Fibroids are benign tumors (non-cancerous) that grow from muscle layers of the uterus. They can grow on the outside, inside or within the smooth muscle of the uterine wall. A single fibroid is called a uterine fibroma. However, the term fibroid is more common as most cases involve six to seven fibromas on average. The fibroid mass is primarily composed of smooth muscle and fibrous tissue, including extracellular matrix (i.e., collagen, fibronectin, proteoglycan). Fibroids often cause an enlargement of the uterus itself, due to the fibromas stretching the walls of the uterus to be as large as that of a pregnant female. A fibroma can vary in size from that of a small bean to as large as a melon. Other names include fibromyomas, fibromas, myofibromas or myomas.
Classification of Fibroids
There are 5 different classifications of fibroids intramural, subserosal, submucosal, intracavity and cervix fibroids
Intramural fibroids: These fibroids are located in the thick wall of the uterus (myometrium) and are the most common type of fibroids, but also the easiest to remove.
Subserosal fibroids: Located outside the wall of the uterus, this type of fibroids can often grow to be the largest. One of two types of fibroids that can form a “stalk” on which the mass is attached termed pedunculated fibroids.
Submucosal fibroids: Fibroids located in the muscle beneath the lining of the uterine wall (endometrium). They also can form pedunculated fibroids.
Intracavity fibroids: This form of fibroids is located in the cavity of the uterus itself.
Cervical fibroids: These fibroids form in the cervix, the neck of the uterus.
Causes of Fibroids
There is no universal consensus on what precisely causes fibroids, but there are several theories. Most recently, it has been observed that women who develop fibroids often have high estrogen and progesterone levels, which occurs primarily during pregnancy. Moreover, when estrogen levels are low such as during menopause, fibroids tend to shrink whereas when estrogen levels are high, fibroids have been seen to swell. This theory is prime reasoning as to why it is common to see overweight women develop fibroids. A higher state of body fat means there is an excess conversion of the body’s sex steroids to the estrogen equivalent, estrone. Increased levels of estrogen and estrone are believed to play a key role in fibroid development and growth. The production of estrone is common in overweight patients because fat cells contain the key enzyme aromatase, which is responsible for this conversion. Other growth factors, such as insulin-like growth factor (IGF) have also been thought to play a role in fibroid development. Meanwhile, many others believe there is a significant genetic component to fibroids because it can be inherited from a mother or family member who has had the disease in the past.
Risk Factors for Fibroids
Fibroids affect at least 20% (1 in 5) women at some point during their life.
Fibroids happen to 1 in 1,000 premenopausal women, versus 1 in 100 women after menopause.
Fibroids are 9 times more likely in black females than white (although racial differences in socioeconomic status and access to healthcare is a probable contribution to this discrepancy).
Women between the ages of 30 to 50 years old are more likely to develop fibroids.
Being obese or overweight can increase a women's risk of developing fibroids
Genetics/Heredity have been shown to play a role in a woman's risk of developing fibroids.
Fibroids and Pregnancy
For the most part, fibroids do not usually affect pregnancy. Nevertheless, there are some instances in which fibroids can make conception difficult and can even lead to miscarriages. When fibroids physically distort the uterine cavity, several complications can arise, including infertility, recurrent miscarriages, premature labor or complications of labor. Thus in cases with large symptomatic fibroids, women may often choose to undergo imaging review of the uterus via hysteroscopy or hysterosalpingography.
Fibroids may also press against and block the entrance to the fallopian tubes preventing the egg from reaching the uterus. When fibroids block the birth canal, they can also interfere with labor and delivery, causing the need for a Caesarean section. Finally, fibroids can play a role in post-delivery recovery as they can increase heavy bleeding and the time it takes for a woman's womb to return to its normal shape and size.
It is also important to note that pregnancy itself can cause fibroids to develop, due to the elevated levels of progesterone and estrogen that occur when a woman is pregnant. However, there is little evidence to support this theory. Pregnancy has also been noted to cause “red degeneration.” This condition cuts off the fibroids’ blood supply causing the fibromas to turn red and die triggering intense abdominal pain and contractions of the womb that can lead to miscarriages.
Benign fibromas (leiomyomas) can transform into leiomyosarcomas, malignant smooth muscle tumors of the uterus, in about 0.1% of fibroids cases. A pathological exam is the only way to observe this rare transformation.
There are many cases in which fibroids are misdiagnosed as adenomyosis, as well as the reverse. However, the main difference is that fibroids are more of a focal condition in which benign singular fibromas arise in several areas of the uterus, whereas adenomyosis is usually, for the most part, more diffuse. Even in cases of focal adenomyosis and adenomyoma adenomyosis, the diseased areas are more spread out and contain small pools of blood as opposed to the single, focal mass that is a fibroma. Adenomyosis is ultimately much more challenging and “messier” to remove than fibroids when it comes to excision surgery.
Heavy and prolonged menstrual bleeding (menorrhagia), which can include clots
Feeling of pressure in the pelvis, which can cause abdominal pain, back pain and bladder and/or bowel dysfunction
Dyspareunia (pain during intercourse). This is common in cervical fibroids
Deep thigh aches with varicose veins
No symptoms at all, which is reported in 75% of women diagnosed. Differences in symptoms may be due to varying size and location of the fibromas themselves
Ultrasound: Just like adenomyosis, an ultrasound (sonogram) is the most commonly used imaging technique used to diagnose fibroids. However, while adenomyosis will often appear as diffuse thickening of the uterine wall, fibroids will be seen as round areas with a discrete border. There are two forms of ultrasound used to diagnose adenomyosis: abdominal and vaginal ultrasound. While an abdominal pelvic ultrasound is used to find large fibroids, a transvaginal ultrasound is a bit more invasive in order to detect small, more nuanced fibroids.
MRI: While ultrasound may be the most common technique, magnetic resonance imaging (MRI) is the most powerful diagnostic tool used for imaging purposes. In the case of fibroids, MRI can distinguish leiomyomas from other intramural lesions. However, when it comes to endometriosis most physicians choose to conduct an ultrasound before an MRI because it can be done in an office setting and is far less expensive.
Direct visualization: These techniques are more invasive and expensive than an ultrasound or MRI. Thus they are usually performed along with surgeries or instances of highly concerning symptoms. Nevertheless, they provide clear and direct imaging of the uterus and in turn fibroids
Hysteroscopy: During this diagnostic procedure, a small telescope is inserted into the vagina to examine the inside of the womb, allowing the surgeon to easily visualize the fibromas
Laparoscopy: This slightly more invasive procedure allows direct visualization of the outside of the uterus and the surrounding pelvic structures, by using a small camera on the end of a tube (laparoscope) that is inserted into small incisions made in the abdominal and pelvic cavities.
Drugs: While there are no medications that will permanently shrink fibroids, there are drugs that can help control fibroid symptoms and can even reduce the size of fibroids. These medications do this by lowering estrogen and progesterone levels, while simultaneously reducing blood flow to the fibroids themselves. However every case is different, and what may work for one patient may not work for another.
Birth control: Often prescribed to reduce heavy bleeding
Short-term GnRHa (3-6 month use): Gonadotropin-releasing hormone agonists (GnRHa) are used to shrink fibroids and are usually the most frequently used medication when it comes to fibroids. They also stop menstrual flow
Long-term GnRHa w/steroid hormones (after 3-6 month use): Long-term use of GnRHa can lead to bone loss density due to the reduced levels of estrogen. Thus long term use of GnRHa is supplemented with steroid hormones of estrogen and progesterone, which are safely employed to extend maximum use of GnRHa without sacrificing efficacy
Innovative medical treatments: There are several innovations that are under investigation for future treatment of uterine leiomyomas
Medicated IUD: Putting a medicated intrauterine device (IUD) into the uterus can decrease a woman’s blood flow and thus reduce the size of her fibroids. However, this is not advised in a uterus greater than 12-weeks in size
Progesterone antagonist: Just as Gonadotropin-releasing hormone has an agonist used for the treatment of fibroids, so does progesterone. In some studies, this agonist has been shown to induce uterine shrinking and can even stop menstrual cycles as a whole for women with fibroids. However, this method is not available in the U.S.
Antifibrotic drug: Used to control prolonged and/or profuse blood flow in women with leiomyomas by diminishing the endometrium.
Androgenic agents: Often referred to as male hormones, synthetic androgens can help slow or stop the growth of fibroids and relieve symptoms such as anemia and menstruation altogether.
Mifepristone: French abortion pill that decreases the size of fibromas and reduces abdominal uterine bleeding.
Myomectomy: This is the surgical removal of myomas via cutting into the uterus, followed by uterine suture repair. There are three types of myomectomies: laparotomic, laparoscopic and hysteroscopic myomectomies
Laparotomic myomectomy: This open abdominal surgery gives the surgeon full visualization to remove the fibroids.
Laparoscopic myomectomy: Minimally invasive abdominal surgery that is the preferred method for removing fewer than 4 small fibroids. This is a much more precise, difficult and longer surgery, but is also extremely effective
Hysteroscopic myomectomy: Minimally invasive vaginal surgery used only for small, pedunculated submucosal fibroids. This procedure does not require an incision into the abdomen
Hysterectomy- The surgical removal of the uterus. This surgery should only be used as a last resort for treating fibroids. If the fibroids are large, diffuse and cannot be treated by any other protocol than a hysterectomy is considered. Very rarely is this form of surgery needed for fibroids, and yet it accounts for ⅓ of hysterectomies in the U.S.
Deep Excision laparoscopic myomectomy: Unlike many other reproductive surgeons, we believe that after decades of learning and operating, Dr. Seckin is highly skilled in treating most cases of fibroids via laparoscopic myomectomy and uterine repair. We also believe that excision surgery is the best method for removing myomas as this is the only way that a fibroma can be removed at its root. In cases of laser ablation, there are often small bits of myoma left underneath the tissue itself. In the case of fibroids very rarely do we see the need for open, invasive myomectomy, let alone a hysterectomy.
It is important to find a surgeon who will perform a myomectomy ensuring complete removal of each underlying fibroma. Through laparoscopic myomectomy, we are able to ensure thorough removal of the patient’s fibroids, all with minimal invasion. We pride ourselves on handling each myomectomy with an extreme sense of precision and attention to detail.
Marilyn M. was diagnosed with fibroids in her early 30’s, after experiencing severe pelvic pain. A few years later Marilyn was told that she also had endometriosis. After several GYN appointments and multiple operations, Marilyn’s half a decade battle led her to be treated by Dr. Seckin. See how Marilyn’s treatment, comprehensive laparoscopic surgery combined with hormonal supplementation medication, has changed her life.
You can read more stories of patients with fibroids, of varying stages, in our testimonial section.