What is Fertility Sparing Management in Uterine Fibroids?
Uterine leiomyoma, more commonly known as fibroids, are non-cancerous growths in the womb. They are the leading type of benign (not harmful in effect) gynecologic tumors, showing up in as many as 70% of women by the time they reach menopause. Despite their prevalence, many fibroids do not produce noticeable symptoms and are discovered only by accident. However, about 25 to 30% of women with fibroids experience a variety of symptoms that can worsen their health and impact their daily life.
The most typical symptoms of fibroids include unusual bleeding from the womb, heavy periods, pelvic pain and pressure, anemia, and bladder or bowel problems. Also, having one or many fibroids could interfere with becoming pregnant. This is because the changes it causes in the shape of the womb can hinder the successful attachment and continued existence of a pregnancy within the womb.
Fibroids can also lead to complications during pregnancy. These include multiple pregnancy losses, premature labor, abnormal placement of the placenta in the womb, an increased need for cesarean section, and severe bleeding after childbirth. As more women are deciding to have children later in life, it is increasingly important to properly manage fibroids while preserving fertility. In this simplified summary, we talk about how fibroids affect women of childbearing age and about the medical and surgical methods available for women with fibroids who wish to have children in the future.
What Causes Fertility Sparing Management in Uterine Fibroids?
Fibroids are harmless growths that develop from the improper expansion of specific cells in the womb, specifically smooth muscle cells and fibroblasts. Even though these growths usually begin in the muscular layer of the womb, called myometrium, fibroids can also grow on the surface of the womb (uterine serosa) or even further down into your pelvis or lower abdomen, and sometimes spreading to the upper abdomen. Additionally, they can develop in the myometrium and extend into the cavity of the womb.
Risk Factors and Frequency for Fertility Sparing Management in Uterine Fibroids
Uterine fibroids can occur in women of any age and background. However, the rate at which they occur can change according to different ages and ethnic groups. For example, 20 to 40% of women of childbearing age are estimated to have fibroids. Among women who are dealing with infertility, 5 to 10% are found to have these fibroids. Of this group, the fibroids are the only fertility issue found in 2 to 4% of the women.
The chance of developing fibroids increases with age until menopause. They’re very common, with around 80% of black women and 70% of white women likely to develop fibroids. The rate is highest in women in their 50s and 60s. Women before menopause have a higher risk due to the role of hormones in fibroid growth.
- Research consistently shows that the risk of fibroids is tripled for black women compared to white women, even when considering other risk factors.
- Black women often develop fibroids at younger ages, have larger uteruses when diagnosed, and are more likely to have anemia from blood loss. This may be partly due to earlier onset of menstruation in black women compared to white women.
- Some inequalities observed are likely due to various social factors affecting health, such as access to healthcare, job stability, and quality health insurance in the black community.
Other risk factors for fibroids include starting menstruation at an early age, having a longer time since your last pregnancy, being overweight, certain diets, family history, and high blood pressure. One study showed that women with high blood pressure have five times the risk of developing fibroids than women without it.
The chance of having fibroids decreases the more full-term pregnancies a woman has. For example, women who have had more than 5 pregnancies have a quarter of the risk of getting fibroids, compared to women who haven’t had any. Using hormonal birth control or a specific type of hormone shot (DMPA) for any length of time has also been shown to help protect against fibroids.
Signs and Symptoms of Fertility Sparing Management in Uterine Fibroids
Fibroids are abnormal growths that can form in the uterus. The size, location, and quantity of these fibroids can greatly influence how they affect an individual. Some women may not have any symptoms, while others may experience severe discomfort. Importantly, fibroids can change over time – they might shrink, harden, calcify, or bleed – and this can cause a person’s symptoms to change as well.
When symptoms do appear, they can include heavy menstrual bleeding, pelvic pain or discomfort, frequent urination, constipation, and difficulties getting pregnant. Some fibroids may disrupt the normal functions of the uterus and cause heavy bleeding, even if they’re small. On the other hand, larger fibroids, especially those that extend out from the uterus into the abdomen, can create symptoms due to their size and pressure they exert on surrounding organs. For instance, large growths at the front of the uterus can cause pelvic pressure and bladder problems, while growths at the back of the uterus can lead to constipation.
Furthermore, these growths can interfere with a woman’s fertility, depending on their location and how they impact the structure and functions of the uterus. This can hinder the transportation of a fertilized egg, hinder its attachment to the uterine wall, or disrupt the early stages of pregnancy. Fibroids can also affect the health and receptivity of the uterine lining, lessen blood flow, and trigger chronic inflammation, which makes it harder for a pregnancy to occur and progress normally.
During a physical exam, a healthcare provider might feel a larger, irregularly shaped uterus if fibroids are present. If the fibroids are located near the back of the uterus, the provider might feel a distinct fullness there and notice that the cervix is positioned more to the front. However, these physical changes might not be noticeable in women who have small fibroids within the uterine wall or lining. Regardless of these findings, further investigation is warranted if a patient reports any of the symptoms described above.
Testing for Fertility Sparing Management in Uterine Fibroids
Leiomyomas, or fibroids, are noncancerous growths that can occur in the womb. The way they are related to the inside of the womb is vital as it can help doctors understand the symptoms and determine the best treatment options. The position of these fibroids is described using a system from the International Federation of Gynecology and Obstetrics (FIGO). This system has three main categories: submucosal (FIGO 0, 1, 2, located in the womb’s lining); intramural (FIGO 3, 4, 5, in the muscle wall of the womb); subserosal (FIGO 6, 7, outside the womb). There are other rare types as well, such as cervical or parasitic (FIGO 8).
A transvaginal ultrasound (a scan using a small probe inserted into the vagina) is often the best tool for evaluating suspected fibroids. If the womb is the size of a 10-week pregnancy or less, this type of scan has a 95 to 100 percent chance of detecting them. On the ultrasound’s image, fibroids usually appear as well-outlined, circular, darkened masses that block sound waves.
Another way to evaluate fibroids is saline infusion sonohysterography (SIS), a more specialized type of ultrasound that uses a saltwater solution to get a better look at the womb’s inside. If it’s hard to tell whether the fibroid is a Type 2 or Type 3 with SIS, a small camera (hysteroscope) can be inserted into the uterus through the vagina. However, compared to ultrasound and SIS, this view isn’t as good for working out the fibroid’s size.
A magnetic resonance imaging (MRI) scan is the most effective at detecting the size and location of fibroids, but because it’s more expensive, it’s not routinely done. Instead, it’s mainly used for surgical planning as it provides in-depth visualization, which can help identify the fibroid’s blood supply, degenerated fibroids (ones that have broken down), location, and depth into the womb’s muscle.
Treatment Options for Fertility Sparing Management in Uterine Fibroids
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What else can Fertility Sparing Management in Uterine Fibroids be?
When evaluating similar symptoms to uterine fibroids, a group of diseases are taken into consideration. Uterine fibroids can cause signs such as uterine growth, heavy menstrual bleeding, problems with fertility, and painful periods. Others problems that could show similar symptoms include pregnancy, adenomyosis (where the inner lining of the uterus breaks through the muscle wall), benign (non-cancerous) or malignant (cancerous) growths in the uterus, endometrial carcinoma (a type of cancer that starts in the uterus), and uterine leiomyosarcoma (a rare form of cancer that affects smooth muscle tissue).
Adenomyosis often shows with a grown uterus, heavy menstrual bleeding, and painful periods. It can be hard to distinguish from fibroids. The person’s uterus may feel soft, round and springy. However, a scan through the vagina often helps to identify features of adenomyosis, such as thickening of the muscle layer, changes in the muscle layer, different types of cysts, and bands of tissue beneath the lining of the uterus.
While a fibroid is usually well-defined, adenomyomas (a type of adenomyosis) blend in much more. They are also harder to remove. Often, this issue only comes to light during an attempt to remove what is thought to be a fibroid. Pathology tests, where tissues are examined under the microscope, are the most accurate way to diagnose these conditions.
Uterine leiomyosarcoma is a serious disease that needs to be distinguished from uterine fibroids. These cancers often seem like fibroids, with symptoms like abnormal vaginal bleeding and a quickly growing uterus. This is especially important to consider in post-menopausal women who seem to have rapidly growing uterine fibroids, as the correct identification is made less than half the time before surgery. To rule out leiomyosarcoma, an excision (removal of parts of the body) followed by a pathological examination is required.
Another important diagnosis to exclude in a patient with uterine bleeding, pain, and a growing uterus is endometrial carcinoma. With ultrasound performed transvaginally, this disease is typically associated with irregular lining of the womb, a mass in the womb, collection of fluid inside the womb, and in severe cases, the disease spreading from the lining into the muscle layer of the uterus. The use of doppler to distinguish benign diseases from cancer is still not definitely validated, and the final diagnosis has to be made by evaluation of a tissue sample by a pathologist.
What to expect with Fertility Sparing Management in Uterine Fibroids
How well a patient does overall depends on the size and number of fibroids and the type of treatment they choose. A large nationwide study that included over 1200 women, called COMPARE-UF, showed that no matter what type of myomectomy (surgery to remove fibroids) was done, all women saw improvements in their health and a decrease in the severity of their symptoms. However, the time it took for them to return to normal activity varied, with those who had a certain type of myomectomy (HSC-M) returning immediately, compared to 3 to 4 weeks for women who had laparoscopic and abdominal myomectomies.
There are several factors that can increase the risk of fibroids coming back after surgery. These include being younger than 35.5 years, having two or fewer fibroids at the time of surgery, having a smaller uterus, and not having any children after surgery. The chance of fibroids recurring is approximately 63.4% eight years after one type of surgery (ABD-M) and 76.2% after another type (LSC-M). The percentage of patients who need additional treatments ranges from 19 to 38% after certain procedures, and can be as high as 54% after others.
For women who become pregnant after having a myomectomy, the way and time the baby is delivered depends on factors such as the type of fibroid removed, the number and location of incisions on the uterus, and whether or not there was an incision into the uterus itself. The main concern during pregnancy for women with certain types of uterine scars is the risk of the uterus tearing, which can be as high as 10%. However, the risk of this happening after a myomectomy is reportedly closer to 1%, similar to the risk after a C-section, with about 90% of women able to have a successful vaginal delivery.
The Society of Maternal-Fetal Medicine (SMFM) recommends that women who have had a prior myomectomy where the uterus was entered should plan for a C-section between 37-38 weeks of pregnancy. If there is significant scarring suggested from the myomectomy, delivery should be considered between 36 and 37 weeks of pregnancy.
Possible Complications When Diagnosed with Fertility Sparing Management in Uterine Fibroids
Every medical procedure, including invasive and non-invasive ones, carries certain risks. It’s important to discuss these possible side effects with patients as they consider treatment options. For example, certain medications can alter bleeding tendencies and even induce menopause-like symptoms, and patients need to be aware of this.
Additionally, patients should be informed about potential complications from surgical procedures. These can include bleeding, infection, injury to nearby organs, scarring, and the possibility of the treatment not working as expected.
Although the chance of needing a hysterectomy due to uncontrolled bleeding during surgery is very low (less than 1 out of 100 women), it’s particularly crucial to discuss this with patients, especially those with multiple large fibroids.
Risk and Side Effects to Consider:
- Possible alteration of bleeding profile due to medication
- Potential induction of menopause-like symptoms due to medication
- Bleeding during or after surgery
- Possibility of infection
- Potential injury to nearby organs during surgery
- Chance of scarring
- Possibility of treatment not working as expected
- Low risk of needing a hysterectomy due to uncontrollable bleeding during surgery
Preventing Fertility Sparing Management in Uterine Fibroids
When a patient comes to the doctor because they’re experiencing symptoms caused by fibroids, it’s crucial to discuss what choices are available for treatment. This discussion should not solely focus on what can potentially relieve the symptoms, but also take into account factors like the person’s general health condition and whether they wish to have children in the future. These factors could elevate their risk of complications with one treatment type over another.
The array of treatment options often falls under three categories: medication, surgery, or procedures performed by a specialist called an interventional radiologist. If a person has fibroids but isn’t experiencing symptoms and doesn’t want any intervention, their doctor might choose to simply monitor their situation closely, a process termed “expectant management”.
For those who don’t intend to get pregnant right away, a common approach is to start with non-surgical or medication treatments. If these don’t work, the next option could be a surgical removal procedure. On the other hand, for patients who wish to conceive soon and whose fibroids pose issues due to their size and location, the initial recommendation is usually to remove the fibroids surgically. This method is generally the quickest way to resolve the issue.
However, it’s important to remember that every patient is unique and treatment should be individualized. This means a joint decision should be made between the doctor and patient, taking into account the risks, benefits, and alternatives of all treatment options. The aim is to ensure the patient understands their choices and gives informed consent for the next phase of their care.
