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.
Uterine fibroid embolization is a procedure that is performed by Interventional Radiologists, specially trained doctors who use X-rays and other imaging techniques to visualize the inside of the body. They guide narrow tubes (catheters) and other very small instruments through the blood vessels of the body to the site of the problem, treating a variety of medical disorders without surgery. Procedures performed by interventional radiologists (IRs) are generally less costly and less traumatic to the patient, involving smaller incisions, less pain, and shorter recovery time.
Q. What are uterine fibroids?
A: Uterine fibroids are the most common tumors of the female genital tract. An estimated 20-40% of women 35 years and older have them. You might hear them referred to as "fibroids" or by several other names, including leiomyoma, leiomyomata, myoma and fibromyoma. Fibroids are noncancerous (benign) growths that develop in the muscular wall of the uterus. While fibroids do not always cause symptoms, their size and location can lead to problems for some women, including pain, bloating, urinary frequency, constipation, and heavy bleeding.
The exact causes for fibroid development are unclear, but researchers have linked them to both a genetic predisposition and to hormone stimulation. Women may have a genetic predisposition to fibroid development and then subsequently develop factors that allow fibroids to grow under the influence of a number of hormones, primarily estrogen. This would explain why certain ethnic groups or racial groups are more likely to develop fibroids, why there tends to be genetic predisposition in some families, and why many fibroids increase in size during pregnancy.
Fibroids range greatly in size from very tiny (a quarter of an inch) to larger than a cantaloupe (10 inches or more). In some cases they can cause the uterus to grow as it would during a pregnancy and the woman looks as though she is pregnant. In most cases, there is more than one fibroid in the uterus.
Fibroids can be located in various parts of the uterus. There are three primary types:
- Subserosal fibroids, which develop under the outside covering of the uterus and expand outward through the wall, giving the uterus a knobby appearance. They typically do not affect a woman's menstrual flow, but can cause pelvic pain, back pain and generalized pressure. The subserosal fibroid can develop a stalk or stem-like base, making it difficult to distinguish from an ovarian mass. These are called pedunculated. The correct diagnosis can be made with either an ultrasound or magnetic resonance (MR) exam.
- Intramural fibroids, which develop within the lining 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 fibroids. Intramural fibroids can result in heavier menstrual bleeding and pelvic pain, back pain or the generalized pressure that many women experience.
- Submucosal fibroids, which are just under the lining of the uterus. These are the least common fibroids, but they tend to cause the most problems. Even a very small submucosal fibroid can cause heavy bleeding — gushing, very heavy and prolonged periods.
Q. What are typical symptoms?
A: Most fibroids don't cause symptoms — 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, spotting between periods, and unusual monthly bleeding that may include clots, which can lead to anemia (a low blood count). This is the most common symptom associated with fibroids.
- An increase in menstrual cramping and/or bloating
- Pelvic pain or, more accurately, pressure or discomfort in the pelvis that is caused by the bulk or weight of the fibroids pressing on nearby organs or structures
- Pain in the back, flank or legs as the fibroids press on nerves that supply the pelvis and legs
- Pain during or after sexual intercourse
- Pressure on the urinary system, which typically results in increased frequency of urination, including the need to get up at night. (Occasionally, an enlarged uterus may press on the ureter connecting the bladder to the kidney, resulting in partial blockage of urine flow from the kidneys.)
- Pressure on the bowel, leading to constipation and bloating
- Abnormally enlarged (distended) abdomen, which can be misinterpreted as a progressive weight gain
If you are experiencing these types of symptoms, consult with your personal physician.
Q. Who is most likely to have uterine fibroids?
A: Uterine fibroids are very common. The number of women who have fibroids increases with age until menopause: about 20 percent of women in their 20s have fibroids, 30 percent in their 30s and 40 percent in their 40s. From 20 percent to 40 percent of women age 35 and older have uterine fibroids of a significant size.
African-American women are at a higher risk: as many as 50 percent have fibroids of a significant size. It is not known why, although genetic variability is thought to be a factor.
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 can dramatically increase in size during pregnancy. This is thought to occur because of the increase in estrogen levels during pregnancy. After pregnancy, the fibroids usually shrink back to their pre-pregnancy size.
Fibroids typically improve after menopause when the level of estrogen decreases dramatically. Fibroids can grow while a menopausal woman is taking estrogen supplements (hormone replacement therapy) or they may not be affected at all.
Q. How are uterine fibroids diagnosed?
A:Typically, fibroids are first diagnosed during a gynecologic internal exam, which enables the doctor to feel if the uterus is enlarged.
The presence of fibroids is most often confirmed by an abdominal ultrasound. This is a painless procedure in which a radiologist or technician moves an instrument (transducer/receiver) about the size and shape of a computer mouse across the outside surface of the abdomen. Sound waves are transmitted through the skin and allow the technician to "see" the size, shape and texture of the uterus. A picture is displayed on a computer screen as the radiologist or technician takes the ultrasound.
In some cases, a transvaginal ultrasound may be necessary. The radiologist inserts an ultrasound probe into the vagina so the inside of the uterus can be seen even more clearly than with the abdominal procedure. There is generally little if any discomfort associated with this procedure
Fibroids also can be confirmed using magnetic resonance (MR) imaging or computed tomography (CT). MR and CT also are painless diagnostic tests that can give accurate and clear information on the presence of fibroids.
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.
Q. What are the treatment options?
A: Appropriate treatment depends on the size, location, and vascularity of the fibroids. The severity of the woman's symptoms are also a factor. If a woman is not experiencing symptoms, then her physician will most likely recomend monitoring the fibroid growth during annual visits and the patient for symptoms.
If symptoms develop, there are a number of options to treat the fibroids:
- Drug therapy which may include birth control pills, hormone therapy, and/or non-steroidal anti-inflammatory drugs (NSAIDs)
- Endometrial ablation may be used for heavy bleeding by treating the endometrial lining of the uterus and not the actual fibroids
- Surgery to remove the fibroids from the uterus (myomectomy) or the surgical removal of the entire uterus (hysterectomy)
- MR guided focused ultrasound ablation is a non-invasive procedure that uses ultrasound waves to burn the fibroids
- Uterine fibroid embolization, a non-surgical, minimally invasive procedure that blocks blood flow to the fibroids causing them to die and shrink