Uterine Fibroids

Definition

Uterine fibroids, also known as fibroid tumors, leiomyomas, fibromas or myomas, are benign (noncancerous) growths on the uterus. Uterine fibroids occur in 20 to 40 percent of all women older than 35 years of age.

Description

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 the size of a basketball. A woman can have one or many uterine fibroids. The growth of uterine fibroids is unpredictable. They may remain relatively stable or they may increase in size rapidly. Rarely do uterine fibroids become cancerous (less than 0.1 percent).

Uterine fibroids are unlikely to shrink or disappear on their own until after menopause. After menopause, no new uterine fibroids are likely to develop, and those already present usually shrink in size.

There are three (3) main types of uterine fibroids - submucous, intramural and subserous.

1. Submucous uterine fibroids grow just beneath the lining of the uterus (called the endometrium).

2. Intramural uterine fibroids grow within the wall of the uterus.

3. Subserous uterine fibroids grow out from the outer wall of the uterus.

If the fibroid has a stalk (called a pedicle) attached, it is called a pedunculated fibroid. The stalk remains attached to the uterine wall, allowing the tumor to move inside the uterus, the abdominal cavity or into the vagina.

Causes and Risk Factors

The cause of uterine fibroids is unknown, but some researchers suspect that the tendency to develop uterine fibroids is:

• inherited

• attributed to ethnicity (African-American and women of Jewish descent are three [3] times more likely to develop uterine fibroids than Caucasian women)

• linked to estrogen level - uterine fibroids may increase in size during pregnancy or when using birth control pills (when estrogen levels are high), and decrease in size after menopause when estrogen levels are low.

• prevalent in women with endometriosis - a condition in which fragments of the endometrium are found in other parts of (or on organs within) the pelvic cavity

Symptoms

Uterine fibroids may be totally symptomless or they may cause problems. The majority of women with uterine fibroids (up to 80 percent) have no symptoms. If symptoms do occur, they may include:

• heavier menstrual flow or menstrual period of longer duration

• increased menstrual cramping

• backache

• irregular or unpredictable bleeding

• lower-abdominal pressure, often described as an achy or heavy feeling or associated with the need to urinate more frequently

• constipation

• abdominal bloating

• infertility

• miscarriage

Diagnosis

Symptoms and a pelvic exam are the basis for diagnosing uterine fibroids. If the doctor finds that the uterus is lumpy, enlarged or irregular in shape, they may suspect uterine fibroids, even if the woman displays no symptoms. However, before they begin additional diagnostic tests, the doctor will do a complete blood profile, Pap smear, pregnancy test and an endometrial sampling to rule out other conditions, such as endometrial cancer or pregnancy.

If the woman is having irregular bleeding or her uterus is enlarged, the clinician will probably recommend a dilatation and curettage (D&C;) without delay, to be certain that she doesn't have an unrelated malignancy or a simple problem like uterine polyps. A D&C; is a procedure in which the endometrium is scraped away.

If uterine fibroids are suspected, the doctor will perform a transvaginal sonogram (ultrasound) to confirm these tumors, their location and size within the uterus.

Treatment

Most uterine fibroids require no treatment at all. If the uterine fibroids are not causing pain, bleeding or discomfort, many doctors recommend leaving them alone and monitoring them over the years.

Uterine fibroids should be surgically removed if:

• they are causing uncontrollable, abnormally heavy bleeding

• they are too large and causing discomfort

• they are rapidly growing

• the fibroid grows after menopause

• there are difficulties in becoming pregnant

• symptoms of urinary tract compression are present

• the fibroids make it impossible to evaluate the appendages

There are two surgical procedures available to remove uterine fibroids. The procedures are myomectomy (fibroid removal from the uterus) and hysterectomy (uterus removal).

The several different myomectomy techniques include the following:

Vaginal, or hysteroscopic, myomectomy. Performed through the vagina and cervix, this procedure uses an instrument called a resectoscope, which allows surgeons to view the uterine fibroids through a small fiber optic device. The surgeons are able to shave off the fibroid growths using a hot electrified wire. This technique is used on small submucous uterine fibroids.

Laparoscopic myomectomy. A surgeon makes a slit in the navel and inserts a hollow tube and a viewing instrument (called a laparoscope) into the uterus. The doctor then slides a tiny laser or scalpel through the laparoscope, chops up the fibroid and then removes the bits through the laparoscope. This technique is usually reserved for uterine fibroids on the exterior surface of the uterus.

Abdominal myomectomy. Through an incision in the abdomen, the uterine fibroids are removed (using either a scalpel or laser). This procedure is best for very large intramural and subserous uterine fibroids.

Myomectomies are recommended for women who want to preserve their fertility, have had repeated miscarriages, experience infertility problems or want to retain their uterus. Unfortunately, up to 40 percent of women who opt for a myomectomy may require a repeat surgical procedure because the uterine fibroids have grown back.

Hysterectomy, can be performed either vaginally, abdominally or assisted by laparoscopy. There are several different hysterectomy techniques:

Total abdominal hysterectomy (TAH): Removal of the uterus and cervix through an incision in the lower abdomen. The fallopian tubes and ovaries are not removed.

Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO): Removal of the ovaries (oophorectomy) and fallopian tubes (salpingectomy) along with the uterus and cervix through an incision in the lower abdomen.

Vaginal hysterectomy: Removal of the uterus and cervix through an incision inside the vagina. The fallopian tubes and ovaries are usually not removed.

Subtotal hysterectomy: Removal of the uterus, but not the cervix. The fallopian tubes and ovaries are not removed.

Although a myomectomy or a hysterectomy seem to be the best solution to uterine fibroids, some doctors prescribe gonadotropin-releasing hormone (GnRH) analogs. The GnRH analogs, such as leuprolide (Lupron) and nafarelin (Synarel), are effective in stopping heavy bleeding and shrinking uterine fibroids. The drugs shut down estrogen production by turning off pituitary stimulation of the ovaries, but these do so by first boosting production, causing an initial increase in estrogen levels and a worsening of uterine fibroids.

After about a month, ovarian hormone production declines and the estrogen-starved tumors shrink dramatically. This treatment can only be used for a limited time. Within four to six months after stopping the treatment, the uterine fibroids will begin to grow back.

This treatment has been used for premenopausal women, for women who have become anemic due to heavy menstrual flow, for women who do not plan to bear children or before a myomectomy.

Questions to Ask Your Doctor

Are there any other tests that need to be performed to diagnose uterine fibroids or rule out any other diseases?

If you recommend waiting before electing surgery?

How often will a check up be needed?

Are there any signs or symptoms that I should report immediately?

Do you recommend trying medication first to try and shrink the uterine fibroids?

Do you recommend a D&C;? Will it help remove any of the uterine fibroids?

Do you recommend surgery? If so, what procedure will be used? What are the risks or complications? Will all the uterine fibroids be removed? Will they come back and how soon do they usually return? How long is the recovery period?