Uterine Fibroids

Table of Content:

1. Overview
2. Symptoms
3. Diagnosis
4. Treatment

1. Overview

What Are Uterine Fibroids?

Uterine fibroids are non-cancerous tumors that grow in the uterus during childbearing years. They are made of the same smooth fibers of muscle as the uterine wall. They can grow singularly or in clusters and can range in size from a small pea to a large melon.

Are Fibroids Common?

Between 40 to 70 percent of women develop fibroids by the age of 50, and about 80% of African American women will develop fibroids at some point in their lifetime. Many women experience no discomfort and do not even know they have fibroids, while others suffer from severe symptoms on an ongoing basis.

Who Is at Risk for Uterine Fibroids?

African American women are 3 times more likely to experience fibroid growth than their Caucasian counterparts, and Hispanic women are 2 times more likely to have fibroids than Caucasian women. Overweight women are also more likely to develop fibroids. Family history, lifestyle, and overall health also play a part in fibroid risk.

Where Do Fibroids Grow?

Uterine fibroids are categorized based on their location within the uterus:

• Subserosal fibroids grow underneath the outer covering of the uterus. They can be attached to the uterus directly (sessile) and grow away from the uterus with a broad base of attachment or they can be pedunculated (attached by a thin stem or stalk).
• Submucosal fibroids grow underneath the inner lining of the uterus and indent the uterine cavity. They can be embedded or attached via a stem/stalk (pedunculated).
• Intramural fibroids are the most common tumors and grow in the muscle which lies in between the uterine cavity and outer covering of the uterus.
• Cervical fibroids grow in the cervix and account for 1-2% of the fibroids located in the body of the uterus.

FIGO Classification

Fibroids are further classified by location from 0-7 from the most central Type 0 to the most peripheral Type 7:

• Type 0 – Pedunculated submucosal fibroids. These fibroids are unusual. They are completely within the uterine cavity and often cause severe bleeding. If small, they can be removed hysteroscopically from a vaginal approach. If they are larger than 3-3.5 cm, they cannot be removed with hysteroscopy alone. They can be removed with a combined, non-surgical approach using Uterine Fibroid Embolization (UFE) followed by hysteroscopic removal 2-3 weeks later to enable the Gynecologist to safely remove these larger tumors hysteroscopically.
• Type 1 – Submucosal fibroids (>50% submucosal). Like Type 0, these fibroids also commonly cause very heavy bleeding. These fibroids are typically best handled with UFE if smaller than 3.5 cm and if larger – a combined UFE/hysteroscopic removal like is done for Type 0 can be performed.
• Type 2 – Submucosal fibroids (>50% intramural). Like Type 0 and 1, they often cause heavy bleeding. These are typically best treated with UFE, regardless of size.
• Type 3 – Intramural fibroids (endometrial contact). When small they often are asymptomatic, but if larger can cause heavy bleeding. If symptomatic, they’re best treated with UFE, regardless of size.
• Type 4 – Intramural fibroids (100% intramural). Like Type 3, when small often asymptomatic. As they enlarge, they cause symptoms based on which direction they grow. If they grow toward the uterine lining and endometrial cavity, they behave like submucosal fibroids and cause heavy bleeding. If they grow outwardly, i.e. away from the uterine cavity, they behave like subserosal fibroids and cause bulk-related symptoms, e.g. pelvic pain and/or pressure, increased urinary frequency, back/buttock/leg pain, constipation, painful sex.
• Type 5 – Subserosal fibroids (>50% intramural). Same as Type 4.
• Type 6 – Subserosal fibroids (<50% intramural). When small, often asymptomatic. As they get larger, they grow away from the uterus and will cause bulk-related symptoms based on where they are in the uterus. Those Type 6 fibroids in the front of the uterus often press on the bladder as it sits right in front of the bladder to cause increased urinary frequency, urinary pressure, and even occasional urinary leaking – incontinence. Those located laterally in the uterus will often press on pelvic nerves to cause pelvic pain, pressure (bloating). Those located in the back of the uterus often press on nerves to cause lower back/buttock pain, while others may press on the colon to cause constipation or painful bowel movements.
• Type 7 – Pedunculated subserosal fibroids. They are the outermost located fibroids and like Type 0, they are connected to the uterus by a thin stalk or stem. They can cause unexpected, sudden sharp pain. This happens when the fibroid twists on its stalk and interrupts the blood flow to the fibroid. This can prompt the woman to seek emergency care.

How Big Do Fibroids Grow?

Fibroid sizes are normally reported in centimeters. To give a common reference point, this size in centimeters can be compared to a similar-sized piece of fruit. A fibroid is considered giant if it is over 25 pounds which is very rare.

Are Fibroids Cancerous?

No! Fibroids are benign tumors and are not cancerous.

What Causes Uterine Fibroids?

Scientists and medical professionals do not know exactly what causes uterine fibroids but they do know it is linked to estrogen dominance.

Can Fibroids Be Prevented?

Because it is not known what causes fibroids, they can not be prevented. However, with certain healthier lifestyle choices, their growth may be slowed down or possibly inhibited.

Can I Get Pregnant If I Have Uterine Fibroids?

Uterine fibroids can inhibit the ability to get pregnant. Certain types of fibroids (usually submucosal) can prevent fertilization and fibroids located on the uterine wall can prevent implantation or can take up the space that a growing baby needs and can prevent a full-term pregnancy. However, the majority of women with fibroids that get pregnant will have uneventful pregnancies.

Will Fibroids Go Away on Their Own?

During a woman’s premenopausal life, fibroid growth tends to occur slowly over time and rarely regresses unless there is a significant lifestyle intervention or procedure performed. Once a woman reaches menopause after 12 consecutive months of no periods, fibroids are typically not an issue for the woman any longer. However, some women will continue to have symptoms, particularly if they are taking hormone replacement. This is usually increased urinary frequency and nocturia – waking up at night to urinate. These patients are often excellent candidates for Uterine Fibroid Embolization (UFE).

2. Symptoms

What Are the Symptoms of Uterine Fibroids?

Some women experience no symptoms from their uterine fibroids and others suffer life-interrupting and disabling symptoms.

Some of these include:

• Heavy, painful, prolonged periods
• Blood clots larger than a quarter
• Bloating
• Pelvic pain and pressure
• Back pain
• Frequent urination
• Painful intercourse
• Infertility
• Anemia

What Does Uterine Fibroid Pain Feel Like?

Pain associated with fibroids can be anything from mild abdominal cramps to severe pain. Large fibroids can create lower back, pelvic pain, or dull achy pain in the thighs or legs. On rare occasions, a woman may experience torsion of a pedunculated fibroid which causes severe sharp pain and requires immediate medical attention.

Can Fibroids Change Over Time?

Fibroids can become larger or smaller over time depending on certain factors. Fibroids thrive on estrogen, so during a pregnancy fibroids tend to get larger while after menopause they shrink and typically are no longer an issue.

Can Fibroids Cause Anemia?

Yes! They often do. Fibroids can cause heavy bleeding and prolonged menstrual cycles which leads to significant blood loss. This blood loss can cause anemia in many instances.

3. Diagnosis

How Are Uterine Fibroids Diagnosed?

Ultrasonography uses sound high-frequency sound waves to create an image.

Magnetic Resonance Imaging (MRI) Like ultrasound it does not use radiation. It produces clear detailed pictures of internal organs through the use of radio waves and a magnetic field. This form of imaging has a much resolution than ultrasound and is considered the best diagnostic tool for fibroids.

Computed Tomography (CT) Processes x-ray images captured from different angles and combines them so bones, blood vessels, and soft tissues from inside your body can be studied. This type of imaging is rarely used for fibroids.

Hysteroscopy is performed through a thin lighted tube that is inserted into the vagina and allows your doctor to examine the uterus and cervix. This can only evaluate FIGO Type 0,1, and 2 fibroids and cannot treat Type 2 or any of the other Type 3-7 fibroids (see above discussion).

Hysterosalpingography (HSG) uses a contrast dye that is injected into a small, thin catheter that is placed from the vagina into the uterine cavity under x-ray. While you can see Type 0, 1, or 2 fibroids, it is not used as a primary imaging tool for fibroids.

Sonohysterography like HSG uses the same type of catheter that is placed into the uterine cavity. Once the catheter is in place a transvaginal ultrasound probe is placed in the vagina. Sterile water is injected (usually ~60cc) into the catheter which fills the uterine cavity and gets much better images of the uterine lining (endometrium) than can be obtained with just transvaginal ultrasound alone. Its main use is to evaluate the endometrium or to differentiate between a Type 0 or 1 fibroid from a uterine polyp.

Laparoscopy is performed through small surgical incisions in the abdomen allowing the surgeon to insert long, metal tubes. The abdomen is then distended with CO2 gas. Surgical instruments are then placed into the pelvis through these cylindrical tubes which include a high-resolution camera; enabling the surgeon to operate in real-time on a video monitor. If the surgeon is actually holding the surgical instruments, this is traditional laparoscopy. If mechanical, robotic arms are holding these instruments and being manipulated by the surgeon who is viewing this on a 3D computer console, that is robotic laparoscopy.

4. Treatment

How Are Uterine Fibroid Symptoms Treated?

Medications are commonly used as first-line therapy for symptomatic fibroids. Over-the-counter non-steroidal anti-inflammatory medications such as ibuprofen, naproxen, etc. can be used to treat mild-moderate symptoms.

Oral contraceptives contain hormones that can lighten bleeding but often cause fibroid growth through exogenous estrogen.

GnRH antagonists or GnRH agonists send your body into medically-induced menopause, but only while you are taking them unless you are very close to menopause. They are expensive, often cause unwanted side effects such as significant hot flashes, bone loss, and their use is limited to 6 months or less.

Fibroids begin to grow again once the medication is stopped. They are typically used in women that want to undergo surgery for fibroids, but their low iron and hemoglobin are too low to operate. Because the woman doesn’t bleed on this medication, it buys time to allow iron and/or blood to be given to boost the iron and hemoglobin levels into a safe range to operate. Alternatively, these women could consider Uterine Fibroid Embolization (UFE). Unlike surgery, there is no blood loss during the procedure and women often undergo UFE safely with iron and hemoglobin levels that could not undergo surgery.

SPRM (Selective progesterone receptor modulator). These medicines are not FDA-approved and were used in the United States on an “off label” basis. Ulipristal is the main example. Its use essentially stopped when many of the patients treated developed significant toxic effects in their liver, some severe enough to require a liver transplant.

SERMs (Selective estrogen receptor modulator). These medicines are best known for the treatment of breast cancer (e.g. tamoxifen). Their use in treating fibroids has been very limited and there has not been enough research to support their use with symptomatic fibroids.

Lifestyle Choices

• Eating healthy and avoiding foods that interfere with the balance of estrogen in the body;
• Getting enough sleep;
• Avoiding personal care products that contain additives that alter the natural estrogen in the body;
• Maintaining a healthy weight because excess fat stores and produces estrogen;
• Exercising regularly will help maintain a healthy BMI and can relieve stress which plays a part in the production of estrogen;
• Vitamin D is a powerful fibroid growth inhibitor; therefore getting adequate sun exposure and supplementing with vitamin D as necessary should be part of a daily routine;
• Iron supplements are recommended for women who experience heavy bleeding to alleviate anemia symptoms.

Fibroid Surgery

Myomectomy is a surgical procedure where fibroids are cut out of the uterus and then the uterus is stitched back together. Typically, the surgeon is unable to remove all the fibroids during a myomectomy, and most patients will require a second procedure within 5 years (11% per year recurrence rate).

Repeat myomectomy should be strongly discouraged due to this high recurrence rate, and patients that recur with symptoms after a myomectomy should consider a procedure that treats all of the fibroids in the uterus like Uterine Fibroid Embolization (UFE). UFE is also advantageous as it is a non-surgical procedure and therefore safer and less invasive than myomectomy. Finally, myomectomy patients have to sign a medical waiver attesting to the fact that they might wake from surgery without their entire uterus, i.e. hysterectomy, due to intraoperative bleeding. This is obviously not a risk for UFE patients.

Hysterectomy is a surgical procedure involving the complete removal of the uterus. While it does eliminate the symptoms from uterine fibroids, it can create a number of significant negative side effects, some of which are permanent.

Women who undergo hysterectomy often struggle psychologically like a man being castrated. There is a lot of sexual dysfunction as well such as loss of libido, loss of orgasm. Urinary leaking or incontinence is also a common side effect of hysterectomy. This is due to the surgical removal of the enlarged fibroid-filled uterus which weakens the pelvic floor muscles leading to urinary leaking. There is significant bone loss post-hysterectomy and it appears that there is also an increased cardiovascular risk, i.e. increased risk of high blood pressure, heart attack, and stroke. Therefore, any woman considering hysterectomy should know about Uterine Fibroid Embolization (UFE). Unfortunately, studies have shown that most of these women are not informed about UFE. Because of the significant side effects associated with hysterectomy, and because UFE treats all of the fibroids too, hysterectomy for benign fibroids should be relegated to a last-resort treatment option.

Interventional Radiology Techniques

Uterine Fibroid Embolization (UFE) is a non-surgical, minimally invasive procedure that is 90% effective in relieving fibroid symptoms. UFE cuts off the blood supply to the fibroids which causes them to die. Once this occurs, the fibroids begin to soften and shrink. UFE is a completely outpatient procedure. It does not require a hospital stay, yields permanent results, and recovery time is typically 5-7 days. Women have also conceived after UFE. These births are typically full-term and vaginal whereas women that have children after myomectomy will not deliver vaginally and instead will undergo a c-section.

Are There Any Risks Related to Fibroid Treatments?

With any medical procedure, there are always risks. Surgical procedures have much more common and more significant risk factors. Surgery, whether open, laparoscopic, or robotic, is more invasive than non-surgical procedures, and the surgeon needs to account for the structures surrounding the uterus (e.g. bowel, bladder, ureter) which can be injured during surgery.

There can be significant blood loss during surgery for fibroids which have a very robust blood supply. Non-surgical procedures such as Uterine Fibroid Embolization (UFE) are much less invasive and therefore much safer than surgery. The risks for UFE are also much less significant than surgery too. Some women (typically over 50 years of age) will stop menstruating and a very small number of women will temporarily pass some fibroid material vaginally. In rare instances, this material may need a non-surgical hysteroscopic removal (like a D&C for a miscarriage).