What causes uterine fibroids, how are they detected and how are they treated?
Uterine fibroids… The phrase alone is intimidating. What are they, and how do they form? Who is at risk, and how are they treated?
Uterine Fibroids are noncancerous tumors that grow from the muscle layers of the womb. These benign growths of smooth muscle can vary from the size of a bean to as large as a melon.
According to the Mayo Clinic, many women have uterine fibroids at some point during their lives, but they don’t know because the fibroids often cause no symptoms. However, 30 percent of women between ages 25 and 44 do experience symptoms of fibroids.
Heavy or painful periods
Bleeding between periods (spotting)
Anemia from heavy or long-term bleeding
Feeling “full” or a mild pressure in the lower abdomen
Pain during sex
Low back pain
Reproductive issues, including infertility, miscarriage and preterm labor
Difficulty emptying the bladder
Fibroids are usually diagnosed during routine pelvic examinations, even in women who aren’t showing symptoms.
There are four types of uterine fibroids:
Intramural fibroids – most common. Embed in the muscular wall of the womb.
Subserosal fibroids – extend beyond the wall of the womb and grow within the surrounding outer uterine tissue layer.
Submucosal fibroids – can develop into pedunculated fibroids, where the fibroid has a stalk and can become quite large. These can push into the cavity of the womb and are usually found in the muscle beneath the inner lining of the wall.
Cervical fibroids – take root in the neck of the womb, known as the cervix.
The cause of fibroids is largely unknown, but womenshealth.gov links it to estrogen and progesterone, as fibroids seem to grow rapidly during spikes of hormone levels. Hormone levels spike during pregnancy and seem to cease growing or began to shrink when menopause hits.
Most women experience no effects from fibroids during their pregnancy. However, a 2010 review suggests 10 to 30 percent of women with fibroids develop complications during pregnancy. Researchers note the most common complication of fibroids during pregnancy is pain. Pain is experienced most often in women with fibroids larger than 5 centimeters, who are in their last-two trimesters. However, fibroids may increase a woman’s risk for other complications during pregnancy and delivery.
Fetal growth restriction: Large fibroids could prevent a fetus from growing fully due to decreased room in the womb.
Placental abruption: This occurs when the placenta breaks away from the uterine wall because it’s blocked by a fibroid. This reduces vital oxygen and nutrients.Preterm delivery: Pain from fibroids can lead to uterine contractions, which can result in an early delivery.
Cesarean delivery: WomensHealth.gov estimates women with fibroids are six times more likely to need a cesarean delivery (C-section) than women who don’t have these growths.
Breech position: Because of the abnormal shape of the cavity, the baby may not be able to align for vaginal delivery.
Miscarriage: Research notes the chances for miscarriage are doubled in women with fibroids.
If fibroids are large, swelling and discomfort can occur in the lower abdomen. They may also cause constipation with painful bowel movements, and in some cases, fibroids can make it harder for the fertilized egg to attach itself to the lining of the womb. A submucosal fibroid growing on the inside of the uterine cavity could change the shape of the womb, making conception more difficult. Also, according to Medical News Today, Leiomyosarcoma is a rare form of cancer that is thought by some to be able to develop inside of a fibroid in very rare cases.
Fibroid ruptures are very rare, with only about 10 cases being reported in the past five years. However, a ruptured fibroid is a very serious medical condition that requires emergency care. Symptoms of a ruptured fibroid include:
Acute abdominal pain
High white blood cell count
Several things could cause a fibroid to rupture, including: the fibroid growing larger than the blood supply can feed, an increase in abdominal pressure, an injury that causes the fibroid to tear away from the uterus, twisting of a fibroid that has grown from a stalk-like structure in the uterus and increase in blood pressure in veins during pregnancy.
For some women, fibroid expulsion—or the fibroid tumor detaching from the uterus and passing from the body—is an unusual occurrence. According to a study published in the Journal of Vascular and Interventional Radiology, fibroid expulsion happens in not quite 5 percent of women.
Treatment widely varies, and there is no best route for treatment. If there are no symptoms, then no treatment is required. Symptoms and their severity are taken into consideration for the route of proper treatment. According to Dr. Aaron Styer, an obstetrician-gynecologist at Harvard-affiliated Massachusetts General Hospital, “For example, is the woman missing work, requiring frequent hospitalizations, or missing out on normal, daily life? If so, that information will guide the treatment I recommend.”
For women who are done having children and would rather not deal with the issue as a whole, hysterectomy is a treatment option. According to Harvard Health Publishing, “Removal of the uterus (hysterectomy) is a popular option for women who are done having children. With the uterus gone, new fibroids can’t form. But traditional hysterectomy, in which a surgeon makes a large incision in the abdomen, is major surgery.” Another option is laparoscopic hysterectomy, where the surgeon removes the uterus through three or four small incisions in the wall of the abdomen. Recovery is quicker, and there are usually fewer complications than with a traditional hysterectomy.
Laparoscopic hysterectomy has historically been accompanied by a procedure called power morcellation. During the procedure, a device cuts the uterus into fragments so it can be removed through the small incisions. But, the FDA recently recommended limiting the use of power morcellation because of the small chance that a woman having surgery to remove fibroids may have undiagnosed uterine cancer. If power morcellation is performed in these women, there is a risk that the procedure will spread the cancer throughout the abdomen and pelvis.
Since uterine fibroids have a correlation with estrogen and progesterone, another treatment route is medication that can help regulate menstrual cycle. Possible medications include:
Gonadotropin-releasing hormone (GnRH) agonists. Medications called GnRH agonists treat fibroids by blocking the production of estrogen and progesterone, putting you into a temporary menopause-like state. As a result, menstruation stops, fibroids shrink and anemia often improves. GnRH agonists include leuprolide (Lupron, Eligard, others), goserelin (Zoladex) and triptorelin (Trelstar, Triptodur Kit). Many women have significant hot flashes while using GnRH agonists. GnRH agonists typically are used for no more than three to six months because symptoms return when the medication is stopped and long-term use can cause loss of bone. Your doctor might prescribe a GnRH agonist to shrink the size of your fibroids before a planned surgery or to help transition you to menopause.
Progestin-releasing intrauterine device (IUD). A progestin-releasing IUD can relieve heavy bleeding caused by fibroids. A progestin-releasing IUD provides symptom relief only and doesn’t shrink fibroids or make them disappear. It also prevents pregnancy.
Tranexamic acid (Lysteda, Cyklokapron). This non-hormonal medication is taken to ease heavy menstrual periods. It’s taken only on heavy bleeding days.
Your doctor might recommend other medications. For example, oral contraceptives can help control menstrual bleeding, but they don’t reduce fibroid size. Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, may be effective in relieving pain related to fibroids, but they don’t reduce bleeding caused by fibroids. Your doctor may also suggest that you take vitamins and iron if you have heavy menstrual bleeding and anemia.
Additional procedures can also address uterine fibroids, such as:
MRI-guided focused ultrasound surgery (FUS). This is performed while you’re inside an MRI scanner equipped with a high-energy ultrasound transducer for treatment. The images give your doctor the precise location of the uterine fibroids. When the location of the fibroid is targeted, the ultrasound transducer focuses sound waves (sonications) into the fibroid to heat and destroy small areas of fibroid tissue.
Uterine artery embolization. Small particles (embolic agents) are injected into the arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die. This technique can be effective in shrinking fibroids and relieving the symptoms they cause. Complications may occur if the blood supply to your ovaries or other organs is compromised. However, research shows that complications are similar to surgical fibroid treatments and the risk of transfusion is substantially reduced.
Myolysis. In this laparoscopic procedure, radiofrequency energy, an electric current or laser destroys the fibroids and shrinks the blood vessels that feed them. A similar procedure called cryomyolysis freezes the fibroids.
If the fibroids are few in number, you and your doctor may opt for a laparoscopic or robotic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. Larger fibroids can be removed through smaller incisions by breaking them into pieces (morcellation), which can be done inside a surgical bag, or by extending one incision to remove the fibroids.
A hysteroscopic myomectomy procedure may be an option if the fibroids are contained inside the uterus (submucosal). Your surgeon accesses and removes fibroids using instruments inserted through your vagina and cervix into your uterus. Endometrial ablation is a treatment performed with a specialized instrument inserted into your uterus and uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow. Typically, endometrial ablation is effective in stopping abnormal bleeding. Submucosal fibroids can be removed at the time of hysteroscopy for endometrial ablation, but this doesn’t affect fibroids outside the interior lining of the uterus. Women aren’t likely to get pregnant following endometrial ablation, but birth control is needed to prevent a pregnancy from developing in a fallopian tube (ectopic pregnancy).