|
Real Women, Real Stories, Real Answers!
(will open in new window)
Uterine Fibroids,
or uterine myomas (short for leiomyoma), affect
more than 30% of women. The terms fibroid and myoma are used
interchangeably. Most fibroids do not cause symptoms, and do not
require treatment. Fibroids may require treatment in the following
circumstances:
- Fibroids are growing large enough to cause
pressure on other organs, such as the bladder.
- Fibroids are growing rapidly
- Fibroids are causing abnormal bleeding
- Fibroids are causing problems with fertility.
Types of Fibroids
 Uterine
Fibroids are classified by their location (see figure), which effects the
symptoms they may cause and how they can be treated. Fibroids that are
inside the cavity of the uterus will often cause bleeding between periods
and often cause severe cramping. Fortunately, these fibroids can usually
be easily removed by a method called "hysteroscopic resection," which
can be done through the cervix without the need for an incision.
Submucous myomas are partially in the cavity and partially in the wall of
the uterus. They too can cause heavy menstrual periods (menorrhagia),
well as bleeding between periods. Many of these submucous fibroids can
also be removed by hysteroscopic resection.
Intramural myomas are in the
wall of the uterus, and can range in size from microscopic to larger than a
grapefruit. Many intramural fibroids do not cause problems unless they
become quite large. There are a number of alternatives for treating these,
but often they do not need any treatment at all. Subserous myomas
are on the outside wall of the uterus, and may even be connected to the uterus
by a stalk (pedunculated fibroid.) These do not need treatment
unless they grow large, but those on a stalk can twist and cause pain.
This type of fibroid is the easiest to remove by laparoscopy.
Diagnosis of Fibroids
Fibroids may be felt during a pelvic exam, but
many times myomas that are causing symptoms may be missed if the examiner relies
just on the examination. Also, other conditions such as adenomyosis
or ovarian cysts may be mistaken for fibroids. For this reason, I
routinely do an ultrasound examination at the time of the first visit when a
woman has symptoms of abnormal bleeding or cramping, or if I feel an abnormality
on examination. Vaginal probe ultrasound only takes a few minutes to do,
is not uncomfortable, and rapidly provides invaluable information if the
examiner is experienced in looking at uterine abnormalities. It is
possible to fill the uterus with a liquid during the ultrasound (saline
enhanced sonography or sonohysterogrami).
While this will often provide additional information to the regular ultrasound,
I usually learn much more by looking inside the uterus with a little telescope.
This exam, called hysteroscopy, is usually a quick office
procedure, that allows directly looking inside the uterus.
Click here
to learn more about hysteroscopy.
One of the most common conditions confused with
fibroids is
adenomyosis. In
adenomyosis the lining of the uterus infiltrates the wall of the uterus, causing
the wall to thicken and the uterus to enlarge. On ultrasound examination
this will often appear as diffuse thickening of the wall, while fibroids are
seen as round areas with a discrete border. Adenomyosis is usually a
diffuse process, and only occasionally can be removed without taking out the
uterus. Since fibroids can be removed, it is important to differentiate
between the two conditions before planning treatment. It is also common to
have some adenomyosis in addition to fibroids. At times adenomyosis can be
treated with medication or a progesterone coated IUD.
MRI scans also provide an excellent picture of
the uterus. MRI is especially helpful in evaluating a large uterus and
helpful in planning a myomectomy. Adenomyosis is frequently confused with
fibroids in an enlarged uterus. MRI is especially good at distinguishing
between fibroids and adenomyosis.
Treatment of Fibroids
The most important question to ask is do the
fibroids need to be treated at all. The vast majority of fibroids
grow as a woman gets older, and tend to shrink after menopause. Obviously
fibroids that are causing significant symptoms need treatment. While
it is often easier to treat smaller fibroids than larger ones, most of the small
ones never will need to be treated. So just because we can treat fibroids
while they are small, it doesn't follow that we should treat them. And
many women have successful pregnancies without removing the fibroids as long as
they are not inside the uterine cavity. The location of the fibroids plays
a strong influence on how to approach them.
Treatment with medicines:
There are not any currently available medicines
that will permanently shrink fibroids. Often heavy bleeding can be
decreased with birth control pills. There are a number of medications in
the family of GnRH agonists, which induce a temporary chemical menopause.
In the absence of estrogen myomas usually decrease in size. Unfortunately,
the effect is temporary, and the fibroids rapidly go back to their pre-treatment
size when the medication is discontinued. Mifepristone, better know as the
'French abortion pill, or RU-486, also may cause a decrease in size of myomas,
and often stops abnormal uterine bleeding. It also has undesirable side
effects. It's use is promising, but it is not currently available in
the United States.
Surgical treatment of Fibroids:
There have been a number of procedures recently
promoted for treatment of fibroids. Some are truly new. Others
are being marketed as new in order to promote the sale of expensive instruments,
without offering any real advantages. Many new procedures prove over
time to be major advances; we may look back on others as not so wonderful.
With any new procedure, it is important to look at studies published in
peer-reviewed medical journals as well as promotional materials by a
physician, clinic, or instrument manufacturer. Ask questions: how
many of these procedures have been done in published studies; what is the
outcome; how long have these patients been followed? In deciding whether
any procedure is for you, you should look at advantages and disadvantages of all
available options.
Intracavitary Fibroids
When a fibroid is inside the uterine cavity, it
will almost always cause abnormal bleeding and cramping. If it is not
currently causing problems, the odds are very high that it will. For this
reason, I usually recommend that they be removed. These can usually
be removed by using a special kind of hysteroscope, or
resectoscope. The resectoscope is a telescope with a built-in
loop that can cut through tissue. It has been used for years to treat
enlargement of the male prostate gland, and has more recently been used inside
the uterus. This is called hysteroscopic resection of myomas.
In skilled hands most myomas inside the uterus can be removed in an
outpatient setting. Learn more about hysteroscopic
resection of myomas.
Submucous Fibroids
Unlike intracavitary myomas, some of
the fibroid is also in the wall of the uterus. Submucous myomas
often cause abnormal bleeding. Many of these can also be treated by
hysteroscopic resection. During the process of removing submucous myomas
by this method the uterus contracts, and tends to push the portion of the myoma
that is in the wall into the cavity of the uterus. The decision on which
myomas should be treated by this method should be made by an experienced
hysteroscopic surgeon. If heavy bleeding is the main reason for
desiring treatment, and fertility is no longer desired, an endometrial
ablation may also be done at the same time.
Intramural and Pedunculated
Fibroids
Myomas that are in the wall of the uterus or on
the outside of the uterus are not accessible to treatment through the cervix.
If these need to be treated, there are essentially three types of procedures:
remove the fibroid(s), destroy the fibroid(s), or remove the uterus. All
of the surgical options available are variations on one of these themes.
Some have been available for years. Others are very new and have had very
little or no long term testing.
Hysterectomy:
Hysterectomy is the only procedure that comes
with a guarantee: no more bleeding and no regrowth of fibroids. Like
any alternative, there are advantages and disadvantages of having a
hysterectomy. Click here to learn
more about hysterectomy.
Removal of the fibroid(s):
This is also called myomectomy.
Myomectomy, with one exception, means making an incision into the uterus and
removing one or more fibroids. If the fibroid is on a stalk (pedunculated)
it is not necessary to cut into the uterus to cut the stalk. Unless
the fibroid is on the outside surface of the uterus, the uterus is repaired,
usually with sutures. One of the major differences in how a myomectomy is
done involves the surgical approach to the uterus. In a laparotomy
an incision is made in the abdomen to reach the uterus. The advantage of
this is that large fibroids can be quickly removed. The surgeon is able to
feel the uterus, which is helpful in locating myomas that may be deep in the
uterine wall. The ability to touch the uterus facilitates repairing the
uterus. The disadvantage of a laparotomy is that it requires an abdominal
incision. Most of my patients who have this procedure spend two nights in
the hospital, and return to work in about four weeks.
 For
pictures of the each type of myomectomy see Dr. Indman's comprehensive web site:
All About Myomectomy for the Removal of Uterine Fibroids (will open in
new window)
Fibroids can also be removed by laparoscopy
or with a surgical robot. The laparoscope is a telescope placed in
the abdomen through the belly button. Other instruments are inserted
through small individual incisions in the abdominal wall. It is easier to
remove fibroids by laparoscopy when the they are on a stalk or close to the
surface. Once the fibroids are removed they are cut into pieces by one of
several instruments designed for this purpose, and removed. The advantage
of laparoscopic myomectomy is that it is usually done as an outpatient, and
allows faster recovery than a laparotomy. One of the disadvantages is the
extended time needed to remove large fibroids from the abdomen, although newer
instruments are improving this. Since the surgeon cannot actually
touch the uterus, it may be more difficult to detect and remove smaller myomas.
In addition, if a woman plans pregnancy after her myomectomy, there is a
question of whether the uterus can be repaired through the laparoscope as well
as it can be by laparotomy.
Click here to learn more about robotic myomectomy for removal of uterine
fibroids.
Although many fibroids can be removed
through the laparoscope, the decision of which myomas should be removed
laparoscopically and which by laparotomy depends on many factors. A woman
should discuss the advantages, disadvantages, and risks of each type of surgery
with a surgeon who is experienced in all treatment methods.
Destruction of the fibroids:
Several procedures have been designed to treat
the myomas by destroying their blood supply instead of removing them. The
first procedure, called myolysis, is done through a laparoscope.
In this procedure, a laser fiber, or more commonly an electrical device, is
placed into the fibroid through the laparoscope, and is used to coagulate the
myoma or the blood vessels feeding the myoma. The dead tissue is then
gradually replaced with scar tissue. This is easier to do than a
myomectomy (although it can be time consuming), and recovery is usually rapid.
There are several disadvantages to the procedure.
Since no sample of the fibroid is sent to the lab, for a biopsy, in the rare
case of malignancy may not be diagnosed. Frequently the procedure
causes adhesions (organs such as intestines stick to the uterus), which could
cause problems later on. Most importantly, I am not aware of any
controlled study comparing the outcome of this procedure with myomectomy or
other treatment. As with any new procedure, there is no long term
information on what will happen over time.
Uterine artery embolization, which is described below, seems to offer many
advantages over myolysis.
Uterine artery embolization:
This is the newest treatment for fibroids.
This procedure involves placing a
small catheter into an artery in the groin and directing it to the blood supply
of the fibroids. Little plugs are injected through the catheter to block
these arteries. This causes the fibroids to shrink, although there may be
pain for a short time afterwards requiring the use of narcotics.
Uterine artery embolization may eliminate the
need for surgical treatment of myomas. As in myolysis, no samples are sent
for biopsy, although the chance of malignancy in fibroids are low.
It is important to seek evaluation from physicians knowledgeable in both
embolization and traditional methods of treatment before deciding on treatment.
For more information about this promising technique, click here to reach the
Fibroid Medical Center of Northern California.
MRI Focused Ultrasound
In this technique an MRI is used to focus an
intense beam of ultrasound through adjacent tissues to destroy the fibroid.
Many women can not be treated because of the location, and the reduction in size
is minimal — much less than UFE. It is my personal opinion that all the
attention this is getting is because of expensive marketing campaigns and the
desire to make money, instead of the best interests of women with fibroids.
Other Abnormal Bleeding topics:
Diagnosis
Hysteroscopy
The Resectoscope
Endometrial Ablation
Menopausal Bleeding
| 
