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Uterine
fibroids are benign (noncancerous) masses
of muscle tissue that enlarge and/or
distort the uterus and sometimes the
cervix. Fibroids originate from the
smooth muscle cells within the myometrium
or wall of the uterus. In most cases
there are multiple fibroids, but occasionally
a single fibroid may occur. Other terms
for uterine fibroids are myomas or leiomyoma.
It is estimated that uterine fibroids
occur in one out of every four to five
American women. African American women
are over three times more likely to
develop fibroids than Caucasian women.
Usually, fibroids develop when a woman
is in her 30s or 40s, and become smaller
after menopause. Most fibroids do not
require treatment. However, they may
cause excessive uterine bleeding, pain,
abnormal pressure sensations, and, less
commonly, infertility, miscarriage,
and premature delivery. Removing the
fibroids surgically can usually correct
these problems. However, there is a
chance that additional fibroids and/or
postoperative scarring will occur. |
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| CAUSES |
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| Increased Estrogen
Levels |
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The
exact cause of uterine fibroids is unclear,
but there is evidence suggesting that they require
estrogen for growth. For example, fibroids some
times grow larger during pregnancy when the
body produces more estrogen.
During menopause when estrogen levels decline,
fibroid growth generally subsides. Consequently,
fibroids rarely require treatment after menopause.
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Fibroids
are usually found in or around the uterus, but
they sometimes occur in the cervix. Fibroids
can be divided into three categories: subserous,
intramural, or submucous. Subserous fibroids
are located in the outer wall of the uterus.
Intramural fibroids are found in the muscular
layers of the uterine wall, and submucous fibroids
are located on the inner wall of the uterus
and may protrude into the cavity. About 55 percent
of fibroids are subserosal; 40 percent are intramural;
and 5 percent are submucosal. |
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SYMPTOMS |
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Many
women with uterine fibroids have no symptoms.
However, approximately one-third report abnormal
uterine bleeding, a feeling of pressure or pain
in the pelvic or lower abdomen, or the presence
of a mass. As fibroids enlarge and grow, the
mass can become very large. Some women notice
that their abdomen is larger and their clothes
are tighter. Others can feel something protruding
from the lower abdomen. |
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Abnormal Uterine Bleeding
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Abnormal uterine bleeding is most common symptom
associated with fibroids and is present in one-third
to one-half of women undergoing fibroid-related
surgery. Large fibroids can distort or enlarge
the uterine cavity, and this creates a larger
surface area for menstrual bleeding. Fibroids
also put pressure on the endometrium and cause
excessive bleeding. Because abnormal uterine
bleeding can result from other causes, such
as endometrial cancer and hormonal problems,
it is important that women experiencing abnormal
vaginal bleeding receive a thorough evaluation,
even if uterine fibroids are present. |
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Pain |
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When
a fibroid begins to grow rapidly, it may outgrow
its blood supply and degenerate or decay, causing
a painful, cramping sensation. This most often
happens during pregnancy. When sudden, severe
pain occurs, it can sometimes be caused by decaying,
inflamed, or twisting fibroids. Large and bulky
uterine fibroids may make intercourse painful. |
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Large fibroids may produce pressure on various
pelvic organs such as the bladder, ureters,
and rectum. Consequently, urinary frequency
or urgency may occur because of decreased bladder
capacity. Continued compression of these organs
can also cause kidney damage if the fibroids
are not removed. Fibroids in the lower uterus
may put pressure on the large bowel and rectum,
which could result in difficult bowel movements,
constipation, or hemorrhoids |
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Fibroids
may contribute to an infertility problem. Most
often, submucosal or intramural fibroids inside
the uterus are associated with infertility.
However, only 2 to 3 percent of infertile women
are unable to conceive due to uterine fibroids.
Because of this, women and their partners should
have a thorough infertility investigation to
identify additional causes of fertility problems.
Infertility may result from uterine fibroids
for several reasons. Changes in the endometrium
may make it unlikely for a fertilized egg to
attach to the uterine wall. In addition, one
or both fallopian tubes may be compressed or
blocked, thus preventing the sperm from reaching
the egg. Conception rates after any of the surgical
techniques (myomectomy) used to remove fibroids
are generally good but depend upon other factors
that influence fertility such as age, previous
pregnancy, ovulatory status, the status of the
fallopian tubes, and the male’s semen
quality. Fibroids may increase miscarriage rates
by impairing successful implantation of an embryo.
Changes in the endometrium or in the blood supply
to the uterus may also cause early miscarriage.
In addition, increased risk of premature delivery
and other pregnancy related problems can be
associated with fibroids. |
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The risk of fibroids being malignant is approximately
0.2 percent. This cancer is called leiomyosarcoma
and is more likely to occur in a postmenopausal
woman. However, if a fibroids begins to grow
very rapidly, this may suggest that it has become
cancerous and requires careful evaluation and
potential removal of the uterus (hysterectomy). |
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Uterine
fibroids can usually be diagnosed during a pelvic
examination. However, because other conditions
such as ovarian tumors, bowel masses, and early
pregnancy can be mistaken for fibroids, it will
probably be necessary to undergo other tests.
Several diagnostic procedures are available
to determine the presence of fibroids. |
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Ultrasound,
either abdominal or vagina, is a procedure that
uses sound waves to create a picture of the
pelvic organs. The physician can look at an
ultrasound picture to see if fibroids are present.
Often, as fibroids vary in size, both transvaginal
and transabdominal ultrasound is necessary to
visualize them accurately. |
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Diagnostic
laparoscopy can help the physician make a definitive
diagnosis and can sometimes be used to remove
fibroids. During this procedure, the physician
will insert a slender, telescope-like instrument
called a laparoscope into the abdominal cavity
through a small incision near the navel. The
laparoscope is used to look for abnormalities
of the internal pelvic organs. This surgery
is usually performed on an outpatient basis
under general anesthesia and requires one to
four days of recovery time. Diagnostic hysteroscopy
is sometimes performed at the same time. In
a few cases, fibroids can be removed during
laparoscopy. This procedure is described later
in this booklet. |
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Diagnostic
Hysteroscopy |
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Diagnostic hysteroscopy
is useful to determine the presence of submucous
fibroids. This procedure involves the insertion
of telescope-like instrument called a hysteroscopy
through the vagina and cervix into the uterine
cavity to look for abnormalities within the
uterine cavity. The surgery can be done under
local or general anesthesia. Sometimes the
fibroids can be removed through the hysteroscope,
but only in the operating room. This procedure
is described later in this booklet.
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Sonohysterography |
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With
sonohysterography, a small catheter is placed
inside the uterus to instill 15-20 cc of fluid
during an ultrasound. This improves the physician’s
ability to identify submucous fibroids which
protrude into or distort the uterine cavity.
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Magnetic
Resonance Imaging |
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Magnetic
resonance imaging (MRI) produces a picture by
absorbing energy from specific, high-frequency
radio waves which can determine if fibroids
are present. The created image can define the
size and location of the fibroids and can help
determine whether or not the fibroids are distorting
the uterine cavity. Although MRI is very accurate,
it is rarely needed to diagnose the presence
of fibroids. |
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Most of the time, fibroids don’t require
treatment. If a woman is not experiencing pain,
a pressure sensation, infertility, or excessive
bleeding, periodic examinations are generally
sufficient to find out if there is a significant
change in the fibroid size. This is especially
true if she is planning a future pregnancy,
when fibroids can grow and affect the pregnancy,
or if approaching menopause, when fibroids generally
shrink. Even if a woman is infertile, the presence
of uterine fibroids is often only coincidental.
Surgery to remove the fibroids should be considered
only after a through evaluation of other factors
which could be causing infertility. In fact,
surgery on fibroids can sometimes make the infertility
problem worse by creating pelvic adhesions (scar
tissue). |
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SURGICAL MANAGEMENT OF FIBROIDS |
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Myomectomy
(Surgical Removal of Fibroids) |
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 Fibroids
that are large enough to cause significant
symptoms or rapidly growing fibroids
may require surgery. Removal of only
the fibroids, rather than the entire
uterus, is called a myomectomy. Myomectomy
is most often performed when the woman
desires a future pregnancy or when she
wishes to retain her uterus. Today,
there are several options available
for this surgery. In most cases, the
size and location of the fibroids will
determine the appropriate surgical technique.
Small fibroids may be removed through
less invasive hysteroscopy or laparoscopy
procedures, but large, multiple, or
inaccessible fibroids usually require
laparotomy for removal.
During a laparotomy, the physician will
make an incision in the abdominal wall
to remove the fibroids from the uterus.
It usually takes about four to six weeks
for a complete recovery. After a patient
has undergone this surgery, a cesarean
section may be needed for delivery because
the muscular wall of the uterus may
be weakened by the removal of many or
large fibroids. The physician can make
this determination at surgery. 
The two major concerns with performing
a myomectomy are minimizing blood loss
and preventing surgically induced adhesions
(scar tissue) that may impair future
fertility. In rare cases, uncontrolled
bleeding may require a hysterectomy.
Sometimes women bank their own blood
several weeks before myomectomy in case
they might need a blood transfusion.
If a woman and her physician decide
that myomectomy is the best option,
there are other risk factors that will
need to be discussed. There is a chance
that fibroids will reoccur and require
further surgery. Pelvic adhesions may
form which can impair fertility by affecting
the tubes or ovaries. A laparoscopy
can be used to evaluate any postoperative
adhesions. |
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Small submucous fibroids located within the
uterine cavity may be removed with operative
hysteroscopy. During this procedure, the physician
will insert a hysteroscope through the cervix
into the uterus. Surgical instruments are then
inserted through a channel in the hysteroscope
to remove fibroids located within the uterine
cavity. Generally, women can return to their
normal activities within two days after operative
hysteroscopy, and complications are rare. |
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Operative
Laparoscopy |
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In
some cases, operative laparoscopy may be used
to remove the fibroids if they are located on
the outside wall of the uterus. During operative
laparoscopy, the physician places a laparoscope
into the abdomen through a small incision near
the navel and then uses surgical instruments
to remove the fibroids. Recovery time is usually
two to seven days. A new techmique, called myolysis,
in which the fibroid is at least partially,
if not completely, destroyed by electrosurgery
or other means is being developed. |
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If
a woman has large fibroids that are symptomatic,
and pregnancy is not desired, a hysterectomy
or surgical removal of the uterus may be recommended.
A vaginal hysterectomy, which removes the uterus
through the vagina, or an abdominal hysterectomy,
which requires a laparotomy, may be necessary.
Recovery time is usually two to six weeks. |
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MEDICAL MANAGEMENT OF FIBROIDS |
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GnRH
analogs can be used to temporarily reduce the
size of fibroids. GnRH analogs decrease estrogen
levels by stopping the signal from the brain
that sends a message to the ovaries to produce
estrogen. This can significantly reduce the
size of the fibroids. However, when GnRH analog
therapy is discontinued, the fibroids usually
return to their pretratment size within three
to six months. GnRH analogs produce menopausal-like
side effects such as hot flashes, vaginal dryness,
mood swings, and sometimes bone loss. These
medications cannot be used for extended periods
of time unless special precautions are taken
to prevent bone loss. Primarily, they are used
before surgery to reduce uterine fibroid size.
In women who have experienced excessive menstrual
bleeding and have become anemic, GnRH anlogs
may decrease vaginal bleeding. This medication,
in combination with iron supplements, may improve
anemia, allowing for the possibility of banking
blood prior to surgery or reducing the need
for a transfusion. |
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Women
who have uterine fibroids may experience many
different feelings. Some women say they feel
defective because the condition involves their
reproductive organs. It is important to remember
that there are many more aspects to femininity
and womanhood than one specific body part. Women
who have experienced a miscarriage because of
fibroids may feel guilty or anxious about future
pregnancies. If a woman is faced with the possibility
of losing her uterus, she may feel angry and
sad, especially if future pregnancy is desired.
It is important for a woman to discuss these
feeling with her physician so that alternatives
to hysterectomy can be discussed and considered.
It is also helpful to seek support from family,
friends, and support groups. |
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Uterine
fibroids are benign masses of smooth muscle
tissue in or around the uterine wall. They are
commonly found in women during their reproductive
years. Fibroids are usually harmless. However,
some women experience abnormal uterine bleeding,
pain, pressure, miscarriages, or infertility
because of fibroids. There is also an extremely
small chance that fibroids can develop into
cancer. Therefore, it is important that a woman
see her doctor at regular intervals to decide
if she should undergo surgical removal of the
fibroids or have a hysterectomy. |
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