;

Fibroid Clinic

What are fibroids?There are many instances of patients being found with uterine fibroids during a routine pelvic exam or a prenatal ultrasound. This is suspected by the doctor if she/he feels any irregularities in the shape of your uterus hinting at the presence of fibroids. In some cases, uterine fibroids are not even detected as they do not show/cause any symptoms at all. The abnormal growths developing inside/on a woman’s uterus are called fibroids. These can be symptomatic or asymptomatic depending on their sizes. For example, sometimes, these tumors can be pretty large causing even abdominal pain and, other times, they are too small to even be detected. Hence, there are no ranges for fibroids. They can be as small as seedlings and in other cases, they can be cumbersome leading to an increased uterus size expanding up to even rib cage in some cases. One can have a single fibroid or multiple counts. Most of these growths are typically benign, or noncancerous. The cause of fibroids is unknown.

Such tumors are usually benign i.e., they are not cancerous. There are no specific causes that we can link to fibroids and hence, it remains an idiopathic disease. Many names have been associated with Fibroids. Some of them are:

  • Myomas / uterine myomas
  • Fibromas
  • Leiomyomas

These uterine fibroids are formed of muscles and connective tissue from the uterine wall. These fibroids can grow as single nodules or can even grow in the form of clusters(groups). The sizes can range diversely from 1mm to >20 cm in diameter (8 inches). These can grow outside the uterus, within the wall of the uterus and also, inside the main cavity. On average, 4 to 8 women out of 10 have fibroids. However, most women don’t experience any symptoms and hence, they don’t even realize that they have fibroids as the fibroids are not even detected. 

Types of Fibroids:

Fibroids are divided into 4 types depending on their respective location of occurrence:

  1. Intramural: These are the most common types of fibroids. These appear within the muscular uterine wall. These can stretch one’s womb as they grow larger and therefore, distort the shape of the womb.
  2. Subserosal: These fibroids are found on the outside of the uterus on the serosa (outermost layer of the uterus). These can sometimes grow larger making your womb appear bigger on one side.
  3. Pedunculated: When the subserosal tumors develop a stem that supports the tumor as a base, then those tumors are called pedunculated fibroids.
  4. Submucosal: These are the rarest types of fibroids as these are found in the myometrium i.e., the middle muscle layer of the uterus.

Uterine Fibroid Causes: 

Even though there is no specific answer to “what causes fibroids?” as the causes of fibroids are unknown. Various factors, however, have been identified that may lead to their formation. These factors can be described as follows:

  1. Hormones: The two major hormones secreted by the ovaries i.e., estrogen and progesterone, can cause regeneration of the uterine wall during menstrual cycles and may stimulate the development of fibroids.
  2. Pregnancy: In the case of pregnancy also, increased production of progesterone and estrogen may lead to the development of fibroids.
  3. Family History: Fibroids can also occur if fibroids run in the family tree.
  4. Other Factors: These include substances that help in maintaining the tissues like the insulin-growth factor which can affect fibroid growth. 

However, doctors have come to believe that uterine fibroids develop from a stem cell in the smooth muscle tissue of the uterus(myometrium). A single cell divides continuously leading to the formation of a stiff mass from the nearby tissues.

Risk Factors for Fibroids?

Women having one or more of the following points are at greater risks for uterine fibroids:

  1. Age: Older women (age 30 or more) are at greater risk than younger women
  2. African American: In people of African American race, fibroids are found to develop at a young age, growing large and that too, with more severity.
  3. Obesity: Obesity can be directly linked to fibroids as in people with obesity, the level of circulating estrogens is higher that can cause fibroids. People with BMI (Body Mass Index) greater than 25 i.e., overweight

Uterine Fibroid Symptoms:

Most of the fibroids are asymptomatic as they do not cause any symptoms at all and hence, do not require treatment. Frequent observation by your doctor would be just fine. But there are also times when fibroids can be large in size and therefore, can cause a range of symptoms (symptomatic). Hence, fibroid symptoms can often give a hint about the size of the fibroids. The symptoms can be:

  • Heavy and painful bleeding during your periods.
  • Pain in the pelvis or lower back region
  • Increased menstrual cramping
  • Increased/frequent urination
  • Pain during intercourse(sex).
  • Constipation
  • Abdomen enlargement/swelling
  • Menstruation lasting longer than usual
  • Inability to completely empty the bladder

Uterine Fibroid Diagnosis:

In most cases, the diagnosis of fibroids is usually done by the healthcare provider during a regular exam. Fibroids can be found in a gynaecologic exam or can be felt by the healthcare provider during a pelvic exam. At other times, the doctor gets alert to consider fibroids in the diagnosis when there is a description of heavy bleeding and other related symptoms given by you. Several tests are there that can be done to confirm if one has fibroids or not and even, the size and location of each fibroid. These tests are:

  1. Ultrasonography: It is a non-invasive imaging test used to create pictures of the internal organs with the help of sound waves. This ultrasound exam can be performed by the transvaginal or transabdominal channel.
  2. Computed Tomography (CT): Most of us have heard about the term CT scan. This scan includes the use of X-ray images to create a detailed image of our internal organs from multiple angles.
  3. Magnetic Resonance Imaging (MRI): An MRI scan also does the same job of creating detailed images of our internal organs, but it uses magnets and radio waves for doing so.
  4. Hysteroscopy: In this, the healthcare provider uses a device called scope which is a thin flexible tube with a camera on its end to give live optic feedback of the internals so that the doctor can look at the fibroids inside the uterus.  This scope is inserted into the vagina through the cervix.
  5. Sonohysterography: In this test, a small catheter is placed through the vagina, and saline is injected into the uterine cavity via the inserted catheter. This fluid helps to create a stronger image of the uterus as compared to the standard ultrasound.
  6. Hysterosalpingography (HSG): Here, a contrast material is injected into the uterus first and then X-rays are taken to get a clear image. This is used in women who are usually undergoing infertility evaluation also.
  7.  Laparoscopy: In this test, a small incision is made by your doctor in your lower abdomen first and then a thin and flexible tube is inserted to get live feedback of the internal organs.

 

Fibroid’s Treatment:

The treatment can differ depending on the size, number, and location of the fibroids.  It also depends on the symptoms being caused by the fibroids. If no symptoms are experienced then there is a high chance of treatment not being required in such a case as it indicates the fibroid being of small size and hence, can be left alone. Some women don’t even have any problems or symptoms due to such fibroids. However, even such fibroids should have regular careful monitoring. Intermittent pelvic exams/ultrasounds should be recommended by your doctor if the size and symptoms associated with such fibroids are considerable. Treatment may be needed if any symptoms are experienced (like blood loss due to heavy bleeding, moderate to severe pain, etc. mentioned above). The treatment also depends on the following factors:

  • The number of fibroids you have
  • Size of the fibroid/fibroids
  • Location of the fibroids
  • Symptoms related to the fibroids
  • Your desire for pregnancy and/or uterine preservation

The best treatment plan for you would be the one that is inclined with your fertility goals in the future. If you wish to have children in the future then you will have to eliminate a few treatment plans as your options. You should talk to your doctor regarding your fertility goals while discussing the treatment option with her/him. 

The treatment options for uterine fibroids/tumors include the following:

Medications:

  • Pain medications: These are the usual over-the-counter pain medications that are used to cope with the discomfort and pain caused by uterine fibroids. Such medications include ibuprofen, naproxen, acetaminophen, etc.
  • Iron Supplements: To cope up with the Iron deficiency caused by heavy bleeding, your doctor may prescribe iron supplements.
  • Birth Control Medicines: Birth control medications have proven to be very helpful in controlling the heavy menstrual bleeding caused due to fibroids. You can use contraceptives, intravaginal contraception, IUDs, etc.
  • GnRH (Gonadotropin-Releasing Hormone) agonists: Such medications are proven to shrink the fibroids for a short period. These are taken via nasal sprays or injections and are usually used before surgeries to shrink the fibroids for easy extraction. You should know something before searching for tablets to shrink fibroids, these medications don’t have any significant effect on the fibroids in the long term. If one stops taking these medicines, the fibroids can grow back. 

*Note: Talking to your doctor about any medication that you take is very important. You should never start a new medication without discussing it with/consulting your doctor.

Surgery:

Not just the size, number, and location of the fibroids affect the surgery but your desire for pregnancies in the future also is a major factor when thinking about having surgery for fibroid removal. Various surgical options preserve the uterus and allow you to carry on with your desired future fertility goals of being a mother. Other options may involve damage/removal of the uterus therefore, removing the option of pregnancy for you.

Myomectomy is the procedure that allows you to be pregnant in the future as the fibroids are removed without damaging the uterus in this procedure. There are a few types of myomectomies. Depending on the size, location, and number f the fibroids involved, your doctor will suggest the best type of myomectomy for you. 

  • Hysteroscopy: In this procedure, the scope is inserted and used by the doctor to remove/cut the uterine fibroids for their extraction. No incisions are made in this process.
  • Laparoscopy: This procedure involves the use of a scope to get rid of the uterine fibroids. This procedure involves making small incisions in the abdomen to insert the scope. This procedure is also done with the help of a robot.
  • Laparotomy: An incision is made in the abdomen in this procedure also, but the fibroids are extracted with a larger cut in this method.

If you are not among the ones considering pregnancy/pregnancies in the future, then you can also opt for the surgeries which are more effective than myomectomy surgeries:

Hysterectomy: This surgery involves the removal of the uterus itself, in order to get rid of the fibroids. By doing so, the fibroids would not come back, and the associated symptoms would not torment you anymore. This procedure is recommended when there is a lot of heavy bleeding being caused by fibroids. It is done with minimally invasive procedures like laparoscopy and/or robotic processes.

Uterine Fibroid Embolization: This is performed by an interventional radiologist working with your gynecologist. Here, a small catheter is placed in either the uterine or radial artery to stop the flow of blood to the fibroid which ultimately, shrinks the fibroid, and hence, the symptoms are improved.

 Conclusion:

As we have already discussed, fibroids are common among women (up to 80% probability of occurrence). These are not troublesome if asymptomatic, but one needs to have regular exams by a competent doctor to keep a check. In the case of people with large fibroids, a competent doctor should stand by your side as you may be needing surgery for fibroids. You need someone not just with knowledge but also, with an ample amount of experience while dealing with fibroids as they can be tricky at times.

;