Uterine Fibroid Primer

What are Uterine Fibroids?

Uterine fibroids are the lay term for a condition of the uterus called uterine leiomyoma. The medical  definition of a fibroid is actually a uterine tumor. The word tumor, encompasses both benign and cancerous growths, and as frightening as uterine tumor sounds it is not likely that this is cancer it is usually a simple smooth muscle tumors. The uterine fibroid is  made up of the same cells that form our uterus to begin with, or cells that can comprise the wall of blood vessels..  The cells get disoriented, whirled around on each other, begin to seek blood supply and ultimately form growths.  They are neither dangerous nor cancerous cancerous growths are uterine sarcomas, and your gynecologist can often differentiate the two. Pain, pressure, heavy periods, or discomfort during intercourse can be signs of uterine fibroids.  In many cases they are noted on otherwise normal routine pelvic exam and  when first found, other than measuring them on ultrasound,  they may simply be observed.  Cat scans and MRI testing can show fibroids but ultrasound is probably the most effective. Many of us now have 3-D capabilities that enable the ultrasound to show the exact location of the fibroid relative to the uterine cavity. 30- 50% of all women have fibroids in their lifetime.  Only the minority of women require treatment.  Fibroids seem to be related to our reproductive cycling and circulating estrogens.  They do not seem to be related to the taking of birth control pills, in fact some studies have implicated they are less likely if you have taken birth control pills or shots.  They grow during our menstrual life and stop growing at menopause.  They can even shrink after menopause, but ones that have gotten to the size of pressure symptoms are unlikely to shrink enough to eliminate those symptoms.  The majority of fibroids do not cause any symptoms at all.  The diagnosis of fibroids on a check up where nothing else is bothering you should not necessitate any treatment whatsoever.That being said, we have yet to find medication that can resolve the fibroids effectively and permanently.

Location Location Location!

Symptoms from fibroids are usually related to where in the uterus the fibroid is located.  If there is a growth inside the uterine cavity (Submucosal fibroid) it can cause very heavy menstrual periods, in some cases dangerously heavy.  In fact this can lead to a serious anemia or low blood count if your diet or iron supplementation dose not keep up with the blood lost. For anyone having heavy menstrual periods a simple office blood test can determine the extent of the anemia. Blood loss, especially with anemia, results in fatigue and possibly even dizziness.  These same fibroids can interfere with fertility because the implantation site of the embryo may be compromised.  If the fibroid is in the uterine wall (Intramural fibroid) it can enlarge the uterus anywhere from a little bit to a great deal.  The largest fibroid I have ever removed was the size of a term pregnancy, almost a foot in diameter.  After this was removed, the uterus returned to normal size. These can also cause heavy bleeding by the way of passing clots. Passing clots can make your periods unusually painful and possibly prevent normal treatment like ibuprofen from being effective..  If the fibroid forms on the outside of the uterus (Subserosal or pedunculated fibroid) it rarely causes problems with bleeding and does not interfere with the uterine function much at all.  However, it can be confused with an ovarian mass, or can grow to be large enough to cause symptoms on this basis alone.  Of course it is possible for there to be several fibroids in several locations.

So when is it recommended to treat fibroids?
  1. If there is excessive bleeding
  2. If there is excessive size
  3. If there is pain
  4. If there is trouble getting pregnant (miscarriages)
  5. If there are pressure symptoms such as urinary incontinence
  6. If there is rapid growth
  7. If there is discomfort with sex
  8. If there are abdominal or gastrointestinal symptoms
  9. If it is associated with endometriosis
  10. If there is anemia due to the heavy menstrual periods

Fibroids that cause bleeding

Fibroids located inside the uterine cavity, submucosal fibroids, interfere with the normal menstrual period and can cause very heavy bleeding with periods or between periods. The periods can be unusually long as well.  When this occurs, it is time to consider treatment.  First we must be certain it is the fibroids that are causing the bleeding.  An ultrasound of the pelvis can help distinguish between conditions such as fibroids, uterine lining polyps, or hormonal conditions leading to a thickened uterine lining. Uterine lining sampling, called an endometrial biopsy, can help identify any uterine lining conditions that also may be causing the heavy bleeding.  It is also important to be aware of other conditions that cause bleeding, such as a blood clotting abnormality like hemophilia, over use of blood thinning medicines such as aspirin, or Von Willebrand’s Diseases. These are rare conditions that are treatable medically, and usually come to attention when you are in your teens or early 20s.  Once the diagnosis is confirmed, treatment can be recommended. Rapid growth, unusual pelvic pain not during menstrual periods, or infertility may mean you have something other than a uterine fibroid.

Fibroid, Grow: But At What Pace or How Large is So Far Unpredictable

Fibroids can be microscopic or quite large; they can be single or too many to count within the uterus. Women probably are genetically predisposed to having one type or another, but that's not been determined either. They can develop rapidly, or more typically, slowly over many years, so it may not be unusual to have had a normal exam and then the next year have a fibroid found, but really most develop slowly.  If the fibroid is small and causing no symptoms, we can and should ignore it.  For women with large fibroids and no symptoms, it's thought you have merely gotten accustomed to your symptoms due to very slow growth. Since we don't technically have a preventative treatment, most physicians state no treatment is needed for small fibroids or asymptomatic fibroids. Heavy menstrual cycles or enlarging size or a fibroid that has grown into a tumor that presses on other vital organs like our rectum or our bladder we can experience serious symptoms that interfere with our quality of life. They can even cause problems with sex.  Fibroids can be located anywhere with in the uterus.  may be either intramural or subserosal fibroids.  Fibroids can grow to almost any size but when they reach the size of a large orange or a grapefruit they tend to have symptoms that require treatment.  We may experience an urge to urinate frequently if the fibroid presses on the bladder or difficulty with bowel movements if the fibroid may be pressing on our rectum.  This tends to get worse in time as the mass grows.  Even though it is a benign mass, (not cancer), it may need treatment.  There has been misinformation in the past that if a fibroid grows rapidly it might be cancer.  This is true less than a tenth of one percent of the time or very, very rarely. Rapidly growing fibroids most often can be treated the same as any similar size fibroid.

Fibroids that cause pain

There are times when usually non-painful fibroids can actually become very tender causing considerable pain.  If a fibroid outgrows its blood supply, this causes some of the muscle tissue to “die” or degenerate.  When smooth muscle dies, it can be painful, like when heart muscle dies causing a heart attack.  The difference is that while every part of our heart muscle is important to the overall function of our heart, and a heart attack is an emergency, the same is not so for the uterus.  When this process occurs in the uterus, it may be very painful, but since we really do not depend on the fibroid tissue for any function, there is no emergency, just pain.  This pain is usually self limited, will stop eventually on its own and can be treated conservatively with pain medicine until the process is over. This can take several weeks.  Other causes of pain are from the pressure of the fibroid pressing on other organs.  If the pain does not completely resolve, removal of the fibroid may be considered.

Treatment options

If treatment is needed for heavy bleeding the options include birth control pills, which reduce menstrual flow in most women, or the use of the long cycle pills where periods occur only every 3 months.  If this is not adequate, and it may not be, there is Lupron, which is a monthly or every three-month injection given at the doctor’s office. This causes temporary reversible menopause, stops the bleeding, and allows us to replenish our blood supply enough to withstand a surgical procedure that would be more definitive.  Low doses of hormones may be given to reduce any menopausal symptoms that might occur.  This is only a short-term solution for 3 – 6 months.  BUT it effectively stops the growth of fibroids and any accompanying bleeding.  This allows for safer surgery, emotional preparation and the possibility that if menopause is near, the avoidance of surgery entirely. At Women's Health Practice we also have many uterine fibroid research studies that we have participated in. There are many medications in development, or available already in other countries. We welcome patients to come and screen for these studies, and for this there is no charge. 

Myomectomy

There are three ways to approach a myomectomy, the removal of the fibroids and reconstruction of the uterus.
 

Hysteroscopy Resection Myomectomy

The simplest is in the case of the isolated submucosal fibroid in the uterine cavity. This can be removed with a resectoscope myomectomy, which is very much like a sophisticated D & C.  This procedure is performed with an anesthesia in a hospital or surgicenter.  The cervix is opened and a telescope, called a hysteroscope, is inserted into the uterus with a cutting wire attached. The fibroid in the cavity is removed piece by piece with the heated wire loop through a procedure called cautery. This removes the fibroid entirely if it is completely in the cavity.  If it is partially in the wall of the uterus as well, the portion in the wall will be left behind, as it is not safe to dig into the wall to remove more than that which is visible in the telescope.  Usually this is all that is necessary to stop the bleeding. Normal activity is resumed the very next day. There may be light bleeding for up to a couple of weeks. The only limitations are that nothing should be in the vagina, no intercourse, tampons, swimming, or baths for 2 weeks while healing occurs (showers are fine).  Otherwise you may resume normal exercise and activity.

Abdominal Myomectomy

If the fibroid is in the wall of the uterus or protruding into the abdomen it may be removed through a “bikini” type incision, much like that done for a c-section, but often these can be much smaller in total length than that. This is about an inch above the pubic bone and can be as long 6 inches in length.  Medicine is used to help control bleeding so that the fibroids can safely be removed from the uterus, depending on the location the goal is to not enter the cavity of the uterus, and to reconstruct the uterus as normally as possible with several rows of stitches.  Most patients will go home the day of surgery. There are ways we can help you manage the discomfort. For most women low doses of short term use of pain medication is all they actually require. Many women have been told by their physician that their fibroids are too large for a myomectomy, that only a hysterectomy will be possible, that the risks of bleeding or the surgical difficulty is too great.  This has not been shown in the scientific literature.  There are many techniques to manage the blood loss of surgery.  Of interest is the cell saver. This is technology where any blood loss is recaptured and returned to the patient in the form of an auto-transfusion.  It is a very effective way to avoid hysterectomy or blood transfusions.  Even the largest fibroids have been successfully removed, as I mentioned before, the largest I have removed was about 25 cm or almost a foot in diameter. If there are several fibroids, this method will succeed as well.  I have removed as many as 25 fibroids from one woman.  Even with these seemingly extreme circumstances, three months after surgery, the pelvic exam was normal and the symptoms were gone! In other cases I have seen return of the fibroids, to even larger than the original size, and in less than a year. This fortunately is not typical.

Laparoscopic Myomectomy

Whenever possible it is best to avoid the abdominal “bikini” incision with a minimally invasive procedure.  Laparoscopic myomectomy involves the placement of a small telescope, the laparoscope, through a half-inch incision in the umbilicus and 2 – 3 other quarter to half-inch incisions in the lower part of the abdomen.  The fibroid is cut away from the uterus and in a fashion similar to the abdominal myomectomy, stitches are placed in multiple layers to close the uterine incision.  The fibroid tissue is most effectively removed in pieces, but the tools to make this available have not been widely available due to some safety concerns on the part of the manufacturer.  This technology cuts fibroid tissue into long strips that can be removed through a half-inch incision.  A laparoscopic myomectomy may require more evaluation including an ultrasound and possibly an MRI. e use of robots just allow the laparoscopic instruments to bend, but the DaVinci procedure is just a laparsocpic procedure with larger instruments.

Fibroid Embolization

Uterine artery embolization is performed by a radiologist in an outpatient setting with sedation.  General anesthesia is not required.  A small tube (a catheter) is threaded through the arteries to the uterine artery.  Through this catheter, pellets are injected to temporarily block the artery and stop the blood flow to the fibroid.  This halts the growth of the fibroid and the associated bleeding.  It encourages shrinkage of the fibroid to approximately half its original size.  This is a reasonable option for women with heavy bleeding and a dominant fibroid who want to avoid surgery.  The vessels reopen after a while and new fibroids may form or untreated fibroids may grow.  Pedunculated fibroids are not treatable by embolization.

Hysterectomy for Fibroids

Hysterectomy should be undertaken if the other alternatives fail or if you have contraindications to the medications or other alternatives. It may actually be logistically simpler to remove the uterus than to perform a laparoscopic myomectomy if there are several fibroids, or if the location of the fibroids is difficult to approach laparoscopically.  If myomectomy has been performed before, it would be reasonable to discuss hysterectomy although sometimes a second myomectomy is possible. Prior surgeries can produce scar tissue that may make repeat surgeries harder, and it's important to have your physician consider techniques or medications that will reduce the risk of future scaring so that repeat surgery is not as dangerous. I have performed as many as 3 separate myomectomies on some patients.  Since fibroids can continue to form, there comes a time that a woman might prefer the certainty of a hysterectomy.  If a woman knows she wants to take estrogen replacement at some point in the future, it is simpler to take without a uterus and will never cause bleeding. We usually recommend ovarian conservation for young women, and there is no need to take ovaries just to treat fibroids.  As long as there is not an issue of future fertility hysterectomy is reasonable.  If future pregnancy is desired, all efforts should be made to save the uterus.

Uterine Fibroid Research

  A large body of research is being done into medications that can shrink fibroids and control uterine bleeding. At www.Clinicaltrial.org or at www.womenshealthpractice.com you can find some of these research trials to follow the progress or to enroll in a study near your home.

Let Us Help You Make Your Own Decision

It is most important to collaborate with your physician.  Get a second opinion, ask questions until you educate yourself about your options and feel comfortable with your decision.  Ask about your doctor’s philosophy about myomectomy and hysterectomy. Bring questions to your appointment. If uterine preservation is important to you, make sure the surgeon is on board and has the same philosophy.  Do not be afraid to ask specific questions about options and the procedures themselves.  Ask about recovery details as well as pain management. 

Remember, if your fibroids are not too large, and not symptomatic simple observation may be all that is required.  Most fibroids do not require treatment, but in those cases when treatment is needed, be an educated consumer.  As a physician, I always appreciate it when the patient participates in the treatment plan.  A collaboration is much more satisfying for both the patient, her loved ones, and the physician and leads to better outcomes.


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