Most women have heard of fibroids, either because they have them or someone they know has them. But I also find most women don’t know exactly what they are. I have even heard different names for them — "the ‘broids," "the fibers," "my uterus tumors" and even "my little babies." When a friend of mine recently went through the process of diagnosis and surgery for her fibroids, here were her main questions and concerns.
What are fibroids?
Fibroids are benign tumors of muscle cells in the uterus. The uterus is a muscular organ that must expand during pregnancy and then contract during labor to push the baby out. It makes sense that these muscle cells must respond to hormones to grow. In the case of fibroids, cells grow abnormally to form a defined tumor of muscle cells. A fibroid is benign, that is, it is not cancerous. Very rarely, cells in the uterus can mutate to become malignant and form a cancerous tumor called a leiomyosarcoma.
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What are the symptoms?
While it is estimated that 75% of women may have fibroids, only about 25% of women have any symptoms. Usually, fibroids are diagnosed when a woman complains of heavy bleeding or pelvic pain, and/or the uterus feels enlarged on a pelvic exam. An ultrasound may be ordered by your doctor to confirm the diagnosis. When the uterus is particularly large, its size is described compared to a pregnant uterus, for example, a 10-week fibroid or a 20-week fibroid. In fact, a woman with fibroids might actually look pregnant. This is often how someone might start describing their tumor as their "baby." When fibroids are large enough and in a particular location, they also may cause constipation or difficulty urinating.
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Can fibroids affect fertility?
Generally, fibroids do not affect fertility. A fibroid that is close to the lining of the uterus (submucosal) or is big enough to alter the shape of the inside of the uterus may interfere with the ability of the fertilized egg to implant and grow. A woman with fibroids who is having problems getting pregnant should not immediately assume that the fibroids are the cause. Other reasons for infertility should be pursued. While fibroids can increase the risk of certain problems during pregnancy, the majority of women with fibroids have no problems.
If your fibroids do require treatment, be clear with your doctor about your thoughts regarding future pregnancy, so that any treatment will attempt to preserve your fertility.
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Can I take birth control or hormone therapy (HT) if I have fibroids?
The growth of fibroids is somewhat dependent on estrogen levels. Fibroids tend to shrink after menopause unless a woman takes estrogen. The effect of birth control pills on fibroids varies. Young women ages 13 to 16 who take oral contraceptives are more likely to develop fibroids later in life. Older premenopausal women with fibroids usually can take birth control pills. Sometimes hormones are actually used to reduce heavy vaginal bleeding associated with fibroids.
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How do you get rid of them?
Medications that decrease estrogen stimulation may reduce fibroid size as well as bleeding from fibroids. Leuprolide (Lupron) given by injection is a potential short-term therapy and is sometimes used to shrink fibroids before surgery.
If you are close to menopause, your physician might recommend holding off on treatment for now. As hormone levels fall during menopause, fibroid symptoms improve, and the fibroid may actually shrink.
The ultimate treatment is hysterectomy, removal of the uterus. If you do not want to get pregnant anymore, then hysterectomy might be the right choice for you.
For women who want to have children, there are other options. At first, it may seem that having laparoscopic surgery, through small incisions, is a great choice. But it is reserved for smaller fibroids. It is not well studied whether the suturing made through laparoscopic incisions is strong enough to endure pregnancy. Fibroids growing into the uterine cavity may be removed with a hysteroscope, an instrument passed through the vagina and cervix. These submucous fibroids are removed by cautery so suturing is not required. Removal of fibroids — myomectomy — through the standard abdominal surgical incision has a low rate of uterine rupture (when the uterus tears open) during pregnancy. Therefore, for many women of childbearing age, standard myomectomy may be recommended if the fibroid is large enough or causing a lot of symptoms. The only downside to surgery to remove just the fibroid is that it may grow back in another area, requiring a repeat surgery if they continue to cause symptoms.
There are other nonsurgical options, but since they can impair fertility, or else they are too new to say whether they affect fertility, they are only recommended if you are not having more children. If you have heavy bleeding, pain or symptoms like constipation or difficulty urinating, you might consider having a treatment such as myolysis with endometrial ablation (destruction of the fibroid with heat and laser to the lining of the uterus) or a newer technique that cuts off the blood supply to the uterus (uterine artery embolization).
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Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.