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.