Fibroids

Fibroids are benign (benign) lesions (tumours) starting from the smooth muscles of the uterine wall (uterus). 70% of all women after the age of 40 have fibroids, but only about 20% of these fibroids cause discomfort (symptoms). 80% of fibroids occur between the ages of 30 and 50.

Fibroids are usually circumscribed nodular, less often diffuse, structures that weigh from a few grams to several kilograms.

We distinguish fibroids according to their localisation

• on the uterine exterior wall (subserous)
• in the uterine wall (intramural/transmural)
• under the mucous membrane (submucous)
• in the ligaments on the side of the uterus (intra-ligamentous)
• near the uterine orifice (cervical)

and their size. The size and localisation of fibroids can best be evaluated with a transvaginal ultrasound. Thus, the uterus will get identified uterus myomatosus with one or various fibroids, regardless of the fibroids' size/location/symptoms. Special forms of fibroids are adenomyosis or adenomyoma. Adenomyosis is a diffuse widening of the uterine wall (myometrium) with inclusions of glandular tissue.

In addition to a genetic predisposition, the cause of fibroid development seems to be a hormonal imbalance. In African American women, for example, the incidence of fibroids is much higher than in Caucasian women. Fibroids show a high estrogen and progesterone receptor density. Thus, an estrogen stimulation promotes growth (for example, during pregnancy), progestin-stressed ovulation inhibitors reduce such growth. After the onset of menopause, a decrease in the size of fibroids is often noted, usually combined with calcification of the same. Malignant degeneration of fibroids occurs very rarely (much less often than 1% of fibroids).

Fibroids can be asymptomatic or cause discomfort depending on their size and localisation. Due to the growth tendency, an initially asymptomatic fibroid may suddenly show many symptoms, such as:

• menstrual changes (too often, too severe, too long) are found in 50% of fibroid patients with concomitant iron deficiency,
• pain: 30% of myoma patients suffer from pain, such as local stretching or pressure pain caused by the myoma mass, painful menstruation (dysmenorrhea) or spasmodic pain caused by uterine contractions in response to the myoma as a "foreign body". Likewise, acute abdominal pain may occur with a stem rotation of the subserous fibroids,
• consequences of the pressure on surrounding structures (such as urinary bladder, ureters, intestines or vessels) are rare but possible on various organ systems; for example, frequent urinating (pollakiuria), renal congestion, constipation, venous drainage of the lower extremities with a possible thrombus formation,
• infertility: submucosal fibroids can significantly reduce fertility, and the removal of those increases fertility again with appropriate care.

A therapy is indicated only with symptoms, i.e. in around a quarter of fibroid patients.

• In principle, a "wait and see" management can be chosen primarily for cases with only a few symptoms, supported by sonographic monitoring of the fibroid size.
• In the case of only painful menstruation (dysmenorrhea), an additional drug therapy with painkillers can be initiated – if necessary, combined with iron substitution.
• Corpus luteum hormone preparations (gestagens) act, due to the relative estrogen overload, such as three-month injections, pill with corpus luteum hormone, gestagen-containing Implanon for the upper arm, or a gestagen-containing coil.
• Esmya (ulipristal acetate) is a so-called progesterone receptor modulator. It blocks the effect of progesterone, and, within a few weeks, the bleeding intensity should decrease. Since an Esmya intake can lead to increased liver values or even liver damage, the preparation was withdrawn from the Swiss market.
• With the GnRH analogues, menopause artificially occurs through hormone therapy. They reduce the fibroid mass by about 40%. Currently, however, GnRH analogues are indicated at most with preparations for surgery (to achieve a reduction with the bleeding tendency during the procedure). As a long-term therapy, they lead to considerable side effects, such as climacteric complaints. Recurrence symptoms are also common once the therapy has stopped.
• Removal of submucous stemmed fibroids during uterine endoscopy (hysteroscopy).
• Enucleation of fibroids, whereby the uterine wall is opened and the fibroid removed; this can be done with laparoscopy or abdominal incision (laparotomy). Depending on the location and size of the fibroids, these operations can be technically difficult and therefore lead to higher blood loss.
• Embolisation of fibroids; embolisation of the supplying vessels, performed by a radiologist.
• With the focused ultrasound, the myoma is thermo-ablated; this can be controlled by MRI or ultrasound.
• New in Switzerland since 2017: radiofrequency ablation of fibroids under transcervical ultrasound control (SONATA® system). With a rod-shaped ultrasound probe, measuring a few millimetres, which is combined with a radiofrequency ablation handpiece, the probe can be placed directly next to the fibroid in the uterine cavity (cavum) through the vagina. On a live ultrasound screen, the fibroid (or several fibroids) can thus be treated specifically by heat application; this only takes a few minutes per fibroid. The fibroid mass shrinks in the following weeks, and 3 months later, the bleeding reduces by 90%.  
• Finally, the removal of the uterus (hysterectomy) through the vagina (vaginal) by laparoscopy or abdominal incision (laparotomy).