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Fibroids: Diagnosis and Treatment

As a gynecologist affiliated with a large academic center in New York City, I see patients with all types of problems and questions. The most frequent question I am asked is, "Do I need a hysterectomy?" About 50% of these women who as this question have recently received a diagnosis of fibroids and are seeking a second opinion.
 

What are Fibroids?
Fibroids, also known as leiomyomas or just plain myomas , are benign, smooth muscle tumors that usually grow in the uterus (womb). They are the most common pelvic tumors in females. They can range in size anywhere from a few millimeters (the size of a sesame seed) to several centimeters (about an inch). Fibroids can occur in different locations in and on the uterus but very rarely on organs outside of the uterus. They are classified into five subtypes based on where they grow:
 

• Pedunculated fibroids grow on a stalk on the outside of the uterus.

• Subserosal fibroids are located under the outer "skin" of the uterus ( serosa ) and do not grow into the muscular wall of the uterus ( myometrium ).

• Intramural fibroids , however, do grow within the wall of the uterus.

• Submucosal fibroids , like intramural fibroids, occur within the wall of the uterus, but these fibroids are located deeper within the wall and grow into the inner most layer of the uterus called the endometrium. The endometrium is the lining of the uterine cavity that is shed each month during a menstrual period, and regenerates during the rest of the cycle in preparation for the possibility of pregnancy.

• Parasitic fibroids are those found on other intra-abdominal organs such as the intestines, on surrounding blood vessels, and on the thin layer of tissue lining the entire abdominal cavity ( peritoneum ).

Who Gets Fibroids and Why?
Between 25% and 50% of all women will eventually develop fibroids. The number may actually be even greater, as many women do not know that they have fibroids, either because their tumors are small and undetectable or because their tumors do not cause symptoms.

While we do not actually know what causes them, we do know that hereditary factors play a role in determining who will eventually develop fibroids. If your mother or sister has been diagnosed with fibroids, you are much more likely to develop these tumors than a woman without a family history. Also, women of African-American descent are three to five times more likely to develop fibroids than Caucasian women.

Fibroid growth is fostered and sustained by the presence of estrogen in the bloodstream, as in pregnancy and with oral contraceptive use. It is suggested that fibroids may enlarge with oral contraceptives or with pregnancy. But after menopause, when estrogen levels decline, fibroids tend to shrink.

Fibroid Symptoms
The significance of having fibroids varies widely. You may have many fibroids and no symptoms, or you may have one small fibroid that troubles you to no end. Usually the symptoms depend on the number, location, and size of the fibroids. If you have fibroids, some of the symptoms you may experience include the following:

• Pelvic or abdominal pain or pressure.
• Painful intercourse ( dyspareunia ).
• Heavy bleeding during menstrual periods ( menorrhagia ).
• Bleeding between menstrual periods ( metrorrhagia ).
• Postmenopausal bleeding.
• Urinary symptoms (such as increased frequency of urination, incontinence, frequent bladder and kidney infections).
• Increased abdominal girth.
• Fertility difficulties (recurrent miscarriages, premature labor, placental abruption).

How Are Fibroids Diagnosed?
Most fibroids of any significant size are usually detected during a routine gynecological exam; however, very small fibroids may go undetected unless they cause symptoms. Whether or not you are having any problems, it is extremely important that you undergo a yearly pelvic exam. You should certainly seek medical attention if you have any of the symptoms listed above. These symptoms are common in women with fibroids, but could also indicate a more serious condition.

The physical exam
If you are having symptoms, your gynecologist will give you a complete physical exam. If fibroids are clearly present, your gynecologist may choose to give you a diagnosis without additional testing.

The pelvic ultrasound
Other times, a pelvic ultrasound ( sonogram ) or other tests may be needed to aid in the diagnosis. A sonogram is a painless exam that uses ultrasound waves to give your doctor a picture of the organs in your pelvis. Some gynecologists are equipped and trained to do sonograms in their offices and they may perform the test at the initial visit. Others may refer you to an imaging center where the test can be done.

In preparation for a pelvic ultrasound you will be asked to drink at least one quart of water prior to the exam in order to completely fill your bladder. Your uterus and other pelvic organs lie next to your bladder and having a full bladder during the exam gives your doctor a better view of the pelvic organs. A device called a probe is placed on your abdomen, which allows the physician or technician to visualize your uterus on a TV-like screen in order to detect and measure fibroids if they are present. Sometimes it is necessary to perform an endovaginal ultrasound, in which a small probe is placed into the vagina to get a better picture of the uterus. This is especially useful when the fibroids are small or submucosal.

Ultrasounds can give your physician additional information regarding size and location of most fibroids; however, it is often difficult to distinguish between small intramural and submucosal fibroids. The exact type of fibroid is important as it affects the type of treatment required. If you have abnormal bleeding, and your doctor suspects a submucosal fibroid, he may do a second, more specialized procedure ( sonohysterogram or hysterosalpingogram ), which will reveal if your fibroid is actually submucosal.

To Treat or Not to Treat

If you have been diagnosed with fibroids, and the locations and symptoms of the fibroids is known, it is time for you and your physician to decide whether treatment is indicated and, if so, to choose the treatment option best for you.

Most fibroids that cause symptoms do require treatment. But if you have fibroids and are not symptomatic, you will probably not require treatment. In this case, although treatment may not be necessary, vigilant surveillance is important – you should have pelvic exams every 6 months to monitor the size and growth rate of your fibroids. Any rapid change in size may warrant further testing and possible treatment.

What are the Available Treatment Options?
Medication
Medical management of fibroids is fairly limited and often used only to reduce symptoms until surgery is necessary. It only provides temporary solution for fibroids, and could cause fibroids to grow larger after discontinuing therapy. Currently two medical agents are used for the management of fibroids:

• Depo-Provera , an intramuscular injection of long-acting progesterone (a commonly used birth control agent) has been used for the management of fibroids that cause heavy vaginal bleeding. Used over time, Depo-Provera stops menstruation ( amenorrhea ). This reduces the vaginal bleeding, but there are troublesome side-effects associated with this process including: weight gain, hair thinning, and irregular vaginal spotting. This medication is of little or no use in treating symptoms of fibroids other than those related to vaginal bleeding.

• Depo-Lupron (Lupron) has also been used in the medical management of fibroids. It is given by injection. Lupron essentially creates a "medical menopause" by decreasing the amount of estrogen circulating in the bloodstream and causing the fibroids to shrink. Like Depo-Provera, Lupron also causes amenorrhea. When used for a short time (from 3 to 6 months), Lupron has proven beneficial in reducing fibroid size making them surgically more manageable. It also helps to reverse the anemia (low red blood cell count) caused by increased vaginal bleeding. However, Lupron cannot be used for more than 6 months, as over-usage leads to bone loss ( osteoporosis ) and significant increases in triglyceride (a fat molecule) and cholesterol levels.

• Abdominal Myomectomy involves the removal of fibroids (pedunculated, subserosal or intramural) from the uterine surface or wall through an incision made in the abdomen. This procedure is indicated if you have symptomatic fibroids and plan to have children in the future. The risks of an abdominal myomectomy include significant blood loss, post-operative infection, accumulation of scar tissue (with possible detrimental effects on fertility), possible need for cesarean section with subsequent pregnancies, and possible growth of new fibroids.

• Hysteroscopy and Submucus Resection is performed through the vagina for the treatment of symptomatic submucosal fibroids. The cervix is dilated and a small camera ( hysteroscope ) is passed through the cervix into the endometrial cavity. This camera allows the physician to see a submucosal fibroid directly. A small wire with a weak electrical current is then used to shave the fibroid from the endometrial cavity. The risks of this procedure include infection, uterine perforation, possible growth of new fibroids with recurrence of symptoms and infertility.

• Laparoscopic Removal of Fibroids and Myolysis involve placing a small telescope ( laparoscope ) through the naval to visualize subserosal and pedunculated fibroids. A laser or electrical wire is then used to remove or dissolve the fibroid. There are very few indications for this procedure. If your fibroids are small enough (<10 cm.) to be treated this way, then you should discuss with your physician whether your fibroids actually need to be treated at all. Myolysis has a risk of leaving scars that could rupture during subsequent pregnancy, thus it is not recommended for those who want to preserve fertility.

• Hysterectomy is the removal of the uterus with or without the removal of the cervix. Hysterectomy is the only definitive treatment for fibroids and can be used for all types. It can be performed in several ways. An abdominal hysterectomy involves removing the uterus through a surgical incision in the abdomen, while a vaginal hysterectomy is done by making an incision in the vagina. In a laparoscopic-assisted vaginal hysterectomy, a laparoscope, inserted through the navel, is used to aid in the removal of the uterus through the vagina. A hysterectomy is indicated if you have symptomatic fibroids that cannot be managed by other means and you are done with child bearing. The type of hysterectomy that should be done depends upon the size and location of your fibroids. The complications of a hysterectomy include bleeding and infection.

Uterine artery embolization
An alternative to medical management or surgical treatment of fibroids is uterine artery embolization . Embolizations are performed by cardiovascular interventional radiologists . Your gynecologist should be able to refer you to one. In this specialized test, a small tube ( catheter ) is placed into the blood vessels going to your uterus. These vessels are then blocked so that the blood flow to the fibroids is greatly decreased. This blocking causes the fibroids to shrink, improving your symptoms. This procedure is indicated if you have symptomatic fibroids that have failed home treatment or therapy with prescription medications, heavy menstrual bleeding causing anemia, and to those who don’t wish to be pregnant again.

Don’t undergo UAE (uterine artery embolization) if you have:
1. history of a pelvic radiation
2. history of kidney failure
3. an active, recent, chronic pelvic infection
4. poorly controlled diabetes
5. inflammation of the blood vessels (vasculitis)
6. a bleeding disorder
7. history of allergy to contrast material containing iodine.

Conclusion

As many as 50% of women will develop fibroids at some point during their life. Symptoms of fibroids can be inconsequential or can affect all aspects of your life. Recognizing the symptoms and seeking medical attention can be life-altering for some women. Self-education regarding current treatment options is extremely important. When considering what treatment or combination of treatments is right for you, your physician must look at all the factors that make your situation unique. Factors such as age, fibroid size, fibroid location, and the desire to remain fertile are important considerations for choosing the best treatment. When making important decisions regarding your personal health, I strongly encourage that you seek a second, and sometimes even a third opinion.