by Tamer Seckin, MD | Posted on June 10, 2020
Fibroids are benign (non-cancerous) tumors that grow on the 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, and 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.
There are 5 different classifications of fibroids: intramural, subserosal, submucosal, intracavity, and cervical.
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 occur primarily during pregnancy. Moreover, when estrogen levels are low such as during menopause, fibroids tend to shrink. When estrogen levels are high, fibroids have been seen to swell. This theory is the 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 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.
Fibroids affect at least 20% of women (1 in 5) at some point in their lives.
Fibroids develop in 1 in 100 premenopausal women, versus 1 in 1,000 women after menopause.
Fibroids are 9 times more likely in black women than white women (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 woman's risk of developing fibroids.
Genetics/Heredity have been shown to play a role in a woman's risk of developing fibroids.
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. As a result, in cases with large symptomatic fibroids, women may often choose to undergo an imaging review of the uterus via hysteroscopy or hysterosalpingography.
Fibroids may also press against and block the entrance to the fallopian tubes, subsequently 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 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 and causes the fibromas to turn red and die, subsequently 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 in the uterus, in about 0.1% of fibroids cases. A pathological exam is the only way to observe this rare transformation.
Patients with fibroids often present with anemia.
There are many cases in which fibroids are misdiagnosed as adenomyosis, or adenomyosis is misdiagnosed as fibroids. However, 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
Urinary incontinence or leakage
Difficulty emptying bladder
Deficiency of blood cells (anemia)
Dyspareunia (pain during intercourse), which is common in cervical fibroids
Deep thigh aches with varicose veins
No symptoms at all, which is reported in 75% of diagnosed women. Differences in symptoms may be due to the varying size and location of the fibromas themselves
Ultrasound: Just like adenomyosis, an ultrasound (sonogram) is the imaging technique most commonly used to diagnose fibroids. However, while adenomyosis often appears as diffuse thickening of the uterine wall, fibroids appear as round areas with a discrete border. There are two forms of ultrasound used to diagnose adenomyosis: abdominal and vaginal. 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. 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. A laparoscop, a tube with a small camera at one end, 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 lower 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.
Short-term GnRHa (3-6 month use): Gonadotropin-releasing hormone agonists (GnRHa) are used to shrink fibroids and are the most frequently used medication for 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. As a result, long-term use of GnRHa is supplemented with steroid hormones of estrogen and progesterone, which are safely employed to extend the maximum use of GnRHa without sacrificing efficacy.
Innovative medical treatments: There are several innovations that are under investigation for the 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 for a uterus greater than 12-weeks in size.
Progesterone antagonist: Just as Gonadotropin-releasing hormone has an agonist used for the treatment of fibroids, as does progesterone. In some studies, this agonist has been shown to induce uterine shrinking and can even stop menstrual cycles 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: 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.
Laparotomic myomectomy: This open abdominal surgery gives a surgeon the full visualization needed to remove fibroids.
Laparoscopic myomectomy: A 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: a 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. Only if the fibroids are large, diffuse, and cannot be treated any other way is a hysterectomy considered. This form of surgery is rarely needed for fibroids, and yet it accounts for ⅓ of hysterectomies in the United States.
Deep Excision laparoscopic myomectomy: With decades of operating experience, Dr. Seckin is highly skilled in treating cases of fibroids via laparoscopic myomectomy and uterine repair. We believe that excision surgery is the best method for removing myomas because it is the only way to remove a fibroma at its root. In cases of laser ablation, there are often small bits of myoma left underneath the tissue. Very rarely do we see the need for open, invasive myomectomy—let alone a hysterectomy—to treat fibroids.
It is important to find a surgeon who will perform a myomectomy, thus ensuring the complete removal of each underlying fibroma. Through laparoscopic myomectomy, we are able to ensure thorough removal of the patient’s fibroids, with minimal invasion. We pride ourselves on handling each myomectomy with extreme 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-decade battle led her to be treated by Dr. Seckin, one of the best fibroid surgeons. Read more on how Marilyn’s treatment and 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.
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