Uterine fibroids, or myomas, develop from the muscle layer of the uterus and the surrounding fibrous tissue. The pathology influences women of the reproductive age, as its main cause is high estradiol level. When elaborating the therapeutic regimen, doctors always consider desire of a woman to have children in the future. Thus, therapeutic measures offered by the specialized healthcare institutions may include pharmacotherapy, minimally invasive and open surgical interventions. Qualitative rehabilitation and relapse prevention also contribute to the improvement of a woman’s health state and ability to conceive and endure pregnancy in the future.
Clinical symptoms and possible complications
Being more frequent in women of the African-Caribbean origin, uterine fibroids affect around 1 of 3 women aged 30 to 50. In most cases the pathology does not affect the quality of life or even manifest itself with any symptoms. Those women who have clinical manifestations may experience:
- Heavy or painful periods, colicky abdominal pains during periods
- Mild to severe abdominal or lower back pain between periods
- Dyspareunia (discomfort or pain during sexual intercourse)
- Frequent pain-free urination without obvious cause
- General weakness, tiredness and impaired concentration due to anemia
- Fertility and pregnancy problems
- Swelling of the lower abdomen (in large myomas)
Nevertheless, even asymptomatic fibroids are associated with risk of miscarriage or premature labor. Visiting a specialist in gynecology is an obligatory part of annual check-up in women of reproductive age. Suspecting nodular pathology of the womb, a doctor refers woman for a set of diagnostic procedures. Timely diagnosis making is important, as myomas always continue growing until the menopause, when estradiol levels fall.
Diagnostics and choosing the therapeutic regimen
Clinically unsuspected fibroids are typically diagnosed during a routine pelvic examination (e.g. pelvic ultrasound). In other cases the pathology is revealed with the help of targeted visualizing studies.
Ultrasound scan is a painless examination that uses high frequency sound waves for creating an image of the internal organs. During an abdominal ultrasound examination the ultrasound probe is placed on the lower abdomen. During a transvaginal ultrasound examination another special probe is inserted inside a vagina. Images produced by the probe are immediately transmitted to the monitor. Thus, doctor sees the real time picture of the uterus. An ultrasound scan may be supplemented by the Doppler scan for the assessment of the blood flow in the uterine arteries.
MRI is noninvasive visualizing procedure that gives more detailed images of uterus and nearby tissues. Based on the MRI results, a doctor can determine quantity and size of myomas.
Hysteroscopy is a more invasive procedure that implies the direct examination of the inner lining of the womb. The endoscope reaches womb through the vagina. With using modern miniature equipment, this does not require making any incisions or anesthesia performing. The whole procedure takes about 5-10 minutes. Hysteroscopy is helpful in detecting and treating submucosal fibroids.
Laparoscopy is the diagnostic surgery that is performed through small incisions in the abdomen. The endoscope with a camera and light source is passed inside and relays images of the outer surface of the womb and nearby organs to a monitor. As laparoscopy is more invasive compared to hysteroscopy, this intervention is performed under the general anesthesia, i.e. a woman stays asleep during the whole procedure. Laparoscopy is informative in subserosal and intramural myomas.
Biopsy is typically performed during the hysteroscopy or laparoscopy. This is harvesting small tissue samples, which are examined under the microscope. Biopsy is performed in unclear cases when it is important to reveal the exact type of neoplasm in the uterus.
Instrumental studies are always supported by the laboratory tests, including the complete blood count and blood coagulation test. This allows preventing and timely treating anemia or coagulopathies.
Non-surgical treatment options
The etiological role of female steroid hormones in the uterine fibroids development is supported by the experimental, epidemiological, and clinical evidence. Thus, medications aimed at blocking action of progesterone and estradiol are the first-line non-surgical treatments in patients of reproductive age. These include:
- Selective estradiol receptor modulators (SERM). Estradiol increases availability of progesterone receptors and thus potentiates biological action of this hormone. Progesterone stimulates myoma development and proliferation of its cells. Three SERMs are available now: tamoxifen (Nolvadex and Soltamox), raloxifene (Evista), and toremifene (Farestone).
- Selective progesterone receptors modulators (SPRMs) directly block biological effects of progesterone. The hormone is still produced by the ovaries and adrenal glands, but cannot influence uterus anymore. SPRM ulipristal acetate is now licensed for the preoperative myomas treatment. Use of the drug for the long-term disease management is still under research. Other SPRMs, such as mifepristone and asoprisnil, are used less often and demonstrate poor efficiency.
- Gonadotropin-releasing hormone (GnRH) agonists and antagonists. GnRH agonists suppress ovaries and make them produce less progesterone and estradiol. In addition, they stop the menstrual cycle and, thus, reduce blood loss and increase hemoglobin levels. GnRH antagonists suppress the pituitary gland, which controls the ovarian function, so that ovaries stop producing both progesterone and estradiol.
Other options of hormonal treatment are taking oral contraceptives or using a levonorgestrel intrauterine system. Birth control pills reduce bleeding during periods and alleviate pain. Levonorgestrel intrauterine system is also a contraceptive agent, but it can additionally stop growth of the myomatous nodes. Symptomatic treatments are also used. These include nonsteroidal anti-inflammatory drugs (NSAIDs) for reducing pain and iron preparations for restoring the hemoglobin levels.
Surgeries and minimally invasive interventions
Surgery comes to the fore in presence of secondary changes in the fibroid (e.g. necrosis or infection), rapid growth (adding 4-5 week pregnancy per year) and large size (12-14 week pregnancy), severe pain, uterine bleedings, infertility or repeated miscarriage, dysfunction of the neighboring organs (e.g. bladder or intestine). Depending on the size and localization of the myoma in the uterine wall, the following techniques may be applied:
- Hysterectomy is partial or total womb removal. This approach is suitable for large fibroids or fibroids that cause excessive bleeding. When possible, surgeon preserves ovaries and prevents early menopause and libido reduction.
- Myomectomy is removing only the fibroid that is located in the muscular layer of the uterus. Laparoscopic myomectomy of uterine fibroids is the sparing procedure that does not require opening the abdomen as the surgical equipment is inserted through small incisions in the abdominal wall. Nevertheless, women with myomas that are located in certain parts of the uterus may need open (abdominal) myomectomy. Open myomectomy provides better visualization and is more convenient for a surgeon.
- Organ-preserving robotic myomectomy with the da Vinci system. The modern da Vinci robot surgeon has 7 degrees of freedom and 2 degrees of axial rotation, which exceeds the usual surgeon’s abilities during the intervention. With the help of one of the robot arms, the surgeon controls the camera and obtains clear images of the operating field, the second and third robot arms imitate the surgeon's right and left hands, and the fourth one serves for additional manipulations, increasing the accuracy of the intervention. The use of the da Vinci robot allows the surgeon to see structures that are invisible to the naked eye, preserve the blood vessels of the uterus, make postoperative period easier and achieve an excellent cosmetic result.
- Hysteroscopic resection of fibroids is performed without cutting the abdominal wall as surgical instruments are inserted through the vagina. Hysteroscope relays images of the operative field to a monitor and a surgeon cuts myoma with miniature surgical instruments under the excellent visual control. Few insertions may be required to remove the fibroid tissue completely. The procedure is painless, as it is performed under general anesthetic.
- Hysteroscopic morcellation of fibroids is somewhat similar to hysteroscopic resection except for inserting the surgical instruments only once. This reduces the risk of uterus injury. Morcellator repeatedly cuts away and removes the fibroid tissue until the uterine wall becomes normal. The procedure requires general or spinal anesthetic.
- Endometrial ablation is removing the endometrium, which is the inner womb layer, with the help of temperature or radio waves (cryoablation, thermal balloon ablation, radiofrequency ablation). With endometrium removal periods become less heavy. This improves significantly clinical course of a fibroids-caused anemia. Endometrial ablation is efficient in submucosal (i.e. superficial) myomas.
- Uterine artery embolization is the more sparing alternative to myomectomy or even hysterectomy. Blocking the uterine artery with an embolus is performed under guidance of the fluoroscopic X-ray imaging. An embolus reduces blood supply of the uterus and, thus, fibroids. This leads to myoma shrinking.
- Uterine fibroid embolization is similar to the uterine artery embolization except for blocking not the entire uterine artery but its smaller branch, which feeds the neoplasm. Both procedures are carried out under the local anesthetic.
- MRI-guided percutaneous laser ablation. First, the precise localization of the fibroid is determined with the help of MRI scan. After that a doctor reaches the targeted neoplasm with fine needles that are inserted through the skin, under the visual guidance. Needles serve as the guide for the laser fiber device, which sends laser light and destroys the myoma.
- MRI-guided focused ultrasound surgery is somewhat similar to the previous procedure, but it uses the high energy ultrasound waves instead of laser light. The intervention is relatively new, its benefits and possible risks are to be investigated yet.
The choice of treatment tactics depends to a large extent on a woman’s reproductive potential. In certain patients surgery may even be postponed in order not to ruin their reproductive plans.
Planning pregnancy with uterine fibroids
In women of reproductive age special importance is given to preserving the childbearing potential. A doctor discusses with a woman two questions:
- How may the fibroid influence fertility and pregnancy? Does it require obligatory treatment?
- If treatment must be performed, then which technique will ensure the best long-term outcomes with regard to fertility and general health state?
Small fibroids that are completely embedded in the wall of the womb (i.e. intramural nodules) and do not affect inner lining of the uterus (endometrium) are not a significant obstacle to conceiving a child. In this case it may be more beneficial to plan pregnancy as is, against the background of pharmacological support. Invasive surgical treatment may be postponed, as the postoperative rehabilitation period lasts for 6 months or even more.
In other cases, due to the size and localization, myoma may affect sperm’s ability to reach the egg, interfere with the implantation of an embryo or placentation. Thus, women with large fibroids located inside the womb (i.e. submucous fibroids) are eligible for surgery. Not all types of surgical procedures are suitable for women who want to preserve fertility. Myomectomy, MRI-guided percutaneous laser ablation, MRI-guided focused ultrasound surgery, hysteroscopic resection or morcellation of fibroids may be considered. Some women may need to deliver a baby via cesarean section since the uterus does not recover after the intervention completely. In addition, doctors pay special attention to the postoperative relapse prevention.
Preventing the relapse of uterine fibroids
When a woman is not concerned about the fertility preserving, a doctor may carry out radical treatment as the ultimate secondary disease prevention measure. This includes performing partial or total uterus resection (hysterectomy) or endometrial ablation (a minor procedure of removing the inner layer of the uterus). During other interventions a surgeon tries to remove the fibroid completely, as its residual mass tends to growing and forming a new fibroid.
In other cases, controlling the estradiol levels comes to the fore. Uterine myoma is the hormone-dependent neoplasm. It has been proven that estradiol stimulates both disease development and progression. Thus, maintaining low estradiol levels improves the long-term prognosis and lowers the postoperative recurrence rate. The most efficacious measures include the following:
- Maintaining normal body mass. The excessive body mass and obesity stimulate estradiol synthesis as this hormone is produced not only by ovaries, but also by the adipose tissue.
- Choosing healthy lifestyle with high content of fruits and vegetables in the diet.
- Taking birth control pills. In addition to controlling the estradiol levels, hormonal contraceptives influence positively the menstrual cycle regularity and increase chances of conceiving baby after their withdrawal (the rebound effect).
- Controlling the arterial hypertension. The connection between blood pressure and myoma development is not clear yet, but the researches show that a lot of women with large fibroids are also diagnosed with the arterial hypertension.
- Receiving enough vitamin D.
World’s leading gynecology hospitals
High estimated prevalence of uterine myomas, as well as significant direct and indirect costs associated with diagnosis making and treatment, are substantial for both healthcare providers and patients. Choosing the well-equipped hospital and the experienced surgeon is more cost-effective, as it improves precision of diagnostics, reduces treatment-dependent complications and leads to better outcomes. German healthcare institutions offer the full range of medical interventions, including all types of surgeries and follow-up diagnostic procedures. German specialists are experienced in the treatment of special patient populations, such as women of reproductive age who want to preserve fertility and women with asymptomatic neoplasms.
List of the best hospitals in Germany includes, but is not limited to:
- University Hospital Rechts der Isar Munich, Department of Gynecology, Mammology, Obstetrics and Perinatal Medicine
- University Hospital Tuebingen, Department of Adult and Pediatric Gynecology, Mammology, Obstetrics
- Charite University Hospital Berlin, Department of Adult and Pediatric Gynecology, Mammology
- University Hospital Ulm, Department of Obstetrics, Adult and Pediatric Gynecology
- University Hospital Carl Gustav Carus Dresden, Department of Adult and Pediatric Gynecology, Mammology and Obstetrics
In addition, Charite University Hospital in Berlin is included in the ranking of the world's best healthcare institutions developed by Statista Inc. (the authoritative global medical market research and consumer data company) in 2019. The estimation considered medical key performance indicators, recommendations of the healthcare professionals and results of independent patient surveys. According to the results, Germany was included in the first edition of ranking.
Treatment of uterine myoma with Booking Health
Choosing the hospital beyond the borders of the native country, patients and their relatives face a number of organizational issues. Without experience of receiving treatment abroad it may be difficult to take into account all the peculiarities of the foreign healthcare system. So that everything goes easily and safely, it is better to use assistance of Booking Health. The company Booking Health is the international provider of medical tourism with the certification ISO 9001:2015 in the relevant field.
Been engaged in arrangement of uterine fibroids treatment abroad for over 15 years, Booking Health provides all-inclusive help to women and their relatives:
- Making choice among the specialized clinics based on the rating and the annual qualification profile
- Establishing communication with the chosen gynecologist and surgeon
- Elaborating the preliminary treatment program in advance, explaining all its stages
- Providing favorable cost for treatment, without additional fees for foreign patients or overpricing (saving up to 50%)
- Booking the appointment or room in the chosen department
- Monitoring medical program at all its stages
- Insurance against the cost of treatment increase in case of complications (а coverage of 200,000 EUR, valid for 4 years)
- Assistance in buying and forwarding of medications
- Communication with the hospital after treatment completion
- Organization of additional procedures, follow-up tests, rehabilitation
- Control of medical bills and return of unspent funds
- Service of the highest level: booking hotels and plane tickets, organization of transfer
To start planning the medical trip, leave the request on the Booking Health website. A patient case manager or medical advisor will call you as soon as possible to discuss the details of your case. After choosing the hospital, doctor and medical program, a personal medical coordinator will stay in touch with you 24/7, which is extremely helpful while being abroad.
Choose treatment abroad and you will for sure get the best results!
Author: Dr. Nadezhda Ivanisova