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Uterine fibroids

Definition


Disease: Uterine fibroids Uterine fibroids
Category: Gynecological diseases

Disease Definition:

Also called leiomyomas, fibromyomas or myomas, uterine fibroids are noncancerous, don't increase a person's chances of developing uterine cancer and almost never turn cancerous. They usually appear during the childbearing years of a woman. Women usually aren't aware that they have uterine fibroids because this condition usually doesn't cause any signs or symptoms. Almost three out of four women will have uterine fibroids at some point in their lives. This condition is usually discovered accidentally during a prenatal ultrasound or a pelvic exam. In case a woman experiences discomfort or annoying symptoms, the uterine fibroids may be shrunk or removed with medical therapy and surgical procedures. In some rare cases, if the fibroids cause sudden and sharp pelvic pain or profuse menstrual bleeding, emergency treatment may be necessary. However, most of the time, this condition doesn't cause any problems and doesn't require treatment.
 

Work Group:


Symptoms, Causes

Symptoms:

In case signs and symptoms do occur, a woman may experience some of these:

  • Difficulty emptying her bladder
  • Backache or leg pains
  • Heavy menstrual bleeding
  • Pelvic pressure or pain
  • Constipation
  • Frequent urination
  • Prolonged menstrual periods, sometimes seven days or more.

 

In some rare cases, if a fibroid outgrows its blood supply, it may cause acute pain. The fibroid will begin to die because it will be deprived of its nutrients. Pain and fever may occur in case the byproducts of a degenerating fibroid seep into surrounding tissue. A woman may also experience pain in case a fibroid that is hanging by a stalk inside or outside the uterus (pedunculated fibroid) cuts off its blood supply by twisting on its stalk. The exact location of the fibroid may cause different signs and symptoms:

 

Submucosal fibroids:

Usually, prolonged and heavy menstrual bleeding is due to fibroids that grow into the inner cavity of the uterus. These are called submucosal fibroids and could cause problems for women who are trying to get pregnant.

 

Subserosal fibroids:

A person may experience urinary symptoms in case the fibroids protrude to the outside of the uterus and press on the bladder. They may also cause backache in case they bulge from the back of the uterus and press on the spinal nerves, or they may cause constipation in case they press on the rectum. In the case of experiencing severe vaginal bleeding or sharp pelvic pain that comes on suddenly, prompt medical care should be sought.

 

A woman should also see a doctor in case she experiences spotting or bleeding between periods, difficulty emptying the bladder, pelvic pain that doesn't go away, difficulty moving bowels, overly heavy or painful periods or pain with intercourse.

 

Causes:

The smooth muscular tissues of the uterus make up uterine fibroids (myometrium). A pale, firm and rubbery mass will be created that is distinctive from neighboring tissue when a single cell reproduces repeatedly. The size of fibroids may range from small lumps that are undetectable to the naked eye, to big masses that could deform and enlarge the uterus. They may appear as a single or multiple masses. In some severe cases, the uterus may reach the rib cage if it becomes severely expanded. The exact cause of uterine fibroids is still not known. However, some of the factors that may contribute to them include:

 

Genetic alterations:

Many fibroids contain alterations in genes that code for uterine muscle cells.

 

Hormones:

The growth of fibroids seems to be supported by progesterone and estrogen which are hormones that stimulate the development of the uterine lining in preparation for pregnancy. Normal uterine muscle cells don't contain as much estrogen and estrogen receptors as fibroids.

 

Other chemicals:

The growth of fibroids may also be affected by substances that help the body maintain tissues, such as insulin-like growth factor.


Other than being a woman of reproductive age, some of the risk factors for developing uterine fibrosis include:

 

Heredity:

A woman will have an increased risk of developing uterine fibrosis in case her mother or sister had the condition.

 

Race:

The risk of black women is much more than those of other races. Black women are also more likely to have more or larger fibroids. They usually have this condition at younger ages.

 

Complications

Complications:

Uterine fibroids can cause discomfort and lead to anemia due to heavy blood loss. However, most of the time they're not dangerous. In some rare cases, fibroid tumors may grow out of the uterus on a stalk-like projection. A woman may experience a sudden, sharp and severe pain in the lower abdomen if the fibroid twists on this stalk. In this case, prompt medical care should be sought and surgery may be necessary.

 

PREGNANCY AND FIBROIDS:

Women who have fibroids are usually worried about their chances of a successful pregnancy because this condition develops mostly during the childbearing years. In some rare cases, the fallopian tubes may be distorted or blocked, or the passage of sperm from the cervix to the fallopian tubes may be hindered. Additionally, the implantation and growth of an embryo may be prevented by submucosal fibroids. Despite all this, fibroids usually don't interfere with conception and pregnancy. Some studies have indicated that pregnant women with fibroids may be at a slightly increased risk of:

  • Premature labor and delivery
  • Miscarriage
  • Separation of the placenta from the uterine wall
  • Abnormal fetal position

 

Additionally, the number, size and location of the fibroids will determine the complications. The types of fibroids that are most likely to cause problems are the large submucosal fibroids and multiple fibroids. Localized pain is one of the commonly experienced complications, particularly between the first and second trimesters. Pain relievers could easily treat this localized pain. Fibroids usually don't require treatment and they don't interfere with pregnancy. Although some fibroids may slightly increase or decrease in size during the first trimester, but most of them remain stable in size. In case a woman has experienced multiple pregnancy losses, has fibroids, has no other causes of miscarriage and the fibroids are distorting the shape of her uterine cavity, she may be recommended removing one or more fibroids so that her chances of carrying a baby will improve. The surgical removal of fibroids has a risk of excessive bleeding. Because of this risk, fibroids aren't removed at the same time of a cesarean section.
 

Treatments:

There are many treatment options for uterine fibroids. Being aware that fibroids exist is usually the best action to take after discovering them.

 

WATCHFUL WAITING:

Watchful waiting may be the best course of action in case the uterine fibroids don't cause any signs or symptoms. Only in some rare cases do fibroids interfere with pregnancy and they're usually benign (noncancerous). Fibroids grow slowly, and when the levels of reproductive hormones drop after menopause, they start shrinking.

 

MEDICATIONS:

The hormones that regulate the menstrual cycles are targeted by the medications that are used in treating uterine fibroids. These medications will treat pelvic pressure and heavy menstrual bleeding, which are some symptoms of uterine fibroids. Although these medications may shrink the fibroids, but they won't eliminate them. Some examples are:

 

Gn-RH (gonadotropin-releasing hormone) agonists:

Gonadotropin-releasing hormone (Gn-RH) is manufactured by the hypothalamus, which is a control center in the brain, in order to trigger a new menstrual cycle. This substance will travel to the pituitary gland, which is a tiny gland that is also found in the base of the brain, and set into motion the events that will stimulate the ovaries to produce progesterone and estrogen. A Gn-RH agonist will produce the opposite effect of the natural hormone when it's taken as a therapy, despite the fact that it acts at the same sites that Gn-RH does. This will cause the menstruation to stop, estrogen and progesterone levels to fall, as well as anemia to improve and fibroids to shrink.

 

IUD (progestin-releasing intrauterine device):

The heavy bleeding and pain that is caused by the fibroids may be relieved by a progestine-releasing UID, in case the fibroids don't distort the inner uterus of the patient. This treatment won't shrink the fibroids or make them disappear; it will only relieve the symptoms of this condition.

 

Androgens:

Androgens (male hormones) are produced by the ovaries and adrenal glands, which are located above the kidneys. The symptoms of fibroid can be improved if androgens are given as medical therapy. Menstruation can be effectively stopped, anemia corrected, the fibroid tumors shrunk and the size of the uterine reduced with the use of danazol, which is a synthetic drug that is similar to testosterone. However, many women may prefer not to take this medication due to its occasional side effects such as unwanted hair growth, acne, a deeper voice, headaches, weight gain and dysphoria, (feelings of depression, uneasiness or anxiousness.)

 

Other medications:

Although NSAIDs can be effective for heavy vaginal bleeding that isn't related to fibroids, however, they can't stop or reduce the bleeding that is caused by fibroids. Additionally, progestins or oral contraceptives may help in controlling the menstrual bleeding; however, they won't be able to reduce the size of the fibroid.

 

HYSTERECTOMY:

Hysterectomy is a major surgery in which the uterus is removed. So far, this is the only proven permanent solution for uterine fibroids. After this procedure, a woman won't be able to bear children. Although most women choose to keep their ovaries, but if a woman chooses to have them removed, menopause will result. After removing the ovaries, a woman should also decide whether she'll take hormone replacement therapy or not.

 

MYOMECTOMY:

In this procedure, the fibroids will be removed without touching the uterus. Unlike hysterectomy, myomectomy has a risk of fibroid recurrence. A woman may choose this procedure if she still wants to have children. This procedure could be done in several ways, some of which are:

 

Abdominal myomectomy:

In order to remove the fibroids, an open abdominal surgical procedure may be done in case the fibroids are very large, very deep or there's more than one of them.

 

Laparoscopic myomectomy:

This procedure is done by using slender instruments that are inserted through small incisions in the abdomen in order to remove the firbroids from the uterus. A laparoscopic myomectomy may be done in case the fibroids are small and few in number. A small camera that is attached to one of the small instruments will allow the surgeon to view the abdominal area. Nowadays, more fibroids or larger fibroids are removed laparoscopicly thanks to a surgical robot.

 

Hysteroscopic myomectomy:

In this procedure, a long, slender scope (hysteroscope) will be passed through the vagina and cervix into the uterus. The fibroids will be seen and removed through the scope. Only an experienced doctor should perform this procedure. In case the fibroids are submucosal (inside the uterus), this procedure may be an option.

 

OTHER PROCEDURES THAT MAY SHRINK OR REMOVE FIBROIDS:

There are several non-surgical procedures that can destroy uterine fibroids, some of which are:

 

Myolysis:

This is a laparoscopic procedure in which a laser or an electric current can destroy the fibroids and shrink the blood vessels that feed them. Cryomyolysis is yet another similar procedure in which liquid nitrogen is used to freeze the fibroids. However, the safety, effectiveness and the associated risk of fibroid recurrence of these two procedures are still not clear.

 

Endometrial ablation:

In this procedure, microwave energy, electric current, heat or hot water is used in order to destroy the lining of the uterus. This procedure will either reduce the menstrual flow or end menstruation altogether. It is performed with a specialized instrument that is inserted into the uterus. Although this procedure won't affect the fibroids that lie outside the interior lining of the uterus, however, it will stop the abnormal bleeding.

 

Uterine artery embolization:

In this procedure, the fibroids are shrunk by injecting small particles called embolic agents into the arteries that supply blood to the uterus. In this way, the blood flow to the fibroids will also be cut off. This procedure is quite effective in shrinking the fibroids and relieving their symptoms. Uterine artery embolization doesn't require an incision and its recovery time is shorter than that of a surgery. However, it should be performed by an interventional radiologist. In case the blood supply to the ovaries and other organs become comprised, complications may occur.

 

FOCUSED ULTRASOUND SURGERY:

There's a noninvasive procedure for uterine fibroids that preserves the uterus. It is called MRI-guided focused ultrasound surgery (FUS). In this procedure, the patient will be inside a specially made MRI scanner, which allows the doctors to see the anatomy of the patient, locate and ablate (destroy) the fibroids that are inside the uterus without making an incision. In this procedure, the fibroids are targeted and destroyed with a focused high-frequency, high-energy sound waves. A single session may take several hours, and is done in an on- and off-again fashion. Despite the fact that the long term effectiveness of this method is still not known, however, the initial results are promising.
 

Prognosis:

Not available

Expert's opinion

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