What is Uterine Leiomyomata?
Uterine fibroids, which are noncancerous growths that form in women’s womb (uterus), are pretty common. A 2003 study showed that by the age of 50, about 70% of white women and over 80% of black women likely have fibroids. These tumors come from muscle cells in the uterus, and their growth is tied closely with the amount of the hormone estrogen in a woman’s body. We’re still not quite sure why fibroids happen.
Fibroids can either go unnoticed and only be discovered through imaging tests, or they could show up with symptoms. These symptoms can include unusual bleeding from the uterus, pain in the pelvic area, pressure on close-by structures like the bowel and bladder, and backache. Typically, fibroids are found in three main places: on the outside of the uterus (subserosal), inside the muscle wall of the uterus (intramural), or inside the uterine cavity (submucosal). These can either be attached by a stalk (pedunculated) or not.
Usually, doctors diagnose fibroids through a physical exam and an ultrasound, which is very effective in detecting these growths. Fibroids remain one of the top reasons why women need to have their womb removed – a procedure called hysterectomy. In fact, it’s estimated that fibroids account for 39% of all these procedures carried out every year, according to a research study. These procedures end up causing significant costs to the healthcare system. A 2013 study estimated that fibroids cost the US between $5.9 billion and $34.4 billion each year. That cost is expected to keep rising in the future.
What Causes Uterine Leiomyomata?
The exact process behind the formation of uterine fibroids, also known as benign tumors in the uterus, isn’t fully understood. Studies suggest that fibroids start with a single cell in the uterus muscle (also known as myometrium). This cell behaves differently than normal and begins to divide in an unusual way.
Fibroids are believed to be dependent on estrogen, a female hormone. They often have more estrogen and progesterone receptors than other parts of the uterus muscle. This means they are more sensitive to these hormones, which can influence their growth and development.
Risk Factors and Frequency for Uterine Leiomyomata
Fibroids, which are tumors that grow in the uterus, are rare before puberty. In fact, no cases have been found in children. However, as women get older, their chances of getting fibroids increase. Some women can have as much as an 80% chance of getting fibroids before menopause.
Fibroids are mainly linked to factors that lead to higher levels of a hormone called estrogen inside the body. Some of these factors include starting their periods early, not having children, being overweight, entering menopause late, and having a family history of uterine fibroids.
Moreover, women of African descent are more likely to get fibroids and they usually have more severe symptoms. On the other hand, the risk of developing fibroids is lower if a woman has had children, started her periods late, smokes, or uses birth control pills.
- Fibroids are not found in children and are rare up until puberty.
- The likelihood of getting fibroids increases with age, up to a chance of 80% before menopause in some cases.
- Factors that increase the risk of getting fibroids include starting periods early, not having children, being overweight, late menopause, and a family history of fibroids.
- Women of African descent are more likely to have fibroids and often have more severe symptoms.
- Factors that decrease the risk include having children, late start of periods, smoking, and using contraceptive pills.
Signs and Symptoms of Uterine Leiomyomata
When a patient experiences unusual bleeding, doctors usually take a detailed menstrual history. They aim to understand the timing, amount, and any factors that might be making the bleeding worse. Abnormal bleeding could present as irregular bleeding between menstrual periods (metrorrhagia), heavy menstrual bleeding (menorrhagia), or both. Some people might also experience less common symptoms like painful sex (dyspareunia), pelvic pain, issues with bowel movements or urination, and symptoms of anemia, which includes feeling tired and weak. These symptoms can often be due to the pressure of fibroids, which are non-cancerous growths in or on the uterus, on surrounding organs. Sometimes, a person may have fibroids but show no symptoms, and the fibroids are only discovered when doing an unrelated imaging test.
Doctors usually do a physical exam involving a speculum (an instrument to examine the vagina and cervix) and a bimanual exam (where the doctor uses two fingers to check the size and shape of the uterus and ovaries). If the uterus feels abnormally large and uneven, it could be a sign of fibroids. Doctors also look out for paleness of the inner eyelids (conjunctival pallor) and any thyroid abnormalities as these might be potential reasons for abnormal bleeding.
Testing for Uterine Leiomyomata
The first step in the evaluation process is to carry out a few lab tests. One of these tests is a beta-human chorionic gonadotropin test done to check for pregnancy. Other tests include CBC (Complete Blood Count), TSH (Thyroid-Stimulating Hormone), and prolactin level. These tests are done to check for non-structural causes that could explain the symptoms. In the case of women who are 35 or older, an endometrial biopsy (a small sampling of the uterus lining) is also recommended.
In terms of imaging studies, transvaginal ultrasound is considered the gold standard for visualizing uterine fibroids, which are noncancerous growths in the uterus. The sensitivity of this imaging technique for detecting these fibroids range from 90 to 99%. This means that if a patient has fibroids, the ultrasound will likely be able to detect them. Saline-infused sonography can be used in conjunction with ultrasound to increase its sensitivity, which ensures better detection of fibroids that are within or beneath the uterine wall. In ultrasound images, fibroids appear as solid, well-outlined masses that are less echoic (dark) than the surrounding tissue.
Another method of visualizing these fibroids is through hysteroscopy. In this process, a hysteroscope is used by the physician to look at the inside of the uterus. This method not only provides a better view of fibroids inside the uterine cavity, but it also allows the physician to directly remove the fibroids during the procedure itself.
Magnetic Resonance Imaging (MRI) provides an even better picture of the number, size, blood supply, and boundaries of the fibroids in relation to the pelvis. However, an MRI is not routinely used when fibroids are suspected because it hasn’t been shown to distinguish between different types of fibroids.
Treatment Options for Uterine Leiomyomata
Treating uterine fibroids requires consideration of factors such as the patient’s age, symptoms, and their desire to have children in the future. The size and location of the fibroids also impact the possible treatment options. They can be grouped into three categories: watchful waiting (surveillance), medication (medical management), and surgery.
Surveillance is the preferred method for women with fibroids who show no symptoms. In these situations, routine scans are not necessary.
Medical management aims to reduce severe bleeding and pain. This can involve hormonal contraceptives like birth control pills or a device inserted into the uterus that slowly releases hormones, known as an intrauterine device (IUD). Although often used to manage abnormal bleeding associated with fibroids, more research is needed to confirm the effectiveness of these contraceptives. The hormonal IUD is the recommended treatment due to its limited side effects and absence of systemic (whole body) impacts. But, extra care should be taken if the fibroids change the shape of the uterus, as this could lead to the IUD being expelled from the body.
GnRH Agonist (Leuprolide) is another medication option that decreases hormone production in the ovaries, thereby slowing the growth of the fibroid. It can reduce the size of the fibroid by up to 45% over six months but isn’t suitable for long-term use because it can lead to significant bone loss. It is most effective when used short-term prior to surgery.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) can help decrease the levels of prostaglandins (chemicals responsible for menstrual pain). Still, they do not reduce the size of fibroids. Other potential medication therapies exist but lack evidence of their effectiveness for fibroids. It’s worth noting that Tranexamic acid, a drug often used to treat heavy menstrual bleeding, has not been shown to decrease fibroid size.
Several surgical options are available depending on the patient’s needs:
Endometrial Ablation: This a good option for those mainly suffering from heavy or abnormal bleeding. However, fibroids that distort the shape of the uterus make this procedure more challenging.
Uterine Artery Embolization: This relatively simple procedure decreases blood flow to the uterus and the fibroids, reducing bleeding. It’s a reasonable choice for those wishing to preserve fertility, but there’s limited evidence on its impact on future fertility.
Myomectomy: This invasive surgery is an option for those who want to preserve fertility. Its effectiveness depends on the fibroid’s location and size. There’s not much conclusive evidence that it improves fertility.
MRI-guided focused ultrasound surgery: This new approach uses MRI and ultrasound waves to target and treat fibroids. However, long-term effectiveness hasn’t been well-studied yet.
Hysterectomy: This surgical procedure, which involves the removal of the uterus, is the definitive treatment for fibroids.
What else can Uterine Leiomyomata be?
There are several health conditions that can have similar signs and symptoms to uterine leiomyomas, which are commonly known as fibroids. These conditions often cause abnormal uterine bleeding and pelvic pain. According to the Federation of Gynecology and Obstetrics, these conditions can be categorized under the acronym PALM-COEIN. This stands for:
- Polyps
- Adenomyosis
- Leiomyoma
- Malignancy
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Adenomyosis is one condition that is often found alongside uterine fibroids and can appear similar on an ultrasound but usually has a more oval shape without clear edges.
It’s very important to remember that leiomyosarcomas, a type of cancer, can also look like fibroids. However, there are some factors that may indicate a higher risk of sarcoma rather than benign fibroids. These can include being postmenopausal, having a predominant mass on the outer layer of the uterus, having one solitary fibroid, rapid growth of the fibroid, and specific signals on a MRI scan.
What to expect with Uterine Leiomyomata
Fibroids, which are abnormal growths in the uterus, can be difficult to treat, especially for patients who want to become pregnant, have limited access to healthcare, or have certain unchangeable risk factors. Hormone and anti-inflammatory treatments can help to slow down the growth of fibroids. However, the focus of treatment nowadays is on using minimally invasive operations that won’t negatively affect a woman’s ability to have children in the future.
Possible Complications When Diagnosed with Uterine Leiomyomata
The exact impact of fibroids on fertility is not completely understood, but it seems that there is a relationship between the presence of fibroids and struggles with infertility. This relationship is likely dependent on where the fibroid is located and how big it is. For example, a study conducted by Pritts and colleagues showed that a type of fibroid that grows under the lining of the womb – submucosal fibroids – can result in lower implantation and pregnancy rates and higher miscarriage rates. This is because these fibroids can alter the shape of the womb lining. However, recent research by Purohit and Vigneswaran has challenged this, stating there’s no evidence to suggest that fibroids that grow on the outside of the womb – subserosal fibroids – affect fertility in any way. Fibroids can also cause other problems like anemia, chronic pain in the pelvic area, and sexual dysfunction.
Possible Complications:
- Decreased rates of implantation and pregnancy
- Increased rates of miscarriage
- Anemia (persistent tiredness due to low red blood cells)
- Chronic pelvic pain
- Sexual dysfunction
Preventing Uterine Leiomyomata
It’s important for patients to know that fibroids, most of the time, are not cancerous. Using words like “neoplasm”, which is another term for abnormal growth or tumor, to describe fibroids can be quite frightening and may negatively affect a patient’s mental health. Also, it should be noted that fibroids can significantly affect a woman’s health, including her ability to get pregnant in the future and her overall quality of life. Therefore, discussing and managing risk factors that can be controlled play a crucial role in treating these patients.
Furthermore, even though there are less invasive treatments that ideally should help with the symptoms of fibroids, there’s little proof from big scientific studies (called randomized controlled trials) that these treatments have positive effects in the long run.
