Fibroids are benign growths of the uterus and are among the most common gynecological findings overall. In Germany, more than 50% of women develop at least one fibroid during their lifetime, particularly frequently between the ages of 30 and 50.
Many fibroids go unnoticed, while others cause heavy bleeding, pain, or impair fertility. The editorial team of the Leading Medicine Guide spoke with Professor Dr. med. Hans-Christian Kolberg to learn more about how this condition progresses and what treatment options are available.
„If fibroids are discovered incidentally, for example during an ultrasound, and the patient has no symptoms, there is absolutely no need for treatment. Fibroids only become medically relevant and require treatment when they cause symptoms.
However, it is important to be certain that the diagnosis is indeed a fibroid. There is an extremely rare but crucial differential diagnosis: sarcoma, a malignant disease that can appear identical to a fibroid on ultrasound and even on MRI. Ultimately, the two can only be distinguished by their growth rate, which is why evaluation by an experienced gynecologist is so important.
One of the first questions in consultation is therefore how long the patient has been aware of the change. If someone has had fibroids for ten years, it cannot be a sarcoma. Although this malignant variant is rare, it should be mentioned and kept in mind.
Aside from that, the general rule is: fibroids only need to be treated if they actually cause symptoms“, explains Prof. Dr. Kolberg, before describing how fibroids develop:
„Fibroids essentially develop like any other benign tumor, because that is exactly what they are: benign tissue that grows in a place where it does not belong. The term “tumor” unnecessarily frightens many people, although it simply means that tissue is forming somewhere it should not.
There are malignant tumors that are dangerous and benign ones that cause no harm. In the case of fibroids, muscle tissue grows outside the functional structure of the uterine wall; it cannot contract and instead forms a lump—this is exactly what a fibroid node is. Why women develop fibroids cannot be attributed to environmental factors, diet, or medication.
A genetic predisposition is the most likely explanation. A specific gene has not yet been identified, and there is no way to predict or test the risk. However, experience shows that women may have an increased risk if their mother or sister also had fibroids, even though this risk cannot be precisely quantified. What remains decisive is that fibroids only become a disease when they cause symptoms.
Regarding growth, there are no fixed rules; assessments are based on experience. If a fibroid is detected for the first time and measures about two centimeters, a follow-up check is often performed after six months. In young women with a regular cycle and normal hormone levels, it is entirely typical for a fibroid to grow to three centimeters during this time.
Growth of one to two centimeters per year is considered normal, although fibroids do not grow linearly but in phases. Some remain unchanged for years. A sarcoma, on the other hand, grows continuously and usually shows a significant increase in size within six months, often doubling. If there is still uncertainty despite monitoring, the fibroid is removed“.
The prevalence of fibroids cannot be determined equally precisely for all population groups, but certain trends are well established.
„Among African women, it is relatively well established that about half of women under 40 have fibroids. At first glance, this seems surprising because many women on the African continent can have several children without difficulty despite this high rate. The explanation lies in the age at which women become pregnant: if a woman starts having children at 16, many pregnancies can occur before fibroids grow large enough to cause symptoms.
If, on the other hand, a woman only begins family planning in her mid-30s, fibroids have much more time to develop and cause problems. For Germany and other European populations, it is estimated that about one in four women over 30 has fibroids.
The prevalence increases with age because fibroids develop and grow over time. They are most commonly found between the ages of 40 and 50. In this age group, up to 50 percent of women may have fibroids—but this does not mean that all of them experience symptoms. Only about 20 percent of those affected actually have symptoms that require treatment“, explains Prof. Dr. Kolberg.
Many women with fibroids initially notice no changes, because these benign tumors often grow slowly and the body adapts to the gradual changes. Symptoms usually arise only when a fibroid reaches a certain size or is positioned in a way that distorts the uterus or presses on surrounding organs.
Prof. Dr. Kolberg explains: „Fibroids do not automatically have to be removed as soon as they cause symptoms, because ultimately it is always the woman herself who decides how much she is affected and whether she wants treatment. Some women find heavier bleeding or occasional pain hardly bothersome and do not wish to take action, while others feel that even minor changes are unacceptable.
Both attitudes are entirely legitimate. A “must” only exists in the extremely rare situation where it is unclear whether the finding is truly a fibroid or possibly a sarcoma. Since sarcomas account for less than two percent of such findings and many fibroids never cause symptoms, they are not treated as a precaution but only when symptoms actually occur.
The symptoms themselves can be broadly divided into three groups. The first group includes everything caused by the expansion of a fibroid: pain, a feeling of pressure, frequent urination, constipation, or other complaints resulting from compression of organs. The second group concerns bleeding disorders.
Many women experience spotting or, in particular, very heavy menstrual bleeding that remains regular but is much heavier than before. This is one of the most common reasons for treatment. The third group concerns infertility. Fibroids can alter the structure of the uterus, block the fallopian tubes, or affect uterine movement, thereby interfering with the transport of sperm.
They can therefore be a cause of infertility, but they do not have to be“. In addition, they can also cause miscarriages or, more rarely, premature births.
Fibroids are almost always located in the uterus, as they arise where smooth muscle tissue is present. They are therefore also referred to as uterine fibroids.
„Fibroids can occur in all layers of the uterine wall or in the supporting ligaments of the uterus, but they do not migrate to other locations. From the outer peritoneal covering to deep within the uterine cavity, they can develop anywhere muscle tissue is present. Heavy or prolonged menstrual bleeding, which can lead to anemia, and cramping lower abdominal pain are common.
Some women feel a sense of pressure or fullness in the pelvis that intensifies when sitting or moving. If a fibroid presses on the bladder, frequent urination or problems with completely emptying the bladder may occur, while fibroids near the intestines can lead to constipation or pressure-related discomfort.
Pain during intercourse or reduced fertility is also possible if fibroids alter the uterine cavity. Despite these possible symptoms, many fibroids remain unnoticed for a long time because small or unfavorably located fibroids cause no symptoms at all. Even larger fibroids may remain inconspicuous if they grow in a way that does not affect the uterine cavity or neighboring organs.
Many women also interpret mild cycle changes or occasional pain as normal fluctuations and only seek medical advice at a late stage. Since fibroids usually grow over years, the body adapts to the changes, so symptoms often only become noticeable when the fibroid becomes significantly larger or changes position.
A gynecological examination is therefore important if bleeding disorders, pain, or pressure symptoms occur, in order to clarify the cause with certainty“, recommends Prof. Dr. Kolberg.
Fibroids are most reliably detected using imaging techniques, as these clearly visualize the uterus and make changes visible at an early stage. Medical evaluation is always important, especially in the case of bleeding disorders, pain, or pressure symptoms, as only a specialist can reliably determine whether a fibroid is present and what significance it has.
„Diagnostics always begin with a consultation, because the key question is what symptoms a woman actually has and how much she is personally affected. Many patients come to our specialized fibroid clinic because they notice symptoms themselves, while others come because their gynecologist detected fibroids during an ultrasound without them having noticed anything.
In such cases where there are no symptoms at all, it is often already clear after the consultation that no treatment is necessary. That is why the first question is always whether and to what extent the patient is affected. In the next step, most of the diagnostics can be clarified by ultrasound.
Transvaginal ultrasound is the most important method, as it allows very precise visualization of where the fibroids are located and whether they could be responsible for the symptoms described. An additional abdominal ultrasound may be useful if the location or size of the fibroids requires it. For specific questions, such as when the exact extent or relationship to certain structures is unclear, magnetic resonance imaging may sometimes be used. CT scans, however, play no role in fibroid diagnostics“, says Prof. Dr. Kolberg.
Transvaginal ultrasound is the most important and most commonly used method, as it provides a very detailed view of the uterus and reliably shows the size, location, and number of fibroids
Modern, gentle treatment approaches for fibroids aim to relieve symptoms while preserving the uterus whenever possible. The most appropriate method always depends on the individual situation—such as the size and location of the fibroids, the symptoms, and the desire to have children.
Prof. Dr. Kolberg explains: „To understand fibroid treatment, one must first consider the fundamental options available. There are both surgical and non-surgical procedures, and it is important to explain both sides thoroughly before discussing specific steps.
A key factor is family planning, as it largely determines which options are appropriate. Women who no longer wish to have children can choose from a broader range of measures, while certain procedures are not suitable for women who still want children. Even though most patients are not yet old—fibroids are, with very rare exceptions, an issue before menopause—not all still wish to become pregnant.
Once menopause begins, fibroids lose their significance anyway, because the hormonal withdrawal prevents further growth and they often even shrink. Surgical options include uterus-preserving procedures, in which fibroids are removed and the uterus is reconstructed, and complete removal of the uterus. Uterus-preserving surgery is particularly considered if a woman still wishes to have children or if non-surgical therapies are not desired or not covered.
If there is no longer a desire to have children and surgery is preferred, removal of the uterus is usually the procedure with significantly fewer complications. It is shorter, carries less risk, and solves the problem permanently, as fibroids cannot recur afterward. While blood is generally no longer required in advance for a hysterectomy, it is almost always cross-matched for fibroid removal due to the higher risk of transfusion.
This does not mean that preserving the uterus is not a valuable goal—on the contrary, it is essential for women who wish to have children—but from a purely medical perspective, hysterectomy is the lower-risk option. In terms of recovery time, about 4–6 weeks should be expected after a hysterectomy, whereas patients are typically able to return to work after about 14 days following uterus-preserving surgery.
Ultimately, the decision always lies with the patient. She alone determines how much she is affected, which risks she is willing to accept, and which solution she finds most suitable. The role of physicians is to clearly present all options, not to dictate a particular course of action.
Uterus-preserving procedures are performed frequently, especially because many young women have fibroids and wish to preserve their organs. However, they are more complex and can take two to three hours in the case of large fibroids“ and emphasizes:
„It is virtually unheard of that a woman who wishes to have children must be told that her uterus needs to be removed. If a patient wants to preserve her uterus, there is no medical reason to deny her that. Even very extensive findings can usually be treated with uterus-preserving surgery.
Many women come to us for a second opinion because they were told in non-specialized facilities that removal was unavoidable. Yet even extreme cases can often be managed differently. Experience shows that even from a uterus with dozens of fibroids—in one case there were sixty—all nodules can be removed, and the woman can still become pregnant later and have a healthy child“.
Surgery becomes necessary when fibroids cause severe symptoms, rapid growth, fertility problems, or diagnostic uncertainty. Very large or unfavorably located fibroids can often only be removed surgically. If there is no desire for children, hysterectomy may also be considered in advanced cases—always depending on the individual symptoms and needs.
Non-surgical treatment options include both medication and various minimally invasive procedures aimed at shrinking fibroids or relieving their symptoms without surgically removing tissue.
„The most important medication-based option today is treatment with so-called GnRH antagonists. These agents block the hormonal stimulation of the ovaries, temporarily placing the woman in an artificial menopausal state. To counteract typical menopausal symptoms, small amounts of hormones are added in a fixed combination, known as add-back therapy.
This treatment can shrink fibroids and significantly reduce symptoms. Many patients use it to gain time: they become symptom-free for a few months and can calmly decide whether and which further treatment they want. The therapy can be used intermittently, paused, and resumed if symptoms recur.
The medications do not need to be taken for life, because any fibroid treatment is only necessary until menopause begins. After that, fibroids lose their hormonal basis, stop growing, and often shrink, so no further treatment is required. Although drug therapy can be used over a longer period, for most patients it is a temporary solution.
Many begin this treatment at an age when menopause is already approaching and use the medication to relieve symptoms or bridge the time until a final decision about further steps is made. In very young women, this therapy is generally not used long-term. It is more often used to prepare for surgery or to calm acute symptoms.
Long-term use would also not be appropriate because pregnancy is not possible under this treatment.“, explains Prof. Dr. Kolberg, adding:
„In addition to drug therapy, there are three non-surgical procedures that directly target fibroids. A commonly offered method is uterine artery embolization. After prior MRI evaluation, material is introduced into the blood vessels supplying the fibroid via angiography.
These small particles block the vessels, reducing blood flow to the fibroid and causing it to shrink. In 70 to 80 percent of patients, symptoms improve significantly. Another option is high-intensity focused ultrasound. In this method, ultrasound waves are concentrated so that they meet at a single point in the body and generate heat there.
Temperatures of 70 to 80 degrees cause fibroids to shrink and symptoms to subside, also with success rates of around 70 to 80 percent. However, both methods are only suitable for fibroids smaller than eight centimeters in diameter. The third option is radiofrequency ablation, a hybrid between minimally invasive and surgical approaches. Under anesthesia, a probe is guided through the uterine cavity into the fibroid, and radiofrequency energy is used to heat and shrink the tissue without cutting anything out.
From all these options, the one that best fits the patient’s symptoms, preferences, and individual fibroid characteristics is selected together with her. Some fibroid types are better suited to certain procedures than others, so the decision is always highly individualized“.
At Knappschaft Kliniken Marienhospital Bottrop, uterus-preserving surgery is not only pursued but made possible in the vast majority of cases. Even complex fibroid conditions are treated with organ-preserving techniques—an essential advantage, especially for women who wish to have children.
„Whether a uterus can be preserved despite many fibroids depends less on an unknown technique and more on surgical experience. When operating on a uterus with twenty, thirty, or forty fibroids, it can look during the procedure as if there had been an explosion in the tissue, and every single part must then be carefully reassembled.
This is technically demanding, time-consuming, and requires a great deal of routine. Those who rarely perform such procedures can hardly imagine that reliable reconstruction is possible—and therefore more quickly recommend removing the uterus. This is precisely why fibroids should be treated in specialized fibroid clinics, where diagnostics and surgery are carried out by teams that regularly handle such cases.
This is similar to oncology: the more experienced the center, the safer and more differentiated the decisions can be made. Many patients who were advised to undergo hysterectomy in non-specialized facilities were able to receive uterus-preserving surgery in specialized centers—especially when they wished to have children.
The principle that the woman ultimately makes the decision plays a central role. There are still colleagues who take a more directive approach and determine themselves what is possible or appropriate. However, whether having children is a realistic goal for the patient is not the physician’s decision. Even if the chances after complex fibroid removal are not perfect, the possibility of pregnancy remains—whereas after hysterectomy it is zero.
In the end, much depends on the individual experience of the surgeon and the resources of the center. The more complex the condition, the more important it is to have someone who performs such procedures frequently and successfully“, emphasizes Prof. Dr. Kolberg, concluding our conversation.
- Long-standing chief physician (over 20 years) and leading expert in gynecologic oncology with particular experience in the treatment of breast cancer and tumors of the female reproductive organs.
- Outstanding surgical expertise, particularly in complex gynecological procedures, fibroids, pelvic floor disorders, and incontinence.
- Pioneer of modern, minimally invasive therapies such as high-intensity focused ultrasound (HIFU) for fibroids and fibroadenomas, as well as intraoperative radiation therapy for breast cancer.
- Internationally recognized scientist and educator, active in professional societies, clinical studies, publications, and as a visiting professor in China and Malaysia.
- Head of a multiple-certified breast and gynecologic cancer center that meets the highest quality standards in diagnostics, therapy, and technical equipment.
- Dedicated obstetrician with expertise in high-risk obstetrics, gentle cesarean sections, and water births.
- Patient-centered medicine characterized by personal support, state-of-the-art medical care, and a commitment to providing individualized and responsible treatment.
