Fibroids, or uterine myomas, are benign growths within the uterus. They are the most common female pelvic tumors, accounting for 35-50% of all hysterectomies performed in the U.S. each year. They vary in size and can be as small as a pea or as big as a melon. By age 50, 80% of African American and 70% of Caucasian women will develop fibroids. They cause symptoms in less than 50% of the cases. Their most common symptoms are abnormal bleeding, pelvic pain and infertility.
What cause fibroids?
- Fibroids arise from the uterine smooth muscle and their cause is unknown.
- What we do know, is that fibroids are estrogen dependent. They develop during the reproductive years and regress after menopause when the ovary becomes hormonally inactive.
- The risk for fibroids decreases in women who had at least 2 full term pregnancies. Women with low BMI, smokers and women who exercise regularly have lower estrogen levels and a lower incidence of fibroids.
- Obese women have higher estrogen levels and a higher incidence of fibroids.
- Fibroid tumors are 2-3 times more prevalent in African American women.
Fibroids can be diagnosed by:
- Pelvic examination. The fibroid uterus is typically enlarged and may have a “bumpy” surface if multiple fibroids are present.
- Ultrasound (fig.1). The pear-shaped uterus is outlined in white. The fibroid has a darker shade and is outlined in yellow.
- Sonohysterogram or Saline Infusion Sonography (fig. 2). The pear-shaped uterus is outlined in white. The saline filling the cavity is the black area within the uterus. The fibroid, outlined in yellow, is pushing into the uterine cavity.
- Hysterosalpingogram(HSG or tubal x-rays) (FIG. 3). The lighter shade represents a fibroid protruding into the uterine cavity.
- MRI (fig. 4). Three fibroids (white arrows) are distorting the uterine cavity (red arrow).
- Direct visualization utilizing surgical procedures such as Laparoscopy and Hysteroscopy
Types of fibroids
- Intracavitary fibroids grow within the uterine cavity.
- Submucosal fibroids can grow within the wall of the uterus in close proximity to the uterine cavity or they may actually impinge upon or distort the uterine cavity. Both submucosal and intracavitary fibroids are likely to cause infertility, abnormal bleeding, pain or miscarriages.
- Intramural or interstitial fibroids grow within the wall of the uterus and may cause pain or pelvic pressure, and can decrease fertility and increase pregnancy loss.
- Subserosal and pedunculated fibroids do not affect the uterine cavity and are not associated with infertility, but they can cause pain and may require treatment.
What to do if you have fibroids?
The primary goals of fibroid treatment are:
- Enhance fertility in women who want to conceive.
- Help manage symptoms of pain and bleeding in women for whom pregnancy is not a concern.
What should you do if you have fibroids and want to conceive?
Not all fibroids cause infertility. So the real dilemma is when to recommend surgery (myomectomy). The surgery is not without risks and the decision to operate will depend on the type, size and number of the fibroids, their proximity to the uterine cavity and on whether other symptoms are present (pain and bleeding). Fibroid surgery is sometimes recommended if a woman has failed previous fertility treatment or if there is no other explanation for her infertility.
Here are some rules of thumb:
- For infertile women with intracavitary or submucosal fibroids which distort the uterine cavity, myomectomy surgery is likely to improve fertility.
- Women with intramural fibroids appear to have decreased fertility and increased pregnancy loss, but it is not clear whether myomectomy will improve their fertility outcome. Generally speaking, if the fibroids are over 4 centimeters in size, myomectomy is often recommended.
- Subserosal fibroids have no obvious fertility implications and surgery to remove them has not been shown to be beneficial. Surgery may be recommended for large fibroids or if they are causing pain or pelvic pressure.
What are the surgical risks of myomectomy?
- Blood transfusions
- Post operative adhesions and infertility
- Uterine rupture during pregnancy
- Risk of cesarean section delivery
What to do if you have fibroids and you do not want to have any more children?
- The goals of care are the minimization of complications such as anemia and pain.
- Most fibroids cause no symptoms and can be left alone.
- Fibroids are estrogen dependent, and will shrink with menopause when the ovaries stop producing significant amounts of estrogen.
- Currently, there are no medicines that can permanently shrink fibroids.
Treatment options for uterine fibroids include:
- No treatment – women with no symptoms may be managed with observation alone. Women who have no immediate fertility considerations require only periodic evaluation by pelvic examinations and ultrasounds to monitor for changes in the size of the fibroid.
- Surgery to remove fibroids (Myomectomy).
- Medical treatment
- Uterine Artery Embolization (UAE).
- MRI Guided High Frequency Ultrasound Therapy.
Surgical treatment (myomectomy)
Surgical procedures for removal of uterine fibroids (myomectomy) include:
Hysteroscopic myomectomy (click to view hysteroscopic myomectomy video)
This procedure is often utilized for fibroid tumors which are located within the uterine cavity (intracavitary or submucosal). During hysteroscopy, a thin fiberoptic tube (the hysteroscope) is equipped with a video camera and is guided through the vagina into the uterine cavity. The cavity is distended with fluid to give the surgeon a good view of the fibroid (fig. 7). A special tool, called the resectoscope, is equipped with a cutting loop which shaves the fibroid into small pieces (fig. 8). The fibroid fragments are removed and the uterine cavity is restored back to normal (fig. 9).
Laparoscopic myomectomy (click to view laparoscopic myomectomy)
For fibroid tumors located within the wall of the uterus (intramural or submucosal)), minimally invasive outpatient Laparoscopic surgery is often advised. A thin fiber-optic tube, equipped with an HD camera, is inserted into the abdomen, through a small incision in the belly button (fig. 10). An image of the uterus is then projected on a monitor screen (fig. 11). The fibroid appears as a bulge in the uterus (fig. 12). Special tools, inserted into the abdomen through two or three additional small incisions, help the surgeon complete the procedure.
Laparoscopic myomectomy is most suitable for fibroids measuring less than 6 centimeters. Some surgeons prefer to treat their patients with Lupron preoperatively. Lupron causes a temporary and reversible medical menopause and takes 6-12 weeks to complete. It causes the fibroid to shrink in size, making it easier to remove. The treatment also decreases the blood supply to the fibroid, reducing the risk of bleeding during surgery.
Robotic laparoscopic surgery is now routinely utilized to remove larger fibroids than was previously possible with traditional laparoscopy. The surgeon controls the robotic arms from a console station, utilizing high-definition 3D camera. Four small incisions are made in the abdomen through which a camera and specialized surgical tools are inserted into abdominal cavity. The robot (fig. 13) is wheeled into the operative field and is docked into position (fig. 14). An incision is made into the uterus and the fibroid is carefully dissected and removed from the abdomen. The uterine incision is closed (fig. 16) completing the surgery.
The procedure is performed through a major abdominal incision (laparotomy). It is indicated for the very large fibroids. Laparoscopic approach may be difficult when the fibroids extend high to the level of the umbilicus. Laparotomy surgery is more painful than laparoscopy and requires 4-6 weeks of recuperation. Complications from myomectomy include bleeding, scar tissue formation and infection. When pregnancy occurs after myomectomy surgery, a Caesarian Section delivery is often necessary to prevent rupture of the uterus during labor.
Medical treatment of uterine fibroids
Fibroids need estrogen to sustain their growth. Fibroids often shrink with menopause because the ovaries no longer produce significant amount of estrogen.
- Lupron, Synarel – suppress pituitary hormones vital to ovarian function, resulting in a temporary, reversible chemical “menopause”. Without estrogen, the fibroids shrink in size. Unfortunately the treatment is associated with side effects, such as, hot flashes and significant bone loss and can not be given for more than 6 months. The benefit from this therapy is therefore only temporary, because fibroid tumors grow back to their pretreatment size shortly after the medicine is discontinued. This treatment is given preoperatively to shrink the size of the fibroids, making it easier for the surgeon to remove them with minimally invasive laparoscopic surgery.
- Mifepristone – anti progesterone medication
- Asoprisnil belongs to a new class of compounds known as Selective Progesterone Receptor Modulators or SPRM. This medication is currently being evaluated for treatment of fibroids in patients who do not desire children. The main advantage of this drug, over other medical therapies, is its ability to bring about cessation of menses with decrease in fibroid size, eliminating bone loss and hot flushes associated with other anti fibroid medications.
- Uterine Artery Embolization (UAE) is a minimally invasive radiological treatment for symptomatic fibroids. It is an alternative to
hysterectomy and myomectomy. In this procedure, a catheter is inserted into the femoral artery and advanced into the uterine artery (fig. 17). Small particles are injected into the uterine artery to block the blood supply to the fibroid (fig. 18). This results in significant reduction in the size of the fibroid and decreased pain and bleeding. The treatment is not currently recommended for infertile women with uterine fibroids. There is about 5% risk of menopause with this treatment, but this occurs most commonly in women over the age of 45.
- MRI Guided High Frequency Ultrasound Therapy is another noninvasive treatment for uterine fibroids. It can take more than 3 hours to complete. It may be associated with mild to moderate pain in 65% of patients and severe pain in another 15%. The procedure is not ideal for patients with fibroids over 10cm in size, fibroids located under the bladder or in patients with abdominal scar tissue.
Can fibroids become cancerous?
Fibroids rarely become cancerous. In fact, cancer is thought to occur in no more than one tenth of 1% of all fibroids. Uterine fibroids are not to be confused with leiomyosarcomas, which are malignant uterine tumors occurring most commonly in post-menopausal women.