Fibroids

Today seems to be fibroid day.  It's funny how it goes like that sometimes.  I don't have any discussions about fibroids for days, and then it's all I do for a day.  A fibroid, or uterine leiomyoma, is a growth in the uterus.  The walls of the uterus are mainly made up of smooth muscle cells.  For some reason, one of these cells starts multiplying and growing into little balls.  Nobody know exactly why this happens.  These balls of cells can grow very big sometimes.  They can occur anywhere in the uterus, and they are very common.  African-American women tend to have more fibroids than Caucasians, but they can occur in any race.  There are almost universally benign with a 0.1% chance of being cancerous.  They can definitely cause problems, however.

Fibroids will often cause heavy, crampy periods.  Sometimes, especially if there is one inside the cavity of the uterus, they can cause spotting or bleeding in between periods too.  As they grow, they can cause pain, bloating, and even expand your belly like a pregnancy.  Fibroids have been linked to infertility, but the data are still a little unclear.  Fibroids inside the cavity of the uterus can definitely impair fertility and lead to miscarriages.  Fibroids that touch the uterine cavity also appear to be a problem.  They are very greedy and need a large blood supply.  They will take it away from the rest of the tissues around them.  There was a very nice study that showed that the lining inside the cavity (where the baby grows) is very thin and abnormal looking next to a fibroid, and it is normal in other places in the same cavity.  So if an embryo tries to implant near a fibroid, it may not be able to get enough blood supply to keep growing.  The fibroids that do not touch the cavity or are on the outside of the uterus are where the data get murky.  Most of the studies say that these should not be a problem, but there are some studies that say that taking them out will improve fertility.  For now, we weigh the risks of taking such fibroids out against the possible benefit and make decisions on an individual patient basis.

Fibroids are usually diagnosed by ultrasound.  A pelvic ultrasound will show round structures in the walls of the uterus.  CT scans and MRI's are sometimes needed, if the uterus is so full of fibroids that they cannot all be seen on ultrasound.  Rarely, another uterine mass called an adenomyoma can be mistaken for a fibroid.  These are also benign and are made up of cells like the ones in the lining of the uterine cavity.  MRI may be helpful in differentiating the two.

Many fibroids do not need to be removed, if they are not causing any symptoms.  If they do have to  be removed, surgery will obviously be necessary.  If the fibroid is inside the cavity of the uterus, a scope can be placed through the cervical canal and into the uterus.  The fibroid is then removed from inside the uterus.  Because there are no incisions, the patient is usually back to normal by the next day.  If the fibroid is in the wall of the uterus, then it must be removed from inside the belly.  Sometimes this can be done through a scope in the bellybutton, and sometimes a larger, c-section-type incision is needed.  If the fibroids are extremely large, sometimes an incision from the belly button down to the pubic bone is necessary to remove them.  The DaVinci robot has made it possible to remove much larger fibroids through a scope than was previously possible, however sometimes a larger incision is still necessary.  Recovery time for removing fibroids through a scope is usually 3-5 days, for the larger incision it will usually take about 6 weeks to recover.  If fertility afterwards is not desired, there are two other treatments too.  A radiologist can thread a small catheter (tube) through the blood vessels in the groin up to the arteries that supply the uterus.  These arteries are then blocked off with small inert spheres.  This will then cause the fibroids to shrink.  The recovery time is 1-2 weeks.  There is also a procedure where concentrated ultrasound beams are aimed at the fibroid to destroy it (ExAblate).  Sedation is given, as it can take an hour or more to destroy multiple fibroids.  The recovery time is usually just a day or two.  For women who do not want children and just have heavy periods from fibroids, a Mirena IUD may be helpful too.  This is a small device that is inserted into the cavity of the uterus.  It secretes a hormone that will keep your periods fairly light.  Some women even stop having any bleeding with the Mirena.  It is a contraceptive, but is reversible when you remove the device.

Fibroids do not usually go away on their own, so ignoring the symptoms is not a good idea with one exception.  They will shrink after menopause.  So if you are close to menopause and the symptoms are not life altering, then it may make sense to wait.  For everyone else, however, please talk to your doctor.  If your periods are so heavy that they are having an effect on your life, if your belly is starting to expand, or if you are unable to conceive;  it's time to do something.  Fibroids tend to just grow and grow, so waiting may mean that they get so big that your doctor will have to make a big incision to remove them rather than being able to take them out through a scope now.  In any case, it certainly won't hurt to talk to your doctor and find out what your options are.