Fibroids

One of the most common results of diagnostic tests evaluating the uterus and fallopian tubes is the discovery of fibroid tumors nestled in uterine tissues. Fibroids, also called leiomyomas are almost always benign, so don’t let the word “tumor” scare you. Fibroids are benign, non-cancerous (99.8% of the time), smooth-muscle tumors that are extremely common. Over 20% of the general female population have them, and more than 50% of the African-American female population has fibroids. In fact, these tumors are one of the most common reasons women are scheduled for gynecological surgery. We aren’t sure why some women get them, and others don’t, but we do know they can cause problems (although they don’t always), and we know how to get rid of them. In some cases, fibroids are diagnosed during a routine pelvic exam because they’re size makes them detectable via your doctor’s well-trained hands. Otherwise, if symptoms indicate fibroids are present, your doctor will order an ultrasound or another diagnostic test to get a better image of your uterus. Fibroids are the cause of infertility in about 10% of all infertile couples. Although they’re very common, the size and location are the indicators of whether or not fibroids will cause infertility.

Location & Size Matter When It Comes to Fibroid Tumors

The size and location of these tumors, as well as any existing symptoms, determines whether or not the fibroids need to come out. Surgical removal of fibroids is typically performed when fibroids cause:

1. Fullness or pelvic pressure that affects the bladder or rectum
2. Abnormal uterine bleeding – when fibroids cause bleeding it is almost certain that they will also cause infertility and/or miscarriages.
3. Infertility
4. Miscarriages

Location is Important

There are four different types of fibroid tumors, and they are named according to their location in the uterine lining:

1. Submucosal Fibroids: These are formed just under the lining of the uterine cavity. As such, they can press partway or fully into the uterus, which affects the space where the fetus needs to grow. The good news is that submucosal fibroids are the least common type. The bad news is that they will almost always cause infertility and/or recurrent miscarriage. For this reason, we always recommend surgical removal for women who want to get pregnant.
2. Intramural Fibroids: The most common type of fibroid, this tumor forms inside the uterine wall. As they grow, they cause the uterus to expand, which can cause a woman to feel full or bulky. Her stomach may notably protrude, not unlike a pregnant woman’s belly, depending on the size of the tumor. Since they are not typically harmful, intramural fibroids are removed if they’re large enough to cause discomfort or if they negatively affect the fallopian tubes or a potential pregnancy outcome, such as siphoning off the blood supply from the placenta.
3. Subserosal Fibroids: These fibroids develop on the exterior layer of the uterus, so they grow outward into the pelvic cavity away from the endometrial cavity. Like intramural fibroids, they’re only removed if they are large and cause a problem.
4. Pedunculuated Fibroids. These tumors grow on a stalk rooted on the outside wall of the uterus.

Size Always Matters

The different locations of fibroids may or may not affect a tumor’s removal, but the size can mandate surgery. For example, submucosal fibroid tumors will always be removed for women with infertility or miscarriages, regardless of how small or large they are. On the other hand, intramural and subserosal fibroids are typically only removed when they are 5 – 6 cm (about the size of a softball) or larger. However, tumors will be removed regardless of their size if they seem to be causing other complications, such as changing the shape the uterus in a way that negatively impacts the fallopian tubes or other pelvic organs.

Complications Associated With Leiomyomas

Regardless of their location or size, fibroid tumors can cause certain complications, depending on the size, shape and condition of their female hostess. Some of the complications include:

• Blood Supply Theft. Tumors have their own blood supply, which they pull from surrounding tissue. So, if a fibroid tumor grows large enough, the amount of blood it steals from the uterus can compromise the uterus itself, or the fetus and placenta developing inside the uterus.
• Cervix Block. Fibroids often grow during pregnancy. If a fibroid is located in the “right” (or “wrong”) spot, it can end up blocking the cervical birth canal. Since surgical removal of the tumor isn’t recommended during pregnancy, this will typically result in a C-section because a vaginal delivery is no longer possible.
• Miscarriage. If a tumor grows so large that it affects the interior of the uterine cavity, it can cause a miscarriage.
• Rapid Growth. Sometimes, a fibroid tumor grows so rapidly that the uterus (the source of the tumor’s blood supply) simply can’t keep up. In these cases, the tumors often begin to degenerate from lack of blood, and this can cause increased pain or discomfort. When this happens the term degenerative fibroid or hemorrhagic fibroid is common.

Surgical Treatment for Fibroid Tumors (Myomectomy)

As previously mentioned, the best time to remove a fibroid tumor is not when a woman is pregnant. We also discourage their removal during a C-section (even though that might seem like an efficient strategy), because it can be difficult to control the bleeding. Therefore, the surgery will be scheduled after a woman is sufficiently recovered from her labor and delivery.

Hysteroscopic Myomectomy

This option is only available for submucosal fibroids. A hysteroscopic myomectomy uses a small blade attached to a small camera. This innovative surgical tool allows the surgeons at NCFMC to visually and surgically access the uterine cavity through the vagina and cervix. The device will be used to remove the fibroid tumor(s), and the procedure eliminates the need for an incision. A hysteroscopic myomectomy is an outpatient surgery, and recovery is usually only 1 – 2 days.

Abdominal (Laparotomy) Myomectomy

If the tumor is a larger serosal, intramural or pedunculated fibroid, you may be scheduled for an abdominal myomectomy. This requires a C-section type incision on the abdomen – also called a bikini cut – through which the surgeon will remove the tumor. This is a more invasive surgery and so the recovery is a more intense, requiring about two to six weeks, depending on the size and number of the tumors removed. Worth Noting: Women with very large fibroid tumors that undergo an abdominal myomectomy, will often have to schedule a C-section when they are pregnant. Babies choose the path of least resistance to leave the uterus. Typically, this is the birth canal. However, even well-stitched and nicely healed uterine tissue will be weaker than the surrounding tissue, so they baby can unknowingly try to pop through the old myomectomy incision, called uterine rupture. A uterine rupture is extremely dangerous. Thus, a C-section will be scheduled before your due date to prevent labor of the uterus muscle that can lead to a uterine rupture. The uterus takes about two to three months to heal completely after a surgical procedure, so this is the amount of time we recommend couples wait before trying to get pregnant again.

Hysterectomy

A full hysterectomy is also a possibility for women who are past their child-bearing years or who are sure they do not want more children. Since fibroids grow from uterine tissue, removing the uterus eliminates existing fibroids and, almost always, prevents future fibroids from developing. Of course, a hysterectomy would only be recommended in cases where the fibroids were causing undue discomfort and/or bleeding.

Other Things to Note

Since tumors have their own blood supply, operating on them can be tricky. Doctors employ several strategies to facilitate a safe and healthy surgery and recovery. For example:

• When women have many fibroids removed at the same time, or very large fibroids, the surgeon may use a machine called a cell-saver. This machine collects the blood that pools in the pelvic cavity and transfuses her own blood back into the patient to minimize the amount of blood that is lost during the operation.
• Your doctor may inject medications that cause the uterus to contract – like an induced Charlie horse. When the uterine muscle fibers contract, they temporarily crimp the blood supply, which keeps it from pooling in the pelvic cavity.
• Even though fibroids are benign 99.8% of the time, your surgeon should still send tissue samples to pathology for analysis – just to be on the safe side.
• If a woman does not conceive several months after the myomectomy, we recommend an hysterosalpingogram to make sure that the uterus healed appropriately, and the Fallopian tubes were not kinked from scar tissue.

The success rates for surgery are excellent. However, in very rare cases, large, submucosal fibroids can cause permanent damage. Again, this is uncommon.

Are There Other Methods to Control Fibroid Tumor Growth?

There are other methods used to prevent the growth of fibroids, or to minimize their development. However, none of them are recommended for women who want children (see below).

Medication-Based Treatment

Lupron is a synthetic gonadotropin-releasing hormone used to treat endometriosis and fibroids. However, while Lupron temporarily shrinks fibroids, the tumors grow right back once the patient goes off the med. Thus, it is typically only used for a few months in women who have bleeding-related anemia. Otherwise, Lupron is not a solution for infertility and/or miscarriages. The following may be good options for women who want to avoid a hysterectomy but do not want children in the future:

1. Uterine Artery Embolization. This procedure blocks uterine arteries, which stymies the blood supply to fibroids as well as the uterus.
2. Myolysis or Cryomyolysis. These procedures use a small abdominal incision, through which special instruments are fed in order to send an electrical current (myolysis) to the tumor, or to freeze the tumors (cryomyolysis). Either way, these procedures eliminate or dramatically curtail the tumors’ blood supply. In both cases, the tumors remain in place.
3. MRI-Guided Ultrasonic Treatment. This method uses MRI-guided imaging and highly concentrated ultrasound waves to destroy fibroid tissue without negatively affecting surrounding organs and tissues.

Women that wish to preserve their fertility should opt for surgery because it this safest and most effective treatment to preserve normal uterine function. The type of surgical approach will depend on the size and location of the fibroids as well as the individual patient. If you believe your infertility problems may be due to fibroids, give us a call. NCFMC physicians are experts at diagnosis and management of fibroids and can help you achieve a healthy pregnancy.