Fibroids

Empowering Women's Health

Uterine Fibroids

Uterine Fibroids, or uterine myomas (short for leiomyoma), affect more than 30% of women. The terms fibroid and myoma are used interchangeably. Most fibroids do not cause symptoms, and do not require treatment. Fibroids may require treatment if they are growing rapidly and/or are large enough to cause pressure on other organs, such as the bladder, are causing abnormal bleeding or causing problems with fertility.

Types of Fibroids

Fibroids are classified by their location. Fibroids that are inside the cavity of the uterus will usually cause bleeding between periods and often cause severe cramping. Submucous myomas are partially in the cavity and partially in the wall of the uterus. They too can cause heavy menstrual periods, as well as bleeding between periods. Intramural myomas are in the wall of the uterus, and can range in size from microscopic to larger than a grapefruit. Many of these do not cause problems unless they become quite large. Subserous myomas are on the outside wall of the uterus, and may even be connected to the uterus by a stalk (pedunculated myoma.) These do not need treatment unless they grow large, and cause symptoms. Those on a stalk can twist and cause pain.

Intracavitary Myomas

When a myoma is inside the uterine cavity, it will almost always cause abnormal bleeding and cramping. These can usually be removed by using a resectoscope. The resectoscope is a telescope with a built-in loop that can cut through tissue. This is called hysteroscopic resection of myomas.

Submucous Myomas

Unlike intracavitary myomas, some of the fibroid is also in the wall of the uterus. Submucous myomas often cause abnormal bleeding. Many of these can also be treated by hysteroscopic resection. During the process of removing submucous myomas by this method the uterus contracts, and tends to push the portion of the myoma that is in the wall into the cavity of the uterus. If heavy bleeding is the main reason for desiring treatment, and fertility is no longer desired, an endometrial ablation may also be done at the same time.

Intramural and Pedunculated Myomas

Myomas that are in the wall of the uterus or on the outside of the uterus are not accessible to treatment through the cervix. If these need to be treated, there are essentially three types of procedures: remove the fibroid(s), destroy the fibroid(s), or remove the uterus.

Diagnosis of Fibroids

Fibroids may be felt during a pelvic exam, especially if they are large, but many times myomas may be missed. For this reason, an ultrasound examination may be very helpful. Ultrasound only takes a few minutes to do, is not uncomfortable, and rapidly provides invaluable information. One of the most common conditions confused with fibroids is adenomyosis. In adenomyosis the lining of the uterus infiltrates the wall of the uterus, causing the wall to thicken and the uterus to enlarge. On ultrasound examination this will often appear as diffuse thickening of the wall, while fibroids are seen as round areas with a discrete border. Adenomyosis is usually a diffuse process, and rarely can be removed without taking out the uterus. Since fibroids can be removed, it is important to differentiate between the two conditions before planning treatment. It is also common to have some adenomyosis in addition to fibroids.

Treatment of Fibroids

The most important question to ask is do the fibroids need to be treated at all. The vast majority of fibroids grow as a woman gets older, and tend to shrink after menopause. Obviously fibroids that are causing significant symptoms need treatment. The location of the fibroids plays a strong influence on how to approach them.

Treatment with medicines:

There are not any currently available medicines that will permanently shrink fibroids. Often heavy bleeding can be decreased with birth control pills. There are a number of medications in the family of GnRH agonists, which induce a temporary chemical menopause. In the absence of estrogen, myomas usually decrease in size. Unfortunately, the effect is temporary, and the fibroids rapidly go back to their pre-treatment size when the medication is discontinued.

Surgical treatment of fibroids:

There have been a number of procedures for treatment of fibroids.

Hysterectomy:

Hysterectomy is the only procedure that comes with a guarantee: no more bleeding and no regrowth of fibroids.

Removal of the fibroid(s):

This is also called myomectomy. The myomas may be removed by means of a laparotomy i.e. an incision is made in the abdomen to reach the myoma. Some myomas can also be removed by laparoscopy. Both methods have advantages and disadvantages and on the merits of each case the doctor will decide the ideal route for that case.

Destruction of the myomas:

Several procedures have been designed to treat the myomas by destroying their blood supply instead of removing them. Uterine artery embolization is the newest treatment for fibroids. This procedure involves placing a small catheter into an artery in the groin and directing it to the blood supply of the fibroids. Little plugs are injected through the catheter to block these arteries. This causes the fibroids to shrink, although there may be pain for a short time afterwards requiring the use of narcotics. Uterine artery embolization may eliminate the need for surgical treatment of myomas. This method is not yet freely available.

It is advisable to plan the treatment of fibroids after a clear discussion with the doctor keeping in mind all factors such as number size and location of fibroids, need for future fertility, and desire for menstrual function

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