Prof. Dr. Ivan Kostov, MD completed his higher medical education at MU-Sofia in 1997. He specializes in obstetrics and gynecology, and obtained a master’s degree in health management in 2005. Prof. Dr. Kostov has extensive post-graduate qualifications in ultrasound in obstetrics and gynecology, colposcopy, gynecology endocrinology, operative gynecology, pediatric-adolescent gynecology, laparoscopy in gynecology, robotic surgery in gynecology on the Da Vinci robot, as well as numerous specializations in Germany, Israel, France, Slovenia, Italy, Turkey, USA. His career began at “Mother’s Home” as a specialist in obstetrics and gynecology and the surgical gynecology clinic of “Pirogov” already as a specialist doctor. In 2008 – 2010 he was the executive director of the Second General Hospital “Sheynovo”, from 2012 – 2017 he was the executive director of the First General Hospital “St. Sofia”, and since April 2017 he has been the executive director of the University General Hospital “Mother’s House” – Sofia. From 2014 to the present, he is a member of the expert council at the State Fund for Assisted Reproduction at the Ministry of Health. Prof. Dr. Ivan Kostov is also the chairman of the “Electronic Health Bulgaria” Foundation in the period 2004 – 2013, as well as an active member of the European Association for Telemedicine and Electronic Health in Brussels. – Prof. Kostov, what is a uterine fibroid? Myoma is a benign tumor of the uterus that affects women of childbearing age and often requires surgical treatment. Fibroids are not a clinical problem in puberty and are rare after menopause, with an incidence of 25% to 30% in patients over 35 years of age. According to the anatomical classification, myomatous nodes are of several types, depending on where they appeared. They can be on the surface of the uterus (subserous), in the entire thickness of the body of the uterus (intramural), or in its cavity submucosa (submucosal). A combination of the three types of myomatous nodules is also possible. When growing in the broad ligament, fibroids are called intraligamentous. Those located in the cervix are called cervical nodes. Myomatous nodes are most often in the body of the uterus (94%), least often in the cervix, round ligaments and labia (places with smooth muscle elements). Subserosal myomatous nodules can have a secondary blood supply from the omentum and break off from the uterus – parasitic myomas. Myomas are separated by a pseudocapsule from the myometrium. They enucleate easily. The fibroid may undergo changes as a result of infection, dystrophy or degeneration. – Why do these formations develop? What are the most serious factors that lead to their development? The etiology of myoma is unknown, but it is believed that in most cases it is hormonally determined – it is caused by increased secretion of estrogen – hyperestrogenemia – from the ovaries. The high concentration of estrogen receptors in the myometrium of the uterus has also been proven. In addition, hereditary factors also have an influence.Myoma often develops in women with obesity, hypertension, mastopathy. Moreover, the combination of myoma with endometriosis, endometrial hyperplasia and polycystic ovaries is often observed. In addition to estrogen and progesterone receptors, prostaglandin, oxytocin, etc. receptors are found in fibroids. Large fibroids produce erythropoietin. Stress and overexertion can become a trigger for the appearance of this disease. And some authors believe that not having children leads to the “birth” of fibroids. – How common is the condition and does it predominate in any particular age group? As I have already indicated, fibroids are not a clinical problem in puberty and are rare after menopause. Its frequency reaches 30% in women over 35 years of age. About 20% – 25% of women develop fibroids around the age of 40. Approximately 5% of women with fibroids have problems urinating. It is estimated that 80% of women with myomatous uterus can benefit from conservative treatment without surgery. Which means that a woman can have fibroids and not need surgical treatment. – What are the risks of fibroids? Does it threaten a woman’s fertility? Since endometriosis in more than 40% of cases is combined with myomatous disease, it causes more than 50% of infertility cases worldwide, that is, myoma itself can be the cause of sterility or risky pregnancy. – Can it be left untreated? To be able to. If there is no clinic (symptomatic) or if the woman has no reproductive plans. – What brings patients to the clinic? Is it possible to have no symptoms? Symptoms in the presence of myoma and myomatous nodes are as follows: abnormal endometrial bleeding (30-40%) – hypermenorrhea, metrorrhagia, menometrorrhagia. These profuse bleedings often do not respond to conservative treatment. There are pains in the lower abdomen and back, fatigue, shortness of breath, even heart complaints. It should be noted that in an extremely small percentage of cases (less than 0.0001%) sarcomatous degeneration can occur. In young women, myoma leads to infertility (5-10%) and often to anemia due to profuse bleeding, to disability and inability to work. Surgery is used when the fibroid interferes with fertility or if the tumor grows rapidly and reaches the size of a 3-month and more than three-month pregnancy, is not affected by conservative treatment and disables the woman. A woman cannot fulfill her social and sexual functions. That is why some authors divide women with a fibroid uterus into “myoma bearing women” and “myoma patients”. Operative treatment is resorted to in “myoma patients”. Surgical intervention is also resorted to when malignant degeneration of the myoma into a sarcoma or endometrial carcinoma is suspected, proven by a separate test. – What is the therapy? The treatment of both myoma and endometriosis is carried out with drugs similar in their chemical structure. Recently, it is consideredthat certain genetic predispositions and genes may be associated with the occurrence of fibroids and especially endometriosis – genes such as BRCA1 and BRCA2. These are preliminary data, and nevertheless this information may lead to improved diagnosis and treatment. Tests include: blood test; trial separated abrasion; hysterography; hysteroscopy; ultrasound; CT; MRI. Treatment usually consists of the administration of blood-stopping and hormonal preparations. Hormonal preparations: contraceptives, progestogens, GTRH agonists, and surgical treatment includes: myomectomy, total hysterectomy. These include laparoscopic surgery, robotic surgery and open abdominal surgery. Often the presence of myoma is discovered accidentally during a preventive examination. An ultrasound is most often used to measure the size of the tumor. A separate test scraping is intended to detect whether precancerous cells are present and to rule out the possibility of endometrial carcinoma. Women who are found to have myomatous nodules undergo periodic gynecological examinations to monitor their development. In the past, fibroids were necessarily operated by removing the myomatous nodes, and very often the entire uterus. Now it is considered that in almost 90% of cases the operation can be avoided, and the fibroid can be treated by other methods, including alternative medicine – herbal medicine. Modern surgical treatment involves hysteroscopic resection – removal – of the nodules inside the uterine cavity, followed by antibiotic treatment and hormonal stimulation in young women to enable them to become pregnant. In the elderly, the resectoscope provides symptom relief and avoids the surgical removal of the uterus. The preoperative administration of GTRH-agonists makes possible the laparoscopic removal of myomatous nodules that have decreased in volume. – If a woman does not have children, can an alternative therapy be offered that does not involve removal of the uterus? In the last 10 years, new drugs called Gonadotropin Releasing Hormone-agonists have been introduced and used, which practically “melt” fibroid nodes and make conception possible in young women with fibroid uterus. After conducting 3 clinical studies with Goserelin* (for endometriosis, uterine fibroids and early endometrial carcinoma) for the first time in Bulgaria together with a pharmaceutical company producing the medicine, it was proved that the maximum reduction of myomatous nodes occurs within 12 weeks (3 months) from the start of treatment. The course of treatment is usually 6 months, but very often it is given for 3 months preoperatively. And in perimenopausal women, these medications can lead to a gradual entry into menopause, avoiding surgery and the need to remove genital organs such as the uterus, tubes and ovaries. The myomatous uterus reverses development at menopause (i.e. shrinks) due to hormonal reasons.Therefore, it is important to consider what to do and what treatment plan to choose until menopause occurs. For fibroids over 6 cm in obstetrics and gynecology, the gold standard is the new high-tech Da Vinci robotic system, also called robot-assisted laparoscopic surgery, which is performed through several small holes in the patient’s body. Control is entirely in the hands of the surgeon, positioned at a console in a comfortable sitting position, without direct contact with the patient. His movements are transmitted filtered and cleaned of random jerks to robotic arms and special tools that are mounted on them with great mobility. A three-dimensional camera inside the patient’s body (also controlled by one of the hands) transmits an image of the operative field in ultra-high resolution and up to 18x magnification on a stereoscopic monitor. The surgeon controls the hands via master controls, while simultaneously seeing the surgical object extremely close. Robotic surgery in gynecology is the method with the least trauma, the highest quality of the operation, lower blood loss and the fastest recovery. That is, in contrast to open operations, robotic surgery allows for easier and faster recovery, and the operated are able to return to their usual way of life within a few days after the manipulation – within 1-2 days the woman can return to an active lifestyle. In women with fibroid disease, as an alternative to surgical treatment, embolization is also used as a method of shrinking and destroying fibroid nodes. Although there is no limitation on the size of the nodules, embolization is not indicated as a treatment for all types of myomatosis. The procedure consists of placing a catheter through the brachial artery of the arm. By injecting contrast material and under X-ray control, the arteries that feed the fibroid nodes are imaged. A specific solution is injected into these arteries, which blocks the blood flow and disrupts the nutrition of the nodes. In this way, a reduction in their development over time and a reduction in complaints is ensured. – If fibroids are present, is it possible to have a normal pregnancy? Yes, it is possible. Even often, fibroid nodes are first diagnosed during pregnancy. Before pregnancy, they were small in size and could not be visualized during an ultrasound examination. Small myoma nodules grow mostly in the second and third trimesters of pregnancy, and larger ones in the first trimester. Uterine fibroids increase in size during pregnancy under the influence of estrogens and progesterone. The reason for this is that fibroid cells have more estrogen receptors than normal myometrium. Fibroids usually do not interfere with pregnancy, although in some cases it is possible for a fibroid to lead to pregnancy loss, especially if it is submucosal. In addition, fibroids can increase the risk of certain complications during pregnancy,such as placental abruption, intrauterine fetal growth restriction or premature birth. Myoma nodules less than 3 cm in size have no particular clinical significance for the course of pregnancy. With a size over 3 cm, the frequency of premature birth, detachment of the placenta, appearance of “painful myoma” increases significantly. Asymptomatic fibroids should not be considered as indications for Caesarean section. Surgical treatment of the fibroid is undertaken 5-6 months after birth. A cesarean myomectomy may be performed at the discretion of the operator. If indicated during a Caesarean section, a total hysterectomy can be performed. In conclusion, I want to draw attention to the fact that uterine fibroids are treated and treated much more conservatively than 10-20 years ago. It is operated as a last resort, when conservative treatment options have been exhausted. And the most important thing is that women go regularly for preventive examinations to monitor their health. – If the uterus is preserved and the growths are removed, what is the risk of them reappearing? Risk always exists. That is why regular preventive examinations and visits to an obstetrician-gynecologist are a guarantee of good health and timely detection of possible diseases. I have always said that the Bulgarian woman should monitor her health regularly, because she deserves the best and timely care. * Generic name of the preparation