Uterine Fibroid

A benign tumor originating in the muscle or surrounding tissue in or around the walls of the uterus is known as a uterine fibroid or leiomyoma (also myoma), which is the most common noncancerous tumor of childbearing women. These tumors vary in size and can be large enough to extend beyond the confines of the pelvis. They occur in women usually in the fourth decade of life and black women are more likely to be affected than white women. By age 50, the incidence of fibroids per a US study was 70 percent in white women as compared with greater than 80 percent in black women. Unfortunately, the cause of fibroids is unknown. Heavy, painful periods are the hallmarks of these pelvic masses but some women experience no symptoms at all. Other symptoms include the feeling of pelvic fullness, infertility or frequent miscarriages, pain with intercourse, frequent urination, or low back pain.

Background

Both internal and external structures comprise the female reproductive anatomy. The uterus or womb is located internally, shaped like a pear, and is normally 7–8 cm in length, 3 cm thick. The main body of the uterus is known as the corpus and the opening to the uterus is the cervix. Most fibroids grow in the walls of the uterus but can also grow within the cavity and on the outside of the uterus. Fibroids developing within the uterus can grow to considerable size and cause the uterus to stretch.

Fibroid risk is influenced by both environmental and reproductive factors. Eating a diet rich in fruits and vegetables along with low-fat dairy products may decrease the risk. Whereas, having a high body mass index may increase the risk. Starting menses early in pubertal development and using estrogen-containing contraceptives may increase the risk of fibroids but using progestin-only injectables may decrease the risk. However, the major risk factors continue to be increasing age and being of African descent.

Uterine fibroids are suspected in women either from palpation of a mass during a pelvic examination or if the woman describes heavy periods. Ultrasonography is the gold standard for confirming the diagnosis because it can differentiate between a pregnant uterus, an adnexal mass (excess tissue often found in the ovaries or fallopian tubes), or a fibroid. Performing an ultrasound is inexpensive and can provide results immediately. Furthermore, the procedure is safe, particularly for an unsuspected fetus. Other testing may include a complete blood count and iron levels to determine if the excessive bleeding from the fibroids has caused anemia. Additionally, thyroid studies should be considered as a potential cause of the excessive bleeding.

Only rarely are presumed fibroids found to be cancerous. Leiomyosarcoma is the cancer that resembles benign fibroids and is extremely aggressive with a poor survival rate. Women undergoing treatment for fibroids should be counseled on the possibility of the uterine tissue containing cancer.

Overview

Multiple methods exist for uterine fibroid treatment and must be individualized to the particular patient. Treatment decisions are based upon a woman’s desire for organ salvation, future children, and the severity of the symptoms. The cost factor also contributes in the decision making process.

Uterine fibroid treatment can be categorized in the following manner: expectant, pharmacologic, invasive, and the newer less invasive methods. Because not all women with fibroids are symptomatic, simply monitoring the progression is a reasonable option. On the other hand, for those women whose symptoms are causing an interruption in activities of daily living, employment problems, or embarrassment from soiled clothes, more aggressive treatment is warranted.

Non-steroidal anti-inflammatory (NSAID) medications can be used initially to control abnormal uterine bleeding as a result of uterine fibroids. Progressive management then escalates to hormonal therapy such as combined oral contraceptives, which contain both estrogen and progesterone. Though the literature is varied on whether combined oral contraceptives decrease fibroid growth, most studies agree that abnormal bleeding is decreased. Gonadotropin-releasing hormones (GnRH), on the other hand, reduce fibroid volume by 46 percent and lesson symptoms. For this reason the GnRH method is sometimes utilized prior to surgery. Vasomotor symptoms and the potential for bone loss are the main disadvantages of GnRH use, which therefore limits its use to 3–6 months.

For years the definitive treatment for uterine fibroids has been hysterectomy, surgical removal of the uterus. In the United States, the lifetime prevalence of the procedure is 47 percent with 3/4 of women choosing this method. This procedure done vaginally, laparoscopically, or abdominally requires hospitalization and permanently eliminates fertility as a future option. Approximately 200,000 hysterectomies are performed annually as compared with 30,000 myomectomies. Many women prefer uterine sparing techniques such as myomectomy, which involves removing only the fibroid. Patients need to be counseled however about the risk of recurrence with myomectomy since the risk can be as high as 25 percent.

Another treatment method is uterine artery embolization, an interventional radiologic procedure that involves injecting particles in the arteries that supply the fibroids. Those particles adhere to the walls of the vessels and cause a clot to form, resulting in a disruption of blood supply and thereby causing the fibroids to shrink. Although slightly invasive, uterine artery embolization, is an additional form of treatment for women who desire sparing the uterus. Uterine artery embolization is not widely used because of concerns regarding future pregnancies and ovarian function.

Magnetic resonance imaging-guided high frequency ultrasound therapy (MRgFUS) was approved by the US Food and Drug Administration in 2004 as an alternative treatment for myomas. This noninvasive thermoablative procedure not only treats symptomatic leiomyomas but also other solid tumors such as pancreas, liver, and breast. To help reduce the damage to surrounding tissue during the ablation, MRI is used to view the anatomy, which assists in providing a more directed beam for the specific treatment area.

The financial impact of uterine fibroids not only includes the direct medical and surgical costs of treatment but also the indirect costs. Days lost from work and disability contribute to costs that roughly range from $4,500 to $30,000 annually per patient. Yet, those figures do not include costs associated with complications from surgery or infertility treatments. The estimated cost to the US is approximately $5 to $34 billion annually.

Bibliography

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Cardozo, E.R., A. D. Clark, and N. K. Banks, eds. The Estimated Annual Cost of Uterine Leiomyomata in the United States." American Journal of Obstetrics & Gynecology 206 (2012): 211. Print.

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Patel, Amrita, M. Malik, and J. Britten, eds. "Alternative Therapies in Management of Leiomyomas. Fertility and Sterility 102 (2014): 649–655. Print.

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