Uterine fibroids or uterine myomas are benign growths of the muscle of the uterus, affecting more than 20% of women mostly in their 40's. Most fibroids are asymptomatic and usually do not require any treatment unless their growth impacts adjacent organs such as the bladder or rectum. Treatment is definitely required for rapidly growing fibroids to rule out cancer, fibroids that cause a significant amount of bleeding and cramping during the menstrual cycle, and fibroids that are affecting fertility.

Types of fibroids.

Fibroids are classified by their location. The symptoms experienced depend upon the location of the growth.

Diagnosis of fibroids

Certain types of fibroids can be identified during a pelvic examination, however, small submucosal fibroids mainly will be expressed as prolonged bleeding and significant pain. Vaginal ultrasound is one of the most convenient, quickest and most precise tools to diagnose fibroids, providing information in regards to the size, the location and the possible treatment plan. New fibroids that are located underneath the lining or inside the intrauterine cavity can be diagnosed via hysteroscopy. This procedure is usually performed in the office and involves the placement of a small camera into the uterus. More recently, MRI is being used for diagnosis of multiple fibroids that are superimposed upon each other.

Adenomyosis is a condition in which the uterine lining starts to grow within the muscular wall of the uterus (myometrium), causing thickening and enlargement. Pelvic examination will reveal a "soft uterus" in which the uterine wall is not as firm as that of normal. Ultrasound can show an enlargement of the walls of the uterus. Laparoscopy can also confirm these findings. Unfortunately, since adenomyosis is a global invasion of glandular elements it is extremely difficult to remove it or to treat it.

Treatment of fibroids

The treatment of fibroids depends upon the symptomatology. Fibroids which significantly impact neighboring organs, such as the bladder and the rectum, need to be surgically removed. Small fibroids that cause significant pain and bleeding can be resected through the vagina and through the cervix via a small telescope. Fibroids affecting fertility need to be removed.

Currently there has been some treatment with medications such as GnRH agonists, which induce a temporary chemical menopause. Since the growth of the fibroid is dependent upon estrogen, a decline in estrogen production usually will reduce the size and the symptoms of the fibroid. Mifepristone better know as RU4-6 (French abortion pill) has been shown to decrease the size of the fibroid and to give temporary relief in the symptomatology caused by those tumors. Recently aromatase inhibitors have been described as a very important tool in reducing the amount of locally produced estrogens and consequently a reduction in the size of the fibroid. Unfortunately, these modes of therapy are temporary, and symptoms will return until the patient is near menopause (near the age of 47, 48, etc).

The treatment of submucous fibroids is relatively straightforward with surgical resection. This is successfully performed via a small camera (hysteroscope) introduced inside the uterine cavity and with the use of different wire loops and vaporizers. This lengthy procedure requires a highly experienced gynecological surgeon.

Intramural or pedunculated fibroids can be removed during an open surgical procedure called a myomectomy. Additionally, a hysterectomy, or complete removal of the uterus may be necessary. The choice of the surgical treatment is dependent upon the size of the fibroid, the location, the desire of the patient for future fertility and pregnancies and the experience of the surgeon.

Recently, uterine artery embolization has been introduced. The goal of this procedure is to reduce the blood supply to the fibroid and consequently to prevent and reduce the size of its growth. Recent reports suggest however that uterine artery embolization may impact fertility as well as induce pregnancy-related complications (repeated pregnancy loss). In a small number of patients, ovarian function will also be lost and consequently the woman becomes prematurely menopausal. A new technology using MRI-directed energy is being used on an experimental basis and appears to be a very promising procedure.