Arzt erläutert anhand eines Vagina Modelles

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.


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.

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