Chapter 67 Myoma
Myomas (or ‘fibroids’) are very common benign uterine tumours in women.
Western medicine view
Description
Uterine myomas (also referred to as myoma, leiomyoma, leiomyomata and fibromyoma) are benign tumours that grow within the muscle tissue of the uterus. They are commonly called ‘fibroids’. Between 20% and 50% of women of childbearing age have uterine myomas. While many women do not experience any problems, symptoms can be severe enough to require treatment.
Myomas range in size from very small to larger than a melon. A very large uterine myoma can cause the uterus to expand to the size of a six- or seven-month pregnancy. There can either be one dominant myoma or a cluster of many small myomas.
There are several types of myomas differentiated according to their location (Fig. 67.1):
Myomas are sometimes attached to the uterine wall by a long stalk which is called a ‘pedicle’: if a myoma has a pedicle, it is called pedunculated.
Uterine myomas are the most common pelvic tumour in women. Myomas may be seen in as many as 1 in every 5 women of childbearing age.
Myomas usually affect women over 30. They are rare in women under 20 or in those who have gone through menopause. They are more common in African-Americans than Caucasians.
The cause of uterine myoma tumours is unknown. However, myoma growth seems to depend on oestrogen. As long as a woman with myomas is menstruating, a myoma will probably continue to grow, usually slowly.
Myomas can be so tiny that they can only be seen under a microscope. However, they can also grow very large. They may fill the entire uterus, and may weigh several pounds. Although it is possible for just one myoma to develop, usually there is more than one.
Clinical manifestations
The main clinical manifestations are as follows:
However, most of the above symptoms and signs appear only when the myoma is large. In many cases, there are no symptoms and no pain.
The treatment options for myomas are detailed in Table 67.1.
Complications
A pedunculated myoma can become twisted and cause a kink in the blood vessels feeding the tumor. This type of myoma causes pain and may require surgery.
A myoma sometimes blocks the fallopian tubes and prevents sperm from reaching and fertilizing eggs, which may cause fertility problems. In some cases, myomas may prevent a fertilized egg from implanting in the uterine lining. However, proper treatment may restore fertility.
After a pregnancy develops, existing myomas may grow due to the increased blood flow and oestrogen levels. The myomas usually return to their original size after the baby is delivered.
Most women are able to carry their babies to term, but some end up delivering prematurely because there is not enough room in the uterus. Some pregnant women with myomas may need a Caesarean section because myomas can occasionally block the birth canal or cause the baby to be positioned wrongly.
Chinese medicine view
In Chinese medicine, myomas are a type of ‘Abdominal Masses’ (in women called Zheng Jia) which were discussed in Chapter 60. ‘Abdominal Masses’ are called Ji Ju. Ji indicates actual abdominal masses which are immovable; if there is an associated pain, its location is fixed. These masses are due to stasis of Blood. Ju indicates abdominal masses which come and go, do not have a fixed location and are movable; if there is an associated pain, it too comes and goes and changes location. Such masses are due to stagnation of Qi. Actual abdominal tumours therefore pertain to the category of Abdominal Masses and specifically Ji masses, i.e. Blood masses.
Aetiology
External Cold
External Cold is a frequent cause of abdominal masses in women. During puberty, after childbirth and during every period, the Uterus is particularly vulnerable to invasions of external Cold: external Cold generates internal Cold and this leads to Blood stasis. Blood stasis, in turn, may lead to the formation of masses. As discussed in Chapter 65, endometriosis may also be considered a form of abdominal masses and external Cold plays a role also in its aetiology.
Emotional stress
Emotional stress plays a role in the aetiology of myomas. Most emotions lead to stagnation of Qi (which may affect not only the Liver but also the Lungs and Heart). In time, Qi stagnation leads to Blood stasis and this to the formation of abdominal masses.
The most common emotions that may lead to stagnation of Liver-Qi and eventually Liver-Blood stasis are anger, frustration, resentment, worry, guilt and fear.
Irregular diet
By ‘irregular diet’ I mean two separate causes of disease. The first is the excessive consumption of fats, greasy, fried foods, sugar and dairy foods which leads to the formation of Phlegm. The other is eating irregularly, i.e. eating in a hurry, eating at one’s desk while working, eating late at night, etc. This irregularity of eating also leads to Phlegm, no matter what one eats.
It is important to note that irregular eating may lead not only to Phlegm but also to Blood stasis especially when it is combined with emotional stress. Irregular eating initially leads to stagnation of Qi which, in time, may lead to Blood stasis.
Although, as we shall discuss below, in myomas there is practically always Blood stasis, some may be due to a combination of Blood stasis with Phlegm.
Excessive physical exercise
Excessive physical work or exercise can weaken the Spleen, Liver and Kidneys and adversely affect the Directing and Penetrating Vessels. This is especially the case during puberty when these two vessels are in a state of change and not yet fully developed. Depending on the constitution of the girl, excessive physical work or exercise will either weaken these two vessels or cause stagnation in the lower abdomen.
Excessive physical exercise includes physical work (such as by girls who are brought up on a farm), sports, running, weight-lifting and also ballet. Excessive physical work affects the Uterus more at its vulnerable times, i.e. during puberty, after childbirth and during every period.
This cause of disease usually starts at a young age but its consequences may cause problems later in life.
Pathology
As always, one must differentiate between Root (Ben) and Manifestation (Biao) and between Emptiness and Fullness. The main aspect of the Manifestation in myomas is definitely Blood stasis. The Root leading to Blood stasis may be Empty or Full. The most common Empty type is Spleen- and Kidney-Yang deficiency: in every mass, there must be initially a deficiency of Upright Qi (Zheng Qi). In fact, if Upright Qi is normal and abundant, it circulates vigorously and prevents the formation of stagnation and therefore masses. However, the Root may also be of the Full type and Liver-Qi stagnation is an example of it. Liver-Qi stagnation (deriving from emotional problems and/or dietary irregularity) may lead to Blood stasis. Blood stasis in the Uterus may also frequently derive from Cold.
Internal Cold (that develops from invasion of external Cold) is a Full condition: this is manifested by a Full-Tight pulse and a Pale tongue with thick, white coating, signs of Full-Cold. Internal Cold, however, may also arise from a deficiency of Spleen- and Kidney-Yang, in which case it is Empty-Cold. It should be noted that Empty-Cold may also develop from Full-Cold: this happens when the retention of Full-Cold injures Yang and this, in turn, leads to Empty-Cold. Thus the Full-Cold is transformed into Empty-Cold (Fig. 67.2).
Cold in the Uterus (whether Full or Empty) is a common cause of Blood stasis in the pathology of myomas. Full-Cold is more commonly seen in young women (as in older women, Full-Cold will have a strong tendency to turn into Empty-Cold by depleting Yang).
Apart from Blood stasis, some types of myomas may be due to a combination of Blood stasis with Phlegm: when this is the case, the myoma (if palpable) feels relatively softer than one from Blood stasis (Fig. 67.3). Figure 67.4 summarizes the pathology of myomas and highlights the interactions among the various aspects of the Root and Manifestation.
Treatment principle
Before discussing the treatment principle, it is important to discuss the question of Bian Bing, i.e. identifying the Chinese disease corresponding to myoma. Two investigations are usually carried out when diagnosing a patient. The first is Bian Bing i.e. identifying to which Chinese medicine ‘disease’ the patient’s disharmony pertains to. As one of the main symptoms of myoma is heavy menstrual bleeding, one of the Chinese diseases it may correspond to is Flooding and Trickling (Beng Lou) which was discussed in Chapter 17
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