What are fibroids?
Fibroids are benign (non-cancerous) fibrous and muscular knots in the muscular wall of the uterus. The scientific name for a fibroid is leiomyoma (roughly, “lump of smooth muscle tissue”) or sometimes just myoma (“lump of muscle tissue”). The wall of the uterus is composed of a specialized smooth muscle type called the myometrium. This is the muscle tissue that pushes the baby down and out (hopefully!) in labor and that contracts and causes cramps with the menstrual cycle.
To the naked eye, fibroids are spherical firm solid lumps that are whitish or tan and have the consistency of hard rubber. Under the microscope, they are composed of whorls of muscle cells and fibroblasts, the firm underlying supportive tissue.
How large are fibroids?
Fibroids can range in size from smaller than a pea to the size of a soccer ball or larger. They are usually but not always multiple. As you might imagine, the larger they are in total, the more likely they are to cause problems. They may be felt on pelvic exam as nodular bumps on the uterus. When they become larger, they can be felt through the abdomen or even seen there, like a growing pregnancy. They may enlarge during pregnancy (sometimes painfully), and they tend to shrink somewhat after menopause.
How common are fibroids?
The American College of Obstetricians and Gynecologists (ACOG) estimates that up to 70% of all women will develop fibroids by menopause. They become more common with age until menopause. Most of the time they are incidental findings that do not cause problems or symptoms of any kind. They 2-3 times more common in black women than in white women. They also tend to occur earlier and become bothersome at younger ages in black women.
What are the different locations of fibroids?
Fibroids may be classified according to their specific location within the wall of the uterus. Those within the middle of the muscular uterine wall are called intramural myomas; those underlying and bulging out from the outer surface of the uterus are subserosal myomas; those underlying the inner lining and bulging into the cavity are submucosal myomas. Fibroids can also be on a stalk (pedunculated) or located in the cervix, the fibrous neck and opening of the uterus that extends into the vagina (cervical).
How are fibroids diagnosed?
Fibroids significant enough to cause symptoms can usually be felt on pelvic exam as irregular, nodular enlargement of the uterus. Pelvic ultrasound can be very useful as a safe and painless method to confirm, measure, and enumerate them. Hysteroscopy is sometimes used to better evaluate fibroids underlying or pressing against the uterine lining (endometrium). In this procedure a thin lighted scope is passed through the cervix into the uterine cavity. Finally, MRI may be used to help in planning for surgery for those select patients for whom surgical removal of fibroids (myomectomy) is considered.
Can fibroids be malignant?
Fibroids are benign (non-cancerous) and there is no evidence that they can become malignant. Leiomyosarcomas, however, are very rare malignant tumors that can mimic fibroids. They occur in about 3-7 per 100,000 women. Unfortunately, they can be impossible to differentiate from fibroids until they have been removed and examined microscopically. They tend to occur in older patients – the average age at diagnosis is 60. Therefore, singular masses that occur or grow after menopause are more worrisome and may prompt surgery.
What are the symptoms of fibroids?
Most (about 75%) of fibroids do not cause symptoms. Those that do can be bothersome. The most common symptom is heavy or prolonged menstrual bleeding. The excessive blood loss is inconvenient and can cause anemia. Fibroids that are located so they press inward against the uterine lining (the endometrium) are termed “submucosal”. These are relatively more likely to interfere with normal bleeding patterns than those that are closer to the outer surface of the uterus.
Fibroids can also cause “bulk symptoms” just due to their sheer size. These can include the sensation of pressure in the pelvis or abdomen, pain, urinary frequency (from compression on the bladder), and constipation.
Finally, fibroids can be associated with infertility and recurrent miscarriages. These problems seem to be caused primarily by submucosal fibroids.
When should fibroids be treated?
Fibroids generally are treated based on the symptoms they are causing and on a patient’s willingness to tolerate the symptoms and her desire for active management. Based on each patient’s findings and a discussion with the best medical information from her doctor, treatment is based on doctor-patient shared decision-making.
Remember most fibroids do not cause symptoms and many may require only “expectant management” or watching and waiting with annual physical exams and possibly ultrasounds. In addition, at menopause fibroids may shrink and bleeding problems will cease.
Fibroids may also be treated when they are over a certain size – many believe they should be treated when they are large enough to be felt manually from the abdomen above the pubic bone. They are also more worrisome if they grow rapidly or increase in size after menopause.
How are fibroids treated?
Treatments for fibroids are directed at mitigating or resolving the symptoms for that patient. Treatment can be divided into three broad categories: Medical, Procedural Intervention, and Surgery. Improvements in available medications and procedures can now prevent many surgeries that would have been performed in the past.
Medical treatments
Medical treatments are mainly effective for bleeding problems associated with fibroids. The most well proven of these are GnRH analogs. GnRH is a hormone released from the hypothalamus in the brain that leads to stimulation of the ovaries to make estrogen and progesterone, which in turn stimulate the growth of fibroids. GnRH analogs block this cycle, producing a low-estrogen state and inhibiting menstrual cycles. Thus, menstrual bleeding reduces significantly or stops altogether, and fibroids may shrink.
GnRH analogs include the GnRH agonists like leuprolide (Lupron®). These are given by injection (every one to three months) and are older, more proven methods. GnRH antagonists are newer drugs with similar effects that can be given orally. They include elagolix and relugolix. A drawback with all GnRH analogs is that given alone they cause menopause-like symptoms like hot flashes and vaginal dryness, and they may reduce bone density. They are commonly given with other hormones to mitigate those side effects.
Combined oral contraceptives (birth control pills) are often tried to help with fibroid related bleeding, although there is less robust scientific evidence of their effectiveness. However, they may be a first-line trial choice because, compared to GnRH analogs, they are readily available, safe, well-tolerated, inexpensive, and provide birth control.
Progestogen-releasing IUD’s may also be used with similar reasoning. See our section on contraception for more information regarding these methods.
Finally, tranexamic acid is an antifibrinolytic, a medication that helps the body control bleeding more efficiently. It may be useful with heavy menstrual bleeding from any cause and can be tried for fibroid-related bleeding.
Procedural Interventions
Several interventional procedures have been tried for the treatment of fibroids. These are in the interest of preventing surgery. They are mainly targeted at reducing the size and bulk symptoms, although they may also help bleeding. The method with the longest track record and best data for results is Uterine Artery Embolization (UAE), a procedure performed by interventional radiologists.
During UAE a catheter is threaded into the arteries that supply the uterus and fibroids. The flow of blood is blocked causing the fibroids to shrink. The patient is often kept overnight for observation and to help control pain that may occur. Up to 90% of patients who undergo UAE have significant improvement, including of both bulk and bleeding symptoms. Studies indicate that benefits last at least five years in most patients, but also that about 25% of patients will ultimately have further treatment needed such as repeat UAE or hysterectomy. However, many of the others may have avoided major surgery.
UAE is not advisable if the fibroids are too large or if they are not in favorable locations. In addition, it is not recommended for those who wish to become pregnant in the future because not enough is known about the safety of that.
Focused ultrasound is similar in concept to UAE but is less invasive, directing high-intensity ultrasound waves at individual fibroids to cause them to coagulate and die. This technique is newer and less widely available than UAE, but that may change in years to come.
Finally, endometrial ablation is a technique where the uterine lining is cauterized to dramatically reduce or stop menstrual bleeding. It is often successful with a normal size and shape uterus (i.e., no fibroids). It may also be helpful with fibroid-related bleeding, but this has not been sufficiently studied for it to be considered a top recommendation.
Surgical interventions – Major
There are two major types of surgery for fibroids: myomectomy (surgical removal of the fibroid(s)) and hysterectomy (removal of the entire uterus containing the fibroid(s)). Either can be performed either by laparoscope (with or without robotic assistance) or by abdominal incision. Hysterectomy can also be performed through the vagina in some cases.
Compared to the abdominal approach, laparoscopy is associated with quicker returns to normal activities and work, shorter hospital stays, and less short-term pain, but is not amenable to some fibroid sizes and locations. Thus, the route of myomectomy is determined by numerous factors including the size, number, and position of the fibroids, as well as the experience of the surgeon and the preferences of the patient and surgeon.
The choice between having a myomectomy or a hysterectomy is most often determined by patient preference. Hysterectomy is the most definitive and permanent procedure, but myomectomy is used when future fertility is desired, or the patient wishes to retain her uterus. The ovaries do not have to be removed in either case.
Surgical Intervention – Minor
Finally, there is the special and very valuable treatment of Hysteroscopic Myomectomy for submucous fibroids to control abnormal bleeding and to assist with fertility and miscarriage problems. This is an outpatient surgery during which the gynecologist inserts a lighted tube through the cervix into the uterus and shaves down fibroids pushing into the uterine cavity.
Summary
Fibroids are very common benign growths of the muscular uterine wall that occur in about 70% of all women. Most fibroids do not cause symptoms and do not require treatment, but they should be monitored with annual physical exams and possibly ultrasound.
However, about 25% of fibroids may cause problems that interfere with quality of life and based on each patient’s desires, may need to be treated. These problems may be characterized within three categories:
- Bleeding – heavy or prolonged menstrual bleeding, sometimes causing anemia.
- Bulk symptoms – pressure, pain, or interference with bowel or bladder function due to their sheer size.
- Fertility problems – some fibroids may be associated with infertility or recurrent miscarriages.
There are many treatments for fibroids, and they must be individualized due to the specific symptoms, the desire for pregnancy, the patients age, and the size of the fibroids. These treatments can range from medications to interventional procedures to minor and major surgeries. The choice for which, if any, treatment is ideally the result of a thorough evaluation and discussion and rests with the patient through the process of patient-doctor shared decision-making.
If you have questions of concerns about fibroids, please call us at 919-916-3333.
Note: This article is intended to provide general information and to summarize the approach of this practice. Each situation requires individual evaluation and decision-making.
