What is uterine fibrosis
Doctor's letter : Fibroids
EXPLANATION The fertilized egg nests in the mucous membrane that lines the uterine cavity in order to mature into a human within nine months. However, the tissue of the uterus is susceptible to pathological changes. These include fibroids: benign tumors that grow in the muscle tissue of the uterus in almost half of women. The mostly rounded structures, which appear individually or in groups, usually do not cause any complaints. However, if they get too big or too numerous, problems can arise. "Normally, the uterus of a woman of childbearing potential is around seven to nine centimeters long, five centimeters wide and weighs around 50 grams," says Bernd Bojahr, team head of gynecology at the clinic for MIC in Berlin-Zehlendorf. “In extreme cases, fibroids can cause it to grow so much that it fills the entire abdominal cavity and weighs up to four kilograms.” However, this is very rare. If symptoms arise, you should do something about the fibroids - either with drugs or surgically.
SYMPTOMS Only in 20 to 50 percent of women affected are fibroids noticeable through symptoms, mostly in the form of painful and increased menstrual bleeding or abdominal discomfort. “Whether the growths cause problems depends, among other things, on their size and their location in the uterus,” says gynecologist Bojahr. Very large fibroids can cause pain when they press on neighboring organs such as the intestine or the bladder and trigger a foreign body sensation or even constipation. They can also interfere with a normal birth at the end of the pregnancy. If the fibroids are in an unfavorable place, they can even affect fertility, for example because they prevent a fertilized egg cell from implanting in the lining of the uterus.
CAUSES The exact causes of the benign growths are so far unknown. One thing is certain: the female sex hormone estrogen plays an important role in this. Therefore, women of childbearing age are particularly affected by them. In girls before their first menstrual period (menarche) and women after menopause, however, they rarely occur. Existing fibroids usually shrink on their own after the menopause. In addition to estrogen, genetic predisposition and metabolic disorders can also favor fibroids.
DIGNOSISGynecologists can often diagnose uterine fibroids during the palpation examination. Another standard method is the ultrasound examination. But more complex procedures such as computed tomography (CT) or magnetic resonance tomography (MRT) as well as diagnostic operations such as mirroring the uterus or the abdomen are used.
THERAPYBecause fibroids are benign growths, they do not necessarily need treatment. "Therapy is especially necessary if the tumors cause symptoms - or if they are very large," says gynecologist Bojahr. In such cases, doctors have different methods available: medicinal and surgical, but also those with ultrasound or so-called embolization, in which the fibroids are obliterated by interrupting their blood supply.
Drug treatment with hormones (progestins) can be used if the patient wants to maintain her fertility, if she is older and menopause will soon occur or if the patient generally does not want operations. It shows particularly good results when it comes to treating bleeding disorders caused by fibroids.
Surgery is required when the fibroid is affecting fertility or causing excessive discomfort. The choice of surgical method depends on the number, size and location of the fibroids as well as the age of the patient and her family planning. Previous operations should also be taken into account when choosing the method. "If the fibroids are in a favorable position, they can be cut out of the tissue so that the uterus is preserved," says Bojahr. This means that a later pregnancy is still possible. "Since the procedure causes deep wounds in the muscles of the uterus, which then scar, the delivery often has to be done by caesarean section." In addition, an organ-preserving operation could lead to the formation of new myomas up to menopause, and if the symptoms recur, another procedure can be performed make necessary. Nevertheless, a complete removal of the uterus - a so-called hysterectomy (see page 46) - should always come last and only be carried out when all other options have been exhausted.
In principle, a uterus can be removed in various ways: minimally invasive, i.e. through small incisions in the abdominal wall, through the vagina, or - in very rare cases - in an open operation with an incision several centimeters long. If the procedure is done through the vagina, it does so without leaving any visible scars. The surgeon separates the uterus from the surrounding tissue and pulls it out of the body. Depending on the size of the organ, such an operation takes between 15 minutes and three hours.
If the natural opening of the body is not an option - for example because the vagina is too narrow - the surgeon removes the organ using the so-called keyhole technique. This minimally invasive procedure is carried out using small incisions on the abdomen, through which only millimeter-thick, long-handled instruments are inserted into the body cavity. These include those with a light source and camera lenses (endoscopes) because the surgeon can only follow the operation on a screen. This procedure takes from 30 minutes to three hours, depending on the size of the uterus. It only leaves small scars. "With this procedure, it is also possible to preserve the cervix," says Bojahr, whose clinic specializes in minimally invasive surgery. “This leaves the vagina untouched, reducing the risk of infection and injury.” Around 30 percent of women who have had their uterus completely removed - including the cervix - would also have a vaginal stump prolapse and incontinence. “As a rule, a uterus up to a weight of 1.5 kilograms can be removed using minimally invasive methods,” says Bojahr. With a special technique in which the organ is operated on one after the other from the left and right side of the body, it is also possible to remove a uterus that already fills the entire abdominal cavity due to the growths.
In certain cases, as an alternative to surgery, it is also possible to treat fibroids with the help of embolization or MRI-guided targeted ultrasound therapy. During embolization, the blood vessels that supply the fibroid are closed. For this purpose, a long, only one millimeter thin plastic tube, a catheter, is inserted into the artery of the right groin and pushed through the blood vessels to the vessels of the uterus that are connected to the myoma. Small plastic balls are injected through this tube, which get caught in the veins and clog them. In the best-case scenario, the fibroid tissue then dies and shrinks, which can take about a quarter to six months. The injected beads remain in the vessels. In ultrasound therapy, the doctors “shoot” the fibroid precisely with sound waves. The tissue is then destroyed by the resulting heat.
The editors of the magazine "Tagesspiegel Kliniken Berlin 2016" compared the Berlin clinics that treat this disease. For this purpose, the treatment numbers, the hospital recommendations of the outpatient doctors and the patient satisfaction were compiled in clear tables in order to make it easier for the patient to choose a clinic. The magazine costs 12.80 euros and is available in the Tagesspiegel shop.
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