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Treatment Options for Fibroids

The good news about fibroids is that these tumors are almost always benign—they do not cause cancer. Although fibroids do have the potential to cause problems if they grow especially large, most women, about 75 percent, manage to live with their fibroids fairly well and never have any trouble with them. In fact, many women—even some who have really large fibroids—aren't even aware they have them.

The bad news is that women are most likely to develop fibroids when they are in their 30s and 40s—a time when many women are trying to become pregnant. The traditional treatment—surgical removal of the uterus in the operation called hysterectomy—is becoming less and less acceptable to women who have not yet completed their families. Fortunately, there are now other options, with still more alternatives in development.

What Is a Fibroid?
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A fibroid is the most common tumor (abnormal mass of tissue) found in the pelvis. Such a tumor develops most often between the ages of 35 and 45 years, seldom before age 20. Fibroids do not occur at all before puberty. After a woman completes menopause, they generally stop growing and may even disappear.

Usually a fibroid is found in the uterus where it is the most common form of uterine mass. A fibroid can also develop on another structure that contains smooth muscle cells. In vary rare cases, it can even “invade” another organ when it grows too large to confine itself to its original location.

A fibroid is a solid tumor that contains mostly smooth muscle held together by fibrous tissue. (That's how it came by its popular name.) Other names for fibroids are leiomyomas, myomas, fibromas, and fibromyomas..

Fibroids usually occur as multiple tumors that tend to grow very slowly. Sometimes, however, a woman may have a single fibroid the size of a grapefruit or even one so large that it fills the entire abdomen. On the other hand, a fibroid tumor may be so small that it can be only seen under a microscope. It can weigh as much as 25 or 50 pounds, with the largest fibroid tumor ever reported weighing more than 140 pounds.

It is difficult to know just how many women have fibroids, since unless they cause a problem, a woman may never realize she has them. It is, however, estimated that fibroids occur in up to 25 percent of women over the age of 30 and in nearly 40 percent of women after the age of 40.

For some reason, black women seem more likely to develop fibroids. Almost half of all black women more than 30 years of age have fibroids compared with 20 percent of white women of the same age-group. Interestingly, studies have found a low incidence of fibroids among women in Africa. Overall, however, fibroids tend to occur earlier and grow faster in black women.

Why They Develop
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Even though fibroid tumors are common, no one is really sure how or why they develop, or why fibroids occur again and again in one woman and not at all in another.

Although the cause of fibroids is unknown, many physicians believe that these tumors grow when the body responds abnormally to the female hormone estrogen. Others disagree. What definitely is known is that fibroids:

Do not occur before puberty, when the body does not release estrogen
Grow bigger when women take oral contraceptives, which contain estrogen
Grow rapidly during pregnancy, when the body produces extra estrogen
Shrink and even disappear as menopause approaches and the body gradually stops making estrogen
Rarely appear after menopause
Grow when women take estrogen supplements to make up for the lack of the hormone
Still, there are many who doubt that estrogen is solely responsible for fibroid tumors. Although fibroids develop in some women who have high levels of estrogen, laboratory tests performed for many women with these tumors show completely normal estrogen levels.

In addition, while fibroids tend to grow larger when a woman is pregnant, there is little scientific evidence to show that these tumors multiply during pregnancy. Some physicians believe that the increased blood supply that occurs during pregnancy may be the cause, since fibroids require a lot of blood to survive.

Types of Fibroids
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The type of problems that fibroids cause depends on their location. Therefore, your doctor's first concern will be to pinpoint the exact location of the tumors. It is this information that determines the best course of treatment.

Fibroids are categorized by their location. The various types include:

Submucous fibroid. This type occurs just beneath the lining of the uterus and can displace the lining as it grows. This displacement can lead to menstrual irregularities and discomfort. After a while, this fibroid may develop a thin stalk called a pedicle. The stalk remains attached to the uterine wall, but the fibroid is able to “travel.” When this happens, the tumor may protrude into the uterus, which will then contract in an attempt to rid itself of this foreign body. The fibroid may also enter the vagina. As the fibroid moves around, the stalk may become twisted and lose blood, causing bleeding between periods. Infection may also occur.

Intramural fibroid. This round tumor is most commonly found within the uterine wall. The uterus can become enlarged as the intramural fibroid grows.

Subserous fibroid. This type grows on the outer wall of the uterus, sometimes jutting out from the lining. A subserous fibroid can grow overly large without causing any recognizable symptoms—until it interferes with other organs, creating problems there.


FIBROIDS: THE FIVE MAJOR TYPES

Classified by their location within and around the uterus, the noncancerous growths known as fibroids can grow for years without causing a problem—and may vanish after menopause. Submucous fibroids lie just below the inner lining of the uterus, subserous below the outer lining, and intramural deep within the uterine wall. If one of these growths develops a stalk, it's called a pedunculated fibroid. When found in the ligaments that support the uterus, it's an interligamentous fibroid. If a fibroid causes any symptoms at all, the first one is likely to be excessive menstrual bleeding.


Pedunculated fibroid. Such a tumor develops when a subserous fibroid grows a stalk called a peduncle. As these tumors get bigger and bigger, the original blood supply may not be sufficient to feed the fibroid. If the tumor becomes twisted or begins to degenerate as the blood supply diminishes, it can cause severe pain.

Interligamentous fibroid. This tumor, which grows sideways between the layers of the broad ligament (band of fibrous connective tissue) supporting the uterus, is extremely difficult to remove without interfering with important organs or the blood supply to the uterus.

Parasitic fibroid. When a fibroid attaches itself to another organ, it transforms itself into the rarest of all types, the parasitic fibroid. As the tumor establishes a new source of blood, its uterine stalk gradually degenerates until the fibroid is no longer attached to the uterus at all.

Reaching a Diagnosis
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A fibroid tumor, one of the masses a physician most frequently feels during a pelvic examination, is easily recognized during exploratory surgery. Many, many fibroid tumors, however, are discovered while a physician is looking for something else—or simply are not discovered at all. If a woman experiences no unpleasant symptoms, there may be no reason to look for them.

On the other hand, the mere presence of fibroid tumors can interfere with the doctor's general assessment of your health. Fibroid tumors that grow near the ovaries can make it impossible for the doctor to feel the ovaries and determine whether they are healthy—a big concern for women older than 40 years of age.

Ultrasound scanning enables physicians to distinguish these tumors. This diagnostic procedure can confirm the presence of fibroids when a woman has symptoms that raise suspicion of the tumors. However, because certain types of fibroids look similar to ovarian tumors, and the fibrous tissue can interfere with the sound waves, the ultrasound reading can be inaccurate.

Sometimes the only way a physician can be sure is to look inside via an operation. The decision to operate depends on the particular symptoms, on what the doctor suspects is the cause, and on considerations such as a woman's likelihood of developing ovarian cancer or other disorders that might be overlooked because of the fibroids.

The Classic Symptoms
Though most fibroids do not produce any symptoms, when they do cause problems—as happens in about 25 percent of those with fibroids—women are most likely to complain of (1) excessive bleeding, (2) pain, and (3) a swollen abdomen. (Actually the stomach isn't any bigger—the problem is the uterus, which stretches as the fibroids grow, pushing the intestines upward.)

Excessive bleeding occurs in about 30 percent of the women with fibroids. Most often the bleeding is caused by a type of fibroid tumor that grows underneath the endometrium, or lining of the uterus. As the tumors grow, the lining stretches, thins, and becomes distorted, all of which produce bleeding.

When a woman develops abnormal bleeding, she notices that her menstural flow is heavier, but that it lasts—at least at first—for the same number of days. She frequently will find, however, that after a while her periods are lasting longer. Some women, in fact, bleed almost constantly. Excessive blood loss drains iron from a woman's body causing anemia.

To determine whether the bleeding is related to fibroid tumors or to some other problem, the doctor may prescribe a certain type of birth control pills. It may also be necessary for the doctor to scrape the inside of the uterus and examine the tissue in a procedure called dilation and curettage or a D & C. One of the physician's major concerns is to make sure that a cancerous growth is not present alongside fibroids.

Pain, if it accompanies fibroids, will generally occur during the menstrual cycle but, more commonly, will not occur at all. With fibroid-related pain, women who have had relatively pain-free menstrual cycles for years may suddenly become very uncomfortable. They experience painful spasms or cramps similar to those felt during labor. Indeed, the fibroid may act like a foreign body, and the uterus responds by contracting, trying to get rid of it.

If a fibroid presses on the pelvic nerves, the woman may feel hip or back pain. If the tumor becomes twisted or begins to deteriorate, the pain may be felt as a sudden severe stabbing in the lower abdomen. Sexual intercourse may also become uncomfortable.

Pain that occurs between menstrual periods is seldom caused by uncomplicated fibroid tumors. When this kind of pain is the problem, the doctor needs to seek another cause. There could be a problem with a previously undiagnosed pregnancy or with a nonfibroid tumor.

Swollen Abdomen. As fibroid tumors grow, they can push other organs out of the way resulting in all kinds of discomfort. A growing fibroid can flatten the bladder, making it necessary to go to the bathroom more frequently and creating a constant feeling of urgency. A woman may also find that she is suddenly unable to control her bladder. In severe cases, the fibroid may push on the urethra or urinary canal so hard that she cannot urinate at all and has to be catheterized. If the tumor extends towards the back and leans on the lower bowel, a woman is likely to develop a backache, become constipated, and find it difficult to have a bowel movement.

Infertility. Fibroids can make it difficult for a woman to become pregnant or, if she does become pregnant, to carry the baby for the full nine months. Many things can happen to interfere with conception, with the fertilized egg's implantation in the uterus, and with the baby's growth. Tumors can block the sperm's pathway to the egg by distorting the uterus or pushing the cervix, or opening of the birth canal, out of alignment with the uterus. Large tumors can pinch the fallopian tubes, interfering with the egg's journey to the uterus.

Most fibroids are found underneath the lining of the uterus. As they grow, the lining above them stretches and may not receive enough nourishment. A fertilized egg may not be able to implant itself properly on the fibroid-distorted lining; and even if the egg does manage to attach itself to the thinned out lining, it may not hold on for the full nine months. The pregnancy will then end in a miscarriage. It is also difficult for the egg to attach itself to the lining if the woman constantly suffers bleeding.

As the pregnancy progresses, fibroids may occupy space meant for the baby. The tumors may also keep the uterus from expanding to accommodate a growing baby. Either of these situations could result in miscarriage or premature labor.

Fibroids may also interfere with the baby's birth, making it necessary for delivery by cesarean section. For example, the uterus may not be able to contract sufficiently, resulting in ineffective labor. Or the baby may not have enough room to assume the proper position for a normal birth. Tumors in or near the birth canal can block the baby's progress. After the baby is born, fibroids may also increase the amount of maternal bleeding.

Fibroids do not prevent most women from conceiving and delivering healthy babies. But when fibroids do cause problems, they are likely to be serious. There are many causes of infertility; only a thorough evaluation can determine whether fibroids are the culprit. If they do prove to be the reason, surgery to remove them will take care of the problem for many women.

Treatment of Fibroids
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The decision to actively treat fibroids can only be made on an individual basis. Most women require no treatment at all. If the tumors are small and cause no problems, most physicians will simply schedule an examination every six months to make sure the fibroids aren't growing.

Reasons for Treatment
Your doctor may decide to treat fibroids if they start growing rapidly, cause serious pain or discomfort, or may interfere with your ability to become pregnant. In the following situations, physicians are likely to proceed more aggressively:

Bleeding. This is often the primary indication for surgery particularly if the woman is experiencing an extremely heavy flow during her menstrual period and notices blood clots. Persistent bleeding greatly reduces the amount of iron in the body, producing anemia that does not respond well to treatment.

Sudden enlargement of fibroids. Rapid growth of fibroids at any age is cause for concern, but this is particularly so after menopause, when the tumors should be shrinking due to decreased estrogen production. The doctor must make sure that not one of the tumors is malignant. Although almost all fibroids are benign, a malignant tumor could be hidden among them.

It is important to note that malignancy is not the only explanation for sudden enlargement of fibroids. This often happens during pregnancy. In women who are not pregnant, bleeding and deterioration inside the tumor are commonly at fault.

Pain, pressure and other discomfort. If the symptoms caused by fibroids become intolerable, the fibroids must be treated. Each woman must decide for herself whether she has reached this stage.

If the fibroids interfere with other organ systems, surgery may clearly be necessary. For example, fibroid tumors that encroach on the urinary system may cause so much pressure and crowding that a woman is almost unable to urinate.

Location of the tumors. Sometimes fibroids must be removed because their location is likely to cause serious problems sooner or later, as with tumors that obscure the ovaries. In addition, certain types of fibroids resemble ovarian tumors—a fact of particular concern for women over the age of 40, when the danger of ovarian tumors increases.

Surgery
When the problems caused by fibroids are severe enough to require treatment, it may be necessary to remove not only the tumors, but also the uterus. The type of surgery performed depends on the woman's age, the type of symptoms she is experiencing, and whether she plans to have children in the future. Following are descriptions of two forms of surgery—myomectomy and hysterectomy.

Myomectomy. Understandably, the prospect of any type of gynecologic surgery is upsetting to a woman who hopes to become pregnant. Yet continued presence of fibroids may in itself make pregnancy impossible. For women faced with this dilemma, a myomectomy is the procedure of choice.

A myomectomy is the surgical removal of each tumor separately without damaging or disturbing the uterus. The procedure is successful in almost all women who choose to have it performed. Generally, it doesn't matter how numerous or how big the fibroids are or where they are located.

When performing a myomectomy, the surgeon tries to remove as many tumors as possible while making as few surgical cuts as possible. It is sometimes feasible to remove certain tumors through the vagina, but in most cases the surgeon has to make an abdominal incision. During the operation, the surgeon closes up the spaces in the uterine lining where the fibroids used to be so that blood will not collect there afterward.

The possibility of blood loss is a major concern during surgery, but there are procedures and drugs that allow surgeons to limit bleeding during and after the operation. Because the fibroids are removed one at a time, surgery can take several hours—much longer than removal of the entire uterus.

It is important to remember that women who have had fibroids once are likely to have them again. The likelihood of a recurrence depends on a woman's age, race, and whether most of her tumors were removed during the procedure. Estimates vary, but one quarter to half of the women who have a myomectomy can expect to eventually develop additional tumors.

While a second—or even a third—myomectomy is an option if the tumors return, multiple myomectomies can lead to problems. The walls of the uterus, for example, can stick together due to scarring. Or the bowel may become blocked. Unfortunately, many, if not most, of the women who develop additional fibroids eventually have to undergo a hysterectomy.

Despite these possible drawbacks, the improved outlook for preserving a woman's fertility makes myomectomy an increasingly popular choice for younger patients.

Hysterectomy. When fibroids cause severe complications, a hysterectomy, or removal of the uterus, will probably be necessary. Removing the uterus effectively removes the fibroids, because most of these tumors are attached to the uterus. Hysterectomy is generally considered the procedure of choice when:

A woman who has completed her family and whose uterus has grown to the size that would accommodate a 12-week old fetus suffers from severe symptoms
There are extensive or especially large tumors
The bleeding caused by fibroids is debilitating
The fibroids are creating problems with other organs in the body
Because a hysterectomy leaves the ovaries intact, a woman does not automatically face menopause after the operation. The decision to preserve or remove a woman's ovaries generally depends on her age at the time of surgery. The current practice is to preserve normal and healthy ovaries in women younger than 40 to 45 years of age.

There has been much criticism of unnecessary hysterectomies; and fibroids are the justification in an estimated 30 percent of cases. Limiting this surgery to older women who do not plan to become pregnant and who have serious symptoms should naturally reduce the number of hysterectomies performed.

Other Options
Physicians are starting to evaluate ways to treat fibroid tumors without surgery. A few have begun using lasers to remove them or reduce the size of fibroid tumors. Several scientific studies are underway to test a new drug treatment that shrinks fibroids. Most of the women who have used the drug had their fibroids shrink to half their starting size. The drug is leuprolide acetate (Lupron), a synthetic form of the naturally occurring substance known as gonadotropin-releasing hormone (also called GnRH).

One drawback is that the drug has to be taken regularly. Another drawback is that women have to inject themselves or use a nasal spray. Furthermore, once treatment stops, the tumors grow back rapidly.

The drug does shrink the fibroids, however, and may help women who are trying to become pregnant or plan to have surgery. The treatment might also be especially useful for women who are nearing menopause—when the fibroids will shrink on their own. It will effectively delay surgery until it becomes unnecessary. Studies of the dru g's side effects and long-term consequences are still continuing.

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