HEALTH TALK: Fibroids

Fibroids are common in women in their 20’s and 30’s and sometimes even into their 40’s.  In fact, fibroids affect more than 30% of women of reproductive age, and women of African origin are much more prone to having them than are Caucasians; the reason is  unknown but they are 3-9 times more common in black women.

WHAT ARE FIBROIDS?

Fibroid is the common term that is used for what is really a MYOMA of the uterus or womb.  In fact, it is more properly called a leiomyoma, but fibroid is easier and shorter, so it’s o.k. if you continue to call it that.  They are masses affecting the womb in various locations and are made up of smooth muscle and, to a lesser extent, fibrous connective tissue.

While they can occur as isolated microscopic growths, they are more commonly multiple and may reach enormous proportions, weighing more than 100 pounds. So quite often when women have large waistlines, and think it’s just fat, on occasion it may be a fibroid or fibroids.  I have seen them the size of watermelons in women’s abdomens.  They become malignant ( cancerous) less than 0.5% of the time, or, put another way, less than 0.5% of fibroids become cancerous.

Fibroids are thought to grow under the influence of estrogen, the main female hormone, although they are not known to actually cause them.  The evidence for the other female hormone, progesterone, is less convincing.  This is why fibroids tend to grow in pregnancy; because more estrogen is around to maintain the pregnancy.  And it’s also why they tend to decrease in size or even disappear after menopause.

TYPES OF FIBROIDS

Fibroids are classified by their location, which affects the symptoms they may cause and how they can be treated.  Those that are inside the cavity of the uterus will usually cause bleeding between periods (metrorrhagia) and often cause sever cramping.  These are intracavitary.  Submucous myomas (fibroids, leiomyomata) are partially in the wall of the uterus.  They too cause heavy menstrual periods (menorrhagia) as well as metrorrhagia (above).

Intramural ones are in the wall of the womb.  They may range in size from microscopic to larger than a grapefruit. Many cause no problems except when they become quite large.  There are a number of alternatives for treating these, but often they require no treatment at all.  Subserous fibroids are on the outside wall of the uterus, and may even be connected to it by a stalk (pedunculated myoma).  These do not need treatment unless they grow large, but those on a stalk can twist and cause pain.  This type is easiest to remove by laparoscopy (cute, fancy surgery where you get one, or at most, two small cuts).

SYMPTOMS OF FIBROIDS

A fibroid does not necessarily produce symptoms, and even large ones may go undetected by the patient, especially if she is obese.  As we’ve just said, symptoms depend on their locations; but also their size, and whether or not the patient is pregnant.  In any event, 35-50% of patients with fibroids will have symptoms which include:

1)    Abnormal endometrial bleeding (the endometrium is the lining of the womb).  This is the most important manifestation of fibroids and is present in about 30% of patients, particularly those with the intracavitary or submucous varieties.  Commonly, remember, there will be prolonged heavy menses, but a woman may display any variant from the entire spectrum of abnormal bleeding.  Premenstrual spotting is common, as is prolonged staining following menses.  Remember that some fibroids will cause metrorrhagia, bleeding between periods.

2)    Pain.  This is uncommon with fibroids, per se, but may result from degeneration within a tumor (fibroid) after circulatory occlusion from degeneration or infection, torsion or a pedunculated fibroid, or uterine contractions to expel a subserous fibroid from the womb cavity.  Large fibroids may produce a sensation of heaviness in the pelvic area or what may be described as the ‘bearing-down’ feeling.  Some may press on nerves and cause pain in the back and lower limbs.  Pain from torsion of a pedunculated fibroid can be excruciating and may appear to be a severe surgical abdominal problem.

3)    Pressure effects.  Some fibroids may distort or obstruct other organs.  Again, depending on type or location, one may get a watery- bloody vaginal discharge, vaginal bleeding, pain during sex, and infertility.  Sometimes the bladder or rectum or the tubes from the kidney to the bladder may be displaced.  In this case, urine gets backed up.  One may get constipation, retention of urine, swelling of the legs or ankles, incontinence of urine and other unpleasant symptoms.

4)    Infertility.  Fibroids are the sole cause of infertility in only 2-10% of patients.  I would say this is a high enough number, though.

5)    Spontaneous abortion.  The incidence of this is probably 2-3 times in women with fibroids as opposed to pregnant women without fibroids.

DIAGNOSIS OF FIBROIDS

Fibroids may be felt during a pelvic exam, but may often be missed, even when causing symptoms, if the examiner relies only on this.  Also, other conditions such as adenomyosis –  don’t bother your head for the time being – or ovarian cysts may be mistaken for fibroids.  This is why it is wise to do an ultra sound scan.  Whether by the skin or vaginally, it only takes a few minutes, and can also rule out a pregnancy if one is not previously otherwise sure there is one.

X-rays are done sometimes if symptoms suggest there is compression, distortion, or displacement of other organs. Fibroids may appear as soft tissue masses or, if calcification occurs, then the study would have been very useful.  Other studies such as hysteroscopy or hysterography can be done as well.  Of course, these will be done by your gynecologist.

FIBROIDS AND PREGNANCY

Removal of fibroids can result in as much as a 40% incidence of pregnancy occurring in someone who had been previously infertile.

In the second and third trimesters, fibroids may cause pain and localized tenderness.  Remember that they will grow in pregnancy.

During labor, fibroids may cause the uterus not to contract, may cause abnormal presentation of the fetus, or obstruction of the birth canal.  Some fibroids may allow a relatively normal vaginal delivery, others, of course, may require a caesarian section, to be performed.  After delivery, they may interfere with effective contraction of the womb, so hemorrhage must therefore be anticipated.

TREATMENT OF FIBROIDS

Remember that most fibroids do not cause symptoms and don’t require treatment.  They do, however, in the following circumstances.

A)    Fibroids are causing pressure on other organs, such as the bladder.
B)    Fibroids are growing rapidly.
C)    Fibroids are causing abnormal bleeding.
D)    Fibroids are causing fertility problems.

TREATMENT WITH MEDICINES

None are currently available that will permanently shrink fibroids.  Often heavy bleeding can be controlled with birth control pills.  A family of drugs called GNRH agonists will decrease the estrogen which fibroids need to grow, but this will induce menopause and the effect is temporary anyway because the fibroids rapidly grow back once the medication is discontinued, because it can only be used for about three months.

RU-486, the “French abortion pill” decreases their size and stops abnormal bleeding.

SURGICAL TREATMENT

I will merely mention the procedures for the different types of fibroids that are recommended by experts.

(Intracavitary fibroids)
Hysteroscopy will usually take care of these.

(Submucous)
Hysteroscopy as well.  Sometimes, what we call endometrial ablation may be done at the same time.

(Intramural and Pedunculated fibroids)
Three types of procedures are essentially done for these: remove them, destroy them, or remove the uterus (hysterectomy).  All of the surgical options available are variations on one of these themes.

HYSTERECTOMY

This is the only one with a guarantee: no more bleeding, and no regrowth of fibroids.  And no cancer of the womb later either. But consider whether your fibroids are symptomatic and how close you are to menopause.  There are advantages, but there are disadvantages too.  ALWAYS DISCUSS AT LENGTH WITH YOUR GYNECOLOGIST.

REMOVAL OF THE FIBROIBS

This is called myomectomy.  Usually, a couple of nights in hospital, a few weeks, and you’re back to work.

DESTRUCTION OF THE FIBROIDS

Myolysis is done through a laparoscope.  A laser fiber or electrical device is placed into the fibroid and the fibroid or blood vessels feeding it, are coagulated. Cool, huh!

UTERINE ARTERY EMBOLIZATION

This is relatively new.  A small catheter is placed in an artery in the groin and directed to the blood supply of the fibroid.  The arteries are blocked by injecting little plugs; essentially we’re cutting off the fibroid’s blood supply and shrinking it.

Fibroid is a word on almost every woman’s tongue.  It’s almost as if everyone expects to get a fibroid.  Many will, but don’t worry; your gynecologist can handle it.  Talk to him and discuss your options.

See you next week.