Uterine Fibroids

Uterine fibroids are noncancerous growths on the uterus which occur in 25 to 50 percent of all women.   They often cause no problems and seldom require treatment.  Most women who have uterine fibroids are unaware of them because they often cause no symptoms.  They are often discovered by a healthcare provider during a pelvic exam or prenatal ultrasound.

Description of Uterine Fibroids

Also known as fibroid tumors, leiomyomas, fibromas or myomas, uterine fibroids are rubbery nodules that begin as irregular cells in the muscular layers of the uterus and grow slowly into tumor-like masses of connective tissue and smooth muscle.
Uterine fibroids may be as small as a pea or as large as a volleyball.   A woman can have one or many uterine fibroids, and the number as well as the growth rate of the fibroids is very hard to predict.  Some grow very slowly, some appear not to grow at all, and some grow very rapidly.  They are almost never cancerous. 
The tumors usually do not shrink or disappear on their own until after menopause. Once menopause has occurred, those fibroids present tend to shrink in size, and new fibroids rarely develop. 

There are three main types of uterine fibroids - submucous, intramural and subserous.

• Submucous uterine fibroids grow just beneath the lining of the uterus (called the endometrium).
• Intramural uterine fibroids grow within the wall of the uterus.
• Subserous uterine fibroids grow out from the outer wall of the uterus.

Sometimes the fibroid has a stalk of tissue attached.  The stalk remains attached to the uterine wall, allowing the tumor to move inside the uterus, the abdominal cavity or into the vagina.

Causes

Uterine fibroids develop from the smooth muscular tissue of the uterus.  A single cell will begin to reproduce repeatedly, eventually creating a pale, firm, rubbery mass unlike the neighboring tissue.

The exact causes of uterine fibroids are not known, but there are several factors thought to influence the presence of fibroids.  Some are:

• Genetic alterations – Some fibroids have been shown to contain alterations in the genes that determine the growth of uterine muscle cells.
• Hormones – Most fibroids contain more estrogen than do normal uterine muscle cells.  Estrogen is one of the hormones that stimulates development of the uterine lining in preparation for pregnancy.
• Other chemicals – Some substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
• Tissue response – Some fibroids appear to cluster around scar tissue from a previous injury to the uterus.

Family history is also important, since women in the same family often develop fibroids.  Race also appears to play a role, since women of African descent are two to three times more likely to develop fibroids than women of other races.  Pregnancy and taking oral contraceptives both decrease the likelihood that fibroids will develop.  Fibroids are not found in girls who have not reached puberty, but adolescent girls occasionally develop fibroids.

Symptoms   

The great majority of fibroids produce no symptoms.  However, sometimes symptoms such as the following occur:

• Abdominal fullness and gas
• Pain during sexual intercourse
• Bleeding between periods or very prolonged bleeding with periods
• Increase in urinary frequency, difficulty in urinating
• Constipation, difficult bowel movements, sometimes with rectal pain
• Heavy menstrual bleeding, sometimes with the passage of blood clots
• Pelvic cramping or pain with periods
• Sensation of fullness or pressure in lower abdomen
• Sudden, severe pain in the lower abdomen

Although uterine fibroids usually aren’t dangerous, they can cause discomfort and may lead to complications such as anemia from heavy blood loss. Rarely, fibroid tumors can grow out of the uterus on a stalk-like projection. If the fibroid twists on this stalk, it may cause sudden, sharp, and severe pain in the lower abdomen, sometimes requiring surgery.

Diagnosing Fibroids

Blood Tests
Blood will usually be tested primarily to determine whether a woman is anemic, or iron-deficient, which is one of the symptoms of fibroids.  The blood sample can also indicate whether the levels of reproductive hormones (such as estrogen) are normal.  Blood tests can neither prove nor disprove the presence of fibroids, but they can provide important clues as to whether further testing should be done. 

Endometrial Biopsy
If a woman is found to have abnormal bleeding, the physician may perform this procedure and remove a few cells from the lining of the uterus for a biopsy. For this test, the woman lies on the examining table with knees bent and feet suspended in footrests. The physician inserts a narrow tube into the uterus through the vagina and cervix, and, with the aid of suction, removes some tissue from the lining of the uterus. Endometrial biopsy is a safe procedure that normally doesn’t require anesthesia and is performed in the physician’s office.

Uterine Ultrasound
Ultrasound is a painless, safe and reliable way to check the uterus and ovaries and to look for uterine fibroids. In this process, sound waves, not radiation, are used to create pictures of the uterus. The procedure usually takes about 15 to 30 minutes and is performed in the physician’s office. 

Hysterosalpingography
This procedure is a type of x-ray test.  The physician inserts a catheter into the cervix and releases a harmless dye.  The dye will make any abnormalities in the uterine cavity and fallopian tubes visible on X-ray images. This procedure is typically performed at the hospital as an outpatient.

Hysteroscopy
This test is performed in the physician’s office or in some cases in the operating room.  The patient lies on her back with knees bent and feet suspended.  The physician inserts a long, slender telescope called a hysteroscope into the uterus through the cervix. Images of the inside of the uterus are then displayed on a monitor.

Treatment for Uterine Fibroids

Treatments range from none at all to medical therapies to surgery.

Medical therapy

The current medications available for fibroids can temporarily relieve the symptoms but cannot affect the fibroids themselves.  Women with heavy bleeding may be advised to try a medical treatment before undergoing surgery.  However, no medicines are currently available for women with pressure symptoms caused by large fibroids.

Oral contraceptives

Women with heavy menstrual periods and fibroids are often prescribed hormonal medications to try to reduce bleeding and regulate the menstrual cycle. The medications will not cause fibroids to shrink nor will it cause them to grow at a faster rate.

Intrauterine Devices (IUD)

Although IUDs are used to prevent pregnancy, they have non-contraceptive benefits as well.  An IUD that releases a small amount of hormone into the uterine cavity has been shown to decrease bleeding related to uterine fibroids. An IUD can be inserted during a routine office appointment.

Surgical Procedures

Myomectomy
Myomectomy is an operation in which fibroids are removed from within the uterus. Stitches are used to bring the walls of the uterus back together. For women with symptomatic fibroids who plan to become pregnant in the future, myomectomy is the best treatment option.
Myomectomy is a very effective treatment, but fibroids can re-grow. The younger a woman is and the more fibroids present at the time of myomectomy, the more likely she is to develop fibroids in the future. Women nearing menopause are the least likely to have problems from fibroids again.
A myomectomy can be performed several different ways.   The method used depends on the size and location of the fibroids.   In some cases, myomectomy may require an abdominal incision; in other cases it may be done through a laparoscope (a telescope-like instrument inserted through an abdominal wall puncture) or a hysteroscope (a telescope-like instrument inserted through the vagina).  

Hysterectomy
A hysterectomy is a major surgical procedure in which the uterus is removed. This option is often chosen by women who no longer wish to have children since it can completely resolve their fibroid symptoms.  After a hysterectomy, menstrual bleeding stops, pelvic pressure is relieved, frequent urination improves and new fibroids cannot grow. The uterus is removed either vaginally or abdominally.  The vaginal hysterectomy requires no incisions in the abdomen, but it is only an option if the fibroids and the uterus have not grown too large.

Uterine Artery Embolization (UAE)
Uterine artery embolization is a treatment alternative to surgery for fibroids.  Embolization means blocking the blood flow to the fibroid.  By stopping the blood flow, the fibroid begins to die and shrink in size. This will often decrease menstrual bleeding and symptoms of pain, pressure, urinary frequency or constipation.The procedure is usually performed in the hospital, and usually takes a few hours.  A medication is given to keep the patient awake but relaxed throughout the procedure.  A needle is placed in an artery in the leg, at the groin crease, and a small catheter is then placed into the artery.  The catheter allows the physician to inject tiny particles into those arteries that provide blood to the fibroid.  The particles cut off the blood flow to the fibroid and it will begin to die and shrink.Some women experience very little pain; others say the pain is similar to menstrual cramping.  Patients usually stay overnight in the hospital, and can often return to full activity in about one week.

Pregnancy and Uterine Fibroids

Because uterine fibroids usually develop during the childbearing years, women with fibroids are often concerned about the effect of the fibroids on their pregnancy.

Although fibroids rarely cause problems during a pregnancy, they can affect fertility.  Some fibroids may distort or block the fallopian tubes, or interfere with the passage of sperm from the cervix to the fallopian tubes.  Also, submucosal fibroids may prevent implantation and growth of an embryo.

Pregnant women with fibroids are at slightly increased risk of miscarriage, premature labor and delivery, abnormal fetal position, and separation of the placenta from the uterine wall. However, the possibility and type of complications will vary based on the number, size and location of the fibroids.  Multiple fibroids and large submucosal fibroids that distort the uterine cavity are the type most likely to cause problems. A more common complication of fibroids in pregnancy is pain, usually only between the first and second trimesters. This is usually easily treated with pain relievers.

In most cases, fibroids don't interfere with pregnancy and treatment isn't necessary.  Very rarely, a fibroid can block the opening of the uterus or block the baby’s passage into the birth canal.  A caesarean delivery is performed in those cases. 

For women who have fibroids and have experienced repeated pregnancy losses, the physician will probably recommend removing the fibroids to improve the chances of carrying a baby to term. 

Remember

One out of every four or five women will have uterine fibroids sometime in her lifetime.  These growths are almost always benign and often present no problems or symptoms in the woman.

If you are diagnosed with uterine fibroids, there are many treatment options, including no treatment at all.  Your physician is the best person to advise you based on your symptoms and medical condition.