Uterine fibroids: types, symptoms, and treatment
Uterine myoma is a hormone-dependent benign neoplasm that occurs in the uterine muscle wall in women of reproductive age. Fibroids are the most common type of tumor in the female reproductive organs. Uterine fibroids are very common, especially among women 30-45 years.
It is a tangle of smooth muscle fibers interlacing with each other and is found in the form of a circular knot. Such nodes are called myomatous nodes.
It is not clear what causes fibroids, but estrogen and progesterone appear to play a role in its growth. Myoma is usually reduced after menopause when estrogen levels decrease.
Types of uterine fibroids
Uterine fibroids are a benign growth of smooth muscles and connective tissue. Fibroids can vary in size from a small pinhead to very large sizes, comparable to a melon. In medical practice myomas weighing more than 9 kg have been registered.
Uterine fibroids, in the everyday sense, is a collective concept. Under uterine myoma, non-specialist women and doctors (to facilitate the patient’s understanding of the situation) understand any benign uterine tumor. However, in terms of structure, uterine fibroids can be represented by various tissues:
- Leiomyoma – a tumor of muscle fibers;
- Fibroma – formed by connective tissue and in its pure form is quite rare;
- Rhabdomyoma – a benign tumor that develops from striated muscle tissue;
- Angiomyoma is a tumor with a well-developed network of blood vessels.
In relation to the muscular layer of the uterus, there are also three types of growth of myoma nodes:
- Internal or intermuscular fibroids grow in the middle and thick layer of the uterus;
- Subperitoneal or subserous fibroids grow from a thin outer fibrous layer of the uterus, the so-called serious. Such fibroids can be both on a broad base and on a narrow stalk.
- Submucosa or submucous fibroids grow from the uterine wall in the direction of the uterine lining – the endometrium. Submucous uterine fibroids can also have a stem or be broad-based.
Classification of uterine fibroids by the number of nodes:
- A single fibroid is a myomatous node that is clearly delimited from the surrounding muscle layer of the uterus by a false capsule formed by compressed muscle tissue. The size of a single node, as a rule, ranges from a few millimeters to 8-10 cm, rarely more.
- Multiple or multinodular uterine fibroids, consisting of two or more myomatous nodes, in some cases having a fancy arrangement “node on the node”
Causes and risk factors for uterine fibroids
Age. Fibroids are most common among women between the ages of 30 and the beginning of the 50s. After menopause, myoma is usually reduced. About 20–40% of women aged 35 years and older have fibroids of considerable size, sufficient to cause symptoms.
Race. Uterine fibroids are especially common in African-American women, they tend to develop fibroids at a younger age than white women.
Family history and heredity. The history of fibroids in a mother or sister may increase the risk.
Hormonal imbalance. Uterine fibroids are formed due to increased production by the body of female sex hormones – estrogen.
Immunological causes. Sometimes a violation of the cellular immune system leads to a decrease in the detection of cells with a broken DNA structure in the body.
Hypoxic hypothesis. Insufficient oxygenation of uterine tissue causes disruption of the metabolism and synthesis of uterine cells.
Other possible risk factors. Obesity and high blood pressure may be associated with an increased risk of fibroids
Uterine fibroids symptoms
Most patients with myoma have no symptoms. It is found by chance during a gynecological examination or ultrasound.
Common symptoms of uterine fibroids may include:
Heavy and prolonged menstrual bleeding. The most common symptom is prolonged and severe bleeding during menstruation. It is caused by the growth of fibroids, bordering the uterus. The menstrual period may also last longer than usual.
Menstrual pain. Severe bleeding and clots can cause severe cramps and pain during menstruation.
Pressure and pain in the abdomen and lower back. Large fibroids can cause pressure and pain in the abdomen or lower back, which occurs between menstruations and resembles menstrual cramps.
Problems urinating. Large fibroids can press on the bladder and urinary tract, causing frequent urination or urge to urinate, especially at night when the woman is lying. Fibroids can also exert pressure on the ureters, which in turn can impede or block the flow of urine.
Constipation. The pressure of fibroids on the rectum can cause constipation.
Pain during intercourse.
An increase in the uterus and abdomen. As fibroids grow, some women begin to feel them as hard lumps in the lower abdomen. A very large fibroid can cause an increase in the abdomen and cause a feeling of heaviness or pressure.
Uterine fibroids diagnosis
Gynecological examination and anamnesis. As already mentioned, the gynecologist can detect some fibroids during a gynecological examination.
During a pelvic examination for fibroids, the doctor will check pregnancy-related rates and other conditions, such as ovarian cysts. You will be asked questions about your family history of fibroids, about the duration and nature of menstrual bleeding. Other causes of abnormal uterine bleeding should also be considered.
Ultrasound. Ultrasound is the standard imaging method for detecting uterine fibroids. Ultrasound can be both transabdominal and transvaginal. In transabdominal ultrasound, an ultrasound transducer moves along the abdominal region. In a transvaginal ultrasound, a sensor is inserted into the vagina.
Hysterosonography. Along with ultrasound, hetero sonography can be performed using ultrasound along with a saline solution that flows into the uterus to enhance visualization of the uterus and gives much more accurate results in identifying pathologies of the uterus, including patency of the fallopian tubes.
Hysteroscopy. Hysteroscopy is a procedure that can be used to determine the presence of fibroids, polyps, or other causes of bleeding. It can also be used during surgery to remove fibroids.
During the procedure, a long flexible tube called a hysteroscope is used. It is inserted into the vagina through the cervix and reaches the uterus. A fiber-optic light source and tiny cameras in a tube allow the doctor to examine cavities in detail. The uterus is also filled with saline or carbon dioxide to inflate the cavity and provide a more comfortable view.
Hysteroscopy is a non-invasive procedure and does not require cuts, however, some women report severe pain during her behavior, therefore local, regional or general anesthesia can be used.
Laparoscopy. In some cases, laparoscopic surgery can be performed as a diagnostic procedure. Taking into account the fact that hysteroscopy allows the doctor to examine the cavities inside the uterus, laparoscopy provides a view outside the uterus, including the ovaries, fallopian tubes, and conduct a general examination of the pelvic area.
Biopsy. In some cases, an endometrial biopsy may be required to determine the presence of abnormal cells in the lining of the uterus, which are harbingers of cancer.
Laboratory tests. It may also require a complete blood count to check for signs of anemia.
The exclusion of other possible causes that can cause excessive bleeding. Almost all women, at some point in their reproductive life, experience severe bleeding during the menstrual period. Therefore, it is very important to exclude other conditions that cause or may cause severe bleeding. The causes and risk factors for heavy menstrual bleeding include:
Uterine fibroids treatment
The age of the woman and the severity of her symptoms are important factors when choosing a method of treatment.
Many women with myoma prefer not to be treated, especially if they are close to the age of menopause. Myoma usually grows slowly, and its growth stops after menopause.
However, if the tumor causes pain, bleeding, or quickly grows, treatment is indispensable. The treatment of fibroids includes various medications and surgical methods.
In modern clinical practice, there are 3 approaches to treatment:
1. Expectant tactics. This approach does not require treatment, especially if the woman is close to achieving menopause, or myoma does not cause any symptoms. Periodic gynecological examinations and ultrasounds can help monitor the condition of the fibroids.
2. Drug therapy.
Anti-inflammatory and painkillers. For pain associated with myoma, women can use acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen.
Hormonal contraceptives. The continuous dosage of oral contraceptives can normalize and shorten the menstrual period. They are also sometimes used to control heavy menstrual bleeding associated with myoma, but, unfortunately, they do not reduce the growth of fibroids. Recently, new types of continuous-dose oral contraceptives have appeared that can reduce the number of menstrual periods a woman has per year. They block or suppress estrogen, progesterone, or both of these hormones.
Intrauterine devices. An intrauterine device containing progestin-releasing can help control excessive menstrual bleeding – menorrhagia. The Mirena intrauterine system containing levonorgestrel-releasing is approved for the treatment of menorrhagia and has shown excellent results. Many doctors now recommend Miren as the first choice for the treatment of heavy menstrual bleeding, especially for women who may experience hysterectomy (removal of the uterus).
GnRH agonists. Acceptance of gonadotropin-releasing and agonists to reduce estrogen and progesterone, lead to a decrease in the size of fibroids due to stopping ovulation. GnRH agonists block the production of reproductive hormones, such as luteinizing hormone (LH) and follicle-stimulating hormone (FSH). As a result, the ovaries stop ovulating and producing estrogen. Simply put, GnRH agonists cause a temporary menopause.
GnRH agonists can be used as a drug treatment for fibroids in women who are close to the age of menopause. They can also be used as a preoperative treatment 3–4 months before surgery, in order to reduce the size of fibroids, in order to perform, ultimately, a minimally invasive surgical procedure.
As an agonist of gonadotropin-releasing hormone (GnRH), capsules are used for subcutaneous administration of Zoladex (goserelin), monthly injections of Leuprolide (Lupron) and nasal spray (nafarelin).
Before using these drugs, the physician must be sure that no other complicating conditions are present, in particular, leiomyosarcoma (cancer). The use of these drugs can weaken the treatment of malignant tumors and lead to serious complications.
Common side effects that can be very serious in some women include symptoms similar to menopause: hot flashes, night sweats, vaginal dryness, weight gain, and depression. The most important problem is possible osteoporosis due to a decrease in estrogen levels. Women should not take these drugs for more than 6 months. It should be remembered that these drugs themselves are not able to prevent pregnancy. In addition, if a woman becomes pregnant while using them, there is some risk of birth defects.
3. Surgical treatment
There are many surgical options ranging from less invasive to very aggressive. They include removal of myoma – myomectomy, removal of the endometrium – endometrium, reduction of blood supply to the uterus – embolization of the uterine arteries, and removal of the uterus – hysterectomy.
Women should discuss each option with their doctor. The decision on a specific surgical procedure depends on the location, size, and the number of myoma nodes. Some procedures affect the fertility of women and are recommended only for women who are not of child-bearing age, or for those who do not plan to become pregnant.
Indications for surgical treatment of uterine fibroids are:
- The rapid growth of fibroids;
- Severe bleeding leading to anemia;
- Multiple fibroids;
- Large fibroids;
- Severe pain syndrome;
- Torsion of legs or necrosis of fibroids;
- The combination of uterine fibroids with ovarian tumor or endometriosis, or a precancerous condition of the cervix ;
- Infertility due to the atypical arrangement of nodes;
- Suspected malignant degeneration of fibroids.
Myomectomy is a surgical procedure aimed at the surgical removal of only myomas. At the same time, the uterus is not affected, which makes it possible to preserve the reproductive function of the woman. This operation can also help regulate abnormal uterine bleeding caused by myoma. Alas, not all women are candidates for myomectomy. If the fibroids are numerous and large, it can lead to significant blood loss.
To perform a myomectomy, the surgeon can use the standard “open” surgical approach – laparotomy, or less invasive ones – hysteroscopy and laparoscopy.
Laparotomy with myomectomy.
Laparotomy is performed by incision of the abdominal wall and the usual “open” surgery. It is used for subserous myomas, which are very large, numerous, when cancer is suspected or when no laparoscopic methods are possible or there are contraindications for their implementation. Recovery from standard abdominal myomectomy takes 6 to 8 weeks. Open laparotomy carries a higher risk of scarring and blood loss, the risk of new myomatous nodes recurring is also higher than with less invasive procedures.
Hysteroscopic myomectomy can be applied to the submucosa or submucous myoma located in the uterine cavity. In this procedure, the fibroids are removed using a tool called a hysteroscopic resectoscope, which is inserted into the uterine cavity through the vagina and cervical canal, after which the doctor uses electrosurgical instruments to remove the tumor.
For women whose size of the uterus is no larger than it would be with a 6-week pregnancy and who have a small number of subserous nodes, laparoscopic surgery may be performed. Laparoscopy requires only tiny incisions, is carried out under visual control and requires much less time to recover than a laparotomy.
Complications of myomectomy are usually the same as for other surgical procedures, including bleeding and infection. This operation is not a method that gives a 100% result. Myomas may reappear after myomectomy.
Uterine fibroid embolization
Uterine artery embolization (EMA), also called uterine fibroid embolization, is a relatively new treatment for fibroids. EMA fibroids deprive her blood supply, causing myoma to contract. EMA is a minimally invasive method and technically non-surgical therapy. It is much less invasive than hysterectomy and myomectomy and has a shorter recovery time than other procedures. The patient remains conscious, albeit under anesthesia, during the procedure, which takes about 60 – 90 minutes.
This procedure is usually performed in the following order:
The patient receives a sedative and a local anesthetic is applied to the skin around the groin.
The interventional radiologist makes a small incision in the skin (about 1 cm) and inserts a catheter into the femoral artery, whose vessels feed the myoma. Particles of a special embolization preparation are inserted through the catheter. These particles block the blood supply to the tiny arteries that feed the fibroids, causing the fibroids to die, being replaced by connective tissue. This leads to a significant reduction or disappearance of myoma nodes.
Patients usually stay in the hospital overnight after the procedure has been carried out and given painkillers. Pelvic convulsions are common for the first 24 hours after the procedure.
The recovery time after the procedure, until the return to work is 1 – 2 weeks, but the reduction of fibroids can take from several months to several years.
Most patients have brownish vaginal discharge for several days after EMA, which can last until the beginning of the next menstrual cycle. Regular menstrual cycles resume within 2 to 3 months after the procedure. Severe menstrual bleeding is reduced by the second or third cycle.
Can I get pregnant after uterine artery embolization?
In general, it is believed that EMA is an option only for those women who do not plan on childbearing. Although in clinical practice there were cases of pregnancies after this procedure. Some evidence suggests that EMA may increase the risk of miscarriage in women who become pregnant. Some women who underwent EMA had a menopause after the procedure. And yet, the onset of menopause in women who have had an EMA is more likely after 45 years.
Studies on uterine artery embolization show a high level of patient satisfaction (over 90%) and a low level of complications. Symptoms of menorrhagia, as well as pain in the pelvic region, improve in 85–95% of patients within 3 months after treatment. Uterine artery embolization is an effective method of fighting myoma for most patients. However, some patients may have recurrent fibroids, requiring repeat embolization or hysterectomy.
Ablation of the endometrium destroys the lining of the uterus (endometrium) and, as a rule, is performed to stop heavy menstrual bleeding. The destruction of the endometrium can be carried out using heat, cold, microwave radiation or other means. This procedure is not advisable for large myomas or myomas that have grown outside the uterine lining. In some cases, it stops menstruation completely. In some women, menstrual bleeding does not stop but significantly reduced.
This procedure is usually done on an outpatient basis and can take as little as 10 minutes. Recovery usually takes several days.
Ablation of the endometrium significantly reduces the chance of getting pregnant. However, pregnancy can still occur, although this procedure increases the risk of complications, including miscarriage. Therefore, women in whom this procedure was carried out, still have to use methods of contraception.
Magnetic resonance focused ultrasound (FUZ-MRI)
FUZ-MRI is a non-invasive procedure that uses high-intensity ultrasound waves to heat and removes uterine fibroids. This is a kind of “thermal ablation.” The procedure is performed using an ExAblate device, which combines magnetic resonance imaging (MRI) and ultrasound.
During the 3-hour procedure, the patient lies inside the MRI machine. He is given a mild sedative to help relax, but remain conscious throughout the procedure. A radiologist uses an MRI scan for accurate sight on a myoma and directs an ultrasound beam to remove its tissue. MRI also helps to monitor the temperature generated by the ultrasound.
FUZ-MRI is suitable only for women on the verge of menopause, or who are not planning a pregnancy. It should also be borne in mind that this procedure is not suitable for all types of myomas. Thus, FUZ-MRI is not recommended if the distance between the uterine myoma and the skin exceeds 12 cm, if the beam’s access to the neoplasm is limited by the scars or loops of the intestine, the diameter of the fibroid should not exceed 10 cm, the number of lesions should not exceed 6 myomas. Pregnancy is a complete contraindication.
Hysterectomy – surgical removal of the uterus. Ovaries can also be removed, although it is not necessary to treat fibroids. Hysterectomy is the only method of treatment that gives a 100% result of getting rid of fibroids and is an option if other methods of treatment did not produce a result or are not possible.
After a hysterectomy, a woman loses her ability to become pregnant forever, but if the ovaries are removed along with the uterus, hysterectomy causes an immediate onset of menopause.
Types of hysterectomy:
- Abdominal hysterectomy
- Vaginal hysterectomy
- Laparoscopic hysterectomy
- Robotic hysterectomy
Abdominal hysterectomy is best for women with large fibroids, when you need to remove the ovaries, or when cancer is present.
Vaginal hysterectomy requires only a vaginal incision through which the uterus is removed.
Robotic hysterectomy is performed using special equipment. This approach is most often used when a patient is diagnosed with cancer, is very overweight, and vaginal surgery is not safe.
Uterine fibroids complications
Impact on fertility. Most fibroids have only a small effect on the fertility of women. Female infertility is usually associated with other factors.
Effect on pregnancy. Myoma can increase the risk of pregnancy complications. These may include:
- Cesarean section;
- Incorrect position of the fetus during childbirth, the child enters the birth canal with legs or buttocks forward;
- Premature labor;
- Placenta previa, i.e. a condition where the placenta covers the cervix partially or completely;
- Postpartum hemorrhage;
Anemia or iron deficiency can develop if fibroids cause excessive bleeding. Oddly enough, small submucous fibroids are more likely to cause abnormally heavy bleeding than large ones.
In most cases, mild anemia is treated with diet and iron supplements. However, prolonged and severe anemia can cause heart problems.
Urinary tract infections.
Large fibroids can put pressure on the bladder and sometimes lead to urinary tract infections. Pressure on the ureters can lead to obstruction of the urinary tract and kidneys.
Myoma is almost always benign, even if they contain cells with pathological forms. Uterine cancer usually develops in the lining of the uterus (endometrial cancer). Only in rare cases (less than 0.1%) does cancer develop due to malignant changes in the uterus, the so-called leiomyosarcoma. However, with a rapid increase in the uterus in premenopausal women or even a slow increase in postmenopausal fibroids, a woman needs a specialist assessment to rule out cancer.