Fibroids

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DEFINITION — Fibroids are growths of the uterus, or womb.

                                                                      Normal anatomy of the female reproductive system

Fibroids may also be found within the muscular wall of the uterus. They are not cancerous or pre-cancerous. They are also called uterine leiomyomas or myomas. They grow from the muscle cells of the uterus and may protrude from the inside or outside surface of the uterus.

Fibroids are very common. At least 25 percent of women have signs of fibroids that can be detected by a pelvic examination or ultrasound.

CAUSES — Although the exact cause of fibroids is unknown, their growth seems to be related to the hormones estrogen and progesterone. When these hormone levels decline at menopause, many fibroid-related symptoms begin to resolve. However, it is not clear that hormones actually cause the fibroids.

RISK FACTORS — A number of factors influence the risk of developing fibroids. These include:

Ethnic background: Fibroids are three times more common in black women. Studies show that black women are significantly more likely to have fibroids, are younger at the time of diagnosis and hysterectomy, and have more severe problems associated with fibroids as compared to white women.

Number of pregnancies: Women with one or more pregnancies that continue beyond 5 months have a decreased risk of developing fibroids.

Use of birth control: Women who use birth control pills have a lower risk of developing fibroids, although women who use the pill at an early age (between age 13 and 16) may have an increased risk. Women who use a continuous progestin contraceptive (eg, Depo Provera®) have a lower risk of developing fibroids.

Diet: Diets that include significant amounts of beef, pork, or other red meats appear to increase the risk of fibroids; diets that include green vegetables appear to decrease the risk. Women who consume alcohol, especially beer, have an increased risk of developing fibroids. However, no study has shown that changing the diet affects the incidence or symptoms of fibroids.

SYMPTOMS — The majority of fibroids are small and do not cause any symptoms at all. However, many women with fibroids have significant bleeding and/or pain that interfere with some aspect of their lives.

The severity of symptoms is related to the number, size, and location of the fibroids, and fall into three main groups: increased uterine bleeding, pelvic pressure and pain, and problems related to pregnancy and fertility. As noted above, symptoms tend to decrease at the time of menopause.

Increased uterine bleeding: Fibroids can cause an increase in the amount and duration of menstrual blood flow. The amount of bleeding is determined mainly by the location and size of the fibroid. Women with fibroids that protrude into the uterus are more likely to have significant increases in bleeding, although women with all types of fibroids can have this problem. If the bleeding is very heavy, anemia (low red blood cell count) can occur.

Pelvic pressure and pain: Fibroids can range in size from microscopic to the size of a grapefruit or even larger. Larger fibroids may cause a sense of pressure and fullness in the abdomen, similar to that caused by pregnancy. Fibroids of variable sizes can cause other symptoms, depending upon where they are located within the uterus. As an example, if the fibroid is pressing on the bladder, frequent urination or difficulty emptying the bladder can occur. A fibroid near the rectum may cause constipation, and cervical fibroids can cause pain during sexual intercourse.

In rare cases, fibroids can cause sudden and severe pain if the fibroid begins to break down (degenerate) or twist on a stalk. The pain usually resolves in a few days to weeks. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, can be used to treat the discomfort.

Problems with pregnancy and fertility: Some studies have suggested a slightly increased risk of problems during pregnancy in women with very large fibroids. In addition, women with large fibroids are at risk of requiring a cesarean delivery. Pregnancy complications are more likely if the placenta is implanted over the area of the large fibroid. Nevertheless, most women with fibroids have completely normal pregnancies without complications.

There is some risk of miscarriage and infertility associated with fibroids that distort the inside the uterus, known as submucosal or intramural fibroids. Typically, these fibroids can be removed with a surgical procedure.

It is not completely clear what role that fibroids play in infertility. An infertile woman who has large or numerous subserosal or intramural fibroids should talk with her doctor. In most cases, couples are counseled to initially try to become pregnant without treating the fibroid. If the couple has difficulty becoming pregnant, all other causes of infertility should be eliminated first.

DIAGNOSIS — Fibroids are often diagnosed during a routine pelvic exam. A clinician may feel the enlarged, irregular outline of the uterus through the abdomen. In certain cases, the clinician may wish to confirm the diagnosis of fibroids and exclude other types of masses. A pelvic ultrasound is generally preferred, which uses sound waves to visualize the uterus.

Hysterosalpingogram: A hysterosalpingogram (also called HSG or tubogram) may be recommended for a woman who is trying to become pregnant. During this test, an x-ray of the uterus and tubes is taken after dye is inserted through the cervix. The dye outlines the shape of the inside of the uterus and fallopian tubes. This test can diagnose the presence, size, and location of fibroids in the uterine cavity, and can show if the fallopian tubes are patent (open).

Sonohysterogram: A sonohysterogram (also called SHG or saline-infusion sonogram), uses ultrasound and a water solution, which is inserted through the cervix, to view the inside of the uterus. This test is most useful in a woman with a normal pelvic ultrasound who has heavy or prolonged menstrual bleeding. A fibroid or endometrial polyp can cause heavy bleeding and not be visible with traditional ultrasound.

TREATMENT:

Medical treatment — Medical treatment includes the use of medications to treat the symptoms of fibroid-related bleeding and pain.

Birth control pills: Birth control pills, which contain a combination of the hormones estrogen and progestin, can be helpful in decreasing heavy menstrual bleeding associated with fibroids. The birth control pill does not shrink the fibroid, thus it is not an effective treatment for women with fibroids who have pelvic pressure, pain, or infertility.

Levonorgestrel intrauterine device: The levonorgestrel intrauterine device (IUD), available in the United States as Mirena®, is another possible option for women with fibroids who have heavy menstrual bleeding. Similar to the birth control pill, the Ievonorgestrel IUD does not shrink the fibroids, although it can significantly reduce menstrual bleeding and provide an effective long-term (up to 5 years) form of birth control. However, in some cases, the shape of the inside of the uterus can be distorted by fibroids, which may decrease the effectiveness of the IUD as a birth control method. Women should discuss this possibility and the need for a second form of birth control (eg, condoms) with their healthcare provider.

Progestin implants, injections, or pills: Progestin is a hormone that works to decrease the thickness of the uterine lining, thereby decreasing menstrual bleeding. It can be taken as a daily pill, an injection given every 12 weeks, or as an implant that is inserted and left under the skin for up to 3 years. Progestin treatments do not decrease the size of fibroids but can decrease fibroid-associated heavy bleeding.

Gonadotropin releasing hormone (GnRH) agonists: Gonadotropin-releasing hormone (GnRH) agonists are the most common medical treatment for fibroids. Leuprolide (Lupron Depot®) is an example of a GnRH agonist. Most women who use GnRH agonists temporarily stop having menstrual periods and have a significant reduction in the size of their fibroid(s). Reducing or eliminating menstrual bleeding can improve anemia. Common side effects of GnRH agonists include hot flashes and night sweats, similar to symptoms experienced by menopausal women. A low dose of estrogen can minimize these side effects without increasing the risk of bleeding or fibroid growth.

However, fibroids rapidly enlarge after GnRH agonists are discontinued. In addition, there are some potentially serious side effects (eg, thinning bones) if GnRH agonists are used for more than 12 months in a row. GnRH medications are usually given as a temporary treatment (for three to six months) while a woman is preparing for surgical treatment.

Antifibrinolytic medications: Antifibrinolytic medications are not intended to treat fibroids, although they can reduce menstrual bleeding by 30 to 55 percent. They are taken by mouth on the days when menstrual bleeding occurs and do not interfere with fertility. Examples of antifibrinolytic medications include tranexamic acid and aminocaproic acid; these medications are not currently available in the United States but are widely available elsewhere.

Danazol: Danazol is an androgenic steroid that may be recommended to temporarily stop menstrual bleeding. However, the use of Danazol is generally limited due to bothersome side effects, including weight gain and mood changes.

Surgical treatment — Surgical treatment may be recommended to provide longer-term relief of fibroid symptoms such as bleeding and pain. In other cases, surgical procedures are done in an attempt to treat infertility. A number of surgical treatments are available.

Hysterectomy: Hysterectomy is the surgical removal of the uterus through the abdomen or vagina. It may be the treatment of choice for women who have completed childbearing, those who are not interested in other surgical treatments, and those with severe symptoms or recurrent symptoms after less invasive surgery.

 Myomectomy: Myomectomy is the surgical removal of a fibroid. It may be done by making an incision in the abdomen and removing the fibroids (called abdominal myomectomy) or by making multiple small incisions in the abdomen and using a telescope to remove the fibroids (called laparoscopic myomectomy). If the fibroids are inside the uterus, a procedure called hysteroscopic myomectomy may be recommended.

Myomectomy preserves the chance of future childbearing and may provide short-term relief of heavy bleeding. However, there is a significant risk that fibroids will recur; between 10 and 25 percent of women who have myomectomy will require a second surgery. Laparoscopic myomectomy slightly increases the risk of uterine rupture during pregnancy or labor; the risk for most women is small.

Endometrial ablation: In this procedure, the lining of the uterus is destroyed with heat by inserting a scope through the vagina and cervix and into the uterus. It can be done in combination with other treatments, such as hysteroscopic myomectomy or myolysis (explained below). Pregnancy is possible, although not recommended, after endometrial ablation; some form of birth control is strongly recommended since ovulation is not affected by the procedure. Endometrial ablation decreases menstrual bleeding without affecting the size of the uterus.

Uterine artery embolization: In uterine artery embolization (UAE or UFE), a small catheter is inserted into a large blood vessel in the groin and threaded up to blood vessels near a fibroid. Tiny particles are injected into the blood vessel, which stops blood flow to the fibroid. This causes the fibroid to rapidly soften and decrease in size within weeks to several months after the procedure.

 Post-procedure Complications of UAE — Complications of UAE are similar to that of other fibroid surgeries. Post-procedure pain is generally moderate to severe; most women stay in the hospital and are given intravenous pain medication after their procedure. Fever occurs in approximately one third of women, but is not usually related to infection.

Pregnancy after UAE- Pregnancy is not usualy recommended for women who have undergone UAE, although normal pregnancies heve occured. UAE can affect ovarian function, potentially increasing the chances for infertility after treatment. In addition UAE can cause problems during pregnancy as a result of abnormal implantation of the placenta in the uterus.