FIBROIDS | Concepts | Treatment | Medical | Surgical
Although generally small, fibroids of the uterus create havoc for many women and lack a consensus regarding the most effective and least invasive therapy. Most women harbor generally innocent but sometimes troublesome tumors within the lining of their womb. Fortunately these nodules of smooth muscle combined with varying amounts of connective tissue remain benign, non-cancerous, throughout their course. Variously known as myomas, fibromas or leiomyomas, most commonly they are referred to simply as fibroids.
Depending on the thoroughness of medical investigation, estimates suggest up to 8 out of 10 women will develop fibroids. Clinical examination in a doctor’s office places the incidence at 1 in 3 females. Ultrasound studies raise the frequency to 50% while more complete microscopic evaluation of the uterus increases the likelihood to approximately 80% which potentially translates to well in excess of 50 million women. By far fibroids represent the most common tumor of the female reproductive system.
Quite unusual in teenagers, the incidence begins to slowly climb during early adult years and peak during mid-life. Since hormonal factors remain central to their continued proliferation, growth ceases after menopause with some of the lesions undergoing a process of involution which includes shrinkage, cystic changes, calcification and cell death. As a corollary, growth of a presumed fibroid during the post-menopausal years requires careful evaluation since the likelihood of a mistaken diagnosis appears substantial.
MOSTLY SMALL AND OFTEN WITHOUT SYMPTOMS
Most women develop multiple fibroids with the average number ranging between 5-10, however only 1 or 2 lesions may come to medical attention. Actually in excess of 20 growths may be present. Interestingly fibroids seem independent of one another with some growing, others shrinking and still others appearing unchanged even within an individual. Some lesions remain constant for awhile only to subsequently undergo transient growth before again entering the resting stage.
Most fibroids are relatively small, however they can approximate the size of a 20 week pregnancy or rarely extend all the way to the ribcage. Most of those brought to medical attention average around 2-4 inches in diameter. But they may be no larger than a grain of sand and only apparent during microscopic examination of the womb.
Risk is not equally distributed throughout the population. African-Americans appear 2-3 times more likely to develop fibroids than whites or Hispanics. Fibroids tend to be relatively less frequent among Asians. Not only do fibroids occur at an earlier age in African-Americans, but lesions appear more numerous and grow more rapidly.
As with everything in medicine, genetics impacts on an individual’s propensity to develop fibroids. A family history may increase the risk by up to 600% with identical twins affected more often than non-identical twins.
Exposure to estrogen seems a major if not essential factor in the genesis of fibroids. The risk appears greater in those with early onset of puberty than among those whose menses are delayed until after age 13 or 14. Questions exist regarding what if any role exists for exposure of the uterus in the unborn fetus to maternal estrogen. Similarly weak estrogens remain common in the environment while governmental agencies uniformly vouch for their safety Others believe almost universal contact with chemicals such as genistein, bisphenol A and polychlorinated bisphenyls or PCBs may lead to long delayed complications.
Obesity also seems to predispose to fibroids. An enzyme in fat cells, aromatase, converts male hormones produced in the adrenal glands and ovary into estrogen. Additionally fat lowers the binding of sex hormones and in doing so increases exposure of the tissues to the free, active hormone. Interestingly culture of fat cells with uterine smooth muscle cells, the main component of fibroids, results in growth of the muscle.
Previous suggestions implicating exposure to birth control pills and post-menopausal hormone replacement therapy appear inaccurate. Neither alcohol, tobacco products, red meat, dairy nor a deficiency of Vitamin D seem related to fibroids. The same situation applies to whole grains, fiber and eggs.
Classification of fibroids and their tendency to cause symptoms depends in large measure on their location. More than half appear within the thick muscular wall of the uterus. These intramural fibroids tend to remain asymptomatic unlike the submucosal fibroids that bulge from the inner wall and impinge on the uterine cavity. At times they may even appear on the cervix or protrude from the uterus through the cervical canal into the vagina. Subserosal fibroids occur on the outer wall of the uterus and depending on their size may protrude into the pelvic or abdominal cavities.
While most fibroids grow with a large attached base and a smaller dome shaped protrusion, at times they may be pedunculated and grow on a stalk in a mushroom like pattern. These pedunculated lesions within the cavity of the uterus tend to cause bleeding while those on the outer wall may actually detach and interfere with normal internal organ function.
SYMPTOMATIC OR NOT
Most fibroids, even fairly large lesions, fail to cause symptoms. When complaints arise they tend to involve atypical uterine bleeding or menstrual disturbances. Excessive menstrual bleeding remains the most frequent issue leading to medical consultation. In some women the situation may be so severe as to require changing sanitary pads several times an hour. This degree of blood loss may lead to iron deficiency anemia with its own associated symptoms of dizziness, lightheadedness and shortness of breath.
In some women periods last longer than a week and may be associated with cramping. Bleeding between periods is not infrequent.
Other common symptoms include discomfort and less often pain. The uterus is positioned between the bladder and bowels. As a consequence it seems perfectly logical that fibroids lead to mechanical symptoms simply by exerting pressure on surrounding structures. Frequent urination, rectal issues and at times low back pain or sciatica-like symptoms ensue. Large lesions can increase the abdominal girth and even mimic the appearance of mid-stage pregnancy.
Less frequently tumor growth exceeds the blood supply. In these instances portions of the fibroid die or become necrotic and irritate the nerves. A sharp stabbing pain uncharacteristic of typical fibroids may result.
INTERFERENCE WITH FERTILITY
Considerable discussion focuses on whether fibroids lead to infertility. While some overlap exists, fibroids probably account for less than 3% of all infertility. In some situations, especially with the submucosal type, fibroids may interfere with normal peristaltic waves necessary to guide sperm in their passage through the uterus into the fallopian tubes. This also disrupts the process of implanting the fertilized egg.
Of more concern however is the potential interference with pregnancy. Women with fibroids suffer a greater likelihood of miscarriage, breech presentations with the baby incorrectly positioned in the uterus and the need for Cesarean section. Preterm delivery and failure of normal labor to proceed according to schedule remain common problems. Placental issues predispose to localized bleeding disorders. Fortunately the majority of pregnancies remain unimpaired and unaffected by the presence of fibroids.
Diagnosis often comes as a surprise resulting from a routine gynecology examination in a totally symptom free individual. Confirmation if appropriate may require ultrasound examination with the sensor placed either on the abdomen or in the vagina. Abnormal bleeding may lead to an endometrial biopsy, a D & C, a CT scan or MRI. Other possible tests include direct visualization of the uterine cavity with an instrument akin to a repurposed colonoscope or alternatively taking an x-ray after filling the uterus with dye.
OTHER POSSIBLE DIAGNOSES
Conditions that must be excluded include endometriosis, uterine or endometrial cancer, ovarian tumors, pelvic infection, IUD related issues and of course pregnancy. Endometriosis often co-exists with fibroids. According to some reports possibly 10-30% or more of women with fibroids also suffer from endometriosis. In these women symptoms may be falsely attributed to the fibroids when the actual culprit is endometriosis.
Microscopically fibroids appear as white to tan, round, well demarcated, firm masses of varying size. While a true capsule does not exist, they compress adjacent tissue in the womb which gives rise to a cleavage plane. Cells appear spindle shaped and uniform in size and shape without significant cell division. These characteristics separate benign, typical fibroids from the much less common but often deadly leiomyosarcoma.
Despite the name fibroid, this common tumor arises from a mutation of a smooth muscle cell or its stem cell in the lining of the uterus. Each tumor arises from its own unique smooth muscle cell. Even in the presence of multiple lesions, each arises as a separate tumor from cells genetically unconnected to any neighboring lesions. Leiomyomas do not possess the ability to spread from one lesion to another. Since fibrous tissue remains a secondary feature rather than a primary abnormality, the tumor appears incorrectly named.
When appropriate, treatment must be aimed directly at the symptoms. Realizing most women are unaware of their condition and lack specific complaints, treatment often appears unnecessary and inappropriate. In others with minimal issues, perhaps aspirin or its related compounds ibuprofen or naproxen or possibly even acetaminophen suffice. The presence of excessive bleeding requires combination birth control pills containing estrogen and progesterone or alternately a progesterone containing IUD. These often restore normal flow.
For some women, especially with large tumors, it may be appropriate to effectively turn off hormone production. Injections or nasal sprays containing Gonadotropin-Releasing Hormone agonists stop the pituitary gland in the brain from releasing signals to the ovary necessary to produce estrogen and progesterone. These drugs including Lupron, Zoladex, Synarel and buserelin may shrink fibroids and minimize the risks for injuring either bladder or bowels during subsequent surgery. Since they induce menopausal symptoms, appropriate use limits prescriptions to a maximum of several months. For women nearing natural menopause, this may provide a sufficient bridge while others achieve only temporary relief.
A novel therapy involves blocking the actions of progesterone. Mifepristone and Ella, the so-called morning after contraceptives, often adequately treat symptoms, reduce tumor size, improve back pain and eliminate urinary symptoms. They cause fewer symptoms of low estrogen contrasted against the Gonadotropin-Releasing Hormones but they increase the risk of miscarriage when taken by unknowingly pregnant women. Neither Mifepristone nor Ella are FDA approved for long term treatment of fibroids.
In the near future, release of SPRM – selective progesterone receptor modulators – for longer term therapy will offer an FDA sanctioned therapeutic avenue. Already approved in Europe, Canada and Australia, release in the United States appears likely by mid-2018. Ulipristal acetate, the same chemical in Ella, will be available as an oral medicine to be taken daily for 3 months with a total of up to of 4 courses. It leads to amenorrhea and lack of menstrual bleeding, together with shrinkage of the fibroids. Several similar chemicals, Elagolix and Vilaprisan, appear poised to enter the market somewhat later.
Some doctors prescribe aromatase inhibitors. These drugs mostly geared to prevent estrogen production in women with breast cancer interfere with estrogen production in fatty adipose tissue. The Danazol era has basically passed. In addition to its mild benefit on fibroids, this drug produced male or androgenic effects including acne, excessive body hair growth, muscle cramps, depression and a decrease in breast size.
MORE INVASIVE THERAPIES
More invasive therapies are commonly necessary in treating fibroids. When one or two dominant lesions causes problems, the individual tumors may be removed by a surgical procedure known as myomectomy. This may be performed by a traditional abdominal incision, through a laparoscopic approach or with an instrument passed into the uterus by way of the vagina and cervix. For women desiring pregnancy, this technique maintains fertility. Pre-treatment with Gonadotropin-Releasing Hormones decreases bleeding and increases the likelihood of success. Only some fibroids can be successfully treated with myomectomy.
Recently interventional radiologists began treating fibroids. They insert a tube into an artery in the groin and with careful imaging direct the catheter to the artery supplying the uterus. Injections of microscopic particles block blood flow to the fibroid which ultimately leads to its shrinkage and cessation of excessive bleeding. Considerable discomfort occurs along with a fever lasting approximately one week.
When the offending fibroid appears close to the inner uterine lining, it may be destroyed by endometrial ablation employing either laser energy, ultrasound or electrical heating. Radiofrequency ablation is a similar technique recently approved by the FDA.
Hysterectomy remains the most common operative procedure in women performed over 600,000 times each year. About 1/3 or 200,000 of these surgeries specifically relate to fibroids. It certainly eliminates problems directly caused by fibroids and unlike other techniques it eliminates the possibility of recurrence.
Removal of the uterus may be accomplished by way of the vagina if the tumors are not too large. Traditional abdominal surgery with a bikini incision has largely been replaced by so-called belly button surgery or laparoscopy. With this latter procedure four small incisions in the abdomen allow access to the uterus.
Recently significant controversy enveloped removal of the uterus by way of laparoscopy. Obviously the uterus and fibroids cannot be delivered through the small laparoscopic incisions. A morcellator that basically grinds tissue gained acceptance in 1995 but met resistance in 2009 when the American College of Obstetricians and Gynecologists recommended vaginal hysterectomy as the preferred procedure. In 2012 it became apparent that morcellation spread cancer throughout the pelvis and abdomen in the rare cases when the suspected fibroid was actually a malignant leiomyosarcoma.
The FDA currently recommends morcellators NOT be utilized but has not yet removed the device from hospitals and surgeries. A simple alternative may combine laparoscopic separation of the attachments mooring the uterus to other structures with removal of the tissue by way of a vaginal incision.
Some women with minimal symptoms opt for a more natural approach. They turn to complementary therapies such as green tea, dandelion, milk thistle, chasteberry, black cohosh root or dong quai. Others opt for garlic, ginger, thyme or fish oil. No medical evidence supports any of these as therapeutic.
With so many possible options available for treating fibroids, it should come as no surprise that the specific recommendations for any given individual will depend in part on symptoms coupled in large measure on the doctor’s personal preferences. No firm guidelines exist to inform doctors or patients of how to proceed. Obviously a second opinion may be worthwhile pursuing in order to make certain your selection matches your wants and desires. Additionally it remains essential that you understand all of the potential choices as well as participate in weighing their benefits and risks.