Fibroids are benign tumors of smooth muscle in a woman’s womb (the uterus). Being benign means that fibroids are not cancer.
Fibroids are more common in black women and less common in women of other races. The chance of developing fibroids increases with a woman’s age. Women who wait a long time to have children or who are heavy have a higher chance of having fibroids.
Not all fibroids cause a problem or need to be treated. The only fibroids that need to be treated are those that cause symptoms. These symptoms can affect a woman’s quality of life, fertility or be life threatening.
Fibroids come in different sizes, numbers and locations in a woman’s womb. Fibroids are named based on their location because it predicts the symptoms and guides treatment decisions that are prescribed.
The uterus is made up of an inside lining called the endometrium, a middle layer called the myometrium, and an outer layer called the serosa.
Fibroids of the inside layer (endometrium) are called endometrial fibroids. These fibroids are mostly responsible for heavy menstrual bleeding (menorrhagia).
Fibroids of the middle or muscle layer are called intramural or myometrial fibroids. These fibroids enlarge the uterus and cause pain and pelvic pressure. They can compress nearby structures like the fallopian tube, the bladder, and the rectum. Long standing pressure on nearby structures can result in infertility, urinary tract infection and inability to control the bladder.
The fibroids of the outer layer of the uterus are called subserosal fibroids. These fibroids compress nearby structures and also cause pain.
Some fibroids are attached by a stalk to the inside or the outside of the uterus and are called pedunculated fibroids. These are easily removed at surgery.
Only women with fibroids that cause symptoms should be offered treatment for fibroids. Currently available fibroid treatments are medication treatment, surgical treatment, and non-surgical treatment.
Two classes of medications used to treat fibroids are low dose estrogen and progestin and gonadotropin drugs.
Low dose of estrogen and progestin drugs are available by mouth and by intrauterine devices and also used for birth control. They work by affecting ovulation and reducing the amount of menstrual bleeding. They do not shrink the fibroids to treat the pressure symptoms. These drugs are widely used and well-tolerated, but can cause blood clots and liver tumors.
Gonadotropin-releasing hormones (GnRH) are used for other treatments as well as for fibroids. They interfere with the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). They stop the heavy menstrual bleeding and shrink the fibroids. Because of side effects they are generally not used for more than 6 months. Side effects include hot flashes and bone loss so they are usually prescribed to buy time before surgery. Fibroids are known to come back when the medication is stopped.
The two main types of surgeries for fibroids are hysterectomy and myomectomy. Hysterectomy is the most common surgery for fibroids and it involves removing the entire uterus. The benefit of hysterectomy is instant stoppage of heavy menstrual bleeding and pressure symptoms. When the uterus is removed to treat fibroids, a woman no longer has the option to conceive.
Myomectomy is performed by making cuts in the uterus and then removing the fibroids and leaving the uterus behind. The benefit of myomectomy is that a woman still has the ability to become pregnant. In some instances, an unplanned removal of the uterus will have to be done to save a woman’s life if she suffers from life-threatening bleeding at the surgery..
Endometrial ablation involves destroying the inside lining of the uterus (endometrium) with heat, cold, or electricity. Endometrial ablation is used only for treating heavy menstrual bleeding. It may require repeated sessions
or hysterectomy to be effective.
Irrespective of the surgery that is chosen, the complications that can happen during surgery include life-threatening bleeding, damage to nearby organs, and infection. Whether or not a woman has complications depends on several factors including, body size, number, location, and size of the fibroids and skill of the Surgeon. Most women generally take an average of 6 weeks to recover from surgery.
Two new types of uterus sparing fibroid treatment are performed by Vascular and Interventional Radiologist. They are a nonsurgical approach to treatment for fibroids and include Uterine Fibroid Embolization (UFE) also referred to as Uterine Artery Embolization (UAE) and MRI guided focused ultrasound ablation of fibroids.
These minimally invasive procedures are an advancement in the treatment of fibroids because they work directly on the uterus to destroy the fibroids. They are same-day procedures and do not cause life-threatening bleeding, injury to nearby structure or side effects in distant organs of the body. They treat both heavy menstrual bleeding and pressure symptoms. The control of heavy menstrual bleeding can be instant and it can take up to one month for the fibroids to begin to shrink.
Uterine Fibroid Embolization (UFE), is a catheter-directed fibroid treatment in which a small catheter is inserted into a blood vessel in the wrist or the groin. The catheter is guided to the artery of the uterus under low dose x-ray. Contrast dye is injected to confirm the presence of the fibroid. The second phase of this procedure is to embolize or block the blood flow to the fibroids. This step is achieved by injecting tiny particles that are made of tris-acryl polymer impregnated with gelatin into the blood supply to the fibroid. Embolization of the two uterine arteries effectively starves all of the fibroids of blood. Blood flow is reestablished to the uterus in 24 hours but not to the fibroids because they are made of abnormal tissue. With UFE all the fibroids are treated in one setting regardless of their number, size, or location. The intense pain after UFE is managed with pain and anti-inflammatory medications. The pain generally improves after the first day and these women are able to return to work in 1 week.
Magnetic resonance high intensity focused ultrasound is not as common as Uterine fibroid embolization. MRI is used to direct multiple high-intensity ultrasound beams on a single fibroid. This focused energy creates heat and destroys the fibroid. The procedure is time consuming, very expensive and not widely available. It is best suited to treat one dominant fibroid that is not deep in a woman’s pelvis.
It is important that women suffering from fibroids familiarize themselves with various treatments for fibroids.
Many factors need to be considered before prescribing a treatment for fibroids because the treatment should relieve symptoms with minimal side effects or complications.
New advances such as Uterine Fibroid Embolization are a game-changer because they are as effective as surgery with faster recovery and fewer complications and as such should be discussed with women suffering from fibroids when treatment is contemplated.
Dr Rotimi Johnson, MD.
