UTERINE FIBROIDS (MYOMAS)

What are fibroids?

A fibroid, also called myoma, or leiomyoma, is a benign (non-cancerous) tumor arising from the smooth muscle of the uterus. Because a fibroid consists of smooth muscle tissue as well as fibrous tissue, the preferred term is myoma.

• It is the most common pelvic tumor, occurring in 70% of women.
• It is extremely rare that it turns malignant (cancerous).

Myomas are usually multiple, but each one starts from a single muscle cell.

Although they are most often seen in the uterus, they may also grow in the cervix and the fallopian tubes.

Uterine myomas are classified according to location:
Intramural
Myomas within the muscle wall of the uterus
Subserosal
The myoma extends to the outer wall of the uterus.
Pedunculated
A subserosal myoma can grow on a stalk from the outer wall.
Submucosal
The myoma grows into the uterine cavity.

Myomas start as small as a pea but can grow to fill the pelvis and they are often small and asymptomatic. Symptomatic fibroids occur in 25% of white women and 50% of black women. Their growth is variable and not predictable.

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What causes myomas?

The cause is unknown as yet.

• It is usually an inherited condition.
• For some reason, it is more common in black women.

Risk factors include:

• Race
• Obesity and overweight

Myomas are estrogen-dependent tumors.

• Growth is associated with exposure to circulating estrogen, the main female    hormone.
• Thus, maximum growth is during the reproductive years, when a woman produces    high concentrations of estrogen regularly. There is a growth spurt in the decade    before menopause.
• They can grow in pregnancy, not just because of high estrogen, but because of    increased blood flow to the - uterus.
• Predictably, they decrease in size after menopause, or other conditions of low    estrogen.

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How do I know I have myomas?

Most myomas produce no symptoms. Therefore, most women learn about it when they are examined by a gynecologist manually or through ultrasound.

When symptoms occur, they usually correlate with –

• The location of the myomas
• Their size
• Any degeneration in the myomas

The most common signs of symptomatic myomas are:

• Menstrual changes – heavy bleeding, more frequent periods, cramping
• Pain in the abdomen and lower back, and during sex
• Pressure symptoms such as
• Frequent urination, or difficulty in urinating
• Constipation, rectal pain, or difficult bowel movement

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Do I need treatment for myomas?

Symptomatic myomas require medical attention.

If you have no symptoms, but are seeking fertility care, your infertility specialist will tell you whether treatment of the myoma is necessary before to proceed to fertility treatment.

Not all myomas necessarily interfere with fertility.

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Signs and Symptoms of Myomas

The most common signs of symptomatic myomas, all requiring medical attention, are:

• Menstrual changes – heavy bleeding, more frequent periods, cramping
• Pain in the abdomen and lower back, and during sex
• Pressure symptoms such as
   - Frequent urination, or difficulty in urinating
   - Constipation, rectal pain, or difficult bowel movement

If the myoma(s) grow big enough, your belly will grow. Doctors often describe the size of a myomatous uterus in terms of comparison to a pregnant uterus. Example: A 6-week uterus or a 12-week uterus.

Excessive menstrual bleeding is often the only symptom. This is due to several factors:

• Increased blood supply to the myomas also brings increased blood supply to the    uterine lining (endometrium) which is shed at menses.
• Fibroids usually increase the size of the uterine cavity, therefore , there is an    increased surface area of the lining.
• Bleeding could also be aggravated by endometritis (inflammation of the lining)    which is frequently observed in the endometrial tissue overlying submucosal    tumors.
• Degeneration of the myoma

Degeneration results because of infection or when the myoma loses its blood supply. The muscle cells and connective tissues are replaced by fat, cysts,
calcification, and/or granular, hyaline or mucoid material characteristic of
necrotic (dying) cells. This often leads to excessive menstrual bleeding.

Excessive bleeding can lead to anemia, usually manifested in fatigue, headaches and lightheadedness.

It can also affect your quality of life, if the bleeding interferes with your
regular activities.

Pain as a symptom is infrequent. It is usually associated with:

• Twisting(tortion) of a fibroid stalk
• Cervical dilatation, if a myoma protrudes through the lower uterine segment
• Carneous degeneration, often associated with pregnancy.
• Adenomyosis (presence of endometrial glands in the uterine muscle) is usually    associated with myomas, and may also cause pain.

Myomas can cause acute severe pain, due to torsion of the stalk or degeneration.

• In such cases, the pain will be localized to the specific area that is affected.
• This can usually improve with pain relievers and go away after two-three weeks.

Obviously, if the pain is unbearable, it is best to see a doctor right away.

Chronic pelvic pain, which is mild but persistent, can also occur. Again, this is generally localized to a specific area.

Low back pain may be experienced, when the fibroids can press against the nerves of the lower back.

Pain or discomfort during sexual intercourse (dyspareunia) may also be experienced. This may be associated only with certain positions, or with the beginning or middle (around ovulation) of your menstrual cycle.

In any case, the doctor must rule out other possible causes of pain that may not be due to the myomas. For example;

• Acute pelvic inflammatory disease (PID)
• Endometriosis
• An ectopic pregnancy
• A ruptured ovarian cyst

A "big belly" when you are not pregnant or particularly overweight can be a sign. Some patients find it difficult to bend over or exercise because of this. Most will feel a continuous sense of heaviness or discomfort in the lower abdominal region.

Pressure symptoms are more bothersome. As myomas grow, pressure is exerted on adjacent pelvic organs, especially the bladder and the rectum.

Pressure on the bladder can cause:

• Frequent urination, because the bladder cannot hold as much as it can; or
• Inability to urinate despite a ‘full’ bladder, because the pressure blocks the    outflow passage for urine.

Pressure on the rectum can result in:

• Constipation
• Difficulty or pain during bowel movement
• A sense of fullness in the rectum
• Sometimes, hemorrhoids

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Possible complications from myomas:

• Stemmed fibroids may twist, causing pain, nausea and fever.
• Infection may lead to degeneration, causing bleeding and other discharge
• Rarely, very rapid growth may be observed. Cancer must then be ruled out.
• Infertility

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Myomas can cause infertility through

• A submucosal myoma, which interferes with implantation.
• A markedly distorted, enlarged uterine cavity that can also interfere with    implantation or with normal sperm transport.
• Myomas can also cause severe displacement of the cervix, which interferes with    the deposition of sperm at the cervical opening
• Some intramural myomas may cause obstuction or dysfunction of the tubal ostia    (the point at which the tube joins the uterus)

In IVF patients, distortion of the endometrial cavity by myomas is associated with;

• Decreased pregnancy rate
• Spontaneous abortion rate up to 50%.
• Recurrent pregnancy loss.

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Myomas very rarely become malignant (cancerous)

It is thought that cancerous uterine growths (leiomyosarcomas) arise by themselves and are not related to benign myomas.

However, rapid growth (for example, an increase in uterine size equivalent to a 6-week pregnant uterus in less than year) must raise a suspicion of malignancy, especially in

• Post-menopausal patients or
• Younger patients who are not pregnant

Surgery to remove the myoma(s) and obtain a biopsy is indicated.

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Diagnosing Myomas (Fibroids)

Uterine myomas may be detected and diagnosed several ways.

• Pelvic exam -During a routine exam, your gynecologist will ‘feel’ it if the uterus is    enlarged or irregularly shaped.
• Ultrasound will confirm a manual exam. Trans-abdominal and trans-vaginal scans    will provide good basic information.
   • Ultrasound shows myomas that are bigger than 1 cm. in diameter.
• Hysterosalpingogram (HSG) and sonohysterogram (SHG) are studies done by a    radiologist.
   • HSG, whuch outlines the uterus and tubes as well as the uterine cavity, usually      detects myomas with their relative locations and measurements.
   • SHG, in which fluid is injected to the uterus in order to distend the cavity, is      additionally recommended to confirm the presence or absence of submucosal      fibroids.
• Hysteroscopy may be an alternative to a sonohysterogram. This is a minor    surgical procedure done in the hospital under sedation anesthesia.
   • It enables the doctor to look directly inside the uterine cavity through the      hysteroscope, a thin telescope with a mini-camera.
   • Submucosal myomas, endometrial polyps (fleshy outgrowths of the uterine      lining) or adhesions (bands of fibrous scar tissue) are easily seen.
   • The advantage is that the doctor can proceed to remove the myomas, polyps      and/or adhesions, using micro-instruments (including laser fiber) that can be      passed through the operating channel of the hysteroscope.
• Pelvic MRI (magnetic resonance imaging)
   • An MRI is generally ordered in order to map the exact location and nature of      the myomas, particularly if surgery is planned.
   • Precise measurement of large fibroids is possible.

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Treatment of Myomas (Fibroids)

Asymptomatic fibroids must be evaluated periodically.

A woman found to have myomas but who remains asymptomatic will be evaluated periodically during her routine gynecological check-ups.

The concern is to assess the size of the uterus and whether symptoms have manifested.

Generally, fibroids will continue to grow until menopause, but the growth is variable and unpredictable.

Only a rapid change in size over a one-year interval may cause concern.

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What treatments are currently available for symptomatic fibroids (myomas)?

Treatment choices include:

• Medical or pharmacologic therapy (using medication)
• Myomectomy (surgery to remove myomas)
• Radiographically-directed procedures

These allow greater management flexibility with safe options that may be tailored to the individual patient.

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Medical therapy for myomas

Medical options are sub-optimal and limited.
• They are used to control bleeding and/or to shrink some myomas
• They have no effect beyond the time they are being used.

There is no medical treatment for pressure symptoms from large myomas.

The basis of medical therapy is to decrease circulating estrogen and thus ‘starve’ the myomas. Several drug types are used for this.

• Exogenous progestins, taken orally, are often used to reduce bleeding but have    no effect on fibroid size.
   - Medroxy-progesterone acetate (Provera) 5-10 mg once a day, or
   - Megestrol acetate 10-20 mg daily
   Either one is prescribed the first 10-14 days of the menstrual cycle. Usually,    bleeding is regulated after 1-2 cycles.
• NB: Provera can also be administered as a single injection (150 mg    intramuscular) once every 3 months.
   - It is recommended to see first whether the patient does not show adverse side      effects (weight gain, depression, and even irregular bleeding) to the oral dose      before trying the injection, because the effects of one shot will last three      months.
• Birth control pill by continuous therapy (daily during the whole month) reduces    bleeding and provides contraception.
• Danazol is an androgenic agent that can suppress fibroid growth but it has fallen    out of favor because of a high rate of adverse effects (weight gain, acne,    hirsutism or hair loss, edema, deepening of the voice, vaginal dryness).
• Lupron (generic name: leuprolide acetate), which is familiar to women undergoing    IVF, is currently the preferred medication to stop heavy bleeding and shrink    myomas until surgery can be done.
   - Acts by blocking the production of estrogen.
   - Generally prescribed 3-6 months before surgery to minimize blood loss at      surgery and facilitate removal of large tumors that have been shrunk.
   - Also used 3-6 months after a Myomectomy to control the growth of any seedling      fibroids not seen at surgery.
   - Administered as a one-a-month injection (depo-Lupron, 3.75 mg intramuscular)
   - Not advisable if surgery is not planned, because myomas will re-grow after it is      discontinued. However, since Lupron decreases estrogen production, it may also      cause menopausal symptoms such as hot flushes.
   - Use for longer than 6 months at a time is not recommended because it may      result    in bone loss.
   - Women younger than 35 will recover the loss after they stop treatment, but      women 35 years or older will not.

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Surgical removal of myomas (myomectomy)

When is surgery advisable?

Myomectomy is advised in case of

• Rapidly growing myoma
• Heavy bleeding which does not respond to medical therapy
• Persistent or intolerable pain/pressure
• Urinary or abdominal symptoms
• Necessity prior to infertility treatment

The first three symptoms in post-menopausal women particularly require immediate attention.

Myomectomy is very effective because it removes the myoma(s), but these can re-grow.

• Re-growth or even new growth post-myomectomy is more likely for younger    women.
• Women close to menopause are much less likely to be troubled about myomas    again.

Myomectomy is also the best option for women who have symptomatic fibroids and desire to bear children.

Removal of the myomas necessitates repair of the uterine wall with stitches at surgery ~ Therefore, such patients are usually warned that they may require a Caesarean section to deliver to avoid rupturing the uterine wall due to the strong muscle contractions during natural childbirth.

The type of Myomectomy depends on the number, size, and location of the myomas.

Abdominal Myomectomy is the treatment of choice when

• Multiple myomas are present, particularly if most are intramural (within the    muscle of the uterus).
• The uterus is significantly enlarged (myomas larger than 5 cm, or uterine volume    greater than 16 weeks size)

Abdominal Myomectomy is a major surgical procedure, generally called a laparotomy (open abdominal surgery).

• It involves general anesthesia, at least two nights in the hospital, and 4-6 weeks    of home rest after surgery.
• At surgery, a 4-inch cut is made at the ‘bikini line’ of the lower abdomen.
• The uterus is exposed, the fibroids are dissected out, and the uterine wall is    repaired in layers with absorbable surgical stitches.
• The cut across the abdomen is sutured. (This will leave a 4-inch scar, but good    sutures which do not get infected usually result in smoothly healed scars.)
• Blood loss during surgery may require a blood transfusion. The patient will usually    be asked to bank her own blood before the operation.
• Antibiotic treatment during and after surgery will minimize risk of wound infection.
• If the patient is planning to have children, she will be warned about the possible    risks of natural childbirth, and that a Caesarean delivery may be necessary.

Myomas can and do recur. Studies show that

• Five years after myomectomy, 50-60% of patients will have new myomas    detected on ultrasound.
• 10-25% will require a second major surgery.

Laparoscopic myomectomy is a less complicated but also major surgical procedure that may be done if:

• The uterus is small enough to be seen in entirety through an operating telescope    instead of through an open abdominal cavity. Usually it should be less than 17    weeks size; and
• Only a small number of myomas, and none greater than 5 cm, are present.

Laparoscopic myomectomy;

• Does not require ‘opening up’ your belly, but it is also done under general    anesthesia.
• Requires 3-4 small cuts – about 1 cm each - in the abdominal region: one just    below the belly button, one just above the public hairline, and one near the hip    (sometimes one near each hip).
• The laparoscope- a thin lighted telescope with a mini-camera set-up – is    introduced through the cut below the belly button. This enables the doctor to see    the pelvic organs.
• The other cuts are used to introduce micro-instruments to grasp the uterus and to    perform the cutting and dissection needed to remove the myomas; and to sew    back the layers of the uterine wall after removal of the myomas.
• After the surgery, only Band-Aids are usually needed for the cuts, which will heal    in a few days.
• You may go home a few hours after surgery but you will be advised to spend 2-4    weeks of home rest.
• Sometimes, during the laparoscopy, the doctor may decide it is necessary to    switch to an abdominal procedure. This possibility is included in the pre-surgery    consent form you are required to sign.

Hysteroscopic Myomectomy is a procedure to take out submucosal myomas those that protrude into the uterine cavity.

• It may be done by itself, if the patient has no intramural or subserosa lmyomas    that require surgery; or
• Just before a laparoscopic or abdominal Myomectomy.

Hysteroscopic Myomectomy is also best done under general anesthesia.

• It does not involve any skin cuts. The whole procedure is done though the vaginal    canal.
• First, a suitable solution is instilled into the uterus through the cervix to distend    the cavity so that its internal walls can be clearly seen.
• A thin lighted telescope (hysteroscope) is then inserted through the cervix in    order to look directly inside the uterine cavity.
• The scope has an operating channel through which the surgeon can pass
   micro-instruments or a laser fiber to scrape away or cut through the myoma and    any other abnormal growths that he may see inside the cavity.
• If hysteroscopy is the only procedure done, the patient stays in Recovery for a    few hours. Some cramping and light bleeding may be experienced. Home rest of    2-4 days is advised.
• If laparoscopy is to be performed to remove subserosal and intramural myomas,    then it can be performed right after the hysteroscopy

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Hysterectomy (Removal of the uterus)

Myomas are the most common indication for a hysterectomy.

• Removing the uterus simply eliminates all symptoms as well as the possibility of    any recurrence.
• It is generally an attractive option for women who have completed childbearing.
• A recent two-year follow-up study of 1,299 women who had a hysterectomy for    myomas and other benign conditions showed that more than 90% found    significant reductions in depression and anxiety levels, and an improvement in    quality of life.

Many women, even if they are past child-bearing age, may have psychological resistance to the idea of having their womb taken out.

In any case, the decision to have a hysterectomy when it is advisable to do so is obviously something that every patient has to weigh carefully.

Statistically, increased incidence of myomas in black women compared to Caucasian women is reflected in hysterectomy statistics:

• 30% of hysterectomies in Caucasians are for myomas, compared to >50% for    black women.
• For women between 25-45 years , the cumulative risk for a hysterectomy is 7%,    compared to 20% for black women.

A hysterectomy can be performed in three ways:

• Vaginal by taking out the uterus through a cut in the vaginal wall.
• Laparoscopic as in laparoscopic myomectomy.
• Abdominal by cutting open the belly as in abdominal myomectomy.

Vaginal hysterectomy is possible if the uterus is not too enlarged.

It is usually best done in conjunction with laparoscopy (laparoscopy-assisted vaginal hysterectomy , LAVH).

LAVH is recommended over laparoscopic hysterectomy alone, because

• It allows the use of conventional instruments that are more efficient than    miniature instruments manipulated through the laparoscope.
• Control of bleeding and suturing the stump (where the uterus is cut off) is much    easier, and in the case of the sutures, more robust.

Laparoscopic hysterectomy, like laparoscopic myomectomy, demands great surgical skill.

Abdominal hysterectomy may be

• Total (TAH, total abdominal hysterectomy): in which the entire uterus including    the cervix is taken out.
   - Women who have had abnormal pap smears are encouraged to have TAH.
• Supra-cervical hysterectomy if the cervix is left in.
   - The patient may have less bladder leakage and vaginal relaxation later in life      but there are no conclusive studies to prove this.
   - Moreover, she will continue to need pap smears.

Are the ovaries also taken out at hysterectomy?

The ovaries and the tubes are both attached to the uterus, but they are not necessarily taken out during hysterectomy.

Some guidelines on whether it is advisable to take them out include:

• If the ovaries look abnormal
• If the patient wants to eliminate the risk of developing ovarian cancer later in life.
• If the woman is already in menopause or close to menopause.
   - Removing the ovaries of a pre-menopausal woman will bring on premature
   menopause and all its symptoms.

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UTERINE ARTERY EMBOLIZATION (UAE)

This is a relatively new technique that is a non-surgical alternative for the treatment of symptomatic myomas.

Embolization means blocking blood flow to the myoma. This will cause its cells to die, so the myoma shrinks.

It has been shown to decrease menstrual bleeding, and relieve pain and pressure symptoms including urinary frequency and constipation.

UAE is performed by a qualified interventional radiologist in a hospital radiology department.

• The procedure is similar to having an angiogram done.
• It requires 8 hours of fasting (no food or drink) before the procedure.
• Painkillers or blood-thinning medicine should not be taken starting 5 days before    the procedure.
• First, the doctor will start an I-V line in one of your arms through which    medication and other agents used for embolization will be passed.
• You will be sedated lightly for the procedure so that you are awake but not    actively so.
• A needle is placed in a suitable artery on one of your legs or in the crease of the    groin.
• A very thin catheter will then be passed through the needle, and dye will be    injected.
• As the dye reaches the blood vessels leading to the uterus, X-rays will be taken to    take images of the blood vessels leading to the fibroid.

The catheter is now directed to these arteries, and polyvinyl particles the size of a sand grain are injected in order to block them.

• The course of the dye is watched carefully to make sure that the particle goes to    the fibroid only.
• Both the right and the left uterine arteries are embolized. The procedure can take    several minutes.
• A repeat arteriogram is done afterwards to confirm that embolization was    successful:
   - The catheter is removed and pressure is held over this area for approximately      15 minutes.
   - After the exam you must be on bed rest for six hours lying flat with your leg      straight.

Some pain may be felt during this time, but the experience varies with each patient.

• Some report no pain at all.
• Those who do say it is similar to menstrual cramps.
• The most significant pain usually occurs immediately following the procedure and    over the next 6 hours.
• Patients stay in the hospital overnight so that the arterial-access site can be    monitored, and adequate pain control given if necessary.
• Most patients can resume full normal activity after a week.

What happens after UAE?

Blocking the blood flow to the fibroid also cuts off oxygen to its cells, and they will begin to die. This will take several weeks.

• 80-90% of patients report improvement of symptoms.
• Fibroids shrink to about half the size, and so does the uterus.

Serious complications may occur in <4% of patients. These include :

• Injury to a blood vessel during the procedure
• Blood clots which may block other vessels
• Injury to the ovaries
• Uterine infection

These are unlikely to happen if the physician performing the UAE is a qualified and experienced interventional radiologist.  
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