Uterine Fibroids
Uterine fibroids (also called fibromyomas, leiomyomas, or myomas) are the most common benign tumors in women. More than 50% of women are diagnosed with fibroids but less than half develop symptoms.
Most fibromas are harmless. A fibroma requires treatment if it stimulates heavy menstrual bleeding, puts pressure on your internal organs, or causes fertility problems. Speak to your doctor or gynaecologist about the many treatments available.
Uterine fibroids are classified as non-cancerous growths: they aren’t associated with increased risk of uterine cancer and almost never develop into malignant tumours.
Fibromas often appear in multiples, although a single fibroma can occur. They are usually small but sometimes grow large enough to occupy most of the uterine wall.
Symptoms
Fibroids can be symptomatic (“active”) and asymptomatic (“inactive”). An asymptomatic fibroid may be discovered during a routine pelvic or uterine examination, but oftentimes small fibroids go undetected. A symptomatic fibroid will make itself known via some combination of the following symptoms:
- Painful menstruation
- Heavy bleeding or prolonged menstruation
- Pelvic pressure or pain
- Frequent urination
- Difficulty urinating
Other possible symptoms are constipation, backache, leg pain, anemia, weight gain, pain during sex and infertility.
Symptoms resulting from uterine fibroids depend on their location, size, and number. Sometimes, a fibroid outgrows its blood supply and begins to necrotize (to die), causing acute pain. Many conditions cause similar symptoms, so self-diagnosis is difficult. If you have concerns about your health, don’t hesitate to see a professional.
Classification
Fibroids are categorized according to size:
- Small (>1cm – 5cm) – the size of a pea to a lychee;
- Medium (5cm – 10 cm) – the size of a peach to a large lemon;
- Large (10cm+) – the size of a mango or larger.
Sometimes fibroids can grow large enough to expand the uterus and affect the pelvic and abdominal cavities. In extreme cases, multiple fibroids can stretch the uterus so much that it reaches the rib cage, causing uncomfortable pressure.
The growth patterns of fibroids vary. Some fibroids go through growth spurts, some shrink on their own, and some don’t change much in size. Fibroids present during pregnancy often shrink or disappear as the uterus returns to normal size and estrogen levels decrease.
Fibroids are also classified according to their location.
Intramural fibroids are lumps that grow between the muscles of the uterus.
There are several types of intramural fibroids:
- the anterior intramural fibroid, located at the front of the uterus
- the posterior intramural fibroid, located at the back of the uterus
- the fundal intramural fibroid, located in the upper part of the uterus
Submucosal (or intracavitary) fibroids bulge into the uterine cavity. As submucosal fibroids grow just beneath the inner lining of the uterus, they often cause more bleeding than the other types. Since most people are quite sensitive to pressure on the bladder, even very small fibroids can cause symptoms.
Submucosal fibroids are also the most likely to lead to problems with fertility and pregnancy. Women with submucosal fibroids tend to experience heavy and prolonged menstrual bleeding.
Subserosal fibroids grow on the outside of the uterus. They often cause the uterus to become enlarged. Because the subserosal fibroid is not located in the uterus, it has room to grow. Such fibroids can grow larger than a grapefruit before symptoms begin to appear.
Pedunculated fibroids develop a stem (called a peduncle) that attaches to the uterine wall. Depending on their size and position, these tumors can make your womb appear bigger on one side.
Correlations & potential causes
As with many female health issues, the direct causes of uterine fibroids are unknown. Researchers have found the following correlations:
Genetic factors
Many fibroids contain changes in genes that differ from those in normal uterine muscle cells. If your family has a history of this condition, you have a higher chance of developing it as well.
Hormones
Estrogen and progesterone (the two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy) appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than normal uterine muscle cells do. They can develop and grow rapidly during pregnancy, and tend to shrink once the baby is born due to a decrease in hormone production. Menopause is known to have a similar effect.
Extracellular matrix (ECM)
The ECM makes cells stick together, like mortar between bricks. In fibroids ECM levels are elevated, making them dense and fibrous. ECM also stores growth factors and causes biological changes in the cells themselves.
Race
Although any woman of reproductive age can develop fibroids, black women are more likely to be affected and tend to have more and larger fibroids, causing more severe symptoms, at an earlier age than many other affected women.
Other factors
Such as early onset of menstruation, obesity, vitamin D deficiency, choosing a diet higher in red meat and alcohol and lower in green vegetables, fruit, and dairy seem to increase the risk of developing fibroids.
Little scientific evidence is available on how to prevent fibroids, but research continues. It may not be possible to prevent fibroids, but fortunately only a small percentage require treatment.
Fibroids & fertility
While uterine fibroids are very common in women of childbearing age, a small percentage of affected women have related fertility problems.
How fibroids interfere with fertility is uncertain. It may be that fibroids block the sperm from reaching the egg, or that fibroids divert blood flow from the uterine lining, impeding implantation. Upon the removal of uterine fibroids, women who were previously unable to conceive usually go on to have successful pregnancies.
In rare cases, fibroids can cause certain complications, such as placental abruption, foetal growth restriction, or preterm delivery.
Diagnosis
Your gynecologist or medical practitioner can perform a pelvic exam for a preliminary diagnosis. The exam will reveal any abnormal changes or lumps suggestive of fibroids, but more tests may be needed to confirm the diagnosis and form a treatment plan, should one be necessary.
The next step is commonly an ultrasound (abdominal or transvaginal). This is to rule out other possible causes of uterine growths. An ultrasound can determine if suspicious lumps are in fact fibroids, and pinpoint their location and size.
In some cases, blood tests are needed to rule out other possible causes, such as bleeding disorders or thyroid problems.
Magnetic resonance imaging (MRI) is commonly suggested for women with a larger uterus and for women approaching menopause. An MRI gathers detailed information on the location, size, shape, and type of tumor, providing your doctor with the information necessary to decide on a suitable treatment.
Hysterosonography, or saline infusion sonogram, uses sterile saline to expand the uterine cavity for clearer ultrasound imaging.
Hysterosalpingography uses X-ray dye to highlight the uterine cavity and fallopian tubes for better X-ray imaging.
Hysteroscopy uses a hysteroscope (a thin tube with a light on the end) inserted through the cervix into the uterus. Then saline is injected into the uterus, expanding the uterine cavity to allow for the examination of the uterine walls and fallopian openings.
Treatment
Not all women with uterine fibroids need treatment. If the tumours are asymptomatic and aren't causing any problems, they often shrink or disappear on their own without requiring treatment.
If you do have asymptomatic fibroids have them checked regularly—yearly should be enough—to ensure they aren’t growing any bigger.
There are many different ways to treat uterine fibroids depending on their location and size and on the patient’s health and age.
Medications target the hormones that regulate the menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids, but may shrink them. Some of these medications include:
- Gonadotropin-releasing hormone (GnRH) agonists treat fibroids by blocking the production of estrogen and progesterone, putting you into a temporary menopause-like state (often accompanied by significant hot flashes). This pauses menstruation, shrinks fibroids, and reverses anaemia. GnRH is typically prescribed for three to six months as prolonged use can decrease bone density, but once the treatment ceases,symptoms return. Your doctor may prescribe GnRH to shrink the fibroids before a planned surgery or to ease the transition into menopause.
- The progestin-releasing intrauterine device (IUD) is a hormonal contraceptive that can be used to relieve heavy bleeding caused by fibroids but doesn’t shrink fibroids or make them disappear.
- Tranexamic acid is a type of non-hormonal medication that can ease the symptoms of heavy periods.
- Oral contraceptives help control menstrual bleeding, but don’t reduce the size of fibroids.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are a class of non-hormonal medications that can be effective in relieving fibroid-related pain related but don't reduce bleeding.
- Over-the-counter anti-inflammatory drugs and pain relievers can help manage some symptoms.
- If you have anemia caused by heavy bleeding, your doctor might suggest taking iron and other vitamin supplements.
In addition to these medications, there are also a number of procedures and surgeries that have been proven successful in managing uterine fibroids—noninvasive procedures, minimally invasive procedures, and traditional surgical techniques.
Noninvasive procedures make no incisions and are done on an outpatient basis (no overnight hospital stays).
An MRI scanner, equipped with a high-energy ultrasound transducer, produces images that show the precise location of the fibroids. Once a fibroid has been located, an ultrasound transducer is used to focus sound waves on the fibroid, heating and eliminating small areas of fibroid tissue.
Minimally invasive procedures:
During a uterine artery embolization, embolic agents are injected into precisely targeted arteries connected to the uterus, cutting off blood flow to the fibroids, which causes them to shrink and die.
This technique can be effective in shrinking fibroids and relieving symptoms, though complications may occur if the blood supply to organs is compromised. Although the risk of this occurring is low, this method is usually recommended when there are no plans to conceive.
Radiofrequency ablation uses RF energy to dissolve uterine fibroids and shrink the blood vessels that feed them. An ablated fibroid continues to shrink over the next 3–12 months, progressively reducing symptoms. This can be done as a laparoscopic or transcervical procedure.
A similar procedure, called cryomyolysis, can be used to freeze and eliminate fibroids.
Traditional surgical techniques:
Myomectomy. If you want to get pregnant in the future, your doctor might suggest a myomectomy. This surgery removes the fibroids but leaves healthy uterine tissue intact.
Depending how many fibroids you have, how big they are, and where they are located, your doctor has three options for how to perform the myomectomy:
- Abdominal myomectomy. This surgery is used if a woman has multiple fibroids and they are large and hard to access. A small incision is made in the lower abdomen to allow for the removal of the fibroids. Once this has been done, the uterine muscles are sewn back together. This procedure requires a hospital stay of several nights and recovery time is usually between 4 and 6 weeks. If you do get pregnant in the future, a C-section may be a safer option than vaginal birth;
- Hysteroscopic myomectomy. This procedure is used if the fibroids are inside the uterus. A hysteroscope is used to visualise the fibroids, allowing the surgeon to remove them with a resectoscope—a fitted wire loop with a high-frequency electrical current running through it. The procedure is short and only a few hours are needed for recovery, after which the patient is free to go home.
- Laparoscopic myomectomy. During this procedure, the surgeon makes multiple small incisions in the lower abdomen in order to remove the fibroids.
After a myomectomy, symptoms usually disappear, however, depending on how many fibroids there were and whether or not they were all successfully removed, there is a chance that the condition may return.
A hysterectomy is a dramatic and irreversible surgery in which the entire uterus is removed, together with all the fibromas that it contains. The procedure leaves you unable to have children. It is an option for those looking for a fail-safe contraceptive but should be considered a last resort.
There is a lot of research to be done before we fully understand the causes of uterine fibroids and how to prevent them. Until then, we must trust our doctors and scientists to use the information they have to the best of their abilities.
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