Charles E. Miller, M.D. & AssociatesCharles E. Miller, M.D. & Associates
Specialists in Minimally Invasive Gynecologic Surgery


Fibroids

What are Uterine Fibroids?

Uterine fibroids are non-cancerous, benign, tumors that arise from the muscle of the uterus. They are the most common tumor of the pelvis and are also known as myomas or leiomyomas. They can occur as a single fibroid or as multiple fibroids, ranging from millimeters to centimeters in size. Approximately, 80% of women have fibroids, but only about 30% will have symptoms from them. Most patients are in their 30-40s when they experience the symptoms from fibroids. It has been noted that African Americans tend to have fibroids more often than Caucasian or Asians.

Fibroids grow in response to the hormones estrogen and progesterone that are secreted in the body or from birth control pills. They are described based on their location. The uterus consists of an outer layer, called the serosa followed by a middle muscle layer, also known as the myometrium. The inner layer of the uterus consists of the endometrial mucosa, which is better known as the layer that is shed every month in the uterine cavity during menses and causes menstrual bleeding. The cervix is the opening to the uterus that is visualized through the vagina. A fibroid that comes off of the outer layer of the uterus, serosa, may have a stalk, and is better referred to as a pedunculated fibroid. A subserosal fibroid lies under the outer layer of the uterus. An intramural fibroid grows within the myometrium or uterine muscle. A submucosal fibroid grows within the endometrial mucosa of the uterine cavity. A fibroid within the cervix is a cervical fibroid. 

Cancerous tumors, called leiomyosarcomas, also arise from the muscle wall of the uterus, however, they do not develop from already existing benign fibroids and occur in less than 1% of the female population. Cancerous fibroids are more of a concern in postmenopausal women with an enlarging pelvic mass, vaginal bleeding and/or pain. These patients should seek medical care as soon as possible.
 
What are the symptoms from Uterine Fibroids?
Most women have no symptoms from fibroids and most of the time they do not even know that they have these benign growths. However, the following are symptoms that a woman may or may not experience:
Abnormal Uterine Bleeding (Please see link Abnormal Uterine Bleeding for a complete description of the terms and definitions of abnormal uterine bleeding.)
o       This is most commonly caused by fibroids that are located within the uterine cavity. The fibroids either have new blood vessels formed, which can open up and bleed, or cause the uterus to not contract down well enough to squeeze the vessels to control the bleeding. The woman may also experience painful periods from the uterus contracting as it is trying to control heavy bleeding. 
o       There may be other causes of abnormal uterine bleeding and a thorough investigation should be completed by your physician.
Bulk symptoms
o       The uterus lies in the pelvis and is surrounded by the bladder, ureters, bowel/rectum, nerves, vessels, lower back and vagina. Hence, symptoms, such as the following, can occur from an enlarged uterus from fibroids compressing these areas:
§         Pelvic pressure
§         Lower back pain
§         Pain with intercourse
§         Bladder pressure causing urinary frequency, urgency, retention or involuntary loss of urine
§         Constipation
§         Rarely, the ureters (tubes connecting from the kidneys to the bladder that carry urine) are compressed causing the kidneys to become dilated and potentially compromising kidney function
Sudden onset pain
o       This can be caused by two ways- 1) A fibroid that is pedunculated, twists upon its attachment, or stalk, cutting off its own blood supply or 2) a fibroid starts to outgrow its blood supply and begins to die, known as a degenerating fibroid.
§         Low grade fever and abdominal tenderness may also be experienced with a twisting or degenerating fibroid. 
§         Usually, in the case of the degenerating fibroid, the pain is self-limited and can be treated with anti-inflammatory medication. If the pain is severe, surgery may be needed.
Infertility/Miscarriage
o       A fibroid may grow near the fallopian tube causing an obstruction for the sperm and egg to meet or for the resultant embryo to travel to the uterine cavity to implant.
o       A fibroid may cause the uterine lining to be inflamed, irregular or thin, which is not a desirable environment for the embryo to implant.
o       If the fibroid is within the cavity itself, the embryo may implant on it providing less blood supply to the embryo that is needed to keep the embryo healthy. However, the embryo does not always implant at the same site with every different pregnancy, and if the embryo implants on healthy uterine lining, then the embryo may survive and continue into a healthy pregnancy despite the location of the fibroid.
Pregnancy
o       Fibroids tend to grow during pregnancy, but usually return to their normal size after the baby is delivered. 
o       Most women have no complications with fibroids during pregnancy, however, a few have been described:
§         Onset of acute pain from a degenerating fibroid
§         Malpresentation of the fetus
§         Preterm labor
§         May require a cesarean section if the fibroid is blocking the birthing canal or the fetus is malpresenting
 
How are Uterine Fibroids diagnosed?
Usually, a physician can perform a physical exam and palpate an enlarged, irregular uterus. Prior to any treatment, however, for uterine fibroids, it is imperative to map out the fibroids and identify their location, size and type. This is most commonly accomplished by utilizing radiologic studies such as a transvaginal and/or transabdominal ultrasound or MRI (Magnetic Resonance Imaging). To better delineate fibroids that may be invading the uterine cavity, a diagnostic hysteroscopy or a transvaginal ultrasound with a small tube instilling fluid into the cavity (Saline-infused sonohysterogram) may be used. In our office, we combine the technology of 3D ultrasound and saline-infused sonohysterogram to adequately map out the fibroids. 
 
How are Uterine Fibroids treated?
Since fibroids are benign and most women have no symptoms from their fibroids, conservative management with every 6-12 month check-ups is appropriate. If a woman is symptomatic from her fibroids, however, conservative management versus medical and surgical management is discussed. Some women experience mild symptoms from their fibroids and choose to just watch their fibroids as their daily lifestyle is not significantly disrupted by the fibroids. Women with moderate to severe symptoms have several options for treatment, depending on the fibroid location and size, woman’s age, fertility options and symptom type.
Medical therapy, commonly, is a temporary measure to help shrink the fibroids and stop heavy vaginal bleeding. Uterine fibroids grow in response to the hormones estrogen and progesterone secreted in the body. A medicine called, Depot Leuprolide (Lupron), is an injection into muscle that is administered on a monthly basis to stop estrogen and progesterone from being produced, similar to the hormonal status of a woman in menopause. Lupron temporarily reduces the size of the fibroids by about 30% after a three month use. After three months, there is not much more shrinkage of the fibroids and discontinuation of the medication will cause resumption of menses and the growth of the uterus and fibroids.   Since the woman is in a menopausal state, postmenopausal symptoms may be experienced, such as hot flushes and vaginal dryness. This can be alleviated by adding a low dose estrogen and progesterone, also known as add-back therapy, to the Lupron treatment. Long-term use of Lupron may be used to prolong symptoms from recurring until menopause is reached, after which the fibroids will shrink approximately 50% of their original size. Osteoporosis is associated with long-term use and therefore add-back therapy is strongly recommended to help prevent bone loss with this treatment. This treatment is expensive and women who choose long-term therapy will have to discontinue the Lupron and see if they continue to menstruate, at which time Lupron will be restarted. This cycling of therapy is continued until natural menopause is established. Uterine fibroids are not a contraindication to the use of hormone replacement therapy (HRT). If fibroids grow while on HRT, the medication can be stopped and the fibroids observed for shrinkage. If the fibroids do not shrink or continue to grow after the cessation of HRT, surgery me be indicated.
Lupron also causes vaginal bleeding to stop. Initially there is a rise in the hormones and at about two weeks from the initial injection, women may experience some breakthrough bleeding. Once this occurs, menses stops. This effect of the medication helps women with heavy bleeding and low blood counts, anemia. During this time of no menses, amenorrhea, the body can build up its own blood level and, if necessary, iron supplements can be given as well to help increase the blood count. This is especially helpful for those women that have symptoms from their low blood counts, such as fatigue, weakness or dizziness, as well as those who are in need of surgery.
There are a few different types of surgery that can be offered to women depending on the location, size and number of fibroids. Removal of a fibroid is referred to as a myomectomy. A hysteroscopic myomectomy may be offered to those women with a fibroid within the uterine cavity (submucosal fibroid). This is a same-day, outpatient procedure performed in the hospital. Most patients are back to work within 1-2 days after the surgery. The procedure may be done with a local anesthetic and sedation, but if the fibroid is large or deep within the uterus, general anesthesia may be recommended. Large fibroids or those that are less than 50% within the cavity may require a second similar operation to complete the procedure so that the body does not absorb too much fluid required to perform the surgery. Please refer to the link for Hysteroscopy to read about the steps of the procedure its potential complications.
An abdominal approach to myomectomy may be recommended if fibroids are less than 50% within the uterine cavity, intramural, subserosal, pedunculated and the patient desires to maintain their childbearing options or wishes to preserve her uterus. General anesthesia is necessary and the procedure takes about 1-3 hours. After the fibroids are removed, new fibroids may grow, but less than 5% of patients will require a second surgery for symptomatic fibroids. This is less for women who are >40 years old and for those women with a low number of fibroids to start with. If 4 or less fibroids are present, the recurrence rate is about 10% versus 25% for more than 4 fibroids present. A myomectomy has no impact on the function of the ovaries. As for attempting pregnancy, it is recommended that a woman waits at least 3 cycles before trying to get pregnant. Depending on the fibroid(s) location, size and number, a cesarean section may be recommended for a subsequent pregnancy. 
A myomectomy can be approached via a laparoscope (use of a camera and telescope with instruments through small 5-10 millimeter abdominal skin incisions) or laparotomy (single, approximately 4-6 inch abdominal skin incision). Laparoscopy requires skilled surgeons who can suture and repair the uterus appropriately with the use of endoscopic instruments. Our physicians have the training and experience to perform difficult myomectomies comfortably through the laparoscope. Laparoscopic myomectomy is associated with less recovery time, pain and scar tissue formation as compared to a traditional laparotomy. Most patients go home the same day or may require a stay in the hospital for one night versus a patient who undergoes a laparotomy, requiring the patient to stay in the hospital for 2-4 days. Most women are back to work within 1-2 weeks after a laparoscopic myomectomy and 4-6 weeks after myomectomy through a laparotomy. Pregnancy rates after a laparoscopic myomectomy are comparable to those performed via a laparotomy. A laparotomy may be indicated if the fibroid uterus is too large to perform through a laparoscope based on the woman’s pelvis size and shape. Please refer to the link Laparoscopy for a description of this technique. 
Another outpatient or same-day surgery is the endometrial ablation. This technique burns the lining of the uterine cavity so that vaginal bleeding can be reduced or stopped. About 40% of women have a reduction in their menses, another 40% have complete cessation of their menses and the other 20% have no improvement with their blood flow during menses. Endometrial ablation is not recommended for woman who still desire future fertility as it alters the uterine cavity and blood flow. An endometrial biopsy or another method for sampling the lining of the uterine cavity is usually recommended prior to an ablation to rule out cancerous causes of abnormal uterine bleeding. Two methods of ablation are commonly used in our practice, the Hydrothermal ablation (HTA) or Novasure ablation. Hydrothermal ablation uses hot water inside the uterine cavity to burn the lining. Women who have large or irregular uterine cavities are excellent candidates for this procedure. In less than 1%, the hot water may leak and cause vaginal burns. Careful attention and appropriate steps are taken to reduce the incidence of this complication. This surgery is performed in a hospital under local anesthesia and sedation or general anesthesia. The Novasure ablation uses electrical energy to burn the uterine cavity lining. This procedure takes about 10 minutes (actual ablation time is 1-2 minutes) and can be performed in the office with local anesthesia and pain medication. This is not recommended for women with a larger, fibroid uterus. Both ablation techniques allow the woman to return to work within 1-2 days.
The most definitive treatment for fibroids is a hysterectomy. This is most commonly chosen by women who have completed childbearing as it prevents fibroids from coming back and resolves symptoms. 
Non-surgical approaches are available for the treatment of uterine fibroids as well. These both involve a physician trained in Interventional Radiology and are not recommended for women interested in future child-bearing.   The first of these procedures is a Uterine Artery Embolization (UAE). It takes about 1-2 hours, under sedation, requiring a small incision over the groin. Under X-ray guidance a small catheter is placed at the blood vessels of the uterus and small particles are pushed to block these vessels. The uterus survives, despite the blockage of these vessels, because it has other vessels that help provide a healthy amount of blood to the uterus. However, the fibroids tend to die or degenerate.   A significant amount of pain and low grade fevers are experienced and the woman generally is kept overnight for pain management with narcotics and anti-inflammatories.   Women can return to work within a week. This technique reduces fibroid size by about 35-40% in 3-6 months, with a 33% recurrence rate of fibroids. Bulk symptoms are improved by about 80% and bleeding by about 90%. UAE is should not be performed for pedunculated, large fibroids, or fibroids that are mostly in the uterine cavity. In about 5% of women, the small particles used to block the uterine vessels may travel and cut off the blood supply to the ovaries, causing diminished or cessation of ovarian function. Post procedure menopause is more commonly seen in women greater than 40 years old.
The other non-surgical approach that we recommend to women to treat uterine fibroids is Magnetic Resonance guided Focused Ultrasound (MRgFUS). This technique was approved in 2004 by the FDA. It is an outpatient procedure that can take up to 4 hours to perform by an Interventional Radiologist. Ultrasound waves are guided by MRI towards the fibroids and cause thermal destruction of the fibroids. There is an approximately 80% success rate and women recover within one day without a hospital stay. This procedure can cause skin burns and bowel and bladder injuries if the fibroids are close to these structures. Insurance coverage is also limited for MRgFUS.
There are many options for a woman to choose from for treating her symptomatic fibroids. However, every woman’s treatment has to be individualized. These choices and options should be reviewed with your physician, so that the most appropriate treatment plan can be offered. In our practice, we want you to understand your options and be comfortable with the choice you make to better improve your quality of life safely and effectively.
 
  
Advancing gynecologic care safely and successfully through minimally invasive means.