Fibroids, or leiomyomata, are growths of a specialized type of muscle tissue. Since fibroids originate in smooth muscle, they can occur anywhere smooth muscle is found. Fibroid tumors occur very often in the uterus. It is believed by many that these tumors develop in a majority of American women, and become symptomatic in one-third of them. Fibroids are the most frequent indication for hysterectomy in the United States. Some predisposing factors have been identified, including later reproduction, African American ancestry, no previous pregnancies and obesity. While no actual cause for fibroids has ever been identified, estrogen and progesterone are recognized as “promoters” of tumor growth, and investigators are currently exploring the role of environmental estrogens in this area. Fibroids may be of any size, from less than 1/8 inch to the size of a watermelon. They often occur as multiple masses; they may vary in number from 1 to our record of 55. They are white to tan or pink and usually very firm, like a rubber ball and appear to be under tension such that cutting across the surface of a fibroid may result in a flowering out or expansion in the operative field. Under a microscope, the cells are characteristically uniform, elongate like spindles, occur in bundles, and have few cells undergoing multiplication or mitosis. They are overwhelmingly benign, meaning they do not act like cancerous tumors with regard to invasion of other tissues or spread to other areas. Approximately 1/1000 of fibroids are actually sarcomas, or malignant (cancerous) tumors. Fibroids in pregnancy The true incidence of fibroids during pregnancy is unknown but reported rates vary from 0.1% to 12.5%. Pregnancy itself may have little or no effect on fibroids, although they are usually followed closely during pregnancy with ultrasound. Fibroids may affect pregnancy and delivery in several ways. Women may experience abdominal pain, miscarriage, an abnormal position of the baby with respect to the birth canal, and difficult or impeded delivery. The size, location, and number of fibroids and their relation to the placenta may predict whether complications will be encountered, and again, ultrasound scanning is helpful. Diagnosis Fibroids that are very large are often felt by a patient even if no symptoms are present as a hard lump or mass in the pelvis or abdomen and may prompt evaluation. The most common tool used to evaluate a pelvic mass is ultrasound, which is very reliable for the diagnosis. However, not all fibroids are visualized by ultrasound, and the degree of malignancy cannot be determined by ultrasound. MRIs have been used as well. On physical examination, a firm pelvic mass that moves with the physician’s manipulation of the cervix strongly suggests a fibroid, but is not definitive. Occasionally an ovarian mass may be misidentified as a fibroid. Treatment Fibroids are extremely common among reproductive age women. The usual indications for treatment of fibroids are: • Excessive bleeding • Pain • Pressure symptoms • Rapid growth • Frequent miscarriage with distortion of the uterine cavity • Subfertility with no other apparent cause Treatment modalities are changing rapidly, and depend on many factors. • Age • Suspicion of malignancy • Specific symptoms • Size and location of fibroids • Desire for fertility • Desire for minimally invasive management Often, no treatment is necessary; if fibroids have been present for some time, are not rapidly changing in size, are not greater than 14 to 16 week size (halfway to the umbilicus), are without symptoms, and have no characteristics suggestive of malignancy, simple observation may be adequate. A very large fibroid or one that is undergoing rapid growth may suggest a malignancy and should be removed. There is some evidence that women who undergo menopause may have regression of fibroids if they are not a very large size. Therefore, in some cases surgery can be avoided by using medical management; generally GnRH analogs can be used to suppress ovarian function and may result in shrinkage of fibroids by 25-30%, which may be enough to ameliorate symptoms until menopause, when symptoms may resolve by natural progression. GnRH analogs often cause symptoms of menopause, however, and should only be used for 6-12 months. Fibroids may be located in any number of places; fibroids that are directly under the endometrial lining of the uterus may prevent attachment of the portion of the lining that sloughs with menses, and may cause heavy and irregular bleeding. Depending on the size and how much of the fibroid extends into the uterine cavity, the fibroid may be removed hysteroscopically. Hysteroscopy involves a one-day procedure in which a camera is introduced through the cervix and into the uterus and the fibroid or a portion of it is surgically removed. Treatment options are so dependent upon the above listed factors, and others, that only a brief and very general description is included here. Please consult your physician for further information. • Observation. See limitations above. • Medical management. Combination oral contraceptives, progesterone, danazol, GnRHs, and other drugs work in different ways to accomplish alleviation of symptoms and in some cases shrink fibroids while they are being used. Other medical therapies investigated include, raloxifene, mifepristone, aromatase inhibitors, and the levonorgestrel-containing intrauterine device see below. However, all of these produce anovulation, a state that prevents pregnancy if pregnancy is desired. So far, none of these medications when used to treat fibroids have been shown to enhance fertility following discontinuation. • Progesterone-containing IUDs (intrauterine devices) may be beneficial in reducing heavy blood flow, but may take some time to be effective. As many as 60% of women may avoid hysterectomy by using this method. • Hysteroscopic resection. This involves physical removal of a fibroid from within the uterine cavity through the cervix using a camera and sophisticated equipment. • Hysteroscopic ablation. “Ablation” means removal of the surface lining of the uterus through any number of means, including freezing, coagulation, heat ablation with a balloon system, heat ablation with free fluid, radiofrequency ablation, and others. This technique is only applicable in certain circumstances where fibroids are involved. • Laparoscopic removal of fibroids. Laparoscopic removal means using very small (1/2”) incisions to remove fibroids in a procedure that may require 1 or 2 day hospitalization. Because removal of the fibroids involves taking them out in small pieces, size of fibroids is not necessarily a limiting factor for this procedure in experienced hands. • Myomectomy. Abdominal surgery with a regular incision measuring variably from 5 to 10 centimeters may be required to remove fibroids from the uterus. In this type of surgery, the uterus itself is left behind and only the fibroids are removed. • Uterine artery embolization. The blood vessels that carry the blood supply to the uterus can be blocked in a very sophisticated procedure performed by an interventional radiologist. This is a new procedure and while recovery is faster than with a myomectomy or abdominal hysterectomy, there are other complications associated with it. • Hysterectomy. This is the ultimate surgical correction for fibroids, and a number of different types of hysterectomy are in use today, including cervix-sparing (supracervical), laparoscopic approaches, combined laparoscopic and vaginal approaches, and abdominal incisions. Any of these can be combined with removal or retention of the ovaries. Again, treatment must be individualized. Women who are diagnosed with fibroids should discuss whether treatment is warranted and what type of treatment is best. References: On request |
| Fibroids |
| Brenda L. Kehoe, M.D. |
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