Cysts, fibroids and other benign lesions

March for research!

Is this a good time to emphasize how important preventive tests are? ;) I think so – every woman should go to the gynecologist at least once a year for a check-up and have an ultrasound and cytology. Basic blood counts should be done at a similar frequency, regardless of gender. I know that time and possibilities vary – but is there really anything more valuable than health?

What are uterine fibroids?

Uterine fibroids are the most common benign tumors of the reproductive tract, arising from the myometrium (or more precisely, from its smooth muscle tissue). The cause of fibroids is the fluctuation of sex hormone levels. The tumors take on a spherical, regular shape and do not result in metastases or invasion of other tissues. Until recently, the formation of fibroids was associated only with the level of estradiol in the body, but currently an increasing role is being attributed to pathways related to progesterone. In any case, their formation and growth is dependent on hormones, which is why in the postmenopausal period, when the ovaries quiet down and stop producing estradiol and progesterone, we often observe involutional changes in fibroids, i.e. their simple reduction or disappearance.

Uterine fibroids – types

Depending on their location, uterine fibroids are divided into:

• Submucosal – in contact with the endometrium. Their size can range from a few to a dozen or so centimeters. The most common symptoms that accompany them are heavy periods and intermenstrual bleeding disorders. People diagnosed with uterine fibroids may have problems getting pregnant due to difficult embryo implantation.
• Intramural – arising from the walls of the uterus. These are the most common fibroids in the reproductive tract. They can cause frequent urination or constipation.
• Subserosal – arising more “outside” the uterus, just under its serosa. They usually do not cause any symptoms, and in pregnant women do not generate any additional discomfort or pathology during pregnancy. When the fibroid grows larger and presses on nerve endings, it can cause back pain, increased abdominal circumference and – similarly to intramural fibroids – constipation and more frequent urination.

The exact classification of fibroids created by FIGO (International Federation of Gynecologists and Obstetricians) is available in the article recommended below :)

Treatment – ​​When Are Fibroids Dangerous?

Not all of these types of tumors require treatment – ​​sometimes observation and check-ups are enough. It all depends on the type of lesion, its growth rate and the accompanying symptoms.

Surgical treatment

In surgical treatment , radical treatment is possible, i.e. total removal of the uterus ( hysterectomy ), amputation of the uterine body ( subtotal hysterectomy ) or possibly fertility-sparing treatment, i.e. enucleation of the fibroids ( myomectomy ).

Subtotal hysterectomy involves removing the uterine body, where fibroids usually form. The fallopian tubes are also removed (as a preventive measure against ovarian cancer, which often develops from their fimbriae), which are useless without the uterine body, because they lose their basic function, which is transporting a fertilized egg to the uterus. During the operation, the cervix is ​​left in place – provided, of course, that there are no fibroids in it. After amputation, we must remember that not only are further check-ups with a gynecologist necessary, but also that regular cytological tests should be continued.

A hysterectomy is a more radical procedure. During this procedure, the entire uterus (body and cervix) is removed, as well as the fallopian tubes. After a hysterectomy, you still need to attend regular doctor's visits, but in this case, they mainly consist of a general assessment of the vagina with a speculum and the pelvis with a transvaginal ultrasound.

Myomectomy

The solution for people planning a pregnancy or who have other reasons to spare their uterus is myomectomy , or enucleation of the fibroids. The fibroid beds are sutured, and the resulting wound heals spontaneously. The entire organ remains unchanged - only the fibroid is removed, and we - after waiting an appropriate amount of time after the surgery - can try to get pregnant. The minimum period is considered to be 3 months, of course depending on the size of the fibroid, its location and possible complications during the surgery. Each procedure is different and each patient requires an individual approach. The time after which we can start trying for a child should be consulted with the doctor who performed the surgery. As with most procedures of this type, we have a choice: laparotomy , minilaparotomy and laparoscopy (different in the level of interference with the abdominal wall). The decision on which procedure is appropriate and best is of course made by a specialist. We usually try to start with the least invasive procedure, i.e. laparoscopy, but unfortunately this is not always possible.

Embolization

Embolization of fibroids is an option for those who are not convinced by surgical treatment. It involves closing the vessels supplying blood to the fibroid. It is not a surgical procedure, so it does not require general anesthesia, and hospitalization lasts similarly to laparoscopy (about 2 days). What does embolization involve? The doctor uses a catheter (under local anesthesia) through the femoral artery to reach the vessels that he wants to "close" and injects an embolization agent into them. The fibroid thus has its nutrition cut off and with time (the effects of the procedure usually appear after about 3 months) it "withers away".

Thermoablation

Another method – thermoablation of fibroids – is performed using a HIFU device ( high-intensity focused ultrasound ). Its strengths include non-invasiveness and effectiveness. The patient leaves the clinic the same day, and the symptoms of fibroids disappear within 6 months. This method of treatment is still at the clinical trial stage in our country and is not widely available, but those interested can easily find a place on the Internet that specializes in it :)

Pharmacotherapy

Pharmacological treatment (hormonal contraception) is used primarily to alleviate symptoms in patients with existing contraindications to surgical treatment.

Cervical cysts

I invite you to read my previous article about the diseases, treatment and prevention of cervical diseases .

One of them are Nabothian cysts , which can take the form of small vesicles. They are filled with pus (in the case of infection) or mucus. The cysts are formed as a result of the clogging of the mucus-producing glands of the cervix by the epithelium that grows in them. Their presence in the body usually affects people of reproductive age, less often younger people.

There are several methods for removing Nabothian cysts - if the doctor decides it is necessary (this applies to symptomatic cysts), they are punctured and their liquid content is removed, and then either the remnants are frozen with liquid nitrogen or they are removed with a laser. Usually, however, they burst spontaneously.

Benign ovarian lesions

Other non-malignant changes that may develop in the reproductive organs are those that develop in the ovaries, i.e. the entire cross-section of their cystic changes and tumors.

Ovarian cyst

Ovarian cysts are cysts that usually form as a result of hormonal disorders in people of reproductive age. They occur singly or in multiple forms. In the latter case, especially if they appear on both ovaries, they can actually affect the possibility of getting pregnant and be the cause of infertility.

Ovarian cyst – types

Ovarian cysts are often detected during routine ultrasound because they may not cause any symptoms. In the case of unabsorbed and symptomatic changes, further diagnostics are necessary (tumor markers, hormone levels) and, above all, determining the type of cyst itself in order to determine further treatment.

Ovarian cysts are divided into:

• Functional , including:

- Follicular cyst . This occurs when the stubborn Graafian follicle, in which the egg matured, did not burst duringovulation and continues to grow and grow. Eventually, it either absorbs on its own or we have to remove the serous cyst that has formed laparoscopically. If blood enters the follicle after it bursts, a hemorrhagic cyst may form.

- Corpus luteum cyst . During the menstrual cycle, the Graafian follicle bursts, which then transforms into the corpus luteum, which disappears if fertilization does not occur (you can read more about this whole process here ). Sometimes, however, this does not happen and a cyst forms in place of the corpus luteum.

• Nonfunctional ovarian cysts:

- Endometrial . They occur with endometriosis, which I wrote about here . In the course of the disease, tissues of the uterine lining can "implant" in the ovary and produce cysts filled with dark brown blood (called chocolate due to their color).

A word about endometriosis – it is an incredible disease, the nooks and crannies of which we are still discovering in new clinical studies. My close friend wrote her doctorate on the subject of endometriosis, and together we did an internship at a center dealing with the treatment of this disease in Germany. I will tell you quite honestly that the experience I have gathered on the subject has led me to the conclusion that there are few diseases that, despite their mild nature, have such a wide range of possibilities for spreading and recurring, and additionally give patients such ailments and symptoms as endometriosis.

- Dermoid (skin-like) , also known as teratomas . A dermoid cyst is filled with ectoderm products, i.e. the germ layer, from which, among other things, epidermal cells and skin products, i.e. hair, nails, teeth and sebum, are formed. Cysts are characterized by the fact that they are more permanent in their structure and unfortunately have a greater probability of being a malignant change, which is why they require rapid surgical intervention.

Ovarian cyst and pregnancy

In a person with a follicular ovarian change, the Graafian follicle does not rupture – the egg cannot be released, so fertilization is not possible. These and other functional ovarian cysts usually only require observation and spontaneously resorb during the next cycle. If this does not happen, hormonal contraceptive therapy is used .

The previously mentioned endometrial (chocolate) cysts also make it difficult to get pregnant. They can impair ovarian function, disrupt the cycle and ovulation, as well as cause corpus luteum failure – hence the need for surgical treatment (laparoscopic).

The appearance of numerous functional cysts may be a symptom of polycystic ovary syndrome (PCOS) , the most common hormonal disorder in the productive age. Getting pregnant in a person struggling with polycystic ovary syndrome is difficult due to impaired (or absent) ovulation. This condition is caused by abnormal levels of hormones that prevent the development of an egg inside the ovary.

Are ovarian cysts during pregnancy dangerous?

If the ovarian cyst is filled with fluid and has fairly thin, flexible walls, it will probably resolve on its own and there is no reason to worry. Regular check-ups and monitoring of the size of the lesion are key.

Treatment options for cysts in pregnant women are limited. Surgical interventions carry the risk of miscarriage, as does leaving the cyst. Any symptoms and disorders are therefore an indication for surgical treatment, which should ideally be performed in the second trimester of pregnancy.

Ovarian Cyst Treatment

So when are medications enough and when is surgery necessary?

Ovarian cyst treatment is usually implemented when the patient is experiencing pain, if she feels an unpleasant pressure on her bladder, and also when she is planning a pregnancy. What we fear most is the "twisting" of the cyst - as soon as you feel severe abdominal pain, do not hesitate and report to your doctor or directly to the hospital as soon as possible. An ovarian cyst can be responsible for the occurrence of abnormal bleeding and disrupt the functioning of the ovary itself, and consequently - our menstrual cycle.

Depending on the symptoms and course, the first course of action for ovarian cysts is medical observation , the second – pharmacological treatment , and the third – surgery .

• Observation is nothing more than reporting for an ultrasound scan as often as your doctor recommends. Often, cysts do not cause any symptoms and then regress on their own. After determining the nature of the change, the doctor may decide that treatment is not necessary.
• In the case of ovarian cysts, drug therapy is possible with the functional changes I mentioned earlier. It consists of taking contraception to regulate the body's hormonal balance.
• Surgical treatment of ovarian cysts, similarly to fibroids, may consist of laparoscopy (most often), minilaparotomy or laparotomy. In my center, we mainly perform sparing treatment – ​​i.e. laparoscopic enucleation of the lesion, of course after excluding in the qualification for the procedure that the lesion may be of a neoplastic nature. For this purpose, during the examination, the possible presence of the CA 125 marker in the blood should be determined.

In some cases, the lesion is too large, is atypically located (technical reasons) or is simply suspicious. In such cases, a laparotomy should be performed. Is it possible to remove the tumour by laparoscopy while maintaining oncological asepsis? Of course, if the centre has special bags for removing the lesion. But this is also a vast subject, often causing disputes among doctors themselves.

Other benign ovarian tumors

Other benign neoplastic changes that can occur in the ovaries include various types of solid and solid-cystic tumors. These include:

• fibromas, granulomas, areolar tumors (arising from the cells of the sex cords and ovarian stroma),
• Brenner tumors (benign tumors of the ovarian mucosa).

Diagnosis and treatment depend on the size, type and symptoms of the lesion. The procedure is similar to that of an ovarian cyst.

A word about the fallopian tubes…

…because they are often neglected ;) The most common changes are peritubal cysts, usually in the form of hydroceles (i.e. simply cysts in which serous content collects). In most cases, they are absorbed by themselves – so their observation and regular check-ups are recommended. Treatment of hydroceles does not require their complete removal, it is enough to simply remove the fluid from them. Unfortunately – the fallopian tube is the most common place for ectopic pregnancy to nest . Here, too, there are several treatment options, but that is a topic for a separate article ;)

I really hope that this text will be helpful to you, and above all – it will encourage you to check any concerns or doubts. Nothing replaces a visit to the doctor, so – if you notice any symptoms or are accompanied by worrying pain – I invite you to the office! :)