Uterine Fibroids

Uterine fibroids, also known as leiomyomas, are common, benign, smooth muscle tumors of the uterus. They are found in nearly half of women over age 40 and infrequently cause problems. Synonyms include Fibroids, Myomas, and Leiomyomata.

Fibroids tend to grow under the influence of estrogen, and regress when the estrogen levels are reduced. Thus, growth frequently occurs during pregnancy, followed by regression following delivery. After the onset of menopause, fibroids generally regress.

High-dose birth control pills, by virtue of their high estrogen content, can cause fibroids to grow larger. Low-dose birth control pills, in contrast, leave circulating estrogen levels the same (or reduced) and do not stimulate fibroid growth. Low doses of estrogen used to treat menopausal symptoms usually do not stimulate fibroid growth.

Symptoms
Most women with uterine fibroids have no symptoms, but some do. Symptoms that might be experienced include:

Heavy menstrual flows: This happens more often with submucous fibroids (just below the surface of the endometrium) that expand the cavity size leaving a much larger surface area for bleeding. Pedunculated fibroids that protrude into the uterine cavity and also cause menorrhagia or heavy bleeding by interfering with the normal contractile mechanisms of the uterus.
Another symptoms can be Bleeding between periods: Pedunculated fibroids and submucosal fibroids can mechanically traumatize the uterine lining, leading to dysfunctional bleeding.
Another symptom is Pain: This may take the form of menstrual cramps, painful intercourse on deep penetration, pain of acute fibroid degeneration, and chronically inflamed fibroids with a dull, aching or heaviness that is mostly constant.
Infertility is sometimes related to fibroids: Fibroids, depending on their location, can interfere with fertility.
There’s also Pelvic Pressure: This heaviness in the pelvis is distracting and annoying but not dangerous.
Stress Urinary Incontinence may be a symptom: The fibroid bulk and irregular contour of fibroids can distort the pelvic anatomy sufficiently to interfere with normal urinary retention and release.
Finally, If large enough and filling the pelvis, fibroids can put pressure on and partially obstruct the ureters, increasing the risk of infection, stones and renal disease.

Clinical Findings are usually straightforward.
The uterus is irregularly enlarged and usually somewhat asymmetrical. It may be tender and may assume very large sizes. Unlike the soft uterus containing a pregnancy or adenomeiosis, the fibroid uterus is very firm.

Confirmation of Diagnosis
The diagnosis is usually based on the clinical findings of an enlarged, irregularly shaped, firm uterus that may or may not be tender. Sometimes, the diagnosis is unclear and diagnostic tests are used to delineate the fibroids and rule out other problems.

Ultrasound is a reliable means to show the fibroids and distinguish between ovarian and uterine growth.

MRI and CT Scanning can be useful, showing, for example, whether the ureter is obstructed and ruling out bowel involvement.
Laparoscopy is Rarely used for diagnostic purposes when considering fibroids, but it might occasionally be used for confirming the diagnosis of fibroids as opposed to an adnexal mass.
As the risk of malignancy in a mass thought clinically to be a fibroid is <1%, histology is only infrequently chosen to make the diagnosis of fbroids, you are concerned because of rapid growth or other quickly evolving symptoms

Let’s consider Management Options.
No single treatment plan is best for all women with fibroids. In most cases, no treatment is required. The fibroids are measured and observed over time, with the expectation that at menopause, they will regress. However, for those with significant symptoms, very large fibroids, or rapidly growing fibroids, a number of treatments can be considered. Important factors in deciding therapy are the severity of the symptoms, associated symptoms, age, and preservation of fertility:

Hysterectomy is the only permanent cure for fibroids. It provides definitive treatment, but requires major surgery, abdominal, vaginal or laparoscopic.

For women who wish to preserve their childbearing capacity, Myomectomy, or removal of just the fibroids, while leaving the uterus alone, could be the best option. Unfortunately, myomectomy is often a more complicated procedure than hysterectomy, involving longer recovery, greater risk of blood transfusion and greater risk of infection. There is no certainty following surgery that other fibroids will not grow.

Birth Control Pill and other Progestins are sometimes used to treat fibroids. While these will not shrink fibroids, they may be effective enough in controlling the symptoms (particularly bleeding) that the patient can make it through to menopause.

GnRH Analogs such as Lupron can also be used. Through suppression of the release of gonadotropins, these GnRH Analogs effectively reduce estrogen concentration to menopause or near menopause levels. This has the desired effect of shrinking the fibroids. Unfortunately, after 6 months, when the GnRH must be stopped, the fibroids will rapidly re-grow, making this only a temporary treatment. But temporary treatment may be very satisfactory if the goal is to shrink the fibroids to a more manageable size prior to surgery. The menopausal symptoms can usually be controlled with add back estrogen, if desired.

Embolization is another option in some areas. Under interventional radiology guidance, a catheter is threaded through the uterine arteries and a bolus of tiny plastic pellets injected. These pellets lodge in the small arterioles leading to the fibroids, reducing their blood flow and causing necrosis. Good results have been reported in a limited number of cases by skilled hands in a few centers. Serious complications have also been noted, leading to emergency surgery and life-threatening problems. Whether this approach will prove to be widely accepted remains to be seen.

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This information is provided by The Brookside Associates, a private organization, not affiliated with any governmental agency. The opinions presented here are those of the author and do not necessarily represent the opinions of the Brookside Associates. The patients presented and discussed here are fictitious and are merely representative of clinical conditions. Any resemblence to real patients is purely coincidental and not intentional.

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