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Uterine
Fibroids, or uterine myomas (short for
leiomyoma), affect more than 30% of women. The terms
fibroid and myoma are used interchangeably. Most
fibroids do not cause symptoms, and do not require treatment.
Fibroids may require treatment in the following circumstances:
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Types of Fibroids
Fibroids
are classified by their location (see figure), which effects the
symptoms they may cause and how they can be treated. Fibroids
that are inside the cavity of the uterus will usually cause
bleeding between periods (metrorrhagia) and often
cause severe cramping. Fortunately, these fibroids can usually be
easily removed by a method called "hysteroscopic resection,"
which can be done through the cervix without the need for an
incision. Submucous myomas are partially in the cavity
and partially in the wall of the uterus. They too can cause heavy
menstrual periods (menorrhagia), well as bleeding between
periods. Some of these can also be removed by hysteroscopic
resection.
Intramural myomas are in the wall of the uterus, and can
range in size from microscopic to larger than a grapefruit. Many
of these do not cause problems unless they become quite large.
There are a number of alternatives for treating these, but often
they do not need any treatment at all. Subserous myomas
are on the outside wall of the uterus, and may even be connected
to the uterus by a stalk (pedunculated myoma.) These do
not need treatment unless they grow large, but those on a stalk
can twist and cause pain. This type of fibroid is the easiest to
remove by laparoscopy.
Diagnosis of
Fibroids
Fibroids may be
felt during a pelvic exam, but many times myomas that are causing
symptoms may be missed if the examiner relies just on the
examination. Also, other conditions such as adenomyosis
or ovarian cysts may be mistaken for fibroids. For this reason,
I routinely do an ultrasound examination at the time of the first
visit when a woman has symptoms of abnormal bleeding or cramping,
or if I feel an abnormality on examination. Vaginal probe
ultrasound only takes a few minutes to do, is not uncomfortable,
and rapidly provides invaluable information if the examiner is
experienced in looking at uterine abnormalities. It is possible
to fill the uterus with a liquid during the ultrasound (saline
enhanced sonography or sonohysterogrami).
While this will often provide additional information to the
regular ultrasound, I usually learn much more by looking inside
the uterus with a little telescope. This exam, called
hysteroscopy, is usually a quick office procedure, that
allows directly looking inside the uterus.
One of the most
common conditions confused with fibroids is adenomyosis.
In adenomyosis the lining of the uterus infiltrates the wall of
the uterus, causing the wall to thicken and the uterus to
enlarge. On ultrasound examination this will often appear as
diffuse thickening of the wall, while fibroids are seen as round
areas with a discrete border. Adenomyosis is usually a diffuse
process, and rarely can be removed without taking out the uterus.
Since fibroids can be removed, it is important to differentiate
between the two conditions before planning treatment. It is also
common to have some adenomyosis in addition to fibroids.
MRI scans also
provide an excellent picture of the uterus. Usually the cost of
the exam is not justified, as all of the information needed to
plan treatment (or not to treat) can be obtained by other methods.
Treatment of
Fibroids
The most important
question to ask is do the fibroids need to be treated at all.
The vast majority of fibroids grow as a woman gets older, and tend
to shrink after menopause. Obviously fibroids that are causing
significant symptoms need treatment. While it is often easier to
treat smaller fibroids than larger ones, most of the small ones
never will need to be treated. So just because we can treat
fibroids while they are small, it doesn't follow that we should
treat them. The location of the fibroids plays a strong influence
on how to approach them.
Treatment with
medicines:
There are not any
currently available medicines that will permanently shrink
fibroids. Often heavy bleeding can be decreased with birth
control pills. There are a number of medications in the family of
GnRH agonists, which induce a temporary chemical menopause. In
the absence of estrogen myomas usually decrease in size.
Unfortunately, the effect is temporary, and the fibroids rapidly
go back to their pre-treatment size when the medication is
discontinued. Mifepristone, better know as the 'French abortion
pill, or RU-486, also cause a significant decrease in size of
myomas, and often stops abnormal uterine bleeding. It's use is
promising, but it is not currently available in the United States.
Surgical
treatment of fibroids:
There have been a
number of procedures recently promoted for treatment of fibroids.
Some are truly new. Others are being marketed as new in order
to promote the sale of expensive instruments, without offering any
real advantages. Many new procedures prove over time to be major
advances; we may look back on others as not so wonderful. With
any new procedure, it is important to look at studies published
in peer-reviewed medical journals as well as promotional
materials by a physician, clinic, or instrument manufacturer. Ask
questions: how many of these procedures have been done in
published studies; what is the outcome; how long have these
patients been followed? In deciding whether any procedure is for
you, you should look at advantages and disadvantages of all
available options.
Removal of the fibroid(s):
This is also called
myomectomy. Myomectomy, with one exception, means making
an incision into the uterus and removing one or more fibroids. If
the fibroid is on a stalk (pedunculated) it is not necessary to
cut into the uterus to cut the stalk. Unless the myoma is on the
outside surface of the uterus, the uterus is repaired, usually
with sutures. One of the major differences in how a myomectomy is
done involves the surgical approach to the uterus. In a
laparotomy an incision is made in the abdomen to reach the
uterus. The advantage of this is that large myomas can be quickly
removed. The surgeon is able to feel the uterus, which is helpful
in locating myomas that may be deep in the uterine wall. The
ability to touch the uterus facilitates repairing the uterus. The
disadvantage of a laparotomy is that it requires an abdominal
incision. Most of my patients who have this procedure spend two
nights in the hospital, and return to work in about four weeks.

Some myomas can
also be removed by laparoscopy. The laparoscope is a telescope placed in
the abdomen through the belly button. Other instruments are
inserted through small individual incisions in the abdominal
wall. Many myomas can be removed by laparoscopy; this is easier
to do when the myomas are on a stalk or close to the surface.
Once the fibroids are removed they are cut into pieces by one of
several instruments designed for this purpose, and removed. The
advantage of laparoscopic myomectomy is that it is usually done as
an outpatient, and allows faster recovery than a laparotomy. One
of the disadvantages is the extended time needed to remove large
fibroids from the abdomen, although newer instruments are
improving this. Since the surgeon cannot actually touch the
uterus, it may be more difficult to detect and remove smaller
myomas. In addition, if a woman plans pregnancy after her
myomectomy, there is a question of whether the uterus can be
repaired through the laparoscope as well as it can be by
laparotomy.
Although many
myomas can be removed through the laparoscope, the decision
of which myomas should be removed laparoscopically and
which by laparotomy depends on many factors. A woman should
discuss the advantages, disadvantages, and risks of each type of
surgery with a surgeon who is experienced in all treatment
methods.
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