Uterine fibroids are very common benign growths that develop in the muscular
wall of the uterus. You might hear them referred to as "fibroids" or
by several other names, including leiomyoma, leiomyomata, myoma and fibromyoma.
They range in size from a few millimeters to the size of a grapefruit. Occasionally,
they can cause the uterus to grow to the size that may simulate a pregnancy.
In most cases, there is more than one fibroid in the uterus. While fibroids
do not always cause symptoms, their size and location can lead to problems
including pain and heavy bleeding.
Uterine fibroids can dramatically increase in size during pregnancy due to
increased estrogen levels. After pregnancy, the fibroids usually shrink back
to their original size. They typically improve after menopause when levels
of estrogen decrease dramatically. However, menopausal women who are taking
supplemental estrogen hormone replacement therapy may not experience relief
of symptoms.
Fibroid tumors of the uterus are very common, but for most women, they either
do not cause symptoms or cause only minor symptoms. Fibroids can cause
very heavy menstrual bleeding, clotting and pelvic pain, leading many women
to seek treatment. Fibroids often fail to respond to medical therapy
and then surgical procedures are often recommended.
Twenty to 40 percent of women age 35 and older have uterine fibroids of significance.
African American women are at a higher risk for uterine fibroids and as many
as 50 percent have them. Uterine fibroids are the most frequent indication
for hysterectomy in pre-menopausal women and, therefore, are a major public
health issue. Over 200,000 hysterectomies are performed annually in the U.S.
due to fibroids.
Fibroids may be located in various parts of the 
uterus.
In most cases, there is more than one fibroid in the uterus. There are three
primary types of uterine fibroids which can be distinguished with either an
ultrasound or magnetic resonance (MR) exam:
Subserosal fibroids develop under the outside covering of the uterus and expand
outward through the wall, often compressing the urinary bladder. They typically
do not increase a woman's menstrual bleeding, but can cause pelvic and back
pain as well as generalized pressure. The subserosal fibroid can develop a
stalk or stem-like base, making it difficult to distinguish from an ovarian
mass.
Intramural fibroids develop within the muscular wall of the uterus and expand
inward; increasing the size of the uterus, and making it feel larger than normal
in a gynecologic internal exam. These are the most common. Intramural fibroids
can result in increased and more frequent menstrual bleeding, pelvic pressure,
as well as pelvic and back pain.
Submucosal fibroids are just under the endometrial lining of the uterus.
These are the least common fibroids, but they are the most symptomatic. A small
submucosal fibroid can cause heavy bleeding as well as very heavy and prolonged
periods.
Most uterine fibroids don't cause symptoms and only 10 percent to 20 percent
of women who have fibroids ever require treatment. Depending on location, size
and number of fibroids, a woman might experience the following:
- Heavy, prolonged menstrual periods and bleeding as well
as clots in between periods. This may lead to anemia.
- Pelvic pain
- Pelvic pressure or heaviness caused by the bulk or weight
of the fibroids pressing on nearby structures
- Back or lower extremity pain as the fibroids may press
on nerves that supply the pelvis and legs
- Pain during sexual intercourse
- Bladder pressure leading to a constant urge to urinate
- Pressure on the bowel, leading to constipation and bloating
- Abnormally enlarged abdomen
If you are experiencing these types of symptoms, consult with your personal
physician.
Uterine fibroids are very common and often they are very small and cause no
problems. From 20 – 40% of women age 35 and older have uterine fibroids.
African-American women are at a higher risk and as many as 50% have fibroids
of a significant size.
Fibroid tumors may start in women when they are in their 20s, however, most
women do not begin to have symptoms until they are in their late 30s or 40s.
Physicians are not able to predict if a fibroid will grow or cause symptoms.
Fibroids may first be diagnosed by your gynecologist during a internal pelvic
examination. Your doctor may conduct a pelvic exam to feel if your uterus is
enlarged. The presence of fibroids is then confirmed by a pelvic ultrasound.
Fibroids also can be confirmed using magnetic resonance imaging (MRI) or computed
tomography (CT).
Diagnostic hysteroscopy also is an option, particularly to evaluate the presence
of submucosal fibroids. A long, thin probe-like instrument is passed through
the vagina and cervix into the uterus, where the physician can check for growths
and take samples of tissue. The lighted hysteroscope illuminates the uterus.
This procedure, which can cause some discomfort, is generally performed by
a gynecologist, and can be done without anesthesia or with a local anesthetic
in an office.
Appropriate treatment depends on the fibroid's size and location, as well
as the severity of symptoms. If a woman is not experiencing symptoms, her doctor
will most likely suggest "watchful waiting" — checking the
fibroid at annual gynecologic examinations and monitoring for symptoms.
If symptoms develop, there are a number of treatment options:
Uterine Fibroid Embolization: is a non –surgical treatment done with
catheterization that causes fibroids to shrink.
MR-guided focused ultrasound: is a new non-surgical treatment that is available
at our Virtua Voorhees location. Please call (888)-847-8823 for our fibroid
coordinator.
Drug therapy: including non-steroidal anti-inflammatory drugs (NSAIDs),
birth-control pills and hormone therapy
Surgical treatments: including myomectomy surgical removal of the fibroids) or
hysterectomy (surgical removal of the uterus)
Also known as uterine artery embolization, is a minimally-invasive endovascular
procedure in which a small catheter is guided directly to the fibroid's blood
supply. This requires only a tiny nick in the skin, and is performed while
the patient is conscious but sedated.
Fibroid embolization is performed by our interventional radiologists, physicians
who are specifically trained in minimally-invasive endovascular procedures.
SJRA was one of the first Interventional Radiology services to offer UFE in
the South Jersey area. Our treatment plan is founded upon a close working relationship
with experienced gynecologists who evaluate our patients prior to any planned
treatment.
The interventional radiologist makes a small nick in the skin (less than
one-quarter of an inch) in the groin to access the femoral artery, and inserts
a tiny catheter (about the size of a piece of spaghetti) into the artery. Local
anesthesia is used so the needle puncture is not painful. The catheter is then
guided through artery into the uterus using live X-ray (fluoroscopy).
The interventional radiologist then injects tiny plastic particles the size
of grains of sand into the artery that is supplying blood to the fibroid tumor.
This cuts off the blood flow and causes the fibroid to shrink. The artery on
the other side of the uterus is then treated. The skin puncture where the catheter
was inserted is cleaned and covered with a bandage.
Fibroid embolization is done as an outpatient procedure with some patients
requiring a hospital stay of one night. Pain medications and NSAIDS are prescribed
following the procedure to treat cramping , pain and fever. Patients
may resume light activities in a few days and the majority of women are able
to return to normal activities within one week.
Embolization to treat uterine fibroids has been performed since 1995. Embolization
of arteries in the uterus has been used successfully by interventional radiologists
for more than 20 years to treat heavy bleeding after childbirth. An estimated
13,000-14,000 UFE procedures are performed annually in the U.S. (as of 2004).
Our interventional radiologists have safely performed the procedure on hundreds
of patients and were the first in the South Jersey area to have performed this
procedure. All of our devices, equipment and medications used for fibroid embolization
are approved by the FDA for use in people.
What are the expected results?
On average, 90% of women who have the procedure experience significant or
total relief of their heavy bleeding with about 93% pain relief. Relief from
pressure from the fibroid tumor may take longer as volume reduction is typically
30% at six months and 50% at twelve months. Recurrence of the treated fibroid
tumors is rare. 73% of women continue to have improvement in symptoms after
5 years. This duration of symptom control is equal or better than that of myomectomy.
There have been numerous reports of pregnancies following uterine fibroid
embolization; however prospective studies are needed to determine the effects
of uterine fibroid embolization (UFE) on the ability of a woman to have children.
One study comparing the fertility of women who had uterine fibroid embolization
with those who had myomectomy showed similar numbers of successful pregnancies.
Fibroid embolization is considered to be very safe; however, there are some
associated risks, as there are with almost any medical procedure. Most women
experience moderate to severe pain and cramping in the first several hours
following the procedure. Some experience nausea and fever. These symptoms can
be controlled with appropriate medications. A small number of patients have
experienced infection, which usually can be controlled with antibiotics. It
also has been reported that there is a 1 percent chance of injury to the uterus,
potentially leading to hysterectomy. These complication rates are lower than
those of hysterectomy and myomectomy. Less than 2 percent of patients have
entered menopause as a result of UFE. This is more likely to occur if the woman
is in her mid-forties or older and is already nearing menopause. In addition,
the recovery time is much longer for myomectomy or hysterectomy, being on average
one to two months.
Please consult your gynecologist about possible risks of any procedure you
may choose.
There are many treatments for uterine fibroids. For many women uterine fibroid
embolization may be the best treatment. However, there are times when alternative
treatments are more appropriate. Our interventional radiologists will work
closely with your gynecologist in evaluating all your options, as well as evaluating
your history prior to any planned procedure.
Most insurance companies pay for fibroid embolization and we will work with
your insurance company to obtain payment.
Drug therapy is usually tried first. This might include:
- the use of non-steroidal anti-inflammatory drugs (NSAIDs)
such as ibuprofen (Motrin) or naproxen sodium (Naprosyn),
- birth-control pills, or
- hormone therapy.
In some patients, symptoms are controlled with these treatments and no other
therapy is required. However, some hormone therapies can have risks and side
effects (menopausal symptoms, erratic or no menstruation, bloating, moodiness)
when used long-term, and generally are used temporarily.
A newer group of drugs being used for fibroids are hormones known as GnRH
analogues, which are administered by injection by the gynecologist. These synthetic
(man-made) hormones act like the hormones that are naturally produced by the
body and reduce the level of estrogen. The result is reduced blood flow to
the uterus and, therefore, to the fibroids, decreasing the size of both. Some
physicians recommend these hormones prior to surgery to reduce the size of
the fibroids and make them easier to remove. The effectiveness of the hormones
is considered temporary as studies show that when the therapy is stopped, fibroids
regrow to their original size in four to six months. The GnRH hormones also
may cause side effects that mimic menopause, including hot flashes, vaginal
dryness, mood swings and a decrease in bone density (osteoporosis).
MR-guided focused ultrasound is a newer treatment that uses focused ultrasound
energy destroy the fibroid tumor which is performed under MRI guidance We perform
this procedure at Virtua Voorhees and are currently the only in group the Tri-State
area to offer it.
Myomectomy is a surgical procedure that removes visible fibroids from the
uterine wall. Myomectomy, like UFE, leaves the uterus in place and may, therefore,
preserve the woman's ability to have children. There are several ways to perform
myomectomy, including hysteroscopic myomectomy, laparoscopic myomectomy and
abdominal myomectomy.
While myomectomy is successful in controlling symptoms about 80 percent of
the time, the more fibroids there are in a patient's uterus, the less successful
the surgery generally is. Recovery time can be two-to three weeks for laparoscopic
myomectomy and four to six weeks for abdominal myomectomy. In addition, fibroids
grow back several years after myomectomy in 10 percent to 30 percent of cases.
In a hysterectomy, the uterus is removed in an open surgical procedure. This
operation is considered major surgery and is performed while the patient is
under general anesthesia. It requires 3 to 4 days of hospitalization and the
average recovery period is about six weeks. Approximately one-third of the
more than half-million hysterectomies performed in the United States each year
are due to fibroids.
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