Uterine fibroids

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• Causes and risk factors
• Symptoms
• Diagnosis
• Treatment
• Risk of developing new fibroids

Uterine fibroids

Uterine fibroids, also known as leiomyomas or myomas, are benign uterine tumors that commonly occur in childbearing-age women. A woman may have one or more fibroids.

The tumor sizes can be small and undetectable by physical examination or very large and discovered by the patient. The uterine fibroids may be stable in size, grow gradually or rapidly, or shrink over time. These changes depend mainly on the hormonal status of the women, e.g., pregnancy or menopausal status.

Fibroids can be grouped by their location, i.e., submucous if they grow into the uterine cavity, intramural if they are limited to the muscular uterine wall, and subserous if they protrude out of the uterus. In some cases, the locations can overlap.

Causes and risk factors

The definitive cause of uterine fibroids is unknown but commonly assumed to originate from myometrial cell overgrowth or a stem cell of the uterus.

Causes and risk factors of fibroids include:

• Ethnic factor: African American women tend to develop fibroids more often, at a younger age, in higher numbers, in a bigger size, and with more severe symptoms than other racial groups.
• Genetic factor: The genes of many fibroids are different from normal uterine cells resulting in more frequent incidents of fibroids in the same family members.
• Hormonal factor: Estrogen and progesterone are responsible for the growth of regular uterine structures and fibroids. More abundant estrogen and progesterone receptors are present in fibroids than in normal uterine muscle cells. Menarche at a younger age (with the early rise of hormones) is also a risk factor. On the other hand, fibroids are likely to become smaller after menopause due to waning hormone production.
• Other factors: Fibroids can be stimulated by other substances, such as growth factors stored in an extracellular matrix (ECM), leading to cellular biological changes.

Diets and nutrition, obesity, vitamin D deficiency, alcohol consumption, and diets rich in red meat or little fruits or vegetables are also risk factors.

Symptoms

Small uterine fibroids usually are asymptomatic. Women may experience symptoms depending on the size, number, and fibroid locations. These may be one or more of the following:

• Heavy or prolonged menstrual bleeding
• Pain during menstruation or dysmenorrhea
• Pelvic pain
• Frequent or difficult urination
• Constipation
• Backache or leg pain

Complications

The complications from fibroids are infrequent. Uterine fibroids rarely develop into cancer. In women with heavy menstruation, anemia and fatigue may occur. Some may even require a blood transfusion.

Fibroids generally do not cause infertility except for submucosal fibroids, which can negatively impact fertility or cause pregnancy loss. In pregnant women with fibroids, fetal growth restriction, placental abruption, or preterm delivery may occur.

When to see a doctor

Consult a doctor when experiencing any of these symptoms: 

• heavy menstrual bleeding
• persistent or acute severe pain.
• Anemia
• spotting or bleeding between menstrual cycles.
• trouble emptying urine or constipation.
• Self-palpable mass especially if it is rapidly growing.

Diagnosis

During a pelvic examination, the gynecologist will inspect the uterine cervix and perform bimanual palpation for abnormalities of the cervix, uterus, and adnexa. Additional imaging or laboratory testing will follow if a suspicious abnormality is detected.

• Abdominal or pelvic ultrasound. The presence of fibroids, their location, and their sizes are commonly assessed from ultrasound images obtained via a transabdominal, endo-vaginal, or transrectal ultrasound probe. The ultrasound may be done at the bedside or in the outpatient clinic.

Other imaging studies: Additional imaging studies may be necessary to acquire more information about the mass for management planning.

• Magnetic resonance imaging (MRI). An MRI can produce detailed images regarding the number, size, location, texture, and their blood supplies. These attributes will help determine appropriate treatment, especially in women desiring to retain fertility, peri- or menopausal women, or women with large fibroids.
• Hysterosonography. Saline solution instillation into the uterine cavity makes for a sharper sonographic image of the uterine lining and submucosal fibroids. Women with heavy menstrual bleeding or those who try to be pregnant may have to undergo this test.
• Hysteroscopy. Uterine cavity visualization by distending the uterine cavity with the instillation of saline solution allows inspection of its lining and the fallopian tubes opening into the uterine cavity.
• Hysterosalpingography. Filling the uterine cavity and fallopian tube lumen with radio-opaque dye helps delineate any intrauterine lesions, submucosal fibroids, and patency of the fallopian tubes. Women with fertility problems may need to undergo this test.
• Laboratory tests. Other laboratory tests may be appropriate, e.g., a complete blood count (CBC) to assess for anemia secondary to heavy menstrual blood loss, hematologic disorders, or a thyroid function test for the possible cause of menstruation-related bleeding problems.

Treatment

Most women with fibroids do not require treatments. In women with symptomatic fibroids, various treatment options are available. The gynecologist will discuss with each woman a suitable treatment for her fibroids.

Surveillance

With no or only minimal symptoms, a watchful follow-up may be adequate.

Medications

Medications used to relieve symptoms caused by fibroids, such as pelvic pain or heavy menstrual bleeding, include synthetic hormones. Fibroids may get smaller but rarely disappear. These drugs are, for example:

• Hormones
  • Gonadotropin-releasing hormone (GnRH) agonists
    The GnRH agonists will cut down estrogen and progesterone hormonal production leading to a temporary menopause-like state. The use of the drug is to shrink large fibroids before surgery. Hot flashes are side effects, and bone loss can occur after more than six months of use. The fibroids may regrow after stopping the drug.
  • Progestin-releasing intrauterine device (IUD)
    This medicated device can reduce heavy menstrual bleeding. However, it does not reduce the size of fibroids or make them disappear.
  • Oral birth control pills
    The pills can reduce menstrual bleeding but cannot shrink fibroids.
• Other medications. For heavy menstrual bleeding, tranexamic acid may improve the symptom; non-steroidal anti-inflammatory drugs (NSAIDs) provide pain relief. Vitamins and iron supplements correct anemic symptoms.

Non-invasive procedure

MRI-guided focused ultrasound surgery (FUS) is a non-invasive treatment for fibroids that help preserve the uterus. It can be performed as an outpatient during an MRI procedure to outline the location of the fibroids. The ultrasound transducer will direct high-energy waves to heat up and destroy the fibroids.

Minimally invasive procedures

These surgical procedures shrink or remove the uterine fibroids instead of the entire uterus. The advantage over major surgery is patients can resume their daily life

Uterine artery embolization

Embolic agents will be injected into the uterine arteries to cut off the blood supply to the fibroids; so, they shrink and waste away. The rate of compromised blood circulation to the ovaries or other pelvic organs is the same as surgical resection of the uterus; however, it can minimize blood loss.

Radiofrequency ablation

Radiofrequency ablation performs through a laparoscope with small abdominal incisions. After a camera-tipped laparoscope insertion, an operator will insert a specialized device tipped with a small needle into the fibroid. The needle will heat up and destroy the fibroid tissue. The fibroids will soften and shrink within 3-12 months.
Ablations perform through the uterine cervix by employing sound waves or ultrasound is also possible.

Endometrial ablation

A device is inserted into the uterus before delivering heat-generating microwave energy or electric current to demolish the uterine lining. It will decrease or stop heavy menstrual bleeding. The chance of future intrauterine pregnancy is low after endometrial ablation. However, ectopic pregnancy may occur without the use of contraception.

Myomectomy

Myomectomy is a surgical procedure removing only the fibroids. It is suitable for treating fibroids in women who want to preserve the uterus for fertility.
Generally, the surgeon will assess the risk of uterine cancer in each woman before myomectomy by reviewing her age, history of rapid growth, symptoms, and features from the imaging study. Cutting into an undiagnosed cancerous tumor is a risk of myomectomies, especially if a pre-existing unsuspecting malignant tumor lurks in the fibroids.
Myomectomy can be accomplished via a minimally invasive procedure through laparoscopy or hysteroscopy.

• Laparoscopic or robotic myomectomy - A laparoscopic or robotic approach is a technique wherein a specialized device inserted through a small abdominal incision is the instrument used for dissection. These techniques are suitable for women with few fibroids. The small fibroids can be removed in toto, whereas the large fibroids are broken or morcellated into smaller pieces inside a surgical bag and removed through small abdominal incisions.
  In robotic surgery, a camera-equipped instrument will produce a 3D version of the uterus on a monitor leading to a more precise surgical procedure. However, it is technically demanding and requires lengthy training and higher skill than other techniques.
• Hysteroscopic myomectomy - In this procedure, submucosal fibroids are excised through the vagina and cervix using an instrument inserted into the uterine cavity. Endometrial ablation can be performed concurrently.

Conventional surgical procedures

• Abdominal myomectomy: This surgical approach is an option for women with several or large fibroids who still wish to retain fertility. Postoperative uterine scarring may decrease the chance of a successful future pregnancy.
• Hysterectomy: When no future pregnancy is wanted, removing the uterus (with fibroids) while preserving the ovaries in pre-menopausal women is the best option. Removal of both ovaries will lead to premature surgical menopause requiring hormone replacement therapy.

While hysterectomy causes a complete loss of fertility, other fibroids treatment options -- uterine artery embolization, radiofrequency ablation, endometrial ablation, myomectomy -- can also adversely affect the chance of a successful pregnancy.  The fertility plan, risks, and benefits of each treatment option should be discussed and weighted against the severity of symptoms before selecting the most appropriate treatment.

Risk of developing new fibroids

One caveat of fibroids extirpation with the uterus remaining in situ and the women still having an active ovarian function is that new fibroids can develop.

Prevention

Although fibroids are not preventable, a healthy lifestyle, including weight control and a high-fiber diet, may help reduce the risk of developing fibroids. Hormonal contraceptives can also lower the risk of fibroids.

Preparing for an appointment

Before an appointment, the women should note down the information the doctor may ask or the questions they have before deciding on the type of treatment:

• Personal and family history of illnesses
• Symptoms regardless of whether they are related or unrelated to uterine fibroids e.g., duration of symptoms (how long have they been, how many days), frequency of symptoms, timing in relation to menstruation, severity, alleviating or aggravating factors, etc.
• Prior or current medications, including dietary supplements
• List the question of concern may include but are not limited to:
• Fibroid features, e.g., number, size, location, etc.
• Investigations or tests
• Health impacts of fibroids, e.g., chance of cancer, effects on fertility, etc.
• Treatment options, their risk, benefits, and expected results, etc.