Fibroids (="Uterine Fibroids", Myomas Or Leiomyomas)

Introduction:

All of these names describe the same thing, namely a benign tumor of the uterus, which consists of smooth muscle cells, the same material that the uterus is made up of. There is a capsule around this tumor and often inside of it a degenerative process begins while the outer layers keep on growing.

It is when there is bleeding into such a fibroid or when the fibroid has reached such a weight and size that it is pulling the uterus into different directions with positional changes, that a woman feels pain. Although a lot of patients are very concerned about whether the fibroid would turn into cancer, a development of cancer in a fibroid is extremely rare (called a sarcoma, when it does occur). Occasionally a fibroid as big as a large orange can develop over several years, which causes pressure symptoms and would eventually lead to surgical removal by hysterectomy.

Symptoms:

Menstrual bleeding can be increased and more severe, particularly if a fibroid is right under the lining of the uterus (=submucosal fibroid) or inside the wall (=intramural fibroid). There can be urinary urgency, if a fibroid grows in front of the uterus and pressure is exerted onto the bladder. If the adjacent large bowel (sigmoid loop) or the rectum in the back of the uterus is pressured by an enlarging fibroid, the constipation and possible lower back pain (triggered from inside the pelvis) can be a problem. Fibroids often occur in multiples throughout the uterus and this can cause problems with pregnancies. Getting pregnant would not be affected, but recurrent abortions, premature labor, breech deliveries or other malpresentations cause concern and often lead to a higher cesarean section rate. Abdominal pain is common, mostly in the lower mid abdomen.

Treatment:

The doctor will do an intravaginal pelvic examination first and likely diagnose the fibroid first that way. Further tests will then be ordered such as an ultrasound, CT or MRI scan. This way it can be determined how big the fibroid is, how many fibroids there are, in case of several ones and whether they are submucosal, intramural or subserosal (on the outside surface of the uterus, but under the membrane that envelopes the uterus). Essentially there are medical means to minimize the impact of fibroids and then surgical techniques to remove symptomatic fibroids.

Treatment options for fibroids

•An asymptomatic patient does not need any treatment, just observation to make sure that growth of the fibroid(s) is within reason. Normally there is a very slow enlargement until menopause and then fibroids decrease in size. The smooth muscle cells of fibroids have estrogen receptors on them, which makes them grow while the ovaries still produce estrogen. After menopause that stimulus is taken away unless hormone replacement is considered and often fibroids reduce in size.

•Using different hormone preparations, partially based on blood test, the gynecologist may want to consider a trial of hormone therapy with progesterone to see whether the bleeding abnormalities can be normalized. Unfortunately in many women this is not very successful and a surgical option has to be considered.

•Surgical options are considered when pelvic pain is intolerable, when urinary or bowel complaints are a problem, when dyspareunia (painful intercourse) has developed or when uterine bleeding has become intolerable. In a couple where infertility or recurrent abortions have been narrowed down to a single large fibroid, a myomectomy (=surgical excision of the fibroid with preservation of the rest of the uterus) can be done.

In cases where multiple fibroids are present or where there is no more wish for children, the simplest procedure is an abdominal or vaginal hysterectomy, where the uterus (and often the ovaries) are removed surgically by the gynecologist. Prior to any of these procedures, there must be a frank discussion between the couple, with the gynecologist and with the family doctor to ensure the best decision is made in this particular case. Prior to surgery the specialist might decide that a brief course with a gonadotropin releasing hormone analogue would be useful to reduce the amount of bleeding and reduce the size of the fibroid. This hormone is now available under the brand name Synarel and can be taken as a nasal spray. However this is only safe for a shorter course of therapy as it has been shown that with longer than 6 month treatments bone density decreases (in other words osteoporosis develops).

•Given the options above, most women will not need anything done but be followed with a yearly Pap test and pelvic exam. Most other women with unbearable symptoms will likely need a hysterectomy, if hormone therapy does not work.

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Disclaimer:

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.

References:

1. DM Thompson: The 46th Annual St. Paul's Hospital CME Conference for Primary Physicians, Nov. 14-17, 2000, Vancouver/B.C./Canada

2. C Ritenbaugh Curr Oncol Rep 2000 May 2(3): 225-233.

3. PA Totten et al. J Infect Dis 2001 Jan 183(2): 269-276.

4. M Ohkawa et al. Br J Urol 1993 Dec 72(6):918-921.

Last Modified: Nov. 26, 2007