Uterine fibroids are benign (not cancerous) growths in the uterus. They are the most common type of growth found in a woman’s pelvis. They occur in about 20-25% of all women. Fibroids are most common in women aged 30-40, but they can occur at any age. Fibroids occur more often in women of African descent. They also seem to occur at a younger age in black women and to grow more quickly. Many women who have fibroids are not aware of them because the growths can remain small and not cause a problem. Although fibroids are not cancer, they can cause problems due to their size, number, and location. Like any growth, fibroids should be checked by a doctor.
Uterine fibroids are growths that develop from the cells that make up the muscle of the uterus. The size, shape, and location of fibroids can vary greatly. They may appear inside the uterus (submucosal), on its outer surface (subserosal) , within its wall (intramural), or attached to it by a stem-like structure (pedunculated). Fibroids can range in size from small, pea-sized growths to large, round ones that may be more than 5-6 inches wide. As they grow, they can distort the inside as well as the outside of the uterus. Sometimes fibroids grow large enough to completely fill the pelvis or abdomen. A woman may have only one fibroid or many of varying sizes. Whether they will occur singly or in groups is hard to predict. They may remain very small for a long time, suddenly grow rapidly, or grow slowly over a number of years. Because it is hard to predict their growth, fibroids can be difficult to treat.
Although fibroids are quite common, little is known about what causes them. The female hormone estrogen seems to increase their growth. The levels of estrogen in the body can rise or fall based on natural events (for example, pregnancy, which causes an increase, or menopause, which causes a decrease) or medications such as birth control pills.
Most fibroids, even large ones, produce no symptoms at all. When symptoms occur, they often include the following:
Most fibroids do not produce symptoms. During a routine pelvic exam, the first signs of fibroids can be detected. There are several tests that may show more information about fibroids:
Ultrasound uses sound waves to create a picture of the uterus or of the pelvic organs. When a vaginal ultrasound is done, it is also possible to see the size, shape and location of the fibroid tumors. If a physician suspects that a fibroid is protruding into the uterine cavity and causing infertility or heavy menstrual periods, it is possible to inject a small amount of water (hysterosonogram) into the uterine cavity so that tumors sitting inside of the cavity can be seen. Other imaging may include CT and MRI scans but ultrasound is the simplest and cheapest way to get adequate images.
Hysteroscopy uses a slender instrument (the hysteroscope) to help the doctor see the inside of the uterus. It is inserted through the vagina and cervix (opening of the uterus). This permits the doctor to see some fibroids inside the uterine cavity. It’s use for the diagnosis of fibroids is somewhat limited since the advent of hysterosonography (see above).
Hysterosalpingography (HSG) is a special X-ray test. It may detect abnormal changes in the size and shape of the uterus and fallopian tubes by injecting a substance in the uterine cavity which can be seen by X-ray. This has also been largely replaced by hysterosonography.
Laparoscopy uses a slender instrument (the laparoscope) to help the doctor see the inside of the abdomen. It is inserted through a small cut just below or through the navel. The doctor can see fibroids on the outside of the uterus as well as those which distort the shape of the body of the uterus.
Although most fibroids do not cause problems, there can be complications. Fibroids that are attached to the uterus by a stem may twist. This can cause pain, nausea, or fever. Fibroids may become infected. This usually happens only when there is an infection already in the area. In very rare cases (far less than 1%), changes occur in the fibroid tissue that cause it to become malignant (cancerous). Very rapid growth of the fibroid and other symptoms may signal cancer. A very large fibroid may cause swelling of the abdomen. This can make it difficult to perform an adequate pelvic exam. Fibroids may also cause infertility. Other factors should be explored before fibroids are called the cause of a couple’s infertility. But when fibroids are thought to be a cause, many women are able to become pregnant after they are treated.
Fibroids that do not cause symptoms, are small, or occur in a woman nearing menopause often do not require treatment. Certain signs and symptoms, however, may signal the need for treatment:
Drugs, such as gonadotropin-releasing hormone (GnRH) agonists, may be used to shrink fibroids temporarily (which might make surgery easier or permit a more conservative approach such as a vaginal or laparoscopic surgical approach rather than abdominal) and to control bleeding prior to surgery (so that anemia might be corrected).
Once you are in good condition, surgery is required to remove fibroids. The fibroids may be removed with myomectomy (removal of the fibroids leaving the uterus in place) or hysterectomy (removal of the uterus). The choice of treatment depends on factors such as your own wishes and medical advice about the size and location of the fibroids.
Myomectomy is the removal of the fibroids, leaving the uterus in place. Because a woman keeps her uterus, she may still be able to have children. If a woman does become pregnant after a myomectomy, she may need to have a cesarean delivery (the baby is born through a surgical cut made in the mother’s abdomen and uterus). Sometimes, though, a myomectomy causes internal scarring that can lead to infertility. Fibroids may develop again, even after the procedure. 20-40% of women who have myomectomies will require further surgery.
Myomectomy may be performed in a number of ways. It may be done by a laparotomy, through the laparoscope, or through the hysteroscope. The method used depends on the location and size of the fibroids. For a laparotomy, an incision (cut) is made in the abdomen. The fibroids are then removed through the incision. If fibroids deep within the wall of the uterus, this is the best method of removal because of the technical difficulties getting a strong anatomic repair of the uterine wall, particularly if the woman wishes to conceive and safely carry a pregnancy. Fibroids can also be removed through the laparoscope, particularly if they are on the outside of the uterus or if a perfect repair of the uterine wall is not a concern. They can be vaporized with lasers or electrical current or they can be dissected from the wall of the uterus and than removed either with an instrument (morcellator) which cuts the fibroid into small pieces, or through an incision at the top of the vagina or through a slightly larger abdominal wall incision. The morcellator is a particularly nice instrument since the incisions do not have to be any larger than what is already done for laparoscopy. This results in a very rapid recovery and return to work within 1-2 weeks.
Hysteroscopy can be used to remove fibroids that protrude into the cavity of the uterus. In this procedure, a hysteroscope is inserted into the uterus through the cervix. The fibroids may be removed with a resectoscope, a tiny wire loop that uses electric power, with a needle point electrode (Versapoint). New instruments (Myosure) have recently been introduced which makes the removal of these tumors safer and faster than the older methods. These instruments can be inserted through the hysteroscope. If you are not intending to become pregnant, this can be combined with a uterine ablation which destroys the entire lining of the uterus so that menstruation stops or is reduced to a bare minimum. This type of treatment is often done with general anesthesia, but you typically do not need to stay in the hospital. The typical recovery from this procedure is a long weekend. There is very little post-operative pain.
Hysterectomy is the removal of the entire uterus. The ovaries may or may not be removed, depending on other factors. Hysterectomy may be considered when:
The hysterectomy is done abdominally if the fibroids are large (bigger than a 14 week size pregnancy). If the surgeon is skilled in laparoscopic and/or vaginal surgery, these methods can be combined into a laparoscopic assisted vaginal hysterectomy, total laparoscopic hysterectomy or even a vaginal hysterectomy to remove mid-sized fibroids. The advantages of this technique are much less pain, a shorter hospital stay, and a quicker recovery. Because of the technical problems associated with this approach, it should be performed only by skilled pelvic surgeons who are comfortable with difficult vaginal surgery.
Uterine artery embolization is a new technique performed by interventional radiologists where they inject into the arteries that feel the fibroid micro-particles which seal the blood vessels. This will effectively kill the fibroid so that it shrinks and heavy bleeding stops. It does not work well with fibroids inside of the uterine cavity. It should not be done if you are planning a pregnancy.
A small number of pregnant women have uterine fibroids. If you are pregnant and have fibroids, they probably won’t cause problems for you or your baby. During pregnancy, fibroids may increase in size. Most of this growth is due to blood flowing to the uterus. Coupled with the extra burden placed on the body by pregnancy, growth of fibroids may cause discomfort, feelings of pressure, or pain. Fibroids usually decrease in size after pregnancy.
Fibroids can increase the risk of having a miscarriage (in which the pregnancy ends before 20 weeks), preterm birth, or a breech birth (in which the baby is in a position other than head down). Rarely, a large fibroid can block the opening of the uterus, or keep the baby from passing into the birth canal. In this case, a cesarean delivery is done. Usually even a large fibroid will move up and out of the fetus’s way as the uterus expands during pregnancy. Women with large fibroids may have more blood loss after delivery.
Usually no treatment of fibroids is needed during pregnancy. If you are having symptoms such as pain or discomfort, your doctor may prescribe bed rest. Potent non-steroidal anti-inflammatory drugs (NSAIDS) such as Motrin, Advil, Ibuprofen, or Indocin may be used for severe pain of a degenerating fibroid before the 30th week of pregnancy. These medicines should never be used after the thirtieth week of pregnancy since they can harm the baby’s heart. Sometimes a pregnant woman with fibroids will be hospitalized for a time because of pain, bleeding, or threatened preterm labor. Very rarely, myomectomy may be performed in a pregnant woman. Cesarean birth may be needed after myomectomy.