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Uterine Fibroids

Definition:
Uterine fibroids are noncancerous growths of the uterus that often appear during your childbearing years. Also called fibromyomas, leiomyomas or myomas, uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer.

As many as three out of four women have uterine fibroids, but most are unaware of them because they often cause no symptoms. Your doctor may discover them incidentally during a pelvic exam or prenatal ultrasound.

In general, uterine fibroids cause no problems and seldom require treatment. Medical therapy and surgical procedures can shrink or remove fibroids if you have discomfort or troublesome symptoms. Rarely, fibroids can require emergency treatment if they cause sudden, sharp pelvic pain.

Causes
:
Uterine fibroids develop from the smooth muscular tissue of the uterus (myometrium). A single cell reproduces repeatedly, eventually creating a pale, firm, rubbery mass distinct from neighboring tissue.

Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. They can be single or multiple, in extreme cases expanding the uterus so much that it reaches the rib cage.

Doctors don't know the cause of uterine fibroids, but research and clinical experience point to several factors:
  • Genetic alterations. Many fibroids contain alterations in genes that code for uterine muscle cells.
  • Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and estrogen receptors than do normal uterine muscle cells.
  • Other chemicals. Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
Risk Factor:
There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Other factors include:
  • Heredity. If your mother or sister had fibroids, you're at increased risk of also developing them.
  • Race. Black women are more likely to have fibroids than are women of other racial groups. In addition, black women have fibroids at younger ages, and they're also likely to have more or larger fibroids.
Inconclusive research
Research examining other potential risk factors has been inconclusive. Although some studies have suggested that obese women are at higher risk of fibroids, other studies have not shown a link.

In addition, limited studies once suggested that women who take oral contraceptives and athletic women may have a lower risk of fibroids, but later research failed to establish this connection. Researchers have also looked at whether pregnancy and giving birth may have a protective effect, but results remain unclear.

When to seek medical advice:
See your doctor if you have:
  • Pelvic pain that doesn't go away
  • Overly heavy or painful periods
  • Spotting or bleeding between periods
  • Pain with intercourse
  • Difficulty emptying your bladder
  • Difficulty moving your bowels
Seek prompt medical care if you have severe vaginal bleeding or sharp pelvic pain that comes on suddenly.

Symptoms:
When signs and symptoms are present, the most common uterine fibroids symptoms include:
  • Heavy menstrual bleeding
  • Prolonged menstrual periods or bleeding between periods
  • Pelvic pressure or pain
  • Urinary incontinence or frequent urination
  • Constipation
  • Backache or leg pains
Rarely, a fibroid can cause acute pain when it outgrows its blood supply. Deprived of nutrients, the fibroid begins to die. Byproducts from a degenerating fibroid can seep into surrounding tissue, causing pain and fever. A fibroid that hangs by a stalk inside or outside the uterus (pedunculated fibroid) can trigger pain by twisting on its stalk and cutting off its blood supply.

Fibroid location influences your signs and Symptoms:
  • Submucosal fibroids. Fibroids that grow into the inner cavity of the uterus (submucosal fibroids) are thought to be primarily responsible for prolonged, heavy menstrual bleeding.
  • Subserosal fibroids. Fibroids that project to the outside of the uterus (subserosal fibroids) can sometimes press on your bladder, causing you to experience urinary symptoms. If fibroids bulge from the back of your uterus, they occasionally can press either on your rectum, causing constipation, or on your spinal nerves, causing backache.

Dignosis:
Uterine fibroids are frequently found incidentally during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus through your abdomen, suggesting the presence of fibroids.

Ultrasound
If confirmation is needed, your doctor may obtain an ultrasound
— a painless exam that uses sound waves to obtain a picture of your uterus — to confirm the diagnosis and to map and measure fibroids. A doctor or technician moves the ultrasound device (transducer) over your abdomen (transabdominal) or places it inside your vagina (transvaginal) to obtain images of your uterus.

Transvaginal ultrasound provides more detail because the probe is closer to the uterus. Transabdominal ultrasound visualizes a larger anatomic area. Sometimes, fibroids are discovered during an ultrasound conducted for a different purpose, such as during a prenatal ultrasound.

Other imaging tests
If traditional ultrasound doesn't provide enough information, your doctor may order other imaging studies, such as:
  • Hysterosonography. This ultrasound variation uses sterile saline to expand the uterine cavity, making it easier to obtain interior images of the uterus. This test may be useful if you have heavy menstrual bleeding despite normal results from traditional ultrasound.
  • Hysterosalpingography. This technique uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Your doctor may recommend it if infertility is a concern. In addition to revealing fibroids, it can help your doctor determine if your fallopian tubes are open.
  • Hysteroscopy. Your doctor inserts a small, lighted telescope called a hysteroscope through your cervix into your uterus. The tube releases a gas or liquid to expand your uterus, allowing your doctor to examine the walls of your uterus and the openings of your fallopian tubes. A hysteroscopy can be performed in your doctor's office.
Imaging techniques that may occasionally be necessary include computerized tomography (CT) and magnetic resonance imaging (MRI).

Other tests
If you're experiencing abnormal vaginal bleeding, your doctor may want to conduct other tests to investigate potential causes. He or she may order a complete blood count (CBC) to determine if you have iron deficiency anemia because of chronic blood loss. Your doctor may also order blood tests to rule out bleeding disorders and to determine the levels of reproductive hormones produced by your ovaries.

Complication:
Although uterine fibroids usually aren't dangerous, they can cause discomfort and may lead to complications such as anemia from heavy blood loss. In rare instances, fibroid tumors can grow out of your uterus on a stalk-like projection. If the fibroid twists on this stalk, you may develop a sudden, sharp, severe pain in your lower abdomen. If so, seek medical care right away. You may need surgery.

Pregnancy and fibroids
Because uterine fibroids typically develop during the childbearing years, women with fibroids are often concerned about their chances of a successful pregnancy.

Fibroids usually don't interfere with conception and pregnancy, but they can occasionally affect fertility. They may distort or block your fallopian tubes, or interfere with the passage of sperm from your cervix to your fallopian tubes. Submucosal fibroids may prevent implantation and growth of an embryo.

Research indicates that pregnant women with fibroids are at slightly increased risk of miscarriage, premature labor and delivery, abnormal fetal position, and separation of the placenta from the uterine wall. But not all studies confirm these associations. Furthermore, complications vary based on the number, size and location of fibroids. Multiple fibroids and large submucosal fibroids that distort the uterine cavity are the type most likely to cause problems. A more common complication of fibroids in pregnancy is localized pain, typically between the first and second trimesters. This is usually easily treated with pain relievers.

In most cases, fibroids don't interfere with pregnancy and treatment isn't necessary. It was once believed that fibroids grew faster during pregnancy, but multiple studies suggest otherwise. Most fibroids remain stable in size, although some increase or decrease slightly, usually in the first trimester.

If you have fibroids and you've experienced repeated pregnancy losses, your doctor may recommend removing one or more fibroids to improve your chances of carrying a baby to term, especially if no other causes of miscarriage can be found and your fibroids distort the shape of your uterine cavity.

Doctors usually don't remove fibroids in conjunction with a Caesarean section because of the high risk of excessive bleeding.

Treatment:
There's no single best approach to uterine fibroid treatment. Many treatment options exist. In most cases, the best action to take after discovering fibroids is simply to be aware they are there.

Watchful waiting
If you're like most women with uterine fibroids, you have no signs or symptoms. In your case, watchful waiting (expectant management) could be the best course. Fibroids aren't cancerous. They rarely interfere with pregnancy. They usually grow slowly and tend to shrink after menopause when levels
of reproductive hormones drop. This is the best treatment option for a large majority of women with uterine fibroids.

Medications
Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don't eliminate fibroids, but may shrink them. Medications include:
  • Gonadotropin-releasing hormone (Gn-RH) agonists. To trigger a new menstrual cycle, a control center in your brain called the hypothalamus manufactures gonadotropin-releasing hormone (Gn-RH). The substance travels to your pituitary gland, a tiny gland also located at the base of your brain, and sets in motion events that stimulate your ovaries to produce estrogen and progesterone.

    Medications called Gn-RH agonists (Lupron, Synarel, others) act at the same sites that Gn-RH does. But when taken as therapy, a Gn-RH agonist produces the opposite effect to that of your natural hormone. Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves.

  • Androgens. Your ovaries and your adrenal glands, located above your kidneys, produce androgens, the so-called male hormones. Given as medical therapy, androgens can relieve fibroid symptoms.

    Danazol, a synthetic drug similar to testosterone, has been shown to shrink fibroid tumors, reduce uterine size, stop menstruation and correct anemia. However, occasional unpleasant side effects such as weight gain, dysphoria (feeling depressed, anxious or uneasy), acne, headaches, unwanted hair growth and a deeper voice, make many women reluctant to take this drug.

  • Other medications. Oral contraceptives or progestins can help control menstrual bleeding, but they don't reduce fibroid size. Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, are effective for heavy vaginal bleeding unrelated to fibroids, but they don't reduce bleeding caused by fibroids.
Hysterectomy
This operation — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. It ends your ability to bear children, and if you elect to have your ovaries removed also, it brings on menopause and the question of whether you'll take hormone replacement therapy.

Myomectomy
In this surgical procedure, your surgeon removes the fibroids, leaving the uterus in place. If you want to bear children, you might choose this option. With myomectomy, as opposed to a hysterectomy, there is a risk of fibroid recurrence. There are several ways a myomectomy can be done:
  • Abdominal myomectomy. If you have multiple fibroids, very large or very deep fibroids, your doctor may use an open abdominal surgical procedure to remove the fibroids.
  • Laparoscopic myomectomy. If the fibroids are small and few in number, you and your doctor may opt for a laparoscopic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. Your doctor views your abdominal area on a remote monitor via a small camera attached to one of the instruments.
  • Hysteroscopic myomectomy. This procedure may be an option if the fibroids are contained inside the uterus (submucosal). A long, slender scope (hysteroscope) is passed through your vagina and cervix and into your uterus. Your doctor can see and remove the fibroids through the scope. This procedure is best performed by a doctor experienced in this technique.
Variations of myomectomy — in which uterine fibroids are destroyed without actually removing them — include:
  • Myolysis. In this laparoscopic procedure, an electric current destroys the fibroids and shrinks the blood vessels that feed them.
  • Cryomyolysis. In a procedure similar to myolysis, cryomyolysis uses liquid nitrogen to freeze the fibroids.

    The safety, effectiveness and associated risk of fibroid recurrence of myolysis and cryomyolysis have yet to be determined.

  • Endometrial ablation. This treatment, performed with a hysteroscope, uses heat to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow. Endometrial ablation is effective in stopping abnormal bleeding, but doesn't affect fibroids outside the interior lining of the uterus.
Uterine artery embolization
Small particles injected into the arteries supplying the uterus cut off blood flow to fibroids, causing them to shrink. This technique is proving effective in shrinking fibroids and relieving the symptoms they can cause. Advantages over surgery include:
  • No incision
  • Shorter recovery time
Complications may occur if the blood supply to your ovaries or other organs is compromised.

Focused ultrasound surgery
MRI-guided focused ultrasound surgery (FUS), approved by the Food and Drug Administration in October 2004, is a newer treatment option for women with fibroids. Unlike other fibroid treatment options, FUS is noninvasive and preserves your uterus.

This procedure is performed while you're inside of a specially crafted MRI scanner that allows doctors to visualize your anatomy, and then locate and destroy (ablate) fibroids inside your uterus without making an incision. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids. A single treatment session is done in an on- and off-again fashion, sometimes spanning several hours. Initial results with this technology are promising, but its long-term effectiveness is not yet known.

Before you decide
Because fibroids aren't cancerous and usually grow slowly, you have time to gather information before making a decision about if and how to proceed with treatment. The option that's right for you depends on a number of factors, including the severity of your signs and symptoms, your plans for childbearing, how close you are to menopause, and your feelings about surgery.

Before making a decision, consider the pros and cons of all available treatment options in relation to your particular situation. Remember, most women don't need any treatment for uterine fibroids.

Prevention:
Although researchers continue to study the causes of fibroid tumors, little scientific advice is available on how to prevent them. Preventing uterine fibroids may not be possible, but you can take comfort in the fact that only a small percentage of these tumors require treatment.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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