Fibroids are growths that arise from a single cell in the wall of a woman’s uterus. About 25 per cent of all women over age 35 have fibroids. They are three to nine times more common in black women.
Fibroids are usually very slow growing and vary in size and location. They are only cancerous in about one in a thousand cases and these often grow rapidly. The size may be as small as a pea or as large as a basketball. They are found anywhere in the uterus wall from inside the cavity to outside the uterus attached by a stalk. The growths probably depend on the presence of the female hormone estrogen since they tend to decrease in size during and after menopause when estrogen levels fall.
Most women who have fibroids do not have symptoms. In those who do, the symptoms depend on the fibroid size and location. The most common is bleeding. Fibroids tend to cause heavier and longer periods than normal. They rarely cause bleeding between periods. Other symptoms include abdominal distention (bloating), pressure, frequent need to urinate, constipation and pain with intercourse. These develop slowly over time. Fibroids can cause abdominal pain and this can be serious enough to take a woman to the doctor. This occurs when a fibroid either twists and cuts off its blood supply or degenerates. The pain is sudden in onset but does not last long. Chronic abdominal pain is not usually caused by fibroids.
Jill is 32 and has experienced difficulty becoming pregnant. Her doctor has discovered fibroids on her uterus at her annual check-up.
Even though fibroids occur less often in women of child-bearing age, they are significant if they do. In about two to three per cent of infertile women, fibroids obstruct the path of the sperm and egg or prevent the fertilized egg from implanting in the uterus. Repeated miscarriages may occur for similar reasons.
Only a small number of women who become pregnant have fibroids. Of those who do, nearly 75 per cent will have complications during pregnancy. The most common is the need for cesarean section. Several other difficulties may occur. These include an incorrect position of the baby at birth such as breech or shoulder first presentation. There may also be premature labour, smaller baby, premature rupture of membranes, early separation of the placenta and bleeding after birth. There may be pain as the fibroids degenerate.
Most fibroids are found when an internal exam is done as part of a complete physical. They may also be found when a cause is being sought (most often by ultrasound) for some of the symptoms mentioned above. Ultrasound helps establish the size and location of a fibroid. Regular monitoring provides reassurance that the mass is indeed a fibroid and not an ovarian cyst, tumor or some other mass. If it is difficult to decide whether the mass extends from the uterus or the ovary, a CT scan or MRI may be done, but this is rare.
Most women do nothing since most fibroids do not cause any problems. If a woman is not troubled, the fibroid is usually followed by a baseline ultrasound and then yearly physical exams to monitor growth. No treatment is needed.
For a woman who has symptoms, the choice of treatment depends on the nature and severity of the symptoms, the location of the fibroid, her wish to have children and how near she is to menopause.
The symptom of heavy periods is first treated with non-steroidal anti-inflammatory drugs (NSAIDs). These are taken one to two days before a menstrual period and through the period. For some women they help decrease the bleeding and the pain with periods. If NSAIDs are not tolerated or are ineffective, low-dose oral contraceptive pills may decrease the amount of flow. If the bleeding is causing anemia, or other symptoms that are intolerable, surgery is an option.
The choice of surgery for fibroids depends on whether or not a woman wishes children in the future, and the location of the fibroids. If the fibroid is inside the uterus, it may be possible to look in with a camera (scope), remove the bulky part of the fibroid and maintain fertility. Women who have fibroids on the outer wall of the uterus and who wish to remain fertile may be treated with a procedure called a myomectomy. This is done either through an abdominal incision or with the use of a scope. It removes only the fibroids, leaving the uterus intact and women can generally become pregnant afterward. However, sometimes the surgery itself may cause blockages in the fallopian tubes and prevent pregnancy. Also, pregnancy after the procedure will often require a birth by cesarean section because the wall of the uterus has been weakened and may rupture during labour. After myomectomy, fibroids recur in about 27 per cent of women.
For women who do not wish to become pregnant, but wish to keep their uterus, a procedure called myolysis may be possible. This is done through a scope and electricity is used to cut off the blood supply to the fibroid. Again, fibroids often recur with this procedure.
The most certain cure for fibroids is a hysterectomy or complete removal of the uterus. This is generally chosen by women who have completed their families and want no recurrence of the fibroids.
There are some medications that may be used for three to six months before surgery. These are known as gonadotropin releasing hormones (GnRH) analogues and cause artificial menopause. They are useful for women who are anemic. Menstrual periods stop and red blood cell levels can increase without a transfusion before surgery. GnRH analogues also shrink the uterus and fibroids and this may make surgery easier. For example, a smaller uterus may allow a vaginal rather than abdominal hysterectomy to be done. This approach results in fewer complications, faster recovery and no abdominal scar. The difficulty from these drugs comes with their side effects which mimic menopause - hot flashes, vaginal dryness, insomnia and osteoporosis.
GnRH analogues may provide a non-surgical option for women who are near menopause. They offer help through that year before the fibroids shrink naturally from decreasing hormone levels. When used along with hormone supplements to help counteract the osteoporosis that occurs, they can help shrink fibroids, decrease symptoms and save the uterus.
GnRH analogues are not useful for younger women because of the osteoporosis associated with long term use. Also, when the medication is stopped, the uterus and fibroids return to their original size within four to six months.
In summary, fibroids or benign growths in the muscle wall of the uterus are extremely common and usually without symptoms. They are often found by chance and can be followed by yearly physical exams. If a fibroid gives symptoms, both medical and surgical options are available. The decision for how to manage a fibroid is a personal one and should be discussed between a woman and her doctor to discover what options best suit her.