• Fibroids - from Mom with Love

    by Renee Cotter, MD
    on Aug 14th, 2015

Fibroids. They sound like something an alien flies around in on its way to abduct a cow in rural Kansas. Maybe they are those small, green, shiny pieces on the inside of your computer that store all your passwords. Or maybe it’s a common medical condition that affects about three million new women every year.

What are fibroids?

Fibroids are smooth muscle tumors of the uterus that affect 25 to 50 percent of women, or 1 in 4 to 1 in 2 women. That’s means that on the low end, if you play a tennis doubles match, one of the women on the court will have fibroids. On the high end, one of two women playing chess will have uterine fibroids.

Thankfully, in almost every case, these tumors are noncancerous, or benign. If you are concerned about the chance of your fibroid being cancerous, it is a less than a ½ percent chance that your fibroid is a leiomyosarcoma. These uterine growths can occur in five different locations of the uterus.

Types of uterine fibroids:

  1. Subserosal: Near the surface of the outer uterus
  2. Submucosal: Near the surface of the uterine lining
  3. Intramural: Deep within the wall of the uterus
  4. Pedunculated Subserosal: Attached by a stem to the outside of the uterus
  5. Intracavitary: Fully within the cavity of the uterus

Fibroids start small and continue to grow unless treated. Thus, they can be as tiny as a marble or as large as a watermelon. All women are different and while some may have slow growing fibroids, others may have fibroids that start small and suddenly jump in size. Fibroids do stop growing and may shrink once menopause is reached so occasionally, if her symptoms are not bad, a woman may just ride it out until menopause.

Because fibroids may not exhibit obvious symptoms right away, it is possible for them to go undetected for years without an annual gynecologic checkup. During a pelvic exam, fibroids can be detected by your gynecologist. Once detected, you will follow up with a pelvic ultrasound to obtain a clearer view of the fibroids and determine their size and location in the uterus. After this, a treatment plan will be tailored to your specific needs depending on type of fibroid, age, and symptoms.

Who and Why?

You are most likely to discover uterine fibroids in your 30s and 40s, however they may develop at any age. African Americans are also more likely to develop fibroids and in many cases they occur at a younger age and grow more quickly.

Fibroids are most often lovely genetic gifts from your mother. If your mom had fibroids, you are three times more likely to develop them yourself. If you have fibroids, take a moment to think back. Did your mother have a hysterectomy? I’ll bet you that it was for fibroids. If you’re unsure, go ahead and ask her! As women, we are very linked to our mothers. Your mom is a great way to understand what’s ahead on the road for you. Age of menopause, fibroids, endometriosis, adenomyosis, and more can be directly determined from your mother.

Symptoms

Some research has also indicated that hormones may play a role in the development of fibroids; however more research needs to be done to confirm this. Though your gynecologist may be able to tell you have fibroids before you experience symptoms, having one or more of the symptoms below may be an indicator that you have fibroids:

Treatment of Fibroids

Treatment of fibroids is dependent several factors including your symptoms, the type and size of your fibroids, and your age. Each woman is different in her needs, so if you have fibroids, it’s important to speak to your gynecologist about treatment options (especially since they can be unpredictable in their growth).

Let's start with the easiest options for treating fibroids and move from there. Again, I want to reiterate that not every treatment option is available to all women and that it truly depends on your unique diagnosis.

Brief Overview of Treatment Methods

Method, What, Who, Fibroid Types:

Progestin IUDLighten and Shorten periods, improve crampsWomen with heavy, painful periodsOuter uterine, small intramural
Birth Control PillsLighten and shorten periods, improve cramps. Chance for accelerated growth of fibroid.Women with heavy, painful periodsAll
GnRH AgonistsTemporarily shrink fibroids. Risk of bone loss with long use.Those about to undergo surgeryAll
Endometrial AblationLighten periods onlyWomen with heavy periods only, no cramping or pelvic pressureSmall fibroids
Hysterectomy (laparoscopic or laparotomy)Remove uterus & fibroids with no possibility of return of fibroidsWomen who are done having children and have tried other methodsAll
Myomectomy (hysteroscopic, laparoscopic or laparotomy)Remove only fibroids. Possibility of new fibroids later on.Women who still wish to have childrenDepends on type of myomectomy
Uterine Artery EmbolisationGoal is to shrink fibroids. 20-23% failure rate.Women who are done having children and are resistant to surgeryAll
MRI-guided ultrasound surgeryNew approach to destroy fibroid. No research on long-term effects.More research neededAll

 

Progestin IUD


Who: 

This option is best for the woman who is experiencing long, heavy periods, bleeding between periods, and menstrual cramps. It works very well at decreasing length and flow of periods as well as menstrual cramps.

How:

The progestin IUD works by thinning the lining of the uterus and thus lightens the period; it does not treat the actual fibroids but the symptoms associated with them. A very good benefit of this option is that once it is in place, it will last for up to five years. The downsides are that women of childbearing age who wish to become pregnant will not be able to do so while using the Progestin IUD to control their fibroid symptoms. 

Types of fibroids: Subserosal, intracavitary, small intramural fibroids


Birth Control Pills

Who:

This option is also good for the women with long, heavy periods, bleeding between periods, and menstrual cramps.

How:

Birth control pills work very similarly to the Progestin IUD in terms of controlling fibroid symptoms. Birth control pills help alleviate cramps, menstrual pain, and length/flow of the period.

The downside of using birth control pills is they may potentially accelerate the growth of fibroids due to the larger amount of systemic hormone, or hormone that circulates throughout your body.

Types of fibroids: all


GnRH agonist (Gonadotropin-releasing hormone agonist)*

*not often recommended or used often

Who:

GnRH agonists are basically only used for a short time in preparation for surgery. 

How:

This type of medication is used to shrink the size of the fibroid by inducing an artificial state of menopause. However, after stopping the use of this medication, fibroids will always return to their previous size and then continue to grow as they normally would have. 

GnRH agonists are only used before a surgery to remove the fibroid and is used for at most, six months. Using it before surgery helps very large fibroids become more easy to remove and reduces bleeding. Because this medication prevents menstruation, it is not for long term use due to the risk of bone loss.

Types of fibroids: all


Endometrial Ablation

Who:

This in office or surgical center procedure is only for women whose primary complaint is heavy bleeding without menstrual cramping, pain or pressure. Endometrial ablation is not for the treatment of fibroids and has no effect on pain or pressure but works well to lighten up the period.

How:

Endometrial ablation works by destroying the lining of the uterus. A balloon-like device is placed into the uterus, filled with water, and then heated until the lining is cauterized, or burned away. This procedure is associated with a 10% failure rate.

Types of fibroid: all 


Hysterectomy

Who:

This procedure is best for women who are finished having children and after other non-surgical treatment options have failed. A hysterectomy is also a good option for women with large fibroids or many, difficult to remove fibroids.

How:

A hysterectomy is the removal of the uterus and the fibroids along with it. After the uterus has been removed, fibroids cannot regrow and new ones cannot develop.

Laparoscopic vs. Laparotomy

There are two main types of hysterectomy: laparoscopic and by laparotomy (abdominal hysterectomy). Laparoscopic hysterectomies are minimally invasive, require only three small incisions, require a short recovery time, and are considered an outpatient procedure (meaning a long hospital stay is not required).

A hysterectomy by laparotomy involves a large incision into the abdomen and increases the risk for infection and recovery time. Many gynecologists are only able to perform a laparotomy, so if your gynecologist does not recommend a laparoscopic hysterectomy, it may be because they are not trained in the laparoscopic approach.

At my office, I have been practicing laparoscopic hysterectomy for 20 years. Recovery time is 2 weeks whereas a traditional procedure requires 6-8 weeks of recovery time. The procedure only requires three incisions that are only a few millimeters long and drastically reduces the risk of infection.

Types of fibroids: all


Myomectomy (remove fibroid while preserving the uterus)

Who:

This type of procedure is best for a younger woman who still wishes to have children. If you are finished having kids or are unable to conceive, a hysterectomy is honestly the recommended option. Even though a myomectomy sounds more simple than a hysterectomy, a myomectomy is actually a more complicated procedure. 

How:

A myomectomy removes uterine fibroids while preserving the uterus. Once fibroids are removed, they will remain gone; however, new fibroids can always develop.

"Even though a myomectomy sounds more simple than a hysterectomy, a myomectomy is actually a more complicated procedure."

Three Types of Myomectomy:

Hysteroscopic Myomectomy:

This type of myomectomy is for fibroids on the inside of the uterus: submucosal and intracavitary. With this procedure, a small scope (camera) is inserted into the vagina and through the cervix to see inside the uterus. Then, the fibroids are removed with another instrument. This procedure is outpatient and has a short recovery time.

For: submucosal fibroids & intracavitary fibroids

Laparoscopic Myomectomy:

This is for the removal of subserosal or intramural fibroids (fibroids on or near the outside of the uterus). It is similar to a laparoscopic hysterectomy because only a few small incisions are made in the pelvis to remove the fibroids. Laparoscopic myomectomies are outpatient, have a low risk of infection, and a short recovery time compared to a laparotomy.

For: subserosal fibroids & intramural fibroids

Laparotomy:

This procedure, like the hysterectomy by laparotomy, requires a large abdominal incision. Subserosal and intramural fibroids may be removed with this technique. It is associated with a lengthy recovery time and an increased risk for infection.

For: subserosal fibroids & intramural fibroids 

Laparoscopy vs. Laparotomy

Most other gynecologists are not trained in a laparoscopic myomectomy and therefore will go straight to a laparotomy with a large abdominal incision. I have been successfully performing laparoscopic myomectomies since 2009. Though myomectomies are less common, they are still a very safe procedure. 

For a young woman who still wishes to conceive and has multiple or large fibroids, this is the best option. However, it is my hope that you understand that if you are beyond childbearing years or do not wish to have children, a hysterectomy is the recommended option because the procedure is shorter and much easier. 

Types of fibroids: Depends on type of procedure


Uterine Artery Embolization (UAE)

This procedure is for women who are done having children but do not want to undergo surgery. During this procedure, a type of X-ray called fluoroscopy is used to release tiny sand-sized particles into the artery in the groin. This cuts off the blood supply to the uterus and the fibroid, causing the fibroids to shrink.

This procedure has a relatively high failure rate of 20-23% in the long term. This means that the fibroids may continue to grow a few years following treatment. Because UAE is also associated with pain and bleeding after the procedure, I do not generally recommend it.

Types of fibroids: all


MRI-Guided Ultrasound Surgery

This is a very new approach to the treatment of fibroids. In this MRI assisted procedure, ultrasound waves are directed at the fibroids, through the skin, in order to destroy the fibroid. Women who have had this type of treatment showed alleviated symptoms of fibroids for up to a year after the procedure. Because this technology is so new, long term effects of the procedure have not been studied in length. For this reason, I am not currently recommending this procedure.

 

Conclusion

Fibroids are a very common condition that affects ¼ to ½ of all women. They are generally passed mother to daughter and begin to affect women in their 30s and 40s. Fibroids grow in size and number until menopause when they stop growing and may even decrease in size. Uterine fibroids can be detected by your gynecologist during a pelvic exam but because symptoms may not be obvious, they may go undetected for years without regular annuals.

The main symptoms of fibroids are long, heavy periods and bleeding between periods. An increase in menstrual cramps is another common complaint of women with fibroids. Fibroids may also cause painful sex, a feeling of fullness or pressure, and difficulty carrying a pregnancy to term.

There are many treatment options for fibroids that depend on your unique diagnosis, age, types and size of fibroids, and symptoms. Options for treatment of fibroids include Progestin IUD, birth control pills, GnRh agonist, endometrial ablation, hysterectomy, myomectomy, UAE, and MRI-guided ultrasound surgery. Myomectomies are commonly asked for however they are only truly recommended for women who still wish to become pregnant.

Seeing your doctor is the best way to design a treatment option for your fibroids. When you’re feeling alone, remember that if you look around you, there are millions of other women with the same problem as you and that treatment of fibroids is very possible.

 

References:

Health Care Specialists of UCSF Medical Center. Fibroids. UCSF Medical Center.
Medline Plus. Uterine Fibroids. U.S. National Library of Medicine.
Uterine Fibroids. ACOG. Frequently Asked Questions; FAQ074. 2011.
Eisinger, S. Uterine Fibroids Fact Sheet. Womenshealth.gov. 2015.
Uterine Fibroids. National women's health network. 2015.
Carrillo, T.C. Uterine artery embolization in the management of symptomatic uterine fibroids: an 
       overview of complications and follow-up. Semin Intervent Radiol. 2008;25(4):378-386.

 

Author Renee Cotter, MD

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Renee Cotter, MD
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