Uterine Fibroids

September 29, 2011

Multiple uterine fibroids removed from a 27 year old woman.

Uterine fibroids are the most common of the noncancerous (benign) tumors of the uterus. The medical term that is synonymous with uterine fibroids is leiomyoma. The cause of fibroids is unknown. However, the hormone estrogen plays a dominant role, since fibroids and associated symptoms are prevalent during the reproductive years and decline during menopause. Fibroid-related symptoms resolve during the menopause and rarely occur during puberty or adolescence. The mean age group for symptoms related to fibroid tumors is between 30 and 50 years old. The incidence of uterine fibroids ranges from 10% to 50%. Factors affecting the incidence include age, race, genetics, and family history. Luckily, most women with uterine fibroids are asymptomatic. Some fibroids may undergo cancerous (malignant) transformation, but fortunately, this is rare. In fact, leiomyosarcoma (the cancerous change of fibroids) is detected in only 0.1% of women with fibroids.

The uterus is normally about the size of a small lemon. There are three regions within the uterus: the inner wall (endometrium), the middle wall (myometrium), and the outer wall (serosal layers). Fibroids even though originating in the myometrium can extend to any or all of these regions. Fibroids are defined as an increase in the smooth muscle component of the uterus. Generally, those originating in the endometrium (called submucosal fibroids) or myometrium (called intramural fibroids) will result in changes within the menstrual cycle. Fibroids originating in the serosa and myometrium tend to be associated with symptoms of pressure on the bladder or the bowels. The size of fibroids can range from the size of a lentil pea to the size of a watermelon. Likewise, the weight may range from a few ounces to several pounds.

Symptoms from uterine fibroids include changes in menstruation, pain, infertility, urinary pressure or urinary retention, constipation, backache, leg pain or swelling, dyspareunia (painful sexual intercourse), pregnancy-related complications, infertility, and increased abdominal girth. In the past, patients were often advised to undergo removal of all or part of the affected uterine tissue (myomectomy or hysterectomy) if the size of the uterus was greater than the size of a normal uterus at 12 weeks in pregnancy. This is no longer true. Today, the caveat is “if your fibroids don’t bother you, we don’t bother them.”

Some patients can experience a range of menstrual complaints associated with fibroids. These include heavier cycles, blood clots, longer duration of menses, and irregular menstruation, constant vaginal discharge, or episodic bloody/fluid (serosanguineous) discharge. Severely affected patients may decrease physical activities and miss work, due to incessant need to change sanitary pads and tampons. Patients who chronically suffer from heavier menstrual cycles may develop anemia (low blood counts) and fatigue.

Other patients have symptoms related to pressure on the bladder. These include complaints of urinary frequency and urgency. Nocturia (having to urinate several times during the night) is also common. Less frequent complaints are stress urinary incontinence, acute urinary retention, urinary tract infections, and pain or difficulty urinating (dysuria). When fibroids enlarge to 16-20 cm, they may put pressure on the ureters, leading to hydronephrosis (swelling of the tube connecting the kidney to the bladder). This may lead to kidney damage on rare occasions.

The least common structure associated with the presence of fibroids is the bowel. Common bowel-related complaints include severe constipation and painful bowel movements.

Collectively, “bulk” symptoms include pelvic heaviness, feeling full, abdominal pressure, and backache. Some patients will also complain of heaviness or a sense that “something is falling out” of the vagina. Some may experience discomfort with intercourse. These symptoms may increase in intensity 1-2 weeks before the menstrual cycle and resolve after menstruation.

Finally, patients with fibroids may note increasing menstrual cramps and pain (dysmenorrhea). Menstrual cramps may escalate 1-2 weeks before menses and be further exacerbated with the menses.

The impact of fibroids on pregnancy and infertility is debatable. Luckily, most women with fibroids do not have reproductive problems. However, fibroids have been associated with premature labor and delivery, persistent breech presentation, postpartum uterine bleeding, more complicated cesarean sections, and early pregnancy-related bleeding. The location of uterine fibroids plays an important role in patients with infertility. Large submucosal fibroids obstructing the endometrial cavity can be associated with difficulty for the egg to implant in the wall of the uterus as is necessary for normal pregnancy (poor placentation), poor sperm migration, and blockage of the fallopian tubes. Likewise, intramural fibroids may impinge on the fallopian tubes or distort the interior of the uterus (endometrial cavity) making pregnancy more difficult. It is important that women experiencing recurrent miscarriages or infertility undergo a thorough evaluation.
The diagnosis of uterine fibroids is often suspected by clinical history and the pelvic examination. Confirmation can be made with pelvic or transvaginal ultrasound. Patients with a normal uterine size but heavy menses may undergo specialized diagnostic procedures that help visualize the uterus better (hys-teroscopy is an imaging procedure that can be done in the doctor’s office) to determine the presence of uterine fibroids, which line the endometrial cavity.

Many factors must be considered when advising a patient with fibroids. Choice of therapy depends upon reproductive desires of the patient, age, size and number of fibroids, and desire for maintaining the uterus. Sometimes, expectant management is indicated in women who are perimenopausal. Patients with minimal complaints nearing menopause may be reassured about resolution of fibroid symptoms once menopause occurs. Some fibroid-related complaints might be simply treated with nonsteroidal medication, low-dose oral contraceptive pills, or hormone (GnRH) therapy. Luckily there are many conventional surgical procedures as well as minimally invasive techniques to treat uterine fibroids. Hysterectomy always solves fibroid-related bleeding and bulk symptoms. However, hysterectomy should rarely be advised in women wanting children. Myomectomy, which involves just the removal of uterine fibroids, should be considered in women who wish to preserve their fertility or in women opposing hysterectomy.

Currently there are several methods available to perform myomectomy including procedures that take place via a small tube (hysteroscopic, laparoscopic procedures), vaginal, or by conventional exploratory laparotomy (conventional surgery). The surgical choice depends upon the size, number, and location of the fibroids. Finally, a newer form of nonsurgical therapy called uterine fibroid embolization (UFE) is a minimally invasive technique performed by a specially trained radiologist (interventional radiologist) who selectively blocks the flow of blood to the fibroid. The blocked blood flow essentially causes the fibroid to break down and resolve.

Patients now have a vast array of options to treat uterine fibroids. Fortunately, most fibroids are benign. For this reason, patients should never feel rushed into making a clinical or surgical decision. Patients with symptomatic uterine fibroids should seek a compassionate and well-trained gynecologist who is knowledgeable about all fibroid options. The decision to proceed with surgery or other minimally invasive options should be made rationally.

See Also: Dysmenorrhea, Infertility, Menstrual cycle disorders

Suggested Reading

  • Bradley, L. D., Falcone, T., & Magen, A. B. (2000). Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding. Obstetrics and Gynecology Clinics of North America, 27(2), 245-276.
  • Clark, A., Black, N., Rowe, P., et al. (1995). Indications for and outcome of total abdominal hysterectomy for benign disease: A prospective cohort study. British Journal of Obstetrics and Gynaecology, 102(8), 611-620.

 

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