What Are Fibroids?

Uterine fibroids are nodules of smooth muscle cells and fibrous connective tissue that form in the wall of the uterus. Fibroids have many names. You may see them referred to as leiomyoma, leiomyomata, and just myoma. These growths are non-cancerous and can grow in different portions of the uterine wall. The location and size of these benign growths can determine the associated symptoms, which include chronic pain and heavy bleeding. Some women may even become anemic (low blood counts).

The development of uterine fibroids have no known risk factors other than being a female of reproductive age. Women of African descent have increased risk and are seen in as many as 50 percent. Incidentally, some investigators have shown that women who have had two or more live born children have one-half the risk of developing fibroids. Therefore, having children seems to be protective.

Fibroids vary considerably in size from less than an inch wide to the width of a cantaloupe (10 inches or more). They can increase in size to that of a five-month pregnancy and can be easily detected, as the women may appear pregnant.

Fibroids occur in different areas within the uterus. There are three primary sites of involvement called Subserosal, Submucosal and Intramural.

Subserosal fibroids: These fibroids occur just under the outer lining of the uterus and can give it a bulbous contour. They usually do not cause excessive bleeding but do frequently cause chronic pelvic pain. In addition, they can compress the urinary bladder causing urinary frequency or compress the lumbar and sacral nerve trunks giving low back and leg pain. They can grow off the uterus and become "pedunculated" or on a stalk. These are best seen with MRI.

Intramural fibroids: These develop within the central muscular wall of the uterus known as the myometrium. This is the most common type and it increases the size of the uterus, giving rise to bulk symptoms, chronic pelvic pain, and heavy menstrual bleeding and lower back pain.

Submucosal fibroids: These occur most infrequently but can be the most distressing. They are located just under the inner lining of the uterus known as the endometrium. When this lining sheds each month it causes menstruation. Fibroids here increase the surface area of the lining and cause heavy bleeding and severe crampy abdominal pain. Many women suffer from chronic blood loss and develop anemia.

TYPICAL SYMPTOMS

The vast majority of women with fibroids never become symptomatic. Only about 10 to 20 percent require some kind of therapy. The following is a list of some of the symptoms associated with fibroids.

• Heavy menstrual bleeding is the most common symptom with some women passing clots. This heavy gush of blood each month can leave some women with low blood counts (anemia) causing chronic fatigue.
• Increased abdominal girth and distention gives rise to bulk and pressure symptoms.
• Intense crampy abdominal pain during menstruation can be seen with many fibroids and are worse when there is prolapse of a submucosal fibroid. This is commonly accompanied by heavy bleeding.
• Chronic pelvic pain from the large size of the fibroids pressing on adjacent structures causing them to shift.
• Low back and leg pain can be seen from large myomas pressing on the lumbar and sacral nerve trunks.
• Infertility can occur by compression of the fallopian tubes or by preventing sperm movement through the uterine cavity. In addition, repeated miscarriages and premature labor have also been linked to fibroid disease.
• Increased urinary frequency is caused by compression of the urinary bladder by a large fibroid.
• Pressure on the adjacent rectum can cause constipation and hemorrhoids.

DIAGNOSIS

Fibroids are usually detected at gynecologic examination. The doctor performs an internal exam for identification of an enlarged uterus. They are most commonly visualized and confirmed by the ultrasound examination. This is a painless test, which uses sound waves not x-rays to image the mass. A sonographer moves a transducer (a small instrument the size of a cassette tape) over the pelvis with the bladder filled. Harmless sound waves are transmitted and the echoes are captured allowing the anatomy to be visualized. The pictures are printed out and the size and location of the fibroids are determined. Sometimes a transvaginal ultrasound is performed for better visualization.

Other methods for detecting and imaging uterine fibroids are MRI and CT. MRI is the most sensitive of the tests and also the most costly. It gives exquisite detail of the pelvic structures and allows for the most precise evaluation of the size and location of the fibroids. This test uses radio waves and magnets to capture the image.

TREATMENT OPTIONS

Medical Treatment:

1. Use of non-steroidal anti-inflammatory agents are used primarily for pain relief
2. Hormonal therapy, such as birth control pills and GnRH analogs, help control the female hormone levels which fibroids are very sensitive to. The GnRH analogs can shrink fibroids after 3 months of treatment by approximately 50 percent. Unfortunately they have side effects including hot flashes (seen in 75%), osteoporosis and increased serum cholesterol levels.

Surgical Treatment:

1. Hysterectomy is most commonly performed in this country for fibroid disease. This procedure removes the entire uterus from the pelvis either through the abdomen or through the vagina. It requires general anesthesia, a hospital stay of about a week and can have a six-week recovery time.
2. Myomectomy is done to preserve the uterine tissue and to remove only the fibroid. This procedure is performed in the operating room under general anesthesia. This can weaken the uterine wall causing future pregnancies to be delivered by caesarean section. Investigators have shown a 40% fertility rate after myomectomy and the recurrence of fibroids are common.

Uterine Fibroid Embolization:

This procedure is performed by an Interventional Radiologist who is specially trained in the endovascular therapy of fibroid disease. This procedure is minimally invasive and is performed in an angiography suite in the hospital with local anesthesia and intravenous sedation. In most cases patients can go home the same or next day and are back at work in one to two weeks.

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