PD MD Heiko B. G. Franz
A fibroid is a benign tumor that develops from muscle cells. Often the term myoma is used in general for the uterine myoma. Myomas in the uterus are the most common benign tumors in women. They are not dangerous in themselves, but can cause unpleasant discomfort and serious complications.
A fibroid is generally a tumor that develops from muscle cells.
Depending on which type of muscle cell is affected, one differentiates between:
The fibroid is one of the benign tumors. Benign means that the tumors grow slowly. They do not penetrate into the surrounding tissue - they are not infiltrating - they merely displace it. In addition, benign tumors do not form secondary tumors (metastases). Fibroids are not dangerous in contrast to malignant tumors. Nevertheless, they too can greatly affect the quality of life of patients and cause dangerous complications.
Depending on where a fibroid develops in the uterus and in which direction it expands, physicians distinguish different fibroid types:
Subserosal fibroid: It sits on the outside of the uterus and grows outward from the muscular layer of the uterine wall into the "outer" layer (serosa or peritoneum). Disorders of the menstrual period do not occur here. Sometimes subserous fibroids are stalked. This style can twist, which can cause pain and complications.
Intramural fibroid: The fibroid only grows within the muscular layer of the uterus. This type of fibroid is most common.
Transmural myoma: Here the fibroid develops from all layers of the uterus.
Submucosal fibroid: This rather rare and often small myoma type grows from the muscular layer of the uterus into the lining of the uterus (endometrium). This usually causes bleeding disorders.
Intraligamentous myoma: This type of myoma develops next to the uterus.
Cervical Myoma: This relative rare myoma type develops in the muscular layer of the cervix (cervix).
What is a uterus myomatosus?
Myomas in the uterus can occur individually or in large numbers. If there is only a single tumor, experts talk about a solitary fibroid. If several fibroids develop at the same time, there is a so-called uterus myomatosus. A uterine myomatosus is usually greatly enlarged and can lead to serious complications.
A leiomyoma of the uterus (uterine myoma) is not uncommon. It is the most common benign tumor in the female genital tract. About ten to twenty percent of all women over the age of 30 have fibroids on the uterus. Usually, fibroids develop between the 35th and the 50th year of life. Before the age of 25, they are very rare.
About 25 percent of all affected women have no symptoms of fibroid disease. The rest had more or less severe symptoms. In 2011, approximately 75,600 women with uterine fibroids were hospitalized.
Fibroids do not cause symptoms in about 25 percent of affected women. The benign tumor in the uterus is usually only discovered by chance during a routine examination at the gynecologist.
In all other cases myomas cause discomfort. What these are and how strong they are depends on the size and location of the fibroid.
Common signs of a fibroid are:
Bleeding Disorders: Myomas can cause increased menstrual bleeding (hypermenorrhoea), increased and prolonged menstrual bleeding (menorrhagia), and bleeding outside the menstrual cycle (metrorrhagia).
Violent, sometimes labor-like pain during menstruation. Myom-related heavy bleeding can form clots, the excretion of which is accompanied by seizures.
Less common complaints with a fibroid are:
How exactly it comes to a fibroid in the uterus is still unknown. Scientists suspect that the female hormone estrogen plays an important role in this process. Estrogen ensures the growth of the mucous lining inside the uterus (endometrium). It can also affect the growth of the muscle layer in the uterine wall. Thus, a dysregulation might be responsible for the leiomyoma of the uterus. When estrogen production diminishes after the menopause (climacteric), fibroids usually do not occur. Existing fibroids stop their growth and usually return to normal.
A genetic cause in fibroid formation is also discussed. Fibroids often appear in certain families. In addition, studies have shown that African women are about nine times more likely to develop a fibroid than European women. Responsible for the formation of fibroid should be a single gene.
Symptoms such as increased menstruation or increased urination may indicate uterine fibroids. In order to investigate such a suspicion, the gynecologist first inquires in detail about existing complaints and any previous medical history (anamnesis).
After collecting the medical history, a gynecological palpation follows (once through the vagina and once through the rectum and across the abdominal wall). The doctor can feel a larger fibroid as well as the presence of several fibroids (uterus myomatosus).
Ultrasound examination (sonography) usually confirms the suspected fibroid. In addition, the exact location and size of the fibroid or the fibroids can be determined. The ultrasound examination can be done via the abdominal wall or via the vagina (vaginal ultrasonography). Mostly the variant is chosen over the scabbard.
If the ultrasound does not provide an accurate diagnosis (such as in a fibroid or in the muscular wall), the doctor may perform a uterine (hysteroscopy) or abdominal (laparoscopic) scan.
If the fibroid presses on the ureter, it may be necessary to examine the kidneys and the urinary tract by means of ultrasound and X-ray imaging with contrast agent (pyelogram).
If the examination results are unclear, the doctor will sometimes order a magnetic resonance imaging (MRI). In addition, if necessary, a blood test (in case of suspected anemia) and a measurement of hormone levels are performed.
As long as fibroids do not cause discomfort, they usually need not be treated. At intervals of six to 12 months, however, a check-up should take place at the gynecologist. Myoma, uterus and any complaints are then assessed accurately.
As soon as a fibroid or multiple fibroids cause symptoms or complications, various treatment options are available. The decisive factors in the choice of therapy are, among other things, the age of the woman, the family planning (desire to have children), the type and extent of the complaints as well as the location and size of the fibroid. Basically, fibroids can be treated medically (GnRH antagonists), surgically (myomectomy) or by more recent procedures (embolization, focused ultrasound). In extreme cases, the uterus can also be completely removed.
There are several options for treating myoma with medications. Used are gestagens, control hormones (GNRH analogues), which reduce the body's own estrogen production, or an active ingredient (ulipristalacetate), which modifies the docking sites (receptors) for the messenger substance progesterone directly on the myoma cells.
Progestogens are hormones that are also found in many anti-baby pills. You are an antagonist of the sex hormone estrogen. Treatment with progestogens can slow fibroid growth and sometimes even shrink fibroids, reducing discomfort or simplifying subsequent surgery. The inhibitory effect of progestagens on the growth of the endometrium can reduce bleeding.
GNRH analogs mimic a specific hormone hormone for the female hormone balance: the gonadoliberin (other terms: gonadotropin-releasing hormone or GNRH). It stimulates the pituitary gland to spurt out the gonadotropin hormone, which in turn stimulates the ovaries to produce estrogens. However, when GNRH analogues are continuously applied, the formation of estrogens is suppressed. The fibroid is no longer stimulated to grow and may even shrink.
The selective progesterone receptor modulator ulipristalacetate modifies the docking sites for the hormone progesterone on myoma cells. Its activity is thereby inhibited. The myoma cells thus lack an important growth stimulus, the fibroids shrink and myoma induced bleeding diminishes. Ulipristalacetat can be used on the one hand before an operation for the improvement of the Myom symptoms and for Myomverkleinerung (simplification of the operation). With a so-called long-term interval therapy (drug intake over twelve weeks with breaks), myoma size and symptoms can even be reduced so much in many cases that surgery is no longer necessary.
For a very large fibroid, severe discomfort from the benign tumor, or multiple myomas (uterine myomatosus), surgery is the drug of choice. Although it is not clear whether it is not a malignant tumor (sarcoma), surgery is necessary. In most cases, the entire uterus is removed (hysterectomy), either via the vagina, rectum or abdominal incision.
If the fibroid is small and the woman still has a desire to have children, it is also possible to remove fibroids in isolation. This happens by exfoliation of the fibroids (Myomenukleation). Depending on the type of myoma, different methods are possible. For example, the doctor can remove the fibroid via an abdominal incision or vagina. In addition, the laparoscopic distance has greatly increased in recent years. Three small punctures are made in the abdominal wall before the doctor cuts out the fibroid with a long narrow tube (the laparoscope).
Another method of treating fibroids in the uterus is percutaneous transcatheter embolization. The doctor closes the blood vessels that supply the fibroid with nutrients. As a result, fibroids recede - ideally within six months to a maximum of one year.
In fibroids, which are in a favorable position, another treatment option comes into consideration: the focused ultrasound. The patient lies prone over a sound source. From this against high-frequency sound waves, which are directed exactly to the place where the fibroid sits. Due to the focusing of the sound waves, so much heat is created at this point that the fibroid dies. It is then broken down by the cells of the immune system. This treatment takes about three hours and is very expensive.
Disease progression in a fibroid depends on the location and size of the benign tumor. Accordingly, different degrees of symptoms and complications may occur. Patients should - even if the fibroids cause no symptoms - go regularly to the check-ups at the gynecologist to avoid any complications.
Possible complications include:
Basically, a fibroid in the uterus is not an obstacle to pregnancy dar. Only in rare cases it comes in affected women to infertility, such as when the fibroid lies in front of the fallopian tube.
During pregnancy, a fibroid can cause several problems. As estrogen-dependent tumors, fibroids grow faster during pregnancy because the body then produces more of the sex hormone. Due to their increasing size and location fibroids can cause pain, cause abnormalities in the child's position (such as breech) or block the birth canal - then caesarean section becomes necessary. Premature labor can also occur - myomas have been shown to increase premature and miscarriage rates. If the fibroid grows directly under the lining of the uterus or in the uterine cavity, it can lead not only to a miscarriage but also to an ectopic pregnancy.
Contrary to previous assumptions, experts no longer believe that cancer (a so-called sarcoma) can develop from a fibroid. Recent genetic studies indicate that a sarcoma develops independently of a fibroid. Nevertheless, follow-up examinations should be performed on a regular basis to detect and treat complications from a fibroid early on.