Myomas: Treatment - from gentle surgery to embolization
The decisive factor as to whether treatment of fibroids is necessary at all is whether or not symptoms are present. The choice of treatment depends not only on the size, location and number of fibroids, but also on the age of the patient and whether family planning has already been completed or whether there is still a desire to have children. They can also play a negative role in an unfulfilled desire to have children. Not every fibroid needs to be operated on.
The “spectrum” of treatment options ranges from purely medicinal symptom control to embolization of the blood vessels of the fibroid to uterus-preserving operations (hysteroscopic or laparoscopic myomectomy). At the end of the treatment spectrum, hysterectomy is the “most radical” but also the only “definitive” therapy. This is used when other therapies have failed, there is a desire for a definitive solution and the desire to have children is complete.
Since fibroids are a predisposition of the uterus, all uterus-preserving procedures – whether surgery, embolization or medication – must be expected to be repeated after 5 years in 15% of cases. As long as a woman is not past the menopause, fibroids can form again.
Myoma therapy with medication
Various medications are available to slow down the symptoms or growth of fibroids:
- Sex hormones (contraceptive pills with oestrogen and progestogen, mini-pill, hormonal coil): Although they cannot inhibit the growth of fibroids, they can at least suppress heavy menstrual bleeding. Of these, the luteal hormone preparations (gestagens) are particularly noteworthy. They can achieve excellent control of menstrual bleeding, particularly in the form of the hormonal IUD.
- GnRH analogs: Ability to slow down or reduce fibroid growth by simulating the menopause for as long as they are used, thus eliminating the stimulation of fibroids by female hormones. Ideally, the fibroid volume can be reduced by up to 50% over a treatment period of 2-4 months. In addition, the blood flow to the fibroids is reduced so that less blood loss can occur during a fibroid operation.
Myoma therapy with medication is suitable for women who cannot undergo surgery (e.g. due to another existing illness) and as preparation for surgery to reduce the size of a very large fibroid. Women also benefit from hormone therapy if they are about to go through the menopause, which means that the body’s own hormone production will decrease over the next few years anyway and with it the growth of fibroids.
Interventional, surgical procedures to remove fibroids
Regardless of whether myoma embolization or removal of a fibroid is performed by surgery: It is important to have an exact picture of the number, location and size of the fibroids before the procedure. Magnetic resonance imaging (MRI) prior to these treatments can therefore be supportive. This not only allows the ideal treatment to be selected, but also, for example in the case of myoma embolization, the response to treatment can be assessed.
Excision of a fibroid – fibroid enucleation
Whereas in the past the entire uterus was sometimes removed in the case of a fibroid, surgeons today take a targeted and gentle approach: They carefully peel the tumor out of the uterine muscle, leaving the uterus intact. This is important for women who want to have children. The surgical procedure is as minimally invasive as possible, i.e. as part of a hysteroscopy or laparoscopy. An abdominal incision is usually only necessary if there are several and/or very large fibroids. It should be noted that fibroids are benign in over 99% of cases. Rarely, however, the lump may contain malignant cells. This is referred to as a sarcoma. Myoma removal using the keyhole technique requires the fibroid in the abdominal cavity to be broken up so that the tissue can be removed through the small incisions. In the rare case of a malignant disease, there is a risk of malignant cells being distributed in the abdominal cavity. This risk can be reduced by crushing the fibroid in a bag that is inserted into the abdominal cavity.
Embolization of the blood vessels of the fibroid (minimally invasive closure)
In this method, a catheter is used to block the blood vessels that supply the fibroid with tiny plastic beads. The fibroid cut off from the blood supply dies, shrinks and the symptoms subside. Since percutaneous catheter myomembolization can lead to pain in the first 24 hours, the intervention is performed during a hospital stay to enable optimal pain therapy. Over 90% of heavy periods are normalized. The fibroids can shrink in volume by over 50% after this procedure.
Restrictions for this treatment method are infections in the pelvic area, vascular diseases, allergies to contrast media used in radiology. However, certain locations of the fibroids can also be a reason why this treatment cannot be carried out. In addition, this treatment method does not allow the tissue to be examined under a microscope.