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Uterine Fibroids
Uterine fibroids are common noncancerous (benign) tumors of the uterus.
They grow from the muscular wall of the uterus (womb) and are made
up of muscle and fibrous tissue. They may enlarge and distort the
uterus and sometimes the cervix. Uterine fibroids are also referred
to in medical terms as myoma, leiomyoma, leiomyomata, and fibromyoma.
Fibroids can grow as a single growth or in clusters /groups of many
small fibroids. Their size can vary from small, coin sized, to even
larger than a grapefruit or melon. A very large uterine fibroid can
cause the uterus to expand to the size of a six or seven-month pregnancy.
Fibroids commonly occur in the 3rd to 5th decade of life. Between
20-50% of women of childbearing age have uterine fibroids. It is three
times more common in African American women than Caucasian women.
Also, African American women tend to get fibroids at a younger age
than do other women. Women who are overweight or obese also are at
a slightly higher risk for fibroids than women who are not overweight.
Women who have given birth appear to be at a lower risk for fibroids.
The exact cause of fibroids is unclear. They may occur as a result
of many factors interacting with each other. These factors could be
hormonal (affected by estrogen levels), genetic (running in families),
environmental, or a combination of all three. Fibroids appear to require
estrogen for their growth. During menopause when estrogen levels decline,
fibroid growth usually subsides.
Types of fibroids:
There are 3 categories based on where they grow. The subserosal fibroids
(about 55%) occur in the outer wall of the uterus; intramural fibroids
(40%) are found within the muscular wall and submucous fibroids (5%)
are located just underneath the lining of the uterus or in the inner
wall of the uterus and may protrude into the uterine cavity. Most
fibroids grow within the wall of the uterus. Some fibroids grow on
stalks (called peduncles) that grow out from the surface of the uterus,
or into the cavity of the uterus.
Symptoms of fibroids:
While many women do not experience any symptoms, sometimes symptoms
can be severe enough to require treatment. Some of the symptoms associated
with fibroids are listed below:
- Abnormal uterine bleeding either because of a distorted uterine
cavity with a larger surface area or pressure on the endometrium.
This includes heavy bleeding or painful periods and bleeding between
periods.
- Pain in the pelvis or lower abdomen. Rapid growth can cause
a painful cramping sensation. Twisting fibroids can cause sudden
severe pain.
- Pressure on the bladder which leads to a constant need to urinate,
incontinence, or the inability to empty the bladder.
- Pressure on the bowel which can lead to difficult bowel movements,
constipation, bloating and or hemorrhoids.
- Enlarging abdominal girth or an enlarged abdomen which may be
mistaken for weight gain or pregnancy.
- Feeling of fullness in the pelvic area (lower abdomen).
- Lower back pain.
- Reproductive problems, such as infertility, having more than
one miscarriage, or having early onset of labor during pregnancy.
Fibroids and Infertility: :
About 2-3% of infertile women are unable to conceive due to fibroids.
Most often submucosal or intramural fibroids are associated with infertility.
Infertility may result because of a distorted endometrial cavity making
implantation difficult or due to compression or blockage of the fallopian
tubes by the fibroids. Fibroids are associated with increased miscarriage
rates and increased risk of premature delivery.
Diagnosis
of fibroids:
Pelvic examination:
Fibroids may be felt during a pelvic exam. The size of the
uterus will be enlarged and its shape may be distorted as well. Often,
the physician will describe how small or how large the fibroids are
by comparing their size to the size of the uterus during pregnancy.
For example, fibroids may increase the uterine size to that of a 8
weeks pregnant uterus. However, a pelvic exam is not always reliable
in making a diagnosis of fibroids. This is because there are other
conditions that may cause enlargement of the uterus and mimic fibroids.
Conversely, fibroids may be missed on a pelvic exam. Therefore, several
diagnostic imaging studies or tests that create "pictures" of the
inside of the body are used to confirm the presence of fibroids. Most
often an ultrasound scan will help confirm the presence of fibroids.
Ultrasound:
Sounds waves are used to produce a picture of the pelvic organs. Vaginal
or abdominal ultrasound examination or both may be used to detect
fibroids. Thus, the presence, location and size of fibroids can be
confirmed.
Sonohysterography:
A small catheter is placed inside the uterus to instill 15-20 cc of
fluid during an ultrasound. This improves the ability to identify
submucous fibroids which protrude into or distort the uterine cavity.
Hysterosalpingography:
A hysterosalpingogram (HSG) is an x-ray of the uterus and fallopian
tubes that reveals abnormalities in the uterine cavity or blockages
in the tubes. During the hysterosalpingogram, a radio-opaque dye is
injected into the uterine cavity that reveals the size, shape, and
symmetry of the uterus. Hysterosalpingograms thus determine the presence
of abnormalities in the uterine cavity or fallopian tubes.
Computerized Tomography (C.T. / CAT scan):
A computer is used to make many pictures of the body from different
angles to provide a more complete image. It is only rarely used to
determine if fibroids are present because of its cost.
Magnetic Resonance Imaging:
MRI scans produce pictures by absorbing energy from high frequency
waves to determine if fibroids are present. It provides an excellent
picture of the uterus and is accurate in determining the size and
exact location of fibroids. Usually the cost of this exam is not justified,
as all of the information needed to plan treatment of fibroids (or
not to treat) can be obtained by other methods.
Besides imaging tests, direct visualizing of the uterus or uterine
cavity by a surgical procedure may be necessary to make a diagnosis
of fibroids. Treatment of the fibroids may be undertaken during these
procedures, described below:
Diagnostic
Hysteroscopy:
This is usually a quick office wherein a long telescope like tube
with a camera is inserted into the vagina and directly into the uterus.
It shows any growths / polyps or submucosal fibroids inside the uterus.
This is important because abnormalities of the uterine cavity may
prevent fertility and can even interfere with pregnancy.
Diagnostic Laparoscopy
This procedure helps in making a definitive diagnosis and sometimes
is used to remove fibroids. During laparoscopy, a telescope-like instrument
is inserted through a small incision at the belly button into the
abdomen. The abdomen is then inflated with carbon dioxide to allow
full visualization of the pelvic organs. One or two small incisions
are made along the lower abdomen where graspers can be inserted to
visualize the entire abdominal cavity. Uterine fibroids are easily
visualized.
Treatment of fibroids:
Watchful waiting: Most fibroids
do not cause symptoms, and do not require treatment. Periodic examination
to determine if there is a significant change in the size of the fibroid
and monitoring to determine if there is progression of symptoms is
sufficient. Several factors are taken into consideration when determining
treatment options for fibroids. These include whether or not the patient
is having symptoms from the fibroids, if patient might want to become
pregnant, the size of the fibroids, the location of the fibroids and
the patients age. At the ReproMed Fertility Center, Dr. Pinto will
discuss all the treatment options with you and help you decide on
the treatment that best suits your needs.
Fibroids may require treatment in the following circumstances:
- Fibroids are growing large enough to cause pressure on other
surrounding organs, such as the bladder.
- Fibroids are growing rapidly .
- Fibroids are causing abnormal bleeding
- Fibroids are causing problems with fertility
Medications:
For mild symptoms, pain medications including over-the-counter anti-inflammatory
drugs, such as ibuprofen, or other painkillers such as acetaminophen
can be used for mild pain.
Hormone
therapy: Treatment with Gonadotropin releasing hormone agonists
(GnRHa) causes a decrease in the size of fibroids. Sometimes they
are used before surgery, to shrink the fibroids, making them easier
to remove. These drugs only offer temporary relief from the symptoms
of fibroids as symptoms recur and the fibroids grow back when the
treatment is stopped.
Surgery may be the best way to treat fibroids with moderate or severe
symptoms. The surgical options are as follows:
- Myomectomy: This refers to a
surgical procedure to remove fibroids without taking out the healthy
tissue of the uterus. There are many ways this procedure can be
performed. The type, size, and location of the fibroids will determine
what type of procedure will be done. Major open abdominal surgery
or laparotomy is performed for large, multiple or inaccessible
fibroids. Minor surgical procedures include laparoscopic or hysteroscopic
myomectomy, wherein small fibroids are removed using laparoscopic
or endoscopic techniques .
- Hysterectomy: Surgical removal
of the uterus is the only sure way to cure uterine fibroids. It
involves a hospital stay and a recovery period. This surgery is
used when a woman's fibroids are large, or if she has heavy bleeding,
and is either near or past menopause and does not want children.
There are various types of hysterectomy that differ in how invasive
they are. Large fibroids may warrant an abdominal hysterectomy
that involves cutting into the abdomen to remove the uterus. If
the fibroids are smaller, a vaginal hysterectomy may be done wherein,
the uterus is removed through the vagina, instead of making a
cut in the abdomen.
- Myolysis - This is a procedure
in which an electrical needle is inserted into the uterus through
a small incision in the abdomen to destroy the blood vessels feeding
the fibroids.
- Uterine fibroid embolization (UFE):
In this treatment, the uterine artery is injected with polyvinyl
alcohol beads, with a catheter. This blocks the flow of blood
to the fibroids cuts off the blood supply to the uterus and the
fibroids and cause necrosis so that the fibroids shrink. UFE is
an alternative to hysterectomy and myomectomy. The recovery time
is shorter, and there is a much lower risk of needing a blood
transfusion than for these surgeries. There is a small risk of
infection in the treated fibroid, but these are usually managed
with antibiotics. Although recent studies suggest that most fibroid
tumors are not likely to re-grow after UFE, more long-term data
is needed.
Not all fibroids can be treated with UFE. All patients must first
be evaluated with ultrasound or MRI to make sure the fibroids will
respond well to this treatment. Doctors called interventional radiologists
perform UFE. The best candidates for UFE are women who have fibroid
tumors that are causing heavy bleeding or are causing pain or pressing
on the bladder or rectum ,women who don't want to have a hysterectomy
and don't want to have more children.
Sometimes after UFE, the beads that are put into the fibroids to cut
off their blood supply have traveled to the ovaries. The ovaries may
stop working for a short time or permanently resulting in early menopause.
Therefore, there is a possibility that UFE can affect fertility.
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Pinto is privileged to be selected by his peers
as one of the Top Doctors in Texas,
"Texas Super Doctors" 2007 |
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