Fibroids Tumors of the Uterus / Leiomyomas – Keith J. Reisler, MD

Submucosal fibroids are located inside the opening of the uterus.  Intramural fibroids are located within the wall of the uterus.  Subserosal Fibroids are located on the outside layer of the uterus and may be connected by a stalk.  They vary in size from being only a few cells to the size of a lemon, orange, grapefruit, or small watermelon.  In fact over 50 percent of all women may have fibroid tumors.  They are not cancer and rarely if ever can become cancer, or sarcomas.  Only if a fibroid tumor is very fast growing should any concern be given to a diagnosis of cancer.   And once again uterine sarcomas (cancerous fibroids) are rare.  The chance of a fibroid tumor being cancer is less than 1 in 10,000.  The three most common types of uterine sarcomas are carcinosarcomas,  leiomyosarcomas, endometrial stromal sarcomas.  When sarcomas are present, they are more likely to be found in women after menopause (average age 51).  We see many patients who are concerned that they have cancer and they are very reassured when we explain the facts.  In fact we have advised some patients not to have surgery recommended by another doctor.

• • Heavy periods, clots and/or prolonged periods
• • Pelvic pressure, pain, feeling of fullness
• • Pain with intercourse
• • Urinary frequency-need to urinate frequently
• • Infertility-unable to become pregnant
• • Difficult bowel movements

 

Depending on the size and location of fibroid tumors any of the above symptoms are possible.  Menstrual periods can become progressively heavier with blood clotting and longer duration.  Periods are considered heavy if they are affecting a woman’s life.  Some women with fibroid tumors can become anemic due to blood loss, causing fatigue and other medical problems.  Some women may even wear a tampon and a pad together to protect themselves from accidents.   As fibroids enlarge they cause symptoms of pain, pressure, fullness, bloating.  A woman may even feel like she is pregnant with the uterus arising out of the pelvis even as high as the umbilicus or higher.  As fibroids grow they cause other symptoms listed above as they put pressure on the bladder and the rectum.

Fibroid tumors can have a negative impact on pregnancy.  Large fibroid tumors can increase the risk of infertility, miscarriage, premature preterm labor and delivery, premature rupture of membranes, short cervix, and increased blood loss at delivery.  Most small fibroid tumors do not impact a pregnancy unless they are located inside the cavity of the womb.  This is one reason that during a patient’s preconceptual visit or planning pregnancy visit, we recommend an initial sonogram is for diagnosis of growths, such as fibroid tumors of the uterus.  There have not been enough studies delineating the effect of fibroids in pregnancy.  However a study published in a well respected journal, Fertility and Sterility Jan 2012, found that fibroid tumors of the uterus,  greater than   5 centimeters in size, increased the risk of the above complications during pregnancy.  The study also found that the number of fibroids present was strongly associated with increasing risk.

 

How do we Diagnose Fibroid Tumors (leiomyomas)?

Many times fibroids are diagnosed on a routine pelvic exam during the annual exam.  The diagnosis is confirmed by pelvic ultrasound, also known as pelvic sonogram.   We have full time sonography in our office and will perform this at the same time as the Pap smear and annual exam if fibroids are suspected.  Sonography will provide quite accurate measurement of the size and location of the fibroids.

 

What are the Treatments for Fibroid Tumors?

Treatment depends on the following factors:

• • The symptoms that a patient has such as bleeding, anemia, pain
• • Age of the patient
• • Whether or not a patient desires future pregnancy
• • The location, number, and size of the leiomyomas
• • The Risk/benefits analysis of the treatment options and patient preference

Treatment options:

1) Observation-No treatment.

Women who do not have symptoms do not require treatment but just observation over time.  Many years ago it was recommended that women with fibroids tumors have a hysterectomy (surgical removal of the uterus) if the uterus had grown to the size of a 12 week pregnant uterus, size of a grapefruit.  The theory was that once the uterus had reached this size, that the gynecologist could no longer adequately evaluate the ovaries for cancer during a routine pelvic exam, since the uterus would be in the way.  With the advent of modern sonography, most obgyns are very easily able to evaluate the ovaries in the office regardless of the size of the uterus and therefore hysterectomy does not need to be routinely performed

2) Medications:

a) Hormonal methods of birth control-These include the birth control pill, the vaginal ring, Deprovera shot, Mirena IUD®, and other hormone methods not listed.   These treatments can sometimes reduce the amount of bleeding and the cramping.    Hormones may not be an option depending on age, medical history, location of fibroids, and patient preference.  Some patients don’t want to add hormones, which can cause side effects, to their bodies

b) Various medications are used to reduce the menstrual flow.  NSAID’S such as Ibuprofen and naproxen can reduce cramps and blood flow in some women.  They should be started before or immediately when the period starts.  A new medication called Tranexamic Acid (Lysteda®) can be help the blood to clot and cause decreased bleeding.  Side effects of this treatment can include headaches, muscle, cramps or pain.

c) Gonadotropin-releasing hormone agonists (GnRH)-These medications are given by injection and work by temporarily placing a woman in menopause and decreasing estrogen stimulation of the fibroid tumors.  They are usually given temporarily for 3 to 6 months to shrink the fibroids.  GnRH agonists are usually not recommended for more than 6 months.   They can decrease the size of the fibroids by as much as 30 to 50%.  Unfortunately when the medicine is stopped the fibroids revert to their original size.  This medicine may be used before surgery to stop the periods and correct anemia and also to shrink the uterus to make surgery easier.

 

3) Surgical Fibroid Treatments

a) Myomectomy-this is a surgery done to remove the fibroid tumors from the uterus.  It is best done in a patient who wants to become pregnant in the future.  There is a recurrence rate of up to 25% so it may not be the best option for patients not desiring future pregnancy.  If the fibroids are only in the opening of the uterus then this procedure can be done by hysteroscopy, a minimally invasive procedure.  This is where a telescope is placed into the cervix without an incision, and the fibroids are removed.  If the fibroids were not in the opening of the uterus then the procedure would need to be done by an abdominal incision or by laparoscopy or robotic myomectomy.  If there are multiple fibroids and pregnancy is desired, then there are not enough studies at this time to prove that the laparoscopic or Robotic techniques will produce an equivalent pregnancy outcome as the abdominal myomectomy.  Dr. Reisler introduced the minimally invasive procedure of hysteroscopic myomectomy to the Plano community.   All of the above surgeries should be performed by an Ob/Gyn with extensive experience in this area.  The technique of the procedures performed can have a direct effect on the success and complications of future pregnancies.

 

b) Endometrial Ablation-this is a minimally invasive treatment which can be done in the Day Surgery Center or the office as an outpatient procedure (go home the same day).  There is no incision and an instrument, which destroys the lining of the uterus, is placed through the cervix.  The procedure can decrease the amount of bleeding and sometimes stop the period completely.  Not all women who have fibroids are candidates for this procedure.  Dr Reisler introduced the endometrial ablation procedure to the Plano community.

 

c) Uterine Artery Embolization (UAE)-This is a procedure done by a radiologist.  After discussion we would refer you if you were an appropriate candidate.  This is done in the hospital usually with an overnight stay.  This procedure can reduce the amount of bleeding and the size of the fibroids.  This procedure is not offered to women desiring future pregnancy.  The doctor inserts a thin tubing into a blood vessel in the upper thigh.  This tube is then threaded through the vessels to the artery that feeds the uterus.  Tiny particles are then injected into this artery.  The blood flow to the uterus is stopped or decreased with shrinkage of the fibroid tumors.  The procedure may be about 80% effective.

 

d) Hysterectomy-this is a surgery to remove the uterus.  Usually this can be accomplished as a minimally invasive surgery, such as, laparoscopic assisted vaginal hysterectomy (LAVH), or Laparoscopic Supracervical Hysterectomy (LASH procedure), or a vaginal hysterectomy.  Sometimes, the uterus is just too large and the safest procedure may be an abdominal hysterectomy.  After removal of the uterus the periods will go away permanently and other symptoms related to the size of the uterus should also disappear.

 

Summary of Fibroid Tumors

 

Fibroid Tumors are benign, non-cancerous growths that can cause a wide range of bothersome symptoms and pregnancy complications.  The modern Gynecologist has an extensive armamentarium of various treatments, ranging from observation to medications to various day surgeries, minimally invasive treatments, and more major procedures.  It is important for the communication between the Ob/Gyn and the patient to be extensive and complete so that all of the appropriate options can be offered to the patient.  Once all options have been explained fully then the patient needs to decide which treatment works best in their unique situation.  Gynecologists who are not trained or comfortable with certain procedures should be willing to make referrals when appropriate.