Uterine Fibroids

What are uterine fibroids?

Also known as leiomyomas, uterine fibroids are growths composed of tissue and muscle forming inside or on the uterus wall. Usually, these growths are benign (non-cancerous) and constitute the most prevalent benign tumors among women and persons assigned female at birth (AFAB).

Uterine fibroids may result in a number of symptoms, including irregular, heavy, and painful vaginal bleeding. In some cases, an individual is asymptomatic and not aware that they have the growths.

Fibroids treatment is usually based on the symptoms present.

Where do fibroids grow?

Fibroids can develop as one growth (single nodule) or in clusters. The size of clusters of growths can vary in diameter, ranging from 1 millimetre to over 8 inches (20 centimetres) or even more. They can be smaller, like a seed or grow as big as a watermelon.

The growths can form in the uterine wall, within the main uterus cavity or on the uterus's external surface.

Types of uterine fibroids

There are various kinds of uterine fibroids based on the location and the way they attach. Some specific uterine fibroid types are:

• Intramural fibroids: These embed into the uterus muscular wall and constitute the most prevalent type of fibroids.
• Submucosal fibroids: These grow just beneath the uterus's inner lining.
• Subserosa fibroids: Grow beneath the uterine outer surface lining and can become somewhat large and extend to the pelvis.
• Pedunculated fibroids: These rarest type of fibroids connect to the uterus by a stem or stalk. Because of the stalk and a broader top, they usually resemble a mushroom.

Common Symptoms of Fibroids

Most people with uterine fibroids are asymptomatic. However, for those who have symptoms, the size, location, and the number can influence them.

Some of the common uterine fibroids symptoms are:

• Heavy bleeding or painful periods

• Prolonged or more frequent periods

• Pelvic pain or pressure

• Frequent or difficulty urinating

• Enlarging stomach area

• Constipation

• Lower back or abdominal pain or discomfort during sex

In rare cases, fibroids can lead to sudden severe pain if they become too large for the blood flow and begin to die.

Causes

Although the precise cause of uterine fibroids is not clear, these factors are thought to contribute:

• Genetic changes: Most fibroids exhibit gene alterations that vary from those in normal muscle cells of the uterus.

• Hormones: Progesterone and estrogen are the two primary hormones causing the uterine lining tissue to thicken during every menstrual cycle in preparation for pregnancy. Both hormones also appear to stimulate the growth of fibroids.

Fibroids have a higher number of cells binding progesterone and estrogen hormones compared to normal uterine muscle cells. After menopause, fibroids shrink because of decreased hormonal levels.

• Additional growth factors: Substances, including insulin-like growth factor, which is responsible for tissue maintenance, may influence fibroid growth.

• Extracellular matrix (ECM): This substance causes cells to adhere to one another, just like mortar and brick. Fibroids contain more ECM, making them fibrous. Moreover, ECM stores growth elements and triggers biological alterations within the cells.

It is believed that uterine fibroids can originate from the stem cell inside the uterine smooth muscular tissue. The single cells undergo repeated divisions, eventually turning into a solid, rubbery mass different from the surrounding tissue.

The uterine fibroids patterns of growth tend to differ. They can develop quickly, slowly, or remain the same size. Also, some undergo growth spurts while others shrink on their own. Those forming during pregnancy might shrink or disappear after childbirth as the womb returns to its normal size.

Risk factors

Apart from being of the reproductive age, other factors that can contribute to uterine fibroids are:

• Race: Every individual born female who is in their reproductive years can get fibroids. However, blacks are usually at a higher risk of having these growths compared to those of other races. Unlike whites, black people tend to develop fibroids while at a young age. Moreover, they are more likely to have clusters or bigger growths accompanied by intense symptoms.
• Family history: You are at a high risk of developing fibroids if your sister or mother has had them.
• Additional factors: Other factors that are likely to increase the risk of fibroids include starting menstruation before 10 years, vitamin D deficiency, obesity, a diet high in red meat and low in leafy vegetables, dairy, and fruits, and alcohol consumption, including beers.

Complications

While uterine fibroids are generally not dangerous, they can trigger pain and cause complications such as anemia. This condition is characterized by reduced red blood cells and can lead to fatigue due to blood loss. Individuals experiencing heavy menstrual bleeding may need to take iron supplements to manage or prevent anemia. A blood transfusion might sometimes be necessary to address significant blood loss.

Pregnancy and Fibroids

Fibroids usually don't prevent a person from getting pregnant. However, some types, like submucosal fibroids, can lead to pregnancy loss or infertility.

Furthermore, fibroids can increase the risk of particular pregnancy complications such as:

• Placental abruption: This is when the placenta, the organ supplying oxygen and nutrients to the unborn baby, is detached from the inner uterine wall.

• Foetal growth restriction: This is when the fetus fails to develop well as expected.

• Preterm delivery: This is when the child is born before reaching 37 weeks.

Diagnosis

How are fibroids diagnosed, and what tests are involved?

Uterine fibroids are normally discovered during a pelvic examination. In most cases, symptoms such as heavy bleeding can alert the doctor to check for fibroids while performing a diagnosis. Several diagnostic tests can also be conducted to confirm their presence and assess their location and size:

• Ultrasonography: A non-invasive imaging test that uses sound waves to create images of the internal organs.
• Magnetic resonance imaging (MRI): Uses magnetic and radio waves to produce detailed pictures of internal organs.
• Computed tomography (CT) scan: Utilizes X-ray technology to create detailed pictures of the internal organs at different angles.
• Hysteroscopy: Involves using a thin, flexible tube attached to a small camera known as a scope to check for fibroids. The scope is inserted into the uterus through the vagina and cervix.
• Hysterosalpingography (HSG): A detailed X-ray that involves injecting contrast material and taking X-rays of the uterus.
• Sonohysterography: An imaging test which is done by injecting saline into the uterus through a tiny catheter inserted inside the vagina. The additional fluid produces a clearer image of the uterus compared to those of standard ultrasound.
• Laparoscopy: Involves making a small incision or cut in the lower abdomen and inserting a thin, flexible tube attached to a camera on the tip. This helps the doctors to examine the internal organs closely.

Treatment and Management

Uterine fibroids treatment depends on their size, location, number, and the symptoms they cause. Treatment may not be necessary if you have no symptoms. Likewise, smaller fibroids can typically be disregarded.

Some individuals don't have any symptoms or may experience problems linked to fibroids. For such cases, the doctor can monitor the fibroids using pelvic examinations or ultrasounds.

On the other hand, having symptoms such as anemia due to excessive bleeding, minor to intense pain, or bowel and urinary tract problems requires treatment. The appropriate treatment plan will be based on some factors:

• The number of fibroids present

• The size of the fibroids

• Location of the fibroids

• Fibroids-related symptoms you have

• The need to retain the uterus

In addition, the ideal treatment choice will be determined by your plans for future pregnancies. Its thus important to discuss your fertility objectives with your provider when considering the treatment options.

The possible uterine fibroids treatment choices are:

Medications

• Over-the-counter (OTC) pain relievers: These drugs assist in managing discomfort or pain associated with fibroids. Examples of OTC medicines are ibuprofen and acetaminophen.
• Iron supplements: Iron supplements may be recommended for those with anemia from excessive bleeding.
• Birth control: This can help manage fibroids symptoms, including menstrual cramps and heavy bleeding during or between periods. Birth control options to consider are oral contraceptive pills, injections, intrauterine devices (IUDs), and rings.
• Gonadotropin-releasing hormone (GnRH) agonists: These help shrink the fibroids and may sometimes be used before surgery to reduce growth size and make removal much easier. These drugs are however, temporary, and fibroids might return if one stops using them.
• Oral therapies: An innovative oral therapy for managing heavy bleeding of the uterus in premenopausal individuals with symptomatic fibroids is elagolix, which can be used for up to 2 years. Discuss the benefits and disadvantages of this therapy with your doctor. Tranexamic acid is another option that helps with heavy menstrual bleeding in those with uterine fibroids.

Always discuss the medications you are taking with your medical provider. It's also important to consult before you start using any drugs so as to know the potential complications.

Fibroid surgery

When it comes to considering the different forms of fibroid removal surgery, there are a few factors to take into account. Apart from the size, number, and location of the growth, your desire for pregnancy in the future could also influence the choice of treatment plan. While certain surgical procedures preserve the uterus for future pregnancy, others can completely remove or damage the uterus.

The surgical option that involves fibroid removal is known as myomectomy. Although there are various types of this procedure, the option that is ideal for your condition is determined by fibroids location, size and number:

• Hysteroscopy: This involves inserting a scope via the vagina and cervix into the uterus. The scope is then used to cut and take out fibroids.
• Laparoscopy: This procedure involves removing the fibroids using a scope. It is done by creating a few tiny incisions in the abdomen through which the scope will be inserted into the body.

• Laparotomy: This procedure is performed by making a big cut in the abdomen, and removing fibroids through it.

For individuals who have no future pregnancy plans, the medical provider can suggest other options. Although these treatments could be more effective, getting pregnant afterward may be impossible. They include:

• Hysterectomy: This procedure, which involves removing the uterus, is the only method of curing fibroids. Total uterus removal prevents the fibroids from recurring and resolves all symptoms. However, menopause will not begin after surgery if the ovaries remain intact. This makes hysterectomy suitable for people who experience too heavy bleeding due to the condition or have big growths. Examples of minimally invasive hysterectomies are laparoscopic, vaginal and robotic approaches.
• Uterine fibroid embolization (UFE): This procedure is conducted by an interventional radiologist with the assistance of a gynaecologist. It involves placing a tiny catheter into the uterine or radial artery and injecting small components that block blood flow to the fibroids. This helps shrink the growth and manage symptoms. However, this option is not suitable for everybody.
• Radiofrequency ablation (RFA): This treatment utilizes microwave (RF) power to treat smaller uterine fibroids and is recommended for individuals who have not started menopause. RFA is generally an effective and safe method.

Can Fibroids Affect Fertility and Pregnancy?

Uterine fibroids can significantly affect a person's fertility and general pregnancy results. Based on the location and size, these benign growths can alter conception and lead to higher complication risks during pregnancy. It's thus essential to consider these key points:

• Fibroid impacts on fertility: Fibroids can obstruct the fallopian tubes or distort the uterus shape, which makes implantation of the fertilized egg difficult. They can also trigger uterine lining inflammation, reducing its receptivity to implantation.

• Fibroids risks during pregnancy: Expectant mothers who have uterine fibroids might be at a high risk of miscarriage, placental abruption, preterm labour or foetal growth restrictions. Factors like the size, location and number of fibroids can influence these complications.

• Fibroids treatment during pregnancy: Managing uterine fibroids during pregnancy is based on factors such as location and size of the growths, symptoms severity, and possible risks to both the child and the mother. Sometimes, treatment is not required, especially if the fibroids are smaller and don't cause any major symptoms. But in case the symptoms worsen or complications occur, medication or surgical options may be recommended.

Women who have fibroids and plan to conceive or are pregnant already should talk with their doctors to determine the right methods of managing and monitoring the condition.

Prevention

The research on the causes of uterine fibroid is ongoing. Additional studies is, however, required on ways of preventing them. While it may be impossible to prevent fibroid tumors, only a small fraction of all cases necessitate treatment.

Reducing the risk of fibroid is possible with healthy lifestyle adjustments. You should, therefore, strive to maintain a healthy weight, exercise regularly, and consume a balanced diet rich in vegetables and fruits.

Some studies claim that birth control pills and long-acting progestin-only contraceptives are likely to minimize the possibility of developing fibroids. However, the use of birth control pills before turning 16 might be connected with an increased risk.

When should I contact my healthcare provider?

You should contact your practitioner if you experience these uterine fibroids symptoms:

• Heavy, irregular vaginal bleeding

• Pelvic pain

• Bleeding between periods

• Painful intercourse

• A sense of pressure or fullness in the abdomen

Since these symptoms of fibroids are also common indicators of other gynaecological problems, it's essential to discuss them with your provider.