Uterine Fibroids; the truth behind them!

Most women tend to have a fear from fibroids, and this fear originates from the misconceptions about them and the main belief that they will transform into cancer. So, I decided to tackle this topic with the purpose of clarifying some general concepts about fibroids, and hopefully to make you more familiar with the medical indications for their treatments and the different available treatment modalities.

Fibroids are the most common benign gynecologic tumors we see. Actually, the woman’s lifetime risk for developing fibroids is 70-80%. They are muscular tumors that arise from the already muscular uterus (womb). They can be in different locations (in the uterine cavity, in the wall of the uterus or on the surface of the uterus, or any combination of the three), and can be found in different numbers, sizes and locations in the same patient.

Of course, there have been multiple risk factors associated with fibroids, yet a cause effect relationship is still to be elucidated. So, what are these risk factors?


Genetics

One of the most important known risk factors for fibroids development, is a family history of fibroids (in your mother, sister, grandmother, aunts …) speaking of a genetic predisposition.


Race

Black women are known to be at a much higher risk for fibroids development compared to white women (2 to 3 times the risk). This is suggested to be stemming from disparities in the genetics, diets, lifestyles, psychological stressors and environmental exposures between different races.


Reproductive History

The reproductive history is thought to be related to the risk of fibroids development because the latter tumors are hormone sensitive and thus their growth is thought to fluctuate with the fluctuating hormonal levels. It was shown that the more babies you have and the more you get pregnant, the lower is the chance for you to develop fibroids. On the other hand, the earlier is your age of menarche (age of first period), the higher is your chance for developing fibroids.
One might ask; if fibroids growth is hormone dependent, can birth control pills cause fibroids development? Well the answer is simply No! Oral contraceptive pills were not shown to be associated with an increased risk of fibroids growth in the general population. 


Obesity

Most studies have shown a potential yet not a very solid relationship between fibroids and body mass index, as fibroids are more commonly seen in obese women.


Diet

Consumption of beef and red meats was shown to be associated with an almost 2 times increase in the risk of fibroids development, whereas the consumption of green vegetables and fruits (especially citrus fruits) halved the risk of fibroid development 

Moreover, new data are showing that Vitamin D deficiency can be associated with an increased risk of fibroids. 

Caffeine was only associated with an increased risk of fibroids, in young women (under the age of 35) with a heavy daily caffeine intake.

Alcohol, especially beer, was shown to be associated with fibroids development!
Some studies show that smoking decreases the risk of fibroids, yet I would never advocate smoking for this purpose.

In addition to the previously mentioned risk factors, there are many other factors that play a role in increasing or decreasing the risk of fibroid development, yet I believe that the strongest influence is that of genetics. I always encourage you to stay fit and healthy, but I would not recommend obsessing about your weight and dietary habits for the sole purpose of preventing fibroids development or growth as the data is still inconclusive. The only preventive measure I would endorse is high physical activity which is associated (as per one study) with a substantial decrease in the risk of fibroid development.

So, we have established for now that fibroids are the most common solid benign gynecologic tumors we encounter, and we have also demonstrated that there are lots of predisposing factors that interplay in predicting the woman’s risk for fibroid development. Now what about the symptoms?

First of all, most fibroids are small and asymptomatic, and thus can only be discovered incidentally by ultrasound on routine annual gynecologic visits. Actually around 35-50% of women coming for routine checkups, turn out to have small insignificant fibroids on their ultrasounds. You should be informed about the presence of these fibroids and your doctor should keep a note of their existence even if they are not causing any symptoms, for the purpose of following them up in subsequent years. Yet, you should relax and keep in mind that small asymptomatic fibroids are ought only to be monitored on a yearly basis by ultrasound with no need to embark on any medical or surgical management plans.

In contrast, many other women have symptomatic fibroids and these symptoms include:


Heavy or Prolonged Menstrual Bleeding

As I have previously mentioned, fibroids can be located in the uterine cavity (on the inner lining of your uterus) subsequently causing heavy and/or prolonged periods. This in turn can cause severe blood loss and iron deficiency anemia (low blood count). The definition of a heavy period always depends on your baseline. Any increase from your baseline bleeding patterns should prompt you to visit your doctor for investigation.


Urinary and Gastrointestinal Symptoms

Also, fibroids can be big enough to cause pressure on the urinary bladder (which is located in front of the uterus) or rectum and large bowels (located behind the uterus). So, big fibroids can cause both urinary or gastrointestinal symptoms such as frequent urination, difficulty in initiating urinary stream or constipation.


Pelvic pressure

Here again, large fibroids can cause a bulky sensation of pelvic pressure and discomfort. This fullness in the abdomen and pelvis mimics the feeling of pregnancy! Whenever you feel such a discomfort it is crucial for you to visit your general health care physician or gynecologist to rule out any mass in your pelvis (including large fibroids)


Pain

Besides the general discomfort of pelvic pressure and fullness just described, sometimes fibroids undergo what we call “degeneration” because of a decrease in their blood supply (if a fibroid is too big it can outgrow its own blood supply, or it can twist around its blood supply), in other easy terms, fibroids sometimes can start "dying" when they can get too large for their own nutrients and oxygen supplies and this causes excruciating pain. Yet this entity is not commonly seen (mainly seen during pregnancy when fibroids can grow fast).


Fertility problems

The only fibroids that were shown to interfere with fertility are those causing harm to the endometrial cavity (the inner lining of the uterus where the embryo normally implants). So, such fibroids were associated with an increased risk of infertility and recurrent pregnancy losses. Hence, part of the workup of infertile couples, is to make sure that the uterine lining is normal and that it does not harbor any structural pathology standing in the way of a healthy normal implantation.
However, keep in mind that most women with uterine fibroids are able to get pregnant on their own, and the presence of fibroids should not conclude the infertility workup as women with fibroids and reproductive problems should still go through a basic infertility evaluation before concluding that the fibroid is the cause of the problem. 


Pregnancy

Most pregnancies in the presence of uterine fibroids go smoothly without complications. But whenever the fibroid is large (more than 5-6 cm at the beginning of the pregnancy), women become more prone to certain pregnancy complications such as preterm contractions (uterine contractions before 37 weeks of gestation), pain during pregnancy, bleeding and higher labor failure rates.


Cancer

It is extremely rare for fibroids to evolve into cancers. Actually, some studies believe that benign fibroids never evolve into malignancy, yet other studies have shown that the risk of a benign looking fibroid to harbor malignancy in them is 0.01-0.2% (which is still extremely rare). So, don’t panic about your fibroids! The uterine cancer known as “Leiomyosarcoma” is a separate entity that has (in addition to the risk factors it shares with fibroids) other unique risks factors (advanced age, postmenopausal status, Tamoxifen use (medication for some breast cancers), pelvic irradiation and hereditary cancer syndromes).

So, fibroids can cause a wide array of symptoms, yet remember again that most fibroids are silent and do not cause any manifestation. However, when symptoms are present and bothersome, treatment becomes warranted. 

Now, what are the different treatment modalities we have? And what is the best treatment for you?


Medical treatment

I will start with the medical treatment before jumping to the surgical one. Most medications used aim to reduce the symptoms of the fibroids (pain, bleeding, anemia…) or shrink the fibroids.
Women with heavy menstrual bleeding and subsequent anemia should start with iron and vitamins for the purpose of correcting the anemia.
Non-steroidal anti-inflammatory (NSAIDs) medications reduce both the bleeding as well as the pain and can also be one of the first line treatments for symptomatic fibroids. Keep in mind that NSAIDs are inexpensive and found over the counter, but be aware of their side effects and do not use them in high doses if you have hypertension or kidney problem (always consult with your physician before starting any medication).

Hormonal birth control methods can also be used to reduce cramps, bleeding and pain during your menstrual period secondary to the fibroids. These birth control methods include “the pill”, Mirena intrauterine device (hormonal IUD), implant, vaginal ring, shots and the skin patch (check with your physician about the mode of use and side effect of each birth control method) (an article tackling this subject will be published in the near future).

Some medications called “Antifibrinolytic” can reduce blood loss but these should only be used temporarily as they do not have any long-term benefits on neither shrinking the fibroid nor correcting the anemia.

Progesterone receptor modulators (Esmya/ulipristal) can be used to shrink your fibroids, but there is an FDA warning about potential liver toxicity with the chronic use of this medicine (check with your physician).

GnRH shots (agonist or antagonist) are also helpful in shutting down your ovaries and preventing the production of hormones (estrogen and progesterone) thus decreasing the bleeding caused by the fibroid and shrinking the fibroid itself. You should keep in mind that such shots should only be used temporarily before surgeries as they have long term side effects mimicking menopause (check with your physician for details)

There is no need for you to bother yourself with all the names and modes of actions of the medications listed above, but the point is that you should be familiar with the existence of such medicines that can sometimes substitute the more drastic surgical management plan!


Surgery

Medicines can help and can alleviate the symptoms, and I believe that they work best in a subset of women, however the conclusive treatment plan remains to be surgery.

Surgery can be limited to the removal of the fibroid itself (a procedure we call “Myomectomy”), or the removal of the whole uterus (called “hysterectomy”). Indeed, a hysterectomy is more definitive than a myomectomy, because with the latter fibroids can still recur.


Myomectomy

This is the surgical removal of the fibroid. Depending on the size and location of the fibroid the surgical technique differs. If the fibroid is small and inside the uterine cavity, then the best treatment plan is “hysteroscopic myomectomy” which is a simple quick relatively easy procedure during which your physician inserts a camera guided instrument in the uterus (through your vagina and cervix) to reach the inside of the uterus and remove the fibroid. Such procedures usually do not last more than 15-30 minutes yet require general or regional anesthesia. You can go home the same day!

If the fibroid is outside the cavity (in the muscle or on the surface of the uterus) then hysteroscopy cannot be helpful and thus you should undergo either an open surgery (just like a cesarean section) or a laparoscopic minimally invasive surgery (camera guided instruments through your belly) in order to remove the fibroid. You should discuss with your physician the pros and cons of each surgical technique and keep in mind that some fibroids are too big to be managed with other than an open surgery.
One of the most important indications for myomectomy is whenever you want a surgical management but still want to maintain fertility, but you should known that fibroids tend to recur, and up to 25% of women will need another surgery for fibroids after a prior myomectomy.


Hysterectomy

If you have completed your family and agreed with your physician to remove the whole uterus then the removal of the latter (“hysterectomy”) can be done using the open, laparoscopic/robotic or vaginal techniques. Again here, each method has its own advantages and disadvantages so always check with your physician for further details.  


Endometrial Ablation

This procedure signifies burning and ablating the inner lining of the uterus to reduce your bleeding.  There are different methods used for endometrial ablation, some can be done in an office setting, yet not all are available in all countries and hospitals (check with your doctor). The problem is that after an endometrial ablation, pregnancy is not recommended and thus a contraceptive method should be instilled.


Other treatment modalities

Other treatments including embolization, radiofrequency ablation and other fancy terms which are beyond the scope of this article as they are rarely used but you can get further details about them from your physician.

Treatments are many, spanning from medical to surgical ones, but what is the right treatment for you?

The treatment choice should be based on a thorough discussion with your doctor. The decision depends on the most bothersome symptoms you are having, your age, and your plan for future fertility. For example, if the bothersome symptoms are heavy cycles but you do not want to proceed with surgery for desire of future fertility, then the best therapy option would be medications to try to reduce the bleeding. On the other hand, if you have a fibroid causing infertility or recurrent pregnancy losses (after extensive workup) then the best option would be for you to remove the fibroid surgically. And keep in mind that sometimes we try medical management first and if it fails we explore our surgical options. Always remember that each patient is unique, so do not compare yourself and your case to that of your mother, neighbor or friend.

Finally let us debunk few myths as usual

Myth 1: Fibroids will become cancers

Fact 1: As I have previously mentioned, fibroids are benign growths from the uterus and they almost never transform into malignancy. The uterine cancer known as ”Leiomyosarcoma” is a different entity with different risk factors

Myth 2: Fibroids should always cause symptoms

Fact 2: No! Most fibroids are small and asymptomatic. They are mostly diagnosed incidentally on routine office ultrasounds

Myth 3: Ultrasound can determine with a 100% accuracy if I have a benign fibroid “leiomyoma” or a malignant tumor “leiomyosarcoma”

Fact 3: This is not true. Ultrasound is a sensitive tool that can show some signs hinting for a potential malignancy, but it cannot determine with a 100% certainty the exact pathology. Your doctor should put together the imaging (ultrasound or MRI) with your age, history and risk factors before taking a plan of action.

Myth 4: Hysterectomy is the only option I have for the management of my fibroids

Fact 4: As I have previously mentioned, hysterectomy is the last resort for the management of fibroids. There are different medical and less invasive surgical techniques that can substitute hysterectomy. However, you should know that the latter is the only definitive treatment that has a 0% recurrence rate.

Myth 5: “I cannot be or stay pregnant when I have fibroids”

Fact 5: Most women with fibroids can get pregnant easily and have smooth pregnancy courses.

Myth 6: “If I remove my fibroid it will not come back”

Fact 6: Myomectomy (the surgical removal of the fibroid) is not a definitive therapy plan, as 10-25% of women will undergo another fibroid related surgery after their first. Fibroids are known to recur; hence the only definitive therapy is hysterectomy (removal of the whole uterus)

Myth 7: Fibroids will continue to grow.

Fact 7: Fibroids are sensitive to their environment. They can continue growing, remain the same size or even shrink with time. Actually 10-40% of incidentally diagnosed fibroids were noted to shrink with time even without any therapy plan. That’s why it is not recommended to manage asymptomatic small fibroids.

Myth 8: All fibroids should be removed

Fact 8: Small fibroids that have no symptoms can only be monitored without removing them. Also, even symptomatic fibroids can be medically managed without removing them.

Myth 9: All fibroids disappear after menopause

Fact 9: After menopause the hormones will decrease in your body and most of the times fibroids do shrink. But this is not the fact in 100% of women, as some continue to have an enlarging fibroid after menopause (which is an indication for evaluation and potentially surgical management), and some fibroids do shrink but do not totally disappear (these can be only monitored on an annual basis by office ultrasound).

Myth 10: Removing a fibroid always requires an invasive surgery

Fact 10: Nowadays with the advances in the surgical techniques, we rarely perform invasive and extensive surgical procedures for the management of fibroids as most of them can be surgically removed with minimally invasive approaches (robotic/laparoscopic and hysteroscopic). The combined average hospital stay for the mentioned minimally invasive procedures is reported to be only 1 day!

In conclusion, we can clearly say that fibroids are the most common benign sold pelvic tumors in women, they are mostly asymptomatic and insignificant, they do not always require treatment, and when treatment becomes medically indicated, they can be managed either medically or surgically.

 

Karam


Disclaimer: I do not encourage you to initiate any medication I mention in my articles before consulting with your physician.

 

 

 

 

 

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