Fibroids — where does the heavy bleed­ing come from and what can be done?

Clin­ic for Gyne­col­o­gy with a Cen­ter for Onco­log­i­cal Surgery

Uter­ine fibroids are growths that form in the wall of the uterus. There is prac­ti­cal­ly no degen­er­a­tion, i.e. the fibroids becom­ing malig­nant. In the vast major­i­ty of cas­es, fibroids are benign in nature, which means that they can­not metas­ta­size or spread. They are often, often com­plete­ly asymp­to­matic. In women between 40 and 50, such tumors are detectable in over 50% of the ultra­sound examination.

Fibroids arise and grow under the influ­ence of female sex hor­mones, which are main­ly pro­duced in the ovaries. Hered­i­tary fac­tors are prob­a­bly also respon­si­ble for the devel­op­ment of fibroids. Fibroids can grow quick­ly or slow­ly, con­tin­u­ous­ly or inter­mit­tent­ly.
Myoma-relat­ed symp­toms prac­ti­cal­ly always dis­ap­pear after the menopause when the estro­gen lev­el (estro­gen is a female sex hor­mone) falls and the fibroids shrink.

How­ev­er, if women now under­go hor­mone (replace­ment) ther­a­py dur­ing or after the menopause, the shrink­age does not occur and there may even be growth, so that the myoma-relat­ed symp­toms persist.

Dif­fer­ent types of fibroids:

• sub­mu­cous fibroids: locat­ed in the uter­ine cav­i­ty just below the lin­ing of the uterus;
• intra­mur­al fibroids: locat­ed in the wall of the uterus;
• Sub­serous fibroids: are locat­ed on the out­side of the sur­face of the uterus.

Uter­ine fibroids are often asymp­to­matic, but depend­ing on their size, loca­tion and num­ber, they can cause both mild and severe symp­toms. The sub­mu­cous fibroids cause bleed­ing dis­or­ders even when they are small, espe­cial­ly increased bleed­ing. Myomas in the uter­ine wall tend to cause painful men­stru­al bleed­ing. Fibroids on the sur­face can grow for a long time with­out caus­ing dis­com­fort until they become notice­able through pres­sure on the neigh­bor­ing organs. 

Women with fibroids report one or more of the fol­low­ing symptoms:

• increased and pro­longed men­stru­al bleed­ing, some­times with clot­ting (clot­ted blood);
• Abdom­i­nal pain;
• Pres­sure, for­eign body, or heav­i­ness in the pelvic area;
• Pain in the back or radi­at­ing into the legs;
• Painful inter­course;
• Feel­ing of pres­sure on the blad­der with increased urge to urinate;
• Feel­ings of pres­sure on the intestines, pos­si­bly asso­ci­at­ed with pain and gas;
• rare: great­ly enlarged waist circumference.

1. Con­sul­ta­tion hour: diag­nos­tics and ther­a­py planning

Larg­er fibroids can be felt dur­ing the pelvic exam­i­na­tion. Dur­ing the ultra­sound exam­i­na­tion, small­er fibroids can be seen. If the find­ings are unclear, a hys­teroscopy or a laparoscopy (laparoscopy / pelvis­copy) can help. The fibroids can also be removed.

At the Char­ité, we offer you the full range of mod­ern diag­nos­tic and treat­ment meth­ods. Fibroids that do not cause symp­toms usu­al­ly do not need to be treat­ed. How­ev­er, if a desired preg­nan­cy does not occur or if mis­car­riages are caused by myomas, removal is advis­able. Like­wise with bleed­ing dis­or­ders or pain and with unchecked growth in size. Removal is almost always pos­si­ble using min­i­mal­ly inva­sive sur­gi­cal tech­niques (laparoscopy or uteroscopy). The uterus can be pre­served. If there are large and numer­ous fibroids and / or if there is no desire to have chil­dren, removal of the uterus can be useful.

Myoma ther­a­py often begins with an attempt to treat med­ica­tion, e.g. with a spe­cial birth con­trol pill or oth­er tem­po­rary hor­mone or hor­mone recep­tor ther­a­py. If this course of treat­ment is not pos­si­ble or unsuc­cess­ful, direct treat­ment or removal of the fibroids should be planned. In prin­ci­ple, this can be done in two ways — by non-inva­sive or less inva­sive radi­o­log­i­cal pro­ce­dures or by so-called min­i­mal­ly inva­sive sur­gi­cal gyne­co­log­i­cal pro­ce­dures. Each of the pro­ce­dures has advan­tages, but also dis­ad­van­tages and side effects. Not every treat­ment method is equal­ly suit­able for every patient.

First of all, your gyne­col­o­gist will advise you. With a cor­re­spond­ing refer­ral, we can then dis­cuss in our clin­ic myoma con­sul­ta­tion which pro­ce­dure is best for you. We advise you in the myoma con­sul­ta­tion hour of the Berlin Char­ité on the Vir­chow-Klinikum cam­pus indi­vid­u­al­ly, com­pre­hen­sive­ly and open­ly about both uterus-pre­serv­ing (i.e. no uter­ine removal) sur­gi­cal pro­ce­dures and non-gyne­co­log­i­cal myoma ther­a­py procedures.

In addi­tion to your wish­es, the size, posi­tion and num­ber of the fibroid nodes that are present are deci­sive for the deci­sion. In addi­tion, the deci­sion-mak­ing should include whether you still want to have chil­dren and whether you, in prin­ci­ple, want the uterus to be pre­served regard­less of this.

We are hap­py to advise you and also offer you the var­i­ous treat­ment meth­ods in the clinic.

With every oper­a­tion and every non-sur­gi­cal treat­ment mea­sure, includ­ing a benign find­ing, you should weigh the risks and com­pli­ca­tions of the pro­ce­dure against the advan­tages and the (expect­ed) gain in qual­i­ty of life. We always rec­om­mend get­ting a com­pe­tent sec­ond opin­ion, at least before a major operation.

Fibroids and pregnancy

In prin­ci­ple, preg­nan­cy is also pos­si­ble with a fibroid, espe­cial­ly if the fibroid is small and / or on the out­side of the uterus.

Var­i­ous fac­tors, both on the male and female part, can pre­vent preg­nan­cy from occur­ring. If the man has been shown to be fer­tile and there are no oth­er med­ical rea­sons for a cou­ple to be infer­tile, changes in the uterus may be the cause. At least those fibroids that nar­row the inte­ri­or of the uterus, in which the fer­til­ized egg is implant­ed and the embryo grows, should be treated.

With every ther­a­py method, oper­a­tive or non-oper­a­tive, the treat­ment risks must be weighed against the expect­ed improve­ments in the sit­u­a­tion for preg­nan­cy. After fibroid surgery, we rec­om­mend not becom­ing preg­nant for about three months. After that, preg­nan­cy should be possible.

2. Oper­a­tive therapies

Fibroid peel­ing

Fibroid peel­ing is a sur­gi­cal pro­ce­dure in which only the fibroids are removed and the uterus is pre­served. There are dif­fer­ent ways to peel the fibroid out, depend­ing on the loca­tion, size and num­ber of the fibroid nodes, the way via the vagi­na (hys­tero­scop­ic), a laparoscopy (laparo­scop­ic) or an abdom­i­nal inci­sion is cho­sen. All inter­ven­tions are usu­al­ly car­ried out under gen­er­al anes­the­sia and require a stay of sev­er­al days in the clin­ic after the operation.

Hys­terec­to­my

The removal of the entire uterus (with or with­out the cervix; the ovaries remain in the body in any case) can, depend­ing on the size of the organ, through the vagi­na, laparoscopy, com­bined laparoscopy and through the vagi­na or, in the case of a very large uterus, also through an abdom­i­nal inci­sion can be per­formed. If fam­i­ly plan­ning has been com­plet­ed, severe myoma-relat­ed symp­toms and the desire to def­i­nite­ly avoid bleed­ing, a hys­terec­to­my is a good treat­ment option. It is usu­al­ly per­formed under gen­er­al anes­the­sia and involves a 3 to 7 day hos­pi­tal stay. Preg­nan­cy is no longer pos­si­ble after the uterus has been removed.

3. Non-oper­a­tive therapies

In the last 10 to 15 years, two meth­ods have become estab­lished that are car­ried out by radiologists.

Uter­ine fibroid embolization

This treat­ment is car­ried out by a spe­cial­ized radi­ol­o­gist. After a local anes­thet­ic in the groin area, a small plas­tic tube is insert­ed pain­less­ly to the uter­ine artery via an access sim­i­lar to that used for a blood sam­ple under X‑ray con­trol (flu­o­roscopy). Through this, small plas­tic or gelatin beads the size of grains of sand are inject­ed into the small arter­ies that sup­ply the uter­ine fibroids with blood. This will cut them off from the blood­stream and the fibroids will shrink by up to 50% with­in a few months of the procedure.

Uter­ine artery emboliza­tion alone is now an estab­lished method for myoma ther­a­py as an alter­na­tive to surgery world­wide. A direct com­bi­na­tion of emboliza­tion with a myoma oper­a­tion one or two days lat­er can be use­ful when it comes to pre­serv­ing the uterus, even though it is very much enlarged by one or more myoma nodes (up to or even over Navel height).

In these cas­es, an oper­a­tion is often dif­fi­cult and can be asso­ci­at­ed with very heavy bleed­ing, which can be sig­nif­i­cant­ly reduced with the emboliza­tion car­ried out (a few days before the oper­a­tion). This increas­es the chances of pre­serv­ing the uterus.

MRI-guid­ed focused ultrasound

The sec­ond method is MRI-guid­ed focused ultra­sound, which can reduce the size of the fibroids by up to 30–40%. Here you lie in a tubu­lar mag­net­ic res­o­nance tomo­graph (MRI). This takes pic­tures of your uterus with the fibroid. Das Ver­fahren basiert auf einem starken Mag­net­feld und der Ein­strahlung von Radiow­ellen, für die der Men­sch nicht empfind­lich ist. With the help of the record­ings, ultra­sound waves are aimed at your fibroid by a radi­ol­o­gist and the fibroid is reduced in size in sev­er­al por­tions by the heat gen­er­at­ed. You do not feel any pain.

4. Fol­low-up care

In prin­ci­ple, with all uter­ine-pre­serv­ing treat­ment mea­sures, both oper­a­tive and non-oper­a­tive, there is a pos­si­bil­i­ty that myomas will devel­op again after a few years. As part of your rou­tine check­ups, you should address any recur­ring symp­toms or new symptoms.