Fibroids

What are fibroids?

Fibroids are growths made of smooth muscle cells and fibrous connective tissue. These growths develop in the uterus and appear alone or in groups. They range in size, from as small as a grain of rice to as big as a melon. In some cases, fibroids can grow into the uterine cavity or outward from the uterus on stalks.

An estimated 20% to 50% of women of reproductive age currently have fibroids, and up to 77% of women will develop fibroids sometime during their childbearing years. Only about one-third of these fibroids are large enough to be detected by a health care provider during a physical exam, so they are often undiagnosed.

In more than 99% of fibroid cases, the tumors are not cancerous and do not increase the risk for uterine cancer.

What causes fibroids?

The cause of fibroids is not known. Research suggests each tumor develops from an abnormal muscle cell in the uterus and multiplies rapidly when encountering the estrogen hormone, which promotes the tumor’s growth.

Who is at risk for fibroids?

Women in their reproductive age are most likely to be affected by fibroids.

Other risk factors may include:

• ♦ Family history of fibroids
• ♦ Obesity
• ♦ Diet high in red meat
• ♦ High blood pressure

Black women are more likely to develop fibroids than other women, they are diagnosed at younger ages and they more often require treatment. It is not clearly understood why fibroids disproportionately affect Black women.

Fibroids Symptoms

It is common that women who have fibroids do not experience any noticeable symptoms. Other women with fibroids experience severe symptoms that interfere with their daily lives. Common fibroid symptoms include:

• ♦ Heavy or prolonged periods
• ♦ Bleeding between periods
• ♦ Abdominal discomfort and/or fullness
• ♦ Pelvic pain
• ♦ Lower back pain
• ♦ Bladder symptoms, such as frequent urination or difficulty emptying the bladder
• ♦ Bowel symptoms, such as constipation or excessive straining with bowel movements

Women with fibroids can also experience:

• ♦ Infertility
• ♦ Complications during pregnancy
• ♦ Pain during intercourse

Emergency Fibroid Symptoms

In rare cases, women with fibroids need emergency treatment. You should seek emergency care if you have sharp, sudden pain in the abdomen that is unrelieved with pain medication, or severe vaginal bleeding with signs of anemia such as lightheadedness, extreme fatigue and weakness.

How are fibroids diagnosed?

Fibroids are most often found during a routine pelvic exam. During this exam, your health care provider will press on your abdomen and may feel a firm, irregular mass that might indicate a fibroid.

To diagnose uterine fibroids, your doctor may order one of the following tests:

• ♦ Pelvic Ultrasound. A procedure during which a small instrument, called a transducer, is either inserted into the vagina or pressed over the abdomen to produce pictures of the internal organs using sound waves. The doctor can see the size, shape and texture of the uterus and evaluate any growths.
• ♦ Magnetic resonance imaging (MRI). This is a form of advanced imaging technology that provides highly detailed images of internal organs. These images help your provider determine the exact location and characteristics of fibroids and, if needed, plan minimally invasive treatments.
• ♦ Hysterosalpingography. This is a type of X-ray exam of the uterus and fallopian tubes. Your doctor will use a special dye to more easily visualize these organs and determine if the fibroids have blocked your fallopian tubes.
• ♦ Hysteroscopy. This is a visual exam of the canal of the cervix and the interior of the uterus using a viewing instrument (hysteroscope) inserted through the vagina

How are fibroids treated?

Since the growth of most fibroids slows as you approach menopause, your health care provider may simply suggest “watchful waiting” if your symptoms are tolerable. With this approach, the health care provider closely monitors your symptoms with frequent follow-up visits and ultrasounds to make sure there are no significant changes in your condition.

Treatment may be necessary if your fibroids cause significant symptoms. Treatment options include medicinal and surgical approaches. Your doctor will recommend treatment based on your symptoms, location and size of the fibroids, your age and medical history, and your health goals such as a desire for pregnancy.

In some cases, women also require treatment for iron-deficiency anemia due to heavy or prolonged periods, or because of abnormal bleeding between periods.

Medicinal Treatment Options

Anti-inflammatory painkillers such as ibuprofen or naproxen may reduce menstrual bleeding caused by fibroids and provide pain relief. This is the most conservative treatment method and is recommended for women with occasional pelvic pain or discomfort due to fibroids.

Hormonal treatment can include:

• ♦ Gonadotropin-releasing hormone agonists (GnRH agonists). This treatment lowers your estrogen level and triggers a temporary “medical menopause.” GnRH agonists are used to shrink the fibroid(s). They are also used to stop your period in preparation for surgery or to improve your blood count. Doctors will not typically administer this medication for longer than a year — and the medication’s effects are reversed once it leaves your system.
• ♦ Oral contraceptive pills (or a patch or vaginal ring) can help reduce bleeding associated with fibroids.
• ♦ Progesterone-containing agents — pills, implant, injection or intrauterine device (IUD) — may also control bleeding.

Procedural Treatment Options

Conservative surgical therapy. Myomectomy is a procedure during which the fibroids are removed but the uterus stays intact. This approach is recommended for women who want to preserve their fertility. There are three primary myomectomy methods:

• ♦ Traditional open myomectomy. The procedure is performed via an abdominal incision and carries some risks, including bleeding and scar tissue formation at the incision site and a longer recovery. This approach may be necessary depending on the size and number of fibroids.
• ♦ Laparoscopic or robotic myomectomy. This outpatient procedure uses small “keyhole” abdominal incisions and a laparoscope. This minimally invasive approach often results in less bleeding and a faster recovery, but it is not suited for all patients. Most patients go home the day of surgery and recover within a few weeks. Your doctor will determine if you are a good candidate for this procedure.
• ♦ Hysteroscopic myomectomy. During this outpatient procedure, your doctor uses a camera inserted through the vagina to shave off visible portions of the fibroid tumors. This method only treats fibroids that have formed inside the uterine cavity.

Uterine artery embolization (UAE), also called uterine fibroid embolization, is a newer technique. This minimally invasive procedure shrinks fibroids by cutting off their blood flow. An interventional radiologist performs UAE, using X-rays for guidance. Health care providers are looking at this procedure’s long-term implications regarding fertility and regrowth of the fibroid tissue.

Magnetic resonance guided focused ultrasound, also a newer technique, focuses sound waves on fibroids that are at the front of the uterus. The potential effects on fertility are not yet understood.

Radiofrequency ablation of fibroids is another newer technique, during which — under laparoscopic and ultrasound guidance — heat is applied into the fibroids to make them smaller and softer. The potential effects on fertility are not currently well understood.

Hysterectomy for Fibroids

During a hysterectomy, the entire uterus is removed. Fibroids are the #1 reason for hysterectomies in the U.S.

The procedure can be performed vaginally or abdominally via a large incision, laparoscopically or robotically, depending on the size of your uterus, location of the fibroids and your medical history.

Because a hysterectomy is a major surgery, it is only recommended to treat fibroid cases for women who are not interested in preserving their fertility. It is the most effective method of fibroid treatment because it eliminates the possibility of recurrence.

Fibroids and Pregnancy

Uterine fibroids can affect fertility in a variety of ways. If fibroids grow and block the uterus or fallopian tubes, they may make it harder to become pregnant. They may also have other negative effects on pregnancy including:

• ♦ Increased risk of miscarriage and preterm labor
• ♦ Abnormal attachment of the placenta
• ♦ Increased likelihood of delivery by cesarean section
• ♦ Postpartum hemorrhage

If you have fibroids and are experiencing infertility, consult a reproductive endocrinologist who specializes in treatment of women with fibroids. A fertility specialist can develop a treatment plan that maximizes your chances of a successful pregnancy. If surgery to treat fibroids is needed before pursuing fertility treatment, myomectomy is likely your best option.

Fibroids After Menopause

Typically, once a woman goes through menopause, fibroids will stop growing or will shrink down. So, postmenopausal women with fibroids do not often experience symptoms related to their fibroids. In some cases, however, surgery may be necessary if the woman has significant symptoms including post-menopausal bleeding, pressure related symptoms or pain. If a fibroid grows during menopause, it might indicate an unexpected cancer such as leiomyosarcoma— additional testing is needed to determine the cause of the fibroid growth and to develop a treatment plan.