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Expert Opinion: Uterine Fibroids

Uterine fibroids (or uterine myomas) are benign tumors formed by myometrium cells. Most often, the disease occurs because of hormonal disorders in women of reproductive age after 30 years.

The disease is always preceded by the metabolic changes in the muscular fibers of the uterus. The facilitating factors for development of uterine fibroids are the following:

  • Abortion
  • Physical inactivity
  • Diabetes
  • Hereditary predisposition
  • Overweight
  • Wearing IUD for a long time
  • Extended exposure to UV radiation
  • Chronic disorders of the endocrine system
  • Physical exhaustion and stress
  • Chronic infections: pyelonephritis, tonsillitis, and others.
  • Gynecological diseases: adnexitis, ovarian cysts, endometriosis, etc.
  • Hormone imbalance in perimenopause or when takingoral contraceptives high in estrogen.

Disease development begins fromthe increased division of the cells in the muscular tissues of the uterus. As a result, a 3-4 mm nodule is formed that can growup to 4 cm.

The uterus increases, as if a woman is pregnant, and size of the fibroid is also determined as weeks of pregnancy (e.g., a fibroidthe size of 9 week pregnancy).

The severity of the symptoms depends on the rate of tumor growth and its location relatively the uterine walls.

At the onset of menopause, due to a drop of the estrogenlevels, the tumor decreases or completely disappears.

For a long time, the disease can be asymptomatic. As a rule, symptoms and signs of uterine fibroids are revealed when a tumor has already grown by a few centimeters. The incubation period can last from six months to several years.

Depending on the localization, size and rate of nodule growth, the symptoms of uterine fibroid includes:

  • Dysuria.
  • Chronic constipation.
  • Pain during sexual intercourse.
  • Metrorrhagia(acyclic uterine bleeding).
  • A nagging pain in the lumbar region and in the lower abdomen.
  • Menorrhagia (prolonged and excessive menstrual bleeding, often leading to anemia).
  • If a nodule the size over 20 weeks, a woman may have shortness of breath and palpitations, especially when lying down.

By the number of nodules, the disease can be classified as a single fibroid (one nodule) and multiple fibroids (several nodules).

Depending on the location of a tumor, there are 5 types of fibroids:

  • Intermuscular (interstitial):It is the most common form, whena neoplasm is formed in the muscular wall.
  • Subperitoneal (subserous): A tumor is located on the outer surface ofthe uterus.
  • Intraligamentary: A kind of subperitoneal form, in which nodules are located in ligaments that support the uterus in the peritoneum.
  • Submucosal (submucous):A tumor grows in the mucosa of the uterine wall.
  • Cervical:A fibroid occurs in the cervix region.

You need to visit a gynecologistfor diagnosis. After anamnesis, you will have the following procedures:

  • Palpation of the abdomen
  • Ultrasound

If there is a chance of multiple nodules, the doctor also may assign MRI of the abdominal cavity, hysteroscopy, angiography (x-ray scan of uterinearteries using the contrast method), laparoscopy and histological examination of the tumor tissue.

Medications can only give temporary relieffor fibroids while they are taken. Therefore, many women who suffer from heavy menstrual bleedings and pains consider surgery.

Drug therapy – whichcan inhibit the growth of the tumor and do not let it to reach a critical size –is prescribed forsubperitoneal and intramuscular fibroids up to 12 weeks only. Painkillers help to relieve pain. Concomitant infections are eliminated with broad-spectrum antibiotics.

Hormone therapy helps to decrease estrogen levels, causing what is called “temporary menopause.”As a result, the growth of nodules stops, pains are gone and bleeding decreases. After discontinuation of the medication course, the menstrual cycle is restored.

But for effectivetreatment of uterine fibroid, medication alone is not sufficient, as it can only stop the tumor growth for a while but do not give a complete cure. To exclude the risk of such complications as infertility, the use of various surgical techniques to eliminate fibroids is recommended.

There are a few types of surgeries withtheir ownadvantages and disadvantages.

When going for surgery, the greatest hope of patients is that pain will leave them forever. And in most cases, pains, indeed, disappear or become weaker after surgery. But each intervention has its risks and consequences. If you have agreedforsurgery, it is worth to be sober-mindedabout the possible consequences and evaluate all the pros and cons carefully. The details of the procedure are determined by the operating physician, depending on the size, localization and number of fibroids. Not all methods are suitable for thosewomen who want to have children in the future.

Prior to surgery, a course of hormonal drugs, GnRH analogues,is prescribed (up to 3 months, whichmakes fibroid tissuesshrink and reduce in size. Due to this, the procedure of fibroid removal is more sparing and, practically, does not affect the layers of the uterine wall. To achieve this goal, German doctors use the medicine Ulipristal.

Removal of a single fibroid of large size is rather complicated, because deep scars can cause uterine bleeding, and, further,this bleeding becomes constant. In addition, there is no guarantee that after surgerythe pain will disappear completely. If,after the intervention, pains do not go over time, the uterus removal can be a solution. It is also possible to use uterine artery embolization, which allows you to get rid radical surgery. With this method, the blood supply to the fibroids is blocked.

Uterine myomectomy involvesthe removal of fibroids, with the preservation of the uterus.

There are several methods to remove fibroids:

  • Hysteroscopic myomectomy, which is performed through vaginal access.
  • Open abdominal myomectomy involves a cut in the lower third of the abdomen.
  • Laparoscopic myomectomyis done using laparoscopic access to the abdomen.

Surgery is carried out under general anesthesia. Which of the above methods is preferable depends on the number of lesions, their location and size. Today, doctors mostly try to avoid open surgery and perform myomectomy with laparoscopy, which is not a radical intervention and does not leave large scars. But with one large myomaor with multiple fibroids of different sizes, the use of vaginal access or laparoscopy is not possible.

The same as with laparotomy, using laparoscopy, it is possible to remove fibroids from the outer wall of the uterus, as well as those located in the abdominal cavity (pedunculated fibroids). Laparoscopy also allows you to remove fibroids that are located in the uterus but bulge outward, partially germinating into other layers.

Hysteroscopic access is used when a fibroid is located in the uterus, closer to the cervix. Myomectomy with vaginal access is considered even a gentler method than laparoscopy. Studies show that surgical intervention through the vagina is quick and does not cause bleeding.

Most of the women who experienced discomfort and pain for a long time feel much better after surgery or do not have any pain at all. Studies show that approximately 90 out of 100 operated women, for a year or two, are satisfied with the result. About 20 out of 100 women examined after surgery were diagnosed with recurrent uterine fibroids.

Studies that surveyed myomectomy show that:

  • 2% of women can have abdominal tissue damage during surgery.
  • Less than 1% of women experience heavy bleeding that is almost impossible to stop. In this case, surgeons undertakea removalof the uterus.

Also, wound infectionsmay result in fever and pains in the lower abdomen. With laparoscopy, blood loss is several times less than with laparotomy and complications, in turn, are rarer.

After a while, adhesions in the abdominal cavity may appear. They are the scar tissues that “stick” the organs of the abdominal cavity to the abdominal wall. Scars and adhesions cause pain in the lower abdomen when moving, rotating and bending. Depending on the location of the adhesions, there may be some problems with the intestines, and the adhesions of the internal genital organs can lead to infertility.

In most cases, the removal of fibroids does not lead to infertility, unless adhesions and large scars form and prevent the ovaries and Fallopian tubes from performing their functions. Studies were conducted to collect statistics on the outcomes of myomectomy among women who wanted to have children and got pregnantafter myomectomy. The results showed that there is no much difference between laparotomy and laparoscopy for women who plan to have pregnancylater. In both groups, almost all patients with the intention of having children after the surgery got pregnant within the next 2 years.

Often, the fibroids are removed for the sake of one single goal –to be ableto get pregnant. If a fibroid, for example, is located in the mucous membrane of the uterus, it can interfere with the process of implantation of a fertilized egg. Unfortunately, there are no studies and statistics on the removal of fibroids to increase the chances of pregnancy. Only few studies have been carried outand they do not fully prove the effectiveness of the surgery to improve fertility.

Hysterectomy is a radical operation, and it is considered, when there is one large fibroid in the uterusor a number of small fibroids that are difficult to remove. Patients gofor hysterectomy with the hope that all their complaints will disappear, once and for all.

As with the removal of fibroids, there are a few waysto remove the uterus: it can be removed by laparotomy, laparoscopy or through a vaginal access. The latter two methods cannot be applied for all women. There is also a technique when the uterus is removed through the vaginawith laparoscopy.

The uterus can be removed completely or partially. Partial removal of the uterus involves the removal of only the body of the uterus with preservation of the cervix and partial secretion of the uterus.

When the uterus is removed, of course, fibroids completely removed as well. This type of surgery will prevent possible bleeding in the future and all complaints associated with it. Some women complain of pain and cramps in the lower abdomen after removal of the uterus, but these symptoms can be causedby diseases of other organs of the small pelvis.

It is difficult to say whichof surgeries is more effective and allows keeping the genital organs healthy for longer, as well as all the advantages and disadvantages of each procedure are not fully studied.

In 5 out of 100 women, serious complications can occur during the operation, such as possible damage to neighboring organs (the bladder, ureters, or intestine) or heavy bleeding. About 2 out of 100 women may need repeated surgery or emergency medical care soonafter the surgery.

Shortly after the procedure, there may be fever, or wound infection, or bladder inflammation. All this can be easily cured if has detected promptly. But when the inflammatory process is not treated, it will give complications. The risk of complications depends on the surgery technique and the surgeon skill and experience.

Removal of the uterus through vaginal access is considered to be the gentlest technique. The risk of infection is also low, in contrast to an abdominal access, as well as, the rehabilitation is 10 days shorter and operating through a small incision does not leave a large scar.

  • Laparoscopy has significant advantages, unlike laparotomy: the risk of infection is less, as the incision is very small. A patient loses much less blood than with a traditional opensurgery. But there is a risk of damage to the bladder or ureters during laparoscopy. This occurs, on average, in 3 women out of 100 when surgery is done with laparoscopy and only 1 out of 100 with laparotomy or vaginal access.
  • Fever, inflammation of the bladder, or wound infections occur in 25 women out of 100 with laparotomy, which is high. With the removal of fibroids by laparoscopy or through a vaginal access, such complications are found in 15 women out of 100. If we compare laparoscopy and removal of fibroids through the vagina, the risks of complications for these two methods are almost identical.

Many women are satisfied after surgery, as their pain is completely gone. But, unfortunately, not all of the patients successfully undergothe operation. Some of them think that hysterectomy has deprived them of femininity. Because of these prejudices, some women procrastinate till the very last moment and do not dare for surgery. It is necessary to explainindividually to every woman in detail what the functions of the uterus are and that it is possible to live a full life without it. Every woman responds to hysterectomy in her own way. Many of thempositively change the attitude towards sex, as it no longer causes any pain, but there are also those who feelemotionallybad after the operation.

Indeed, women who have the uterus removed, enter the menopause earlier. Worsening of blood flow to the ovaries, which leads to decrease in female hormone production, is that cause early menopause. If, the ovaries are removed together with the uterus, the climacteric comes much earlier than in women with preserved ovaries.

It also happens that the removal of the uterus affects the functional activity of the bladder. Most patients do not experience this problem, but the risk of bladder weakness is always remains. One of the symptoms of bladder weakness is if urine slightly leaks when coughing, sneezing, laughing, or lifting heavy objects.

The cervix is located in close proximity to the bladder and rectum. When removing the uterus, the bladder and rectum partially lose their support and sag. Vaginal prolapse also can happen. As a consequence, a woman experiences discomfort and a pressure in the lower abdomen. There is also a risk of pelvic prolapse, which is higher in women who had weakness of the pelvic floor prior to surgery.

Whether there are advantages of a partial removal of the uterus before total removal, it is not enough studied yet. All the data from the studies undertaken till now does not prove any great difference between the methods, as well as their negative effects on the bladder function or sexual activity. After partial removal of the uterus, minor bleedings may occur, which results from the functioning of the basal cells at the base of the cervix.

The risks of complications after myomectomy or hysterectomy are equally high. The advantages and disadvantages of each method have not been sufficiently studied, as a short time has passed since the introduction of methods and no major studies have been conducted on these issues. Myomectomy has a great advantage if the patient wants to have children after the operation. The surgery to remove uterine fibroids, in many cases, eliminates all complaints of the patient, and so does hysterectomy. But it is also possible that the lesions will appear again, causing pain and discomfort. There are no repeated complaints when the uterine body is removed.

As a rule, surgery to remove uterine fibroids is not an exigency. So, you need to know all the pros and cons of each method to understand the situation better and make the right choice.

If a woman feels pressure from her private gynecologist, it is better to seek the advice of another doctorand listen to his or her opinion. The patient's family and friends should also study the situation and think it over in order to help her make the right decision. Although only a doctor can decide what treatment is best in each individual case, there aremany other factors to be considered.

The method of surgeryalso depends on the experience and skill of the operating doctor. Quite often, doctors in clinicsare skillful only in one technique and, therefore, only this technique will be suggested. That is why it is very important to have one more opinion of an independent specialist, who can impartially assess the situation and offer an alternative or agree with your doctor's decision.

2018-06-13 Uterine fibroids GermanMedicalGroup + 49 (7221) 39-65-785 Flugstrasse 8a 76532 Baden-Baden Germany Uterine fibroids Uterine fibroids Uterine fibroids
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