In 1984, Lesli Hicks complained to her gynecologist that her lower back hurt. She was told that she'd probably lifted something incorrectly. She sought a second opinion and an ultrasound examination. At this time, cysts, endometrial tissue, and fibroids were discovered around Lesli's ovaries and were removed by laparoscopy. In 1997, Lesli began experiencing problems again. This time the culprit was a tennis ball-sized fibroid above her uterus.
Fibroids are tumors composed of smooth muscle cells wrapped in a fibrous covering. They are found in the wall of the uterus and sometimes on the cervix. If you held one in your hand, it would almost look like a little pink rubber ball, says Dr. Sheri Maxwell, Fellow of the American College of Obstetrics and Gynecology. Also called myomas, leimyomas, or fibromyomas, these overgrowths of uterine tissue are rarely cancerous. According to Maxwell, less than 0.8% are actually cancerous.
At age 34, Lesli is in the prime age bracket for developing fibroids. They occur in at least 20%-30% of women of reproductive age in the US and are the most frequent basis for hysterectomy . There may be a genetic predisposition to getting fibroids, and for unknown reasons, fibroids strike African-American women twice to three times as often as other women.
Symptoms Fibroids may produce wide-ranging symptoms, including: None at allHeavy and prolonged menstrual cyclesBackachePelvic painUrinary frequency and/or incontinenceA sensation of pelvic heavinessPain with sexual intercourse In some cases, fibroids are responsible for recurrent miscarriages . In rare cases, they have also been linked to infertility . Fibroids can form inside or outside the uterus, or within the uterine wall. They can grow larger than a grapefruit or remain as tiny as a pea. "We grade fibroids in the same manner as you would grade gestational age of a fetus. Any gynecologist in the world understands when I say that my patient's fibroids are about 16 weeks in size," says Maxwell. "I've had women walk into my office who look seven months pregnant (from a fibroid)," she adds. Estrogen affects the growth of fibroids. Many fibroids are discovered during pregnancy because they tend to become larger as pregnancy causes an increase in estrogen. Conversely, as estrogen production tapers off during menopause ; fibroids may shrink or even disappear. Diagnosis Fibroids are often discovered during a gynecologic checkup. An ultrasound examination may be used to confirm the diagnosis. If the fibroid is large enough, you may be able to feel it yourself by placing your hand on top of it.
If you are found to have fibroids, you will probably be monitored for a few months to determine their growth rate. If they're not especially large or problematic and aren't suspected as a cause of infertility, continued monitoring ("watch and wait") may be the right treatment for you. Treatment The position of the American College of Obstetrics and Gynecology is that, barring any unusual complications, treatment is usually not indicated until the fibroids are greater than 12 weeks in size (weighing anywhere from 280-320 grams). "Instead, we try to follow these patients conservatively," Maxwell reports. Medications When treatment is required, there are a variety of options . Medication is often a first option, in an effort to control bleeding and/or shrink the fibroid. Commonly used drugs include antiprostaglandins, such as Motrin. "We have women take this medication 2448 hours before the onset of their menstrual cycle and take it throughout the cycle to help decrease uterine blood flow. Of course it may help decrease cramping too," says Maxwell. Another type of drug is often used to shrink fibroids. Gonadotropin releasing hormone (GnRH) agonist drugs, such as leuprolide (Lupron) or nafarelin (Synarel), decrease blood flow to the uterus, thus depriving the fibroids of an important growth source. Because these drugs often cause the side effects associated with menopause (eg, hot flashes, vaginal dryness, decreased libido), they are not usually taken for more than three to six months. The fibroids usually recur within several months after the GnRH drugs are stopped if the patient doesn't undergo surgery. These drugs are sometimes used to shrink fibroids prior to surgery so that the surgical procedure is less arduous.
Surgical Options If drug therapies prove unsuccessful, surgery is an alternative. Individual fibroids can be removed using a procedure called myomectomy , which removes the fibroids, but retains the uterus. There are three approaches to this particular surgery. Laparotomy The abdomen is surgically opened and the fibroids are removed under direct vision. Depending on the size and location of the fibroid, this procedure can require several days in the hospital and a six- to eight-week recuperation. Laparoscopy A laparoscope is inserted through a small abdominal incision and used to view the fibroids. Fibroids are surgically removed through the laparoscope or destroyed by a laser. Hysteroscopy A hysteroscope is inserted through the cervix and into the uterine cavity. Fibroids inside the uterus are located through this telescopic device and can be removed with a wire loop device or a laser. Myomectomy is intended to leave the reproductive tract intact, but is not without risks. Excessive bleeding during surgery can require an emergency hysterectomy (removal of the uterus). In 10%-30% of women who have had a myomectomy, fibroids recur.
The only definitive cure for fibroids is hysterectomy, which is the surgical removal of the uterus. Each year, approximately 180,000 women undergo fibroid-related hysterectomies in the United States. This is a third of all the hysterectomies performed in the United States. Hysterectomy is usually recommended when fibroids become very large or if bleeding is life threatening. Several newer, less invasive procedures are used in some instances. Among them: Myolysis A needle is inserted into the center of the fibroid to destroy it by electrocution.Cryomyolysis A freezing probe is inserted into the fibroid to destroy it by freezing it from the center outward.Uterine fibroid embolization The blood supply to the fibroid is cut off leading to shrinkage. Making a Choice According to Maxwell, "If you were 45 and you needed surgery, I would counsel you for hysterectomywhy come back?" Procedures less than a hysterectomy are more likely to have to be repeated due to fibroid recurrence. "But if you were 23 and we had to do something, I would counsel you to have a myomectomy," says Maxwell. Remember, though, that ultimately the decision is yours. It behooves you to be well-read, well-informed, and well-aware of all your alternatives.
RESOURCES: American College of Obstetricians and Gynecologists http://www.acog.org The American Society for Reproductive Medicine http://www.asrm.com References: Christiansen JK. The facts about fibroids: presentation and latest management options. Postgraduate Medicine. 1993;94:129-137. Dranov P. When the diagnosis is fibroids. American Health. 1993;12:68-70. Fibroids: symptoms and treatment. National Women's Health Report. 1996:1815. Hutchins FL. Uterine fibroids: diagnosis and indications for treatment. Obstetrics and Gynecology Clinics of North America. 1995;22(4):659-665. Last reviewed February 2007 by Jill D. Landis, MD Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.