveal an enlarged uterus with areas of greater consistency than usual. The second step is usually a transvaginal ultrasound scan, which generally confirms the presence of uterine fibroids, if present, in 95% of women affected by uterine myomatosis.

If the woman does not present major alterations and the size calculated by transvaginal ultrasound does not exceed 5 cm, it is not usually necessary to study uterine myomatosis further. 

On the other hand, if the accompanying symptoms cause intense symptomatology or major alterations in the daily life of the affected woman and the need for surgery to eradicate the fibroids must be considered, it is necessary to go deeper into the diagnosis to confirm the specific type of fibroid, its extension, its depth and its relationship with other abdominal organs with which it may come into contact.

For the continuation of the study it may be necessary to carry out a nuclear magnetic resonance (NMR) that allows us to improve the diagnosis in terms of its typology and confirm the presence of interactions with the rectum or bladder. Prior to any surgical procedure, it may be necessary to perform a hysterosalpingography, which consists of a series of abdominal X-rays after injecting a contrast agent into the uterus through the vagina.

This diagnostic technique will show how the cavity of the uterus is filled, and thus whether or not the fallopian tubes (tubes that connect the uterus to the ovaries and which should normally be permeable) are obstructed by fibroids.

Finally, it may be necessary, especially if it is essential to take biopsies of the myoma, to perform a diagnostic hysteroscopy. This technique involves the introduction of a metal tube with an optic at its distal end that allows the gynaecologist to visualise the uterus inside and, through one or two holes in the tube, to introduce small surgical forceps that allow the biopsy to be taken. This type of diagnostic technique allows a real observation of the intrauterine space, which gives the specialist a better idea of the current situation of the fibroids and the uterus.

Uterine myoma can be treated by two types of therapeutic interventions. One is through medical treatment, generally based on a combination of oestrogens and progestogens (similar to contraceptive pills) which, due to the intense relationship between uterine fibroids and female sexual hormones, can reduce their size and even make them disappear.

This type of therapeutic intervention for uterine myomatosis has two objectives: the first is to reduce the size of fibroids prior to scheduled surgery, and the second is to reduce the size of small fibroids in women who have not fulfilled their reproductive wishes or who, due to their own personal characteristics, do not require surgical treatment.

The other type of therapeutic intervention is surgical removal of uterine fibroids. At the present time there are a multitude of different techniques that increasingly seek to reduce the incidence of the intervention and focus more on the removal of fibroids without the need to completely remove the uterus. 

Abdominal myomectomy, laparoscopic myomectomy and surgical hysteroscopy are the techniques of choice for young women who do not wish to have their uterus removed.

However, for older women in whom the presence of uterine myomatosis is very severe and who have already fulfilled their reproductive wishes, removal of the uterus by hysterectomy is currently the safest option for a definitive solution to uterine myomatosis.