One of the most commonly heard of problem in women of the reproductive age is fibroids in the uterus. These noncancerous growths on any of the different layers of uterus are called uterine fibroids. In many cases, uterine fibroids go unnoticed as many of them do not produce any symptoms. Uterine fibroids are found in about 20-40% of women with an age of 35 or above. About 50% of African American women have uterine fibroids of significant size leading them to higher risk of hysterectomy in premenopausal women. One third of the total cases of hysterectomies in United States are caused due to fibroids.1
What are Uterine Fibroids?
Uterine fibroids are benign muscle tumors i.e., noncancerous growths on the different layers of uterus. Uterine fibroids appear during child bearing years. Uterine fibroids are also called myoma, uterine leiomyoma, leiyomata or fibroleiyoma.
Uterine fibroids develop into a solid rubbery mass from a single cell. The growth patterns of fibroids vary as it can be rapid or slow. The size and shape of uterine fibroids also vary, as it can be as small as a seedling and also huge that it can expand the uterus to look like five months pregnancy.2
Classification & Types of Uterine Fibroids
The uterine fibroids can be classified into three types. This classification of uterine fibroids is based on the growth and location of fibroids, as it determines the symptoms and problems of uterine fibroids. The types of uterine fibroids are:
Subserosal Fibroids: These types of uterine fibroids develop under the mucosal surface of the uterus and expand outward making the uterus look knobby. These uterine fibroids may develop a stem-like base, which makes it difficult in differentiating it from ovarian mass. These type of are known as pedunculated fibroids that separate from uterus forming parasitic leiomyoma. These type of uterine fibroids can cause pressure, back pain and pelvic pain.
Intramural Fibroids: These types of uterine fibroids are asymptomatic and are located in the wall of uterus. These form of uterine fibroids expand inward making the uterus look enlarged. These are a common type of uterine fibroids, which can cause distortion of uterine cavity and show symptoms like heavier menstrual bleeding, back pain, pelvic pressure etc.
Submucosal Fibroids: These types of uterine fibroids are located under the endometrium of uterus that distorts the uterine cavity. These uterine fibroids are not commonly found, but when occur, they cause a lot of problems. Even a small uterine fibroid can cause prolonged periods and infertility. A pedunculated lesion in the cavity, called intracavitary fibroid may pass through cervix.3, 4
Besides these, the other types of uterine fibroids are:
Cervical Fibroids. These types of uterine fibroids are found on the wall of the cervix.
Fibroids in other areas. In rare instances, fibroids are found in supporting areas of uterus like uterosacral ligament, broad ligament and round ligament. Most fibroids develop in the muscular wall of uterus and may develop into a lesion. This can lead to cystic changes, hemorrhage and calcification in fibroids.
What are the Causes of Uterine Fibroids?
The causes of uterine fibroids are not known. However, fibroids tend to develop in the reproductive years, as the estrogen and progesterone influence its growth. Fibroids shrink and disappear with the reduced hormonal levels after menopause. In contrary, if after menopause hormone replacement therapy is given, the uterine fibroids remain of the same size or could grow further.5
What are the Signs & Symptoms of Uterine Fibroids?
The symptoms of uterine fibroids may be mild or there may be no signs or symptoms at all from uterine fibroids. However, if the symptoms of uterine fibroids occur, it consists of following:
Pelvic Pain in Uterine Fibroids:
- Pelvic pressure and pain.
- Abdominal pain and pressure.
- Pain in lower back and legs.
- Pain during intercourse.
Menstrual Problems in Uterine Fibroids:
- Prolonged menstrual periods causing anemia.
- Heavier and painful periods.
- Spotting between periods.
- Unusual monthly bleeding.
Urinary Problems in Uterine Fibroids:
- Pressure in the bladder leading to frequent urination.
- In rare instances, blockage in kidney leading to ureter blockage can occur in Uterine Fibroids.
- Urinary incontinence i.e. leakage of urine can be a symptom of in Uterine Fibroids.
Other Symptoms in Uterine Fibroids:
- Abnormally large abdomen.
- Constipation and bloating.
- Difficult bowel movements.
- Premature labor.
Only about 10-20% of women show critical symptoms from uterine fibroids and require treatment and the rest of them have uterine fibroids that are mostly asymptomatic.6
Histopathology of Uterine Fibroids
The uterine fibroids appear in varied shapes and sizes. A fibroid is a solid nodule in white or tan color, usually round and circumcised. Under a microscope, these fibroid cells are similar to normal elongated and spindle-shaped cells and form whorled bundles.
The cells of uterine fibroids can be classified into three variants:
- Atypical cells.
- Cellular fibroids.
- Mitotically Active Fibroids.
How is the Diagnosis of Uterine Fibroids Made?
The diagnosis of Uterine Fibroids can be done with the help of the following:
- Gynecologic Ultrasonography (Ultrasound): This is a standardized tool in assessing and diagnosing uterine fibroids. The location and the dimensions of the fibroid can be measured through ultrasound.
- Magnetic Resonance Imaging (MRI): MRI helps in getting the size and location of fibroids from different angles.
- Sonohysterography: This diagnostic tool is used to measure the growth of fibroids in the uterine cavity.
- Computerized Tomography (CT) Scan: CT scan helps in getting the images of the fibroids and measurement of its size.7
The diagnostic techniques mentioned above don’t differentiate between uterine leiomyoma and uterine leiomyosarcoma. However, a surgery is indicated in both the cases.
What are the Associated Complications of Uterine Fibroids?
- Anemia or Iron deficiency. The heavy menstrual bleeding due to uterine fibroids may lead to anemia or iron deficiency.
- Constipation or Bloating. The difference in the bowel functions may lead to constipation or bloating tendencies in women suffering from uterine fibroids.
- Hydronephrosis. Hydronephrosis may be caused due to compressed ureter due to rapid growth of cells of uterine fibroids.
- Infertility. Infertility can occur due to the growth of fibroids on the side of endometriosis.
- Adenomyosis. Adenomyosis tend to be similar to uterine fibroids and may coexist with them.
- Renal Cell Cancer Syndrome. In rare instances, the uterine fibroids may develop into or show early signs of renal cell cancer syndrome.8
What is the Treatment of Uterine Fibroids?
The treatment of uterine fibroids isn’t required until they show signs of other disorders, as the uterine fibroids shrink and disappear after menopause. If the uterine fibroids are causing any symptoms then the treatment consists of:
Medication for Uterine Fibroids. The medications for treating symptoms of uterine fibroids include:
- Oral Contraceptive Pills: These help in minimizing the uterine bleeding and cramps.
- Vitamin D3: To increase iron absorption for treating anemia. Iron supplements can also be given.
- Levonorgestrel Intrauterine Devices: Levonorgestrel- IUDs can be given to reduce the excess menstrual blood flow and other problems related to uterine fibroids.
- Ulipristal Acetate: Ulipristal acetate is used as a progesterone receptor modulator.
- Cabergoline: Cabergoline shrinks the fibroids, if taken moderately.
- Danazol: Danazol has anti-estrogenic effects that treats symptoms of uterine fibroids and shrinks fibroids effectively.
- Aromatase Inhibitors: Aromatase inhibitors are tested to diminish fibroids by decreasing the estrogen levels and by partially inhibiting aromatase in fibroids.
- Gonadotropin Releasing Hormone Analogs: Gonadotropin releasing hormone analogs are used in rare instances to treat fibroids by decreasing estrogen levels.9
Surgical Treatment for Uterine Fibroids
- Uterine Artery Embolization. It is a noninvasive tool to treat symptomatic fibroids. Uterine artery embolization (UAE) is an endovascular procedure that treats fibroids using interventional radiology. Uterine Artery Embolization treats uterine fibroids by occluding the uterine arteries and reducing blood supply to fibroids. Under local anesthesia, a catheter of 1 mm is inserted into the femoral artery. From there the interventional radiologist will inject small particles to both the uterine arteries to block the blood supply to fibroids. This will shrink the fibroids and treat the symptoms related to uterine fibroids. However, there is a higher risk of miscarriage to women who have undergone Uterine Artery Embolization (UAE).
- Uterine Artery Ligation. This is a less invasive surgery that limits blood supply in the uterus through a surgery done through laparoscopy or transvaginally. It is similar to UAE, yet an easier technique for treating uterine fibroids.
- Myomectomy. This is a type of surgery that removes one or more fibroids. Myomectomy is a fertility preserving surgery and can be classified into three types:
- Hysteroscopic Myomectomy. Also called trans-cervical resection, it is used in removing fibroid with the help of resectoscope inserted through cervix and vagina.
- Laparoscopic Myomectomy. This surgery to treat uterine fibroids consists of removing fibroids through an incision in the navel and leads to quicker recovery.
- Laparotomic Myomectomy. Also called abdominal myomectomy, it is an invasive technique to remove fibroids. The incision is done in abdominal wall..
- Radio Frequency Ablation. Radio-frequency (RF) electrical energy is used to treat uterine fibroids by inserting a needle-like device through abdomen . This helps in shrinking the fibroids for women who have crossed reproductive years and don’t want to undergo hysterectomy.
- Hysterectomy. This is a classical technique to treat uterine fibroids where the uterus is removed completely. Hence, it is used as the last alternative in treating uterine fibroids.
- Magnetic Resonance Guided Focused Ultrasound. It is a non-invasive tool that destructs the fibroid tissues using the ultrasound waves without incision.
- Endometrial Ablation. This procedure can be used to treat fibroids within the uterus. However, there are higher chances of recurrence of intramural fibroids.10
Precautions to be Taken after Treatment of Uterine Fibroids
The precautions that are needed after treating uterine fibroids to avoid their recurrence include:
- Post surgery, the patient should take a walk as it helps in reducing the chances of getting pneumonia and the risk of clotting in the surgical area.
- The patient shouldn’t lift heavy objects and should avoid climbing upstairs after treatment of uterine fibroids.
- The patient should take painkillers and medicine to treat nausea and reduce the pain from the surgery for treating uterine fibroids.
- To relieve the abdominal pain while coughing, where the surgery is conducted a pillow should be held gently.
- Breathing exercises should be done after surgery for treating uterine fibroids, as it helps in relieving gas pains and bloating, which is frequent after surgery.
- The patient may have mood swings due to the loss of reproductive capacity, which should be taken care of and seek medical help if required.
- Hysterectomy may help in minimizing the chances of recurrence of uterine fibroids, as there is a higher risk of recurrence of fibroids after treatment. However, this would lead to fertility problems.
Prevention of Uterine Fibroids
The prevention of uterine fibroids cannot be done using any specific treatment; however, keeping your body fit and healthy helps in preventing uterine fibroids.
What is the Prognosis of Uterine Fibroids?
The lesions formed due to the fibroids could turn malignant in 1 case out of 1000, which is most likely if the growth of fibroids is after menopause. There is no available statistics related to the development of a sarcoma from leiomyoma.11
The knowledge about the growth of uterine fibroids and its treatment and proper care can help to overcome this disorder. Uterine Fibroids can be prevented by maintaining a healthy body. Although in most cases, uterine fibroids would not induce a symptom, yet if any of the symptoms are obvious, seek medical help without delay.
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