Issues and Procedures in Women's Health Uterine Fibroids

Uterine fibroids are one of the most common medical conditions affecting women. Despite the fact that at least 1 out of every 4 women has fibroids, there is a considerable amount of misinformation regarding the effects of fibroids and their treatment. In order to fully understand these common uterine tumors, one needs to understand their cause, possible symptoms, diagnosis, and treatment options.

Uterine fibroids, or “leiomyomata” in medical terminology, are extremely common smooth muscle tumors of the uterus. The uterus (womb) is basically a large muscle. Most of the time this muscle goes unnoticed, although during periods muscle spasms (cramps) may develop, and during childbirth the uterus contracts to help push out the baby. For reasons that currently remain a mystery, a single cell in the uterus may begin to grow rapidly. The resulting tumor is called a fibroid. (The word ‘tumor’ often evokes fear because it is commonly associated with cancer, but ‘tumor’ in medical terminology simply means “new growth”). While it is possible that a fibroid tumor can become cancerous, this is extremely unlikely. When a uterus is cut open fibroids usually have a whorled appearance, somewhat similar to a cut onion.

Fibroids can occur in many locations throughout the uterus. Some may occur within the wall of the uterus, while others can grow within the uterine cavity (called the endometrium). Pedunculated fibroids are attached to the outside of the uterus by a thick stalk, similar to the root of a plant. Some women have only one, small fibroid, while others have dozens of them. Even though most are small (less than golf ball sized) others can grow to the size of a watermelon! It is the combination of size, number, and location that can produce symptoms. It is impossible to predict who will get fibroids. African-American women get them more often than Caucasian women, and some researchers estimate that up to 50% of African-American women will develop fibroids. In some cases a small or medium-sized fibroid will stay the same size, or even become smaller, but in other cases it may slowly grow and develop symptoms over time. Many women have fibroids and never know it, but other women may develop significant symptoms that bring them to their physician’s office.

In many (probably most) cases, fibroids do not cause symptoms. A small fibroid buried deep in the uterine wall should not produce symptoms, while a grapefruit sized fibroid on the back wall of the uterus might cause severe constipation or other rectal problems. A fibroid within the uterine cavity (endometrium) may irritate it and cause heavy bleeding. If a fibroid grows towards the side, it may press against and damage the tubes leading from the kidneys to the bladder, called ureters, causing kidney infections or even kidney damage. Additionally, larger fibroids may cause heavy, painful periods, irregular bleeding between periods, pain with intercourse, loss of urine, severe pelvic pressure, or other symptoms. Although infertility is probably not very common in women with fibroids, in some cases a fibroid may alter the structure of the uterus, making it difficult to carry a baby. When women visit doctors for recurrent miscarriages, part of the evaluation is to rule out fibroids or other intrauterine problems. Again, most fibroids probably do not cause any symptoms at all, and usually do not require treatment. Simply having a fibroid is not cause for alarm, as they are quite common and almost always benign. But, when symptoms develop one’s health care provider can usually easily diagnose fibroids and offer a number of treatment options.

Fibroids are fairly easy to diagnose. In some cases a simple pelvic examination, using one or two fingers in the vagina along with a hand on the lower abdomen, will allow your doctor or other health care provider to gauge the size of your uterus. A normal uterus is about the size of a pear, or an orange. A fibroid uterus, however, will often measure much larger, for example the size of a large grapefruit, a soccer ball, or even a watermelon. Some women present to their doctor for the first time with a uterus that has grown past the belly button, as if she were in the last few months of pregnancy! Amazingly, despite this large size, in some cases there are no symptoms, whereas in other women with even a small fibroid there can be troublesome symptoms. Another diagnostic option is an ultrasound (also called a sonogram). This test involves either a painless probe placed on one’s abdomen, or a tube, called a vaginal probe, placed in the vagina. Neither should be painful when diagnosing fibroids. Regular x-rays are rarely helpful, but a specialized test, called an MRI (for magnetic resonance imaging), is very useful for diagnosing fibroids. Unfortunately, it is very expensive and is probably not much more helpful than the less expensive and less difficult ultrasound scan. Finally, two similar tests can be used to diagnose fibroids that have grown into the endometrial cavity. One is called sonohysterography (basically a vaginal ultrasound using sterile water inside the uterus) and the other is called hysteroscopy (using a small, lighted tube to visualize the inside of the uterus). The choice of diagnostic tool depends on the symptoms and the result of the physical exam.

There are a number of treatment options available for fibroids. Small and asymptomatic fibroids can usually be managed by an annual examination to check for growth. In cases where there are symptoms, women can be offered medications or surgery. Heavy bleeding can often be managed by specific anti-inflammatory medications of the ibuprofen class, which block an important chemical made by the tissue within the uterine cavity. Some studies have shown regular use of these medications to cut down uterine bleeding by 1/2 the amount. Birth control pills probably do not increase the size of fibroids, and in some women may decrease heavy bleeding. Other women may benefit from a powerful, and somewhat controversial, drug called a “GnRH agonist.” This medication, given as either a monthly injection, nasal spray, or implant under the skin, essentially tricks your body into making less estrogen and progesterone, which usually shrinks the fibroids. Unfortunately, while this class of medication is usually successful in shrinking the fibroids, in some cases even dramatically, it can produce severe side effects. Some women never develop side effects, while others report headaches, joint pain, severe hot flashes, difficulty concentrating, and other symptoms of menopause (the “change of life”). Your doctor can give you small amounts of estrogen and/or progesterone to counteract these side effects. This medication is usually not used for more than 3-6 months as it can cause loss of bone tissue. Unfortunately, in most cases the fibroids regrow within 4-6 months after the medication is stopped. Therefore, most doctors prescribe GnRH agonists prior to surgery so that the surgery is easier, or to women who want to shrink their fibroids prior to becoming pregnant, or to those nearing menopause, since fibroids often decrease in size after menopause.

Fibroids account for about 2 out of every 3 hysterectomies done in the United States. There is considerable controversy about the use of hysterectomy, or other surgical treatments, for uterine fibroids. There are basically 4 surgical treatments for fibroids: myomectomy, hysteroscopic resection, myolysis, and hysterectomy. A myomectomy is a surgical procedure where the fibroid (or fibroids) is removed via a major operation involving an incision into the abdomen, or via laparoscopy, which is an outpatient procedure utilizing a long tube inserted into the belly button. The choice of procedure depends on the size, number, and location of the fibroids. Regardless of the method chosen, the fibroids are removed but the uterus is not. Women desiring more children, or who simply do not want removal of their uterus, may benefit from myomectomy. This is generally a safe surgery, but as with all surgical procedures, complications are possible. These may include heavy bleeding up the point of blood transfusion, damage to internal organs and blood vessels, the need for an emergency hysterectomy, and occasionally the need for a cesarean section with future pregnancies. Furthermore, in 1 out of every 4 cases the fibroids grow back despite the myomectomy, often prompting further surgery, including hysterectomy.

Hysteroscopy involves a thin tube inserted into the uterus during an outpatient (same day) surgery,. The fibroid is simply shaved off and removed in pieces. This technique does not work for fibroids buried deep in the uterine wall, or pedunculated fibroids. Myolysis is a somewhat newer surgery (at least in the US) involving a needle inserted into the fibroid during laparoscopy, which cauterizes the blood supply to the fibroid, making it shrink over time. Although this appears to be a promising technique that can be done as an outpatient procedure, there are really not enough data to support it’s use in women who may want to become pregnant later. Thus, for now it is mostly a procedure for women who are past the point of childbearing or who do not desire further children. A final technique that is another newer development involves placing a catheter into a blood vessel, and threading this into the blood vessel that feeds the fibroid. Material is injected that clots off the blood vessel, causing the fibroid to shrink over time. Athough this also looks promising, it is a new technique and further research is needed.

Some researchers estimate that 1 out of every 3 women will undergo hysterectomy in the US. This is the second most common surgical procedure performed in the US, and for many reasons has become rather controversial. Although hysterectomy is the only true curative surgery for fibroids (they cannot return after removal of the uterus) most women with fibroids will never need a hysterectomy. Others, after learning about the risks and benefits of this surgery, will choose to undergo hysterectomy because it offers the best choice given their set of symptoms. Despite what one might read in the newspaper or on the Internet, doctors do not make women undergo hysterectomy. A doctor has the responsibility to educate his or her patient on all available treatment options and their potential risks and benifits, whereas the patient has the responsibility to educate herself on her condition and the treatment options. Then the patient chooses which treatment she would like and she and her physician formulate a game plan. Sometimes you will start out with one plan, and change this if the situation changes or side effects develop.

A uterus can be removed either abdominally or vaginally. Most gynecologists choose the vaginal route because healing is much faster, there is no visible scar, there is usually less time spent in the hospital, and there are fewer side effects such as bleeding and damage to urinary organs. On the other hand, removal via an abdominal incision is often necessary in cases of a very large uterus, or in some cases in patients who have never had children or who have scar tissue around the uterus. In some cases using the laparoscope can help change an abdominal hysterectomy into a vaginal procedure. There is no need to remove the ovaries, since removal of the uterus itself cures the fibroids. Hysterectomies are an important and often necessary treatment for fibroids, but as with all major operations, one should be well aware of the possible risks and alternative treatments that do not require major surgery. Your doctor should be able to provide you with the information you need to decide which treatment s best for you.

To summarize, fibroids are an extremely common, almost always benign, and usually asymptomatic smooth muscle growth of the uterus. When symptoms develop there can be abnormal bleeding, pelvic pressure, loss of urine, or rectal complaints. Some women may have recurrent miscarriages. The diagnosis is best obtained by a good physical examination and perhaps an ultrasound. Certain medications may treat this condition, but surgery is sometimes necessary. The choice of treatment is very complicated but with time and a close professional relationship between you and your physician is often successful.

Photo of huge fibroids. Normal uterus is at bottom right of picture. Normal-sized, white ovary can be seen at very bottom of photo.

D. Ashley Hill, M.D.
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency
Orlando, Florida
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