fibroid

Myoma: description

A fibroid is generally a tumor that develops from muscle cells. Depending on which type of muscle cell is affected, a distinction is made between:

• leiomyoma: develops from smooth muscle cells. These are found in the internal organs, such as in the uterus (uterine myoma), in the kidneys and in the stomach.
• rhabdomyoma: develops from striated muscles located at the heart and skeletal muscles.
• Fibroleiomyom: also develops from smooth muscle cells, but also contains parts of connective tissue.

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 those affected and cause dangerous complications.

Fibroids: classification according to the situation

Depending on where a fibroid develops in the uterus and in which direction it expands, physicians distinguish different myoma types:

• Subserous 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 grows here only 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 uterine lining (endometrium). This usually causes bleeding disorders.
• Intraligamentous fibroid: This type of fibroid develops next to the uterus.
• Zervixmyom: This relatively rare myoma type arises 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, a so-called uterus myomatosus is present. A uterine myomatosus is usually greatly enlarged and can lead to serious complications.

facts and figures

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.

Myoma: symptoms

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 fibroids 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 cramps.

Less common complaints with a fibroid are:

• Lower abdominal pain
• Back pain and / or leg pain when the myoma pushes in the spinal cord, where nerves leak.
• Kidney or side pain
• Strong urinary urgency when the fibroid presses on the adjacent bladder.
• Constipation (constipation) when the fibroid presses on the adjacent rectum.
• Pain during intercourse

More about dysfunctions of adjacent organs (such as the intestine) and more complications If you have a fibroid (such as in the case of pregnancy) read the section “Course of the disease and prognosis”.

Myoma: causes and risk factors

How exactly it comes to a fibroid in the uterus is still unknown. Scientists suspect that the female hormone estrogen plays an important role. 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 may 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.

Also one genetic cause in fibroid formation is 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.

Myoma: examinations and diagnosis

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 possible pre-existing conditions (anamnese).

After the survey of the medical history follows one gynecological palpation examination (once through the vagina and once through the rectum and over the abdominal wall). The doctor can feel a larger fibroid as well as the presence of several fibroids (uterus myomatosus).

With the Ultrasound examination (sonography) can the fibroid suspicion usually confirm. In addition, the exact location and size of the fibroid or the fibroids can be determined. The ultrasound examination can take place 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 Reflection of the uterus (hysteroscopy) or the abdomen (laparoscopy) carry out.

If the fibroid presses on the ureter, it may be necessary to use the kidneys and urinary tract via Ultrasonic and X-ray imaging with contrast agent (pyelogram) to investigate.

If the examination results are unclear, the doctor sometimes becomes one Magnetic Resonance Imaging (MRI) Arrange. In addition, if necessary, a blood test (in case of suspected anemia) as well as one Measuring the hormone level carried out.

Myoma: treatment

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 discomfort 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.

Myoma: drug treatment

There are several options for treating myoma with medication. Used are gestagens, control hormones (GNRH analogues), which reduce the body’s own estrogen production, or an active substance (ulipristalacetate), which directly modifies the docking sites (receptors) for the messenger substance progesterone on the myoma cells.

progestins are hormones that are also found in many anti-baby pills. You are an antagonist of the sex hormone estrogen. Treating with progestogens can slow fibroid growth and sometimes even shrink fibroids, reducing discomfort or simplifying subsequent surgery. The inhibitory effect of progestins on the growth of the endometrium can reduce bleeding.

GnRH analogues imitate a specific hormone hormone for the female hormone balance: the gonadoliberin (other names: 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 analogs are used continuously, the formation of estrogens is suppressed. The fibroid is no longer stimulated to grow and may even shrink.

Of the selective progesterone receptor modulator ulipristal acetate changes the docking sites for the hormone progesterone on the myoma cells. Its activity is thereby inhibited. The myoma cells thus lack an important growth stimulus, fibroids shrink and myoma-induced bleeding diminishes. On the one hand Ulipristalacetat can be used before an operation for the improvement of the Myom symptoms and for myom reduction (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.

Caution: The drug containing ulipristal acetate for the treatment of fibroids is suspected to cause severe liver damage.The suspected connection is currently under scrutiny by the European Medicines Agency (EMA). Until a final result, the following precautions are recommended (as of 09.02.2018):

• Women taking the drug should have their liver function checked at the doctor’s office at least once a month. To do this, the doctor measures the liver values ​​in the blood. If they are conspicuous, the myoma drug should be discontinued and liver function monitored for a while.
• If signs of liver damage occur, women should contact their doctor immediately. Such warning symptoms include, for example, upper abdominal pain, nausea, vomiting, poor appetite, tiredness and yellowing of the skin or eyes.
• Long-term interval therapy: Women who have just completed a course of taking ulipristal acetate should not start a new interval.
• For the time being, doctors should not prescribe the drug to new patients.

Note: The active substance ulipristalacetate is also included in the “morning after pill”. This is taken but only once. In addition, there are no reports yet that it can also cause liver damage. The warning of the EMA applies only to the ulipristal preparation for myoma treatment.

Myoma: Surgical treatment

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, this will be the entire Womb 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. That happens through Excision of myomas (myoma nucleation), 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).

Myoma: embolization

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.

Myoma: Focused ultrasound

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. Since the procedure is relatively new, the costs are usually not covered by the health insurance.

Myoma: Disease course and prognosis

Disease progression in a fibroid depends on the location and size of the benign tumor. Accordingly, different degrees of symptoms and complications may occur. Affected women should – even if the fibroids cause no complaints – go regularly to the check-ups at the gynecologist to avoid any complications. To the possible complications belong:

• Urinary tract infections and urinary painwhen the fibroid presses on urinary bladder / ureter
• Dysfunctions on bladder, bowel or kidneyswhen the fibroid presses on these organs
• anemia in severe and / or prolonged menstrual bleeding due to iron deficiency (iron deficiency anemia)
• sudden handle rotation in a pedunculated subserous fibroid, causing severe pain and requiring rapid surgery
• Problems with the fertility or during the pregnancy

Myoma & pregnancy

Basically, a fibroid in the uterus is not an obstacle to pregnancy dar. Only in rare cases it comes to infertility in affected women, 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 trigger 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 – fibroids 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, miscarriage can also lead to ectopic pregnancy.

No cancer risk

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. Nonetheless, checkups should be performed regularly to avoid complications fibroid recognize and treat early.