What are Fibroids?

Fibroids, also known as uterine myomas or uterine leiomyomas, are benign growths within the uterus. They are the most common tumors in the female pelvis and are responsible for 35-50% of the hysterectomies performed in the U.S. each year. By age 50, 80% of African American and 70% of Caucasian women will develop fibroids. Fewer than half of these, however, cause symptoms. The most common symptoms in women with uterine fibroids are abnormal bleeding, pelvic pain and infertility.

What cause fibroids?  

• Fibroids arise from the uterine smooth muscle and their cause is unknown.
• They appear to be estrogen dependent because they develop during the reproductive years and regress after menopause when the ovary becomes hormonally inactive.
• Risk of fibroids decreases in women who had at least 2 full term pregnancies, and with leanness, exercise and smoking, presumably by decreasing the estrogen levels.
• Obesity is associated with increased risk for fibroids presumably by increasing estrogen levels.
• Fibroid tumors are 2-3 times more prevalent in African American women.

Diagnosis

Fibroids can be diagnosed by:

• Pelvic examination
• Ultrasound
• Saline Infusion Sonography (SIS)  
• Hysterosalpingogram  (HSG or tubal x-rays)
• MRI scanning
• Direct visualization utilizing surgical procedures such as Laparoscopy  and Hysteroscopy

Types of fibroids

• Intracavitary fibroids grow within the uterine cavity.
• Submucosal fibroids can grow within the wall of the uterus in close proximity to the uterine cavity or they may actually impinge upon or distort the uterine cavity. Both submucosal and intracavitary fibroids are likely to cause infertility, abnormal bleeding, pain or miscarriages.
• Intramural or interstitial fibroids grow within the wall of the uterus and may cause pain or pelvic pressure, and can decrease fertility and increase pregnancy loss.
• Subserosal and pedunculated fibroids do not affect the uterine cavity and are not associated with infertility, but they can cause pain and may require treatment.

What to do if you have fibroids?

Treatment options for fibroids depend on whether the goal is to restore fertility or manage symptoms (pain and bleeding).

What should you do if you have fibroids and want to conceive?

Not all fibroids cause infertility, so the real dilemma for infertile women with fibroids is when to recommend fibroid removal surgery (myomectomy). The surgery is not without risks, and the decision to operate will depend on the type, size and number of the fibroids, their proximity to the uterine cavity, whether other symptoms are present (pain and bleeding), whether a woman has failed previous fertility treatment or whether there is no other explanation for her infertility.

Here are some rules of thumb:

• For infertile women with submucosal fibroids that distort or impinge upon the uterine cavity, myomectomy surgery is likely to improve fertility.
• Women with intramural fibroids appear to have decreased fertility and increased pregnancy loss, but it is not clear whether myomectomy will improve their fertility outcome.
• Subserosal fibroids have no obvious fertility implications and surgery to remove them is of no benefit.

What are the surgical risks of myomectomy?

• Infection
• Bleeding
• Blood transfusions
• Post operative adhesions and infertility
• Uterine rupture during pregnancy
• Risk of cesarean section delivery

What to do if you have fibroids and you do not want to have any more children?

• The goals of care are the minimization of complications such as anemia and pain.
• Most fibroids cause no symptoms and can be left alone.
• Fibroids are estrogen dependent, and will shrink with menopause when the ovaries stop producing significant amounts of estrogen.
• Currently, there are no medicines that can permanently shrink fibroids.

Treatment options for uterine fibroids include:

• No treatment - most women with fibroids have no symptoms and they can be managed with observation alone. Women who have no immediate fertility considerations require only periodic evaluation by pelvic examination and ultrasound to monitor changes in the size of the fibroid.
• Surgery to remove fibroids (Myomectomy).
• Medical treatment
• Uterine Artery Embolization (UAE).
• MRI Guided High Frequency Ultrasound Therapy.

Surgical treatment (myomectomy)

Surgical procedures for removal of uterine fibroids (myomectomy) include:

• Hysteroscopic myomectomy
• Laparoscopic myomectomy
• Laparotomy (major abdominal surgery) myomectomy
• Robotic computer assisted laparoscopic myomectomy

Hysteroscopic myomectomy (click to view hysteroscopic myomectomy video)

This procedure is often utilized for fibroid tumors which are located within the uterine cavity (intracavitary or submucosal). During hysteroscopy, a thin fiberoptic tube (the hysteroscope) is equipped with a video camera and is guided through the vagina into the uterine cavity.  The uterine cavity is distended with fluid to give the surgeon a good view of the uterine cavity. A special tool called the resectoscope is equipped with a cutting loop which is help shave the fibroid into small pieces. When the fibroid is unusually large, the surgery may take longer to complete and it may not be possible to remove the entire fibroid in one operation, because there  is a risk of absorbing too much fluid into the blood stream. In such a case, to be on the safe side, a second procedure is scheduled later to complete the myomectomy.

Laparoscopic myomectomy (click to view laparoscopic myomectomy)

For fibroid tumors located within the wall of the uterus (intramural or submucosal)), minimally invasive outpatient laparoscopic surgery   may be performed. During laparoscopy a thin fiber-optic tube, equipped with a video camera is inserted into the abdomen, through a small incision in the belly button. Two or three other small incisions are made through which additional tools, such as tissue graspers or a CO2 laser can be inserted into the abdomen to facilitate the surgery. Laparoscopic myomectomy is most suitable for fibroids measuring less than 6 centimeters. Sometimes your surgeon may elect to treat you with Lupron or Synarel which cause temporary and reversible medical menopause to decrease the size of the fibroid. The smaller the fibroid gets, the easier it is to remove it by laparoscopic surgery, thus, avoiding major surgery. Pre-operative treatment with Lupron also decreases the blood supply to the fibroid, lowering the risk of bleeding during surgery.

Laparotomy myomectomy 

The procedure is performed through a major abdominal incision (laparotomy). It is indicated for fibroids larger than 6 cm, or if multiple fibroid tumors are present. Laparotomy surgery is more painful than laparoscopy and requires 4-6 weeks of recuperation. Complications from myomectomy include bleeding, scar tissue formation and infection. When pregnancy occurs after myomectomy surgery, a Caesarian Section delivery is often necessary to prevent rupture of the uterus during labor.

Computer Assisted Robotic Laparoscopic Myomectomy

More recently, Robotic laparoscopic surgery   is being increasingly utilized to remove larger fibroids than was previously possible with traditional laparoscopy. The surgeon controls the robot arms from a console station away from the operating room table, utilizing high-definition 3D vision. This technique allows the surgeon to operate with greater precision and control than was previously possible.

Medical treatment

Fibroids need estrogen to sustain their growth. Fibroids often shrink with menopause because the ovaries no longer produce significant amount of estrogen.

• Lupron, Synarel - suppress pituitary hormones vital to ovarian function, resulting in a temporary, reversible chemical "menopause". Without estrogen, the fibroids shrink in size. Unfortunately the treatment is associated with side effects, such as, hot flashes and significant bone loss and can not be given for more than 6 months. The benefit from this therapy is therefore only temporary, because fibroid tumors grow back to their pretreatment size shortly after the medicine is discontinued. This treatment is mostly utilized to shrink the size of the fibroids before surgery which may allow your surgeon to remove the fibroids by laparoscopy and avoiding major surgery.
• Mifepristone - anti progesterone medication
• Asoprisnil belongs to a new class of compounds known as Selective Progesterone Receptor Modulators or SPRM. This medication is currently being evaluated for treatment of fibroids in patients who do not desire children. The main advantage of this drug, over other medical therapies, is its ability to bring about cessation of menses with decrease in fibroid size, eliminating bone loss and hot flushes associated with other anti fibroid medications. 
• Uterine Artery Embolization (UAE) is a minimally invasive radiological treatment for symptomatic fibroids that is an alternative to hysterectomy and myomectomy. In this procedure, a catheter is inserted into the femoral artery and advanced into the uterine artery. Small particles are injected into the uterine artery to block the blood supply to the fibroid (see diagram below). This results in significant reduction in the size of the fibroid and improvement of symptoms, such as, pain and bleeding. The treatment is not currently recommended for infertile women with uterine fibroids. There is about 5% risk of menopause with this treatment, but this occurs most commonly in women over the age of 45.

• MRI Guided High Frequency Ultrasound Therapy is another noninvasive treatment for uterine fibroids. It can take more than 3 hours to complete. It may be associated with mild to moderate pain in 65% of patients and severe pain in another 15%. The procedure is not ideal for patients with fibroids over 10cm in size, fibroids located under the bladder or in patients with abdominal scar tissue.

Can fibroids become cancerous?

Fibroids rarely become cancerous. In fact, cancer is thought to occur in no more than one tenth of 1% of all fibroids. Uterine fibroids are not to be confused with leiomyosarcomas, which are malignant uterine tumors occurring most commonly in post-menopausal women.