Fibroid tumors, medically known as myomas or leiomyomas of the uterus, are almost always benign tumors. The normal uterine muscle tissue looks pink while most fibroids are white in appearance. They were originally called fibroids because they were white like fibrous tissue. When the microscope was developed their true origin was understood. Fibroids are generally round and therefore compared to fruits when talking about their size. The blood supply that feeds them comes from any location around them..
Each fibroid represents an individual mutation of a single uterine muscle cell. They are 3 times more common in women of African descent than Asian, Hispanic, and Caucasian women. They tend to run in families. Current research is focused on chromosome 7 as the possible site of the fibroid gene. Estrogen is involved in fibroid growth. We know they will shrink after menopause or when GnRH agonists(medications that temporarily stop ovarian estrogen production) are given. Other factors influence growth however. Progesterone antagonists, and agonist/antagonists compounds have recently been demonstrated to also shrink fibroids and reduce or stop menstrual flow. The great feature of these meds is the lack of hot flashes and other menopausal symptoms of GnRH agonists since they do not inhibit ovarian estrogen production.
The incidence of cancer in fibroid tumors is 1-2/1000 cases. Neither rapid growth nor degeneration has been shown to predict cancer preoperatively. The American College of OB/GYN(ACOG) recommends treating fibroids as benign. Women with small fibroids and minimal problems should be encouraged to wait to intervene, as it may not be necessary, without worry. The medical and surgical options should be discussed in relation to symptoms and individualized to the patient.
Common symptoms are:
- Abnormal uterine bleeding – As fibroids grow they can cause heavier and abnormal bleeding. A woman may have heavy bleeding that stops her from leaving her home for hours or even days because the flow is so heavy that she will soak through and on to her clothing in as little as 15-30 minutes.
- Increased cramping – As the normal uterine muscle contracts during a menstrual period to reduce flow, the fibroid tumor acts as a space-occupying lesion. The muscle contracts against the fibroid, and as the fibroid grows the woman may experience increased and prolonged cramping that may be unresponsive to over-the-counter or prescription medications.
- Infertility – Fibroids appear to reduce fertility and can increase the likelihood of miscarriage. Not all fibroids need to be removed before a woman tries to conceive. It is important for a woman considering pregnancy to talk to her physician about her risk based on number, size, and location of fibroids.
- Bladder pressure – The bladder is located behind the pubic bone and above the uterus. As uterine fibroids grow and expand the uterus, this leaves less room for the bladder to expand. This causes the woman to urinate more frequently. She may no longer be able to sleep through the night, and have to get up several times to use the bathroom. Some women develop urinary incontinence because of enlarging fibroids. Fibroid enlargement has been known to cause urinary retention and the need for catheterization.
- Rectal pressure – The rectum is located behind the uterus and as the fibroids grow and expand, this may create the sensation of constipation, and make bowel movements uncomfortable.
- Pain with intercourse – Enlarging fibroids can result in a backstop to the normally flexible and soft portion of the posterior vagina. This can cause pain during intercourse.
- Feeling an abdominal mass – As fibroids grow, they can expand into the tummy area. Many women cannot buckle their jeans and begin to look pregnant. The soft abdomen starts to feel hard.
- Pelvic and abdominal pain – As fibroid tumors increase the uterus from the size of an avocado to orange, grapefruit, cantaloupe, or larger, it can push organs out of the way to expand. Depending upon the location and size, pain may radiate from one or multiple sources in the abdomen.
Fibroid tumors may be suspected when a woman is found to have an enlarged uterus on pelvic examination. Not all uterine enlargement is caused by fibroids. Ultrasound is usually the first technique to diagnose fibroids. In some cases CT- scans or a MRI may be ordered. Small submucosal fibroids may only be diagnosed through hysteroscopy.
Generally, it is felt that 30-40% of women have fibroid tumors by the age of 40. Approximately 50% of women with fibroids will require surgery. Just because a woman has a fibroid does not automatically necessitate an operation.
Approximately 30-50% of women are likely to develop new fibroids within 5 years of their operation. Some women will have to undergo a second operation. The younger a woman is when diagnosed, the more likely she will require another procedure. Women who have more than 3 fibroids at the time of surgery are more likely to have recurrence than women who have less than 3.
There are medications that can shrink fibroids called GnRH agonist. This medication prevents the ovaries from producing estrogen and will shrink the fibroids by 10-50% in 3 months. However, this medication causes menopausal symptoms that may not be well tolerated. It is not a permanent cure. The fibroids will grow to their original size after the medication is stopped. It is generally used to shrink the fibroids prior to an operation.
Depo-medroxyprogesterone acetate also reduces ovarian estrogen production. This medication can be used to keep fibroids from growing larger, but does not appear to shrink fibroids. There are medications in development that may be taken in pill form and might in the future offer a medical solution to fibroid management.
We know of no scientific information that shows that herbs, diet, or acupuncture actually shrink fibroids. A controlled scientific trial of therapy is more important than opinion. Recommendations from this practice are base on available scientific literature. Problems that do not yet have conclusively proven solutions will require an opinion with appropriate discussion of various differences in approach.
Submucosal Myoma -
This kind of fibroid grows from the uterine muscle wall into the uterine cavity, thus interfering with the function of the endometrium(uterine lining). They cause bleeding problems such as heavy and/or prolonged flow, as well as bleeding between periods. Increasing cramps are frequently associated with this type of tumor. Submucosal fibroids may create symptoms even when small and may not be considered when the uterus is not enlarged. Ultrasound is the best way to diagnose the submucosal fibroid.
Interstitial Myoma -
Fibroids that arise in the middle of the uterine muscle wall are called interstitial, or intramural fibroid. If an interstitial fibroid grows large it may be called a transmural myoma. As these interstitial fibroids grow larger they distort the cavity causing abnormal bleeding and bulk pressure symptoms.
Subserosal Myoma -
The fibroid grows from the uterine muscle wall outwardly into the abdominal cavity. They can grow on stalks, which would be known as a pedunculated myoma. This type of fibroid does not cause bleeding issues generally. They are generally diagnosed accidentally at an annual exam or when the woman presents because of bulk symptoms or abdominal mass.