Fibroids Unveiled: Understanding Causes, Symptoms, and Treatment

A fibroid is a growth that forms from muscle cells in the uterus and is the most common benign growth of the female reproductive system. In about half of all affected women, fibroids do not cause any symptoms. However, the other half suffers from the typical symptoms associated with a fibroid. A fibroid can also cause complications and affect, for example, the desire to have children or an existing pregnancy. What are the symptoms of a fibroid, what types of fibroids are there, and what can be done about the benign tumour?

What is a fibroid?

A fibroid is a benign growth (benign tumour) that forms from the smooth muscle cells of the womb (uterus). It is, therefore, also referred to as a uterine myoma. In contrast to a malignant tumour, a fibroid does not grow into adjacent tissue and does not form metastases in other parts of the body.

Fibroids develop at the earliest when the first menstrual period begins. After the last menstrual period ( menopause ), new fibroids no longer form.

Approximately every fifth to every second woman is affected by one or more fibroids. The frequency cannot be determined precisely since, in many cases, fibroids do not cause any symptoms and are, therefore, not always diagnosed. If several fibroids are present simultaneously, one speaks of a uterine fibroid.

 

Causes: How does a fibroid develop?

Very little is still known about why fibroids develop. Because the muscle cells in the uterus that form the fibroid naturally respond to fluctuations in estrogen levels, changes in hormone levels are thought to encourage fibroid growth. This is probably also why fibroids mainly appear between the ages of 35 and 55, as hormonal changes can occur more frequently at this age.

Whether and to what extent psychological causes, such as stress or feelings of anxiety, can influence the development or growth of a fibroid has not yet been clarified – even if the psyche can influence the release of hormones in the body and vice versa.

However, various studies have shown other risk factors for fibroids: The risk of developing a fibroid is exceptionally high in black people. There is also a familial cluster. Both indicate a genetic component.

Other risk factors that promote the development of fibroids are diabetes mellitus, obesity and high blood pressure.

What types of fibroids are there?

Depending on where the fibroids are located, a distinction is made between:

1. Intramural fibroids,  which grow only in the muscular layer of the uterine wall
2. Subserous fibroids, which grow from the uterine wall towards the outside of the uterus under the peritoneum lining (i.e. they grow towards the abdominal cavity)
3. Submucosal fibroids,  which are just under the lining of the uterus (they grow towards the uterine cavity)
4. Cervical fibroids, also called cervical fibroids, develop in the cervix’s muscle cells.
5. Intraligamentous fibroids, which grow in the connective tissue on the side of the uterus
6. Pedicled intracavitary fibroids that  protrude from the uterine wall into the interior of the uterus

Intramural fibroids are particularly common, while cervical fibroids are rare.

 

How big can a fibroid be?

The growth behaviour of fibroids is very different, so it is difficult to make a prognosis regarding the size in individual cases. Generally, the fibroid size can be between a few millimetres and 30 centimetres.

What are the symptoms of fibroids?

Whether fibroids cause symptoms or not depends on where and how they grow and how big they are. The uterus is deep in the abdomen and borders the bladder at the front and the large intestine at the back.

• A constant urge to urinate can occur if a fibroid grows forward and presses on the bladder.
• For example, backward growth in the direction of the intestines can disrupt defecation, i.e. cause constipation.
• If the fibroids grow into the interior of the uterus, bleeding disorders such as increased menstrual bleeding or bleeding between periods can occur. Severe menstrual pain, reminiscent of labour, is also possible.
• Larger fibroids can also press on adjacent nerves. This can cause back pain or pain in the flanks, kidney area, or legs.
• In particular, during sexual intercourse, during sports or when bending over, the fibroid can cause a feeling of pressure or be perceived as a foreign body.

Complications from fibroids

A particular case is stalked fibroids, which do not grow directly as a “tuber” in the muscles but are attached to a narrow “stalk”. This can twist and thus lead to an acute abdomen. It is characterized by severe abdominal pain, nausea and vomiting, as well as circulatory problems up to and including circulatory shock. Acute abdomen is a life-threatening complication that requires intensive medical care.

In addition, intraligamentous fibroids can lead to urinary retention due to pressure on the ureter, which, if left untreated, can result in an enlargement of the renal calyx and renal pelvis (hydronephrosis).

If the fibroids cause heavy menstrual bleeding, this can lead to anaemia.

Depending on where the fibroid is and how big it is, it can increase the risk of miscarriage or prevent pregnancy.

However, the fear that fibroids could burst is unfounded. However, this is entirely possible in rare cases with cysts, which can also occur in the uterus.

 

Can a fibroid cause bloating?

In individual cases, a large fibroid can cause bloating. In extreme cases, the swollen stomach can be visually reminiscent of pregnancy. However, such large fibroids usually cause symptoms in advance, as it usually takes several years for a fibroid to reach this size. They are usually discovered beforehand and grow slowly.

Mom: Diagnose

The first point of contact if a fibroid is suspected is the gynaecologist. First, the medical history is taken, and the exact symptoms are asked (anamnesis).

In the case of larger fibroids, a uniform enlargement or nodular changes in the uterus can be felt during the gynaecological examination. Depending on the location, the fibroid can also be seen near the cervix.

The definitive diagnosis can almost always be made by ultrasound. The ultrasound examination is carried out through the vagina (vaginal sonography). Magnetic resonance imaging ( MRI ) can also be done.

A laparoscopy is also rarely necessary to clarify the situation. Here, too, the choice of method depends on the location of the fibroid: if it grows from the muscle layer of the uterine wall into the uterine lining or is limited to the uterine muscle, a hysteroscopy is performed; if it grows towards the outer side of the uterus, a laparoscopy is performed.

What therapy is there?

Small fibroids that cause no or only minor symptoms are only checked regularly every six to twelve months using ultrasound.

Treatment is only required if health problems occur or a fibroid is enormous. The type of therapy depends not only on the symptoms but also on the age of the patient, any desire to have children and the location and speed of growth of the fibroid.

In principle, all forms of treatment can have advantages or side effects. The attending gynaecologist must decide which therapy is best for the specific case.

 

contraceptives to relieve symptoms

If bleeding disorders such as increased or prolonged menstruation are in the foreground, then an attempt at treatment with hormonal contraceptives can help. For example, oral contraceptives, i.e. the birth control pill, reduce the intensity of bleeding.

An intrauterine device that continuously releases a hormone also positively affects bleeding intensity. However, since both procedures have no effect on the fibroid itself and this can continue to grow, close-meshed ultrasound controls must be carried out.

Hormone treatment with GnRH analogues

A more radical hormone treatment with so-called GnRH analogues has a more significant impact on the hormone balance. GnRH analogues stimulate the ovaries to produce estrogen and trigger ovulation. However, with the continuous intake of GnRH analogues, the ovaries stop responding to this stimulation after a period of time, which is why estrogen production eventually decreases.

This leads to a reduction in the size of the fibroids while taking it. In principle, this corresponds to an artificial menopause with the possible associated health problems, such as an increased risk of osteoporosis or hot flashes.

If treatment is stopped, the fibroids will also grow again. This makes it clear that this cannot be a long-term therapy – also because of the strong side effects. As a rule, GnRH analogues are used for six months. However, the therapy is suitable, for example, to bridge the time until an operation if the fibroid causes severe symptoms. The reduction in size of the fibroids can also mean that they can be removed more easily.

Other medications used to treat fibroids

Ulipristal acetate and the Relugolix combination tablet are available as further means of drug therapy.

Ulipristal acetate is an active ingredient that is also contained in the morning-after pill. It suppresses the growth-promoting properties of progesterone on the uterus muscle cells and inhibits or suppresses ovulation. The active substance can thus reduce the size of the fibroids and the associated symptoms to such an extent that an operation is no longer necessary.

Since January 2021, however, ulipristal acetate has only been used in women who have not yet reached menopause and for whom surgical treatment has not led to any improvement in symptoms or cannot be carried out. Even in the run-up to an operation, ulipristal acetate must no longer be used to alleviate the symptoms. The reason for this change was reports of severe liver damage caused by taking the active substance. If the active substance is prescribed, the liver values ​​should be checked regularly.

Another drug to take for fibroids is the Relugolix combination tablet. This contains the active ingredients Relugolix, Norethisterone and Estradiol. The tablet suppresses ovulation and, at the same time, has a contraceptive effect after the end of the first month of intake.

Since otherwise, similar to therapy with GnRH analogues, menopausal symptoms such as bone loss could occur, Relugolix is ​​combined with the hormones norethisterone and estradiol to reduce these side effects. Among other things, hot flashes, increased sweating and prolonged or particularly heavy bleeding from the uterus are among the common side effects of the drug.

 

Removing a fibroid: what are the options?

In addition to the drug treatment of fibroids, there are also different ways to remove them.

Hysterectomy and myomectomy

Surgical intervention is the treatment of choice for severe symptoms or rapid growth in size. Various surgical procedures are available here, from buttonhole surgery to an abdominal incision. Which procedure is chosen depends on the size and location of the fibroid.

These factors are also decisive for whether the tumour can be removed in isolation, i.e. the fibroid is peeled out (fibroid nucleation) or – especially if there are several fibroids – the uterus must be removed. In this case, it is called a hysterectomy.

In most cases, a hysterectomy is not a suitable option for younger women who want to have children. A hysterectomy is generally only considered if there is severe pain and multiple fibroids, and treatment with medication has not brought any improvement in the symptoms. This is also often avoided in older patients since fibroids can recede independently during menopause.

Myomectomy can also involve risks. For example, neighbouring organs can be injured during the operation, or uterine muscle weakness can occur.

Von Myomen embolization

A newer treatment option is the embolization of fibroids. In this minimally invasive procedure, a tube is inserted into the artery on both sides and tiny plastic particles are injected into the bloodstream via a catheter. The blood vessels supplying the myoma (left and right arteria uterina) are embolized with these plastic particles, i.e. closed.

The blood supply to the uterus itself is not disturbed by this. The fibroids gradually recede over a year after treatment, and the symptoms subside.

Since fibroid embolization can, in rare cases, lead to infertility (if plastic particles accidentally get into the arteries of the ovaries) and repeated X-ray screening during the procedure, the procedure has so far only been used in women whose family planning has ended.

 

Magnetic resonance-guided focused ultrasound

During magnetic resonance-guided focused ultrasound (MRgFUS therapy), high temperatures of up to 90 degrees are generated in a nuclear spin tomograph by high-frequency sound waves directed at the respective fibroid. This heat ensures that the body destroys and breaks down the fibroid. The therapy can be carried out on an outpatient or inpatient basis, lasting around four hours.

MRgFUS therapy can only be used for smaller fibroids with a maximum size of ten centimetres. In addition, it must be ensured that the treatment can injure no adjacent organs. Rarer side effects include burns and inflammation of adipose tissue.

desire to have children and pregnancy

Fibroids can make conception difficult and promote miscarriage because, depending on their location, they can grow into the uterus, preventing implantation of the egg or causing premature labour. They can also put pressure on the fallopian tubes and block them. The desire to have children and pregnancy are, therefore, unique situations in connection with fibroids.

In the second half of pregnancy, in particular, there is a risk that the child will be undersupplied when the placenta sits over the fibroid. There is also a tendency for premature births. Huge fibroids can also block the vaginal opening, making natural childbirth more difficult.

The removal of a fibroid can always involve risks that affect having children later. In addition, if the fibroid is removed, it is recommended to refrain from pregnancy for about six months to a year to avoid complications.

However, if miscarriages have occurred, there are difficulties in conceiving. Naturally, if the fibroid is more significant or in the uterine cavity, it should be removed before pregnancy.

Prognosis for a fibroid

After menopause, fibroids, or at least the symptoms caused by the lower estrogen levels, usually recede. Depending on the size of the fibroids, the age of the person affected and the severity of the symptoms, a cure without therapy is possible.

Drug therapy is intended to inhibit the growth of the fibroid and alleviate health problems, but usually does not (or not permanently) lead to a reduction in existing fibroids. A surgical intervention or MRgFUS therapy is required here.

If the uterus is completely removed, new uterine fibroids will never form. With organ-preserving operations, there is always a risk that fibroids will develop again. However, the risk here is shallow, around five per cent after two years.

In sporadic cases (less than one per cent), the fibroid can turn into a malignant myosarcoma. For this reason, regular check-ups are essential.