What are the symptoms and causes of this complex disorder and what therapies can be used to treat it? We take a close look at the subject with Prof. Rodolfo Milani – Gynecologist/Urogynecologist at Columbus Clinic Center
Uterine fibroids are the most common benign tumor in women of child-bearing age. This disorder is estimated to be present in about 20-30% of women over 35 years of age.
The risk factors are genetic, racial and iatrogenic, with black women having a three times higher risk than white women. The risk also seems to be three times higher in obese women, independently of race. Furthermore, there is a family predisposition, with a two-fold increases risk in first-degree relatives in families with two or more women with fibroids. Finally, nulliparous women have a higher risk than women who have given birth.
It is currently believed that oral contraceptives play a role in protecting against the development of fibroids.
Fibroids are benign tumors formed of smooth muscle cells and a variable proportion of fibrous tissue. They are hormone-sensitive tumors: both estrogens and progesterone are involved in the development of fibroids. When estrogen levels are decreased, such as during the menopause, the volume of the fibroids may decrease, while estrogen-progesterone replacement therapy in the menopause can lead to an increase in their volume.
Fibroids may be of various sizes and develop in different sites in the uterus; most fibroids develop in the body of the uterus, with subserosal (towards the external surface of the uterus), intramural (within the thickness of the uterine wall) or submucosal or intracavitary (towards the inside of the uterine cavity) growth.
A fibroid is separated from the surrounding healthy uterine muscle by a thick layer of clear connective tissue that makes a capsule; this difference in tissue is exploited during the operation of myomectomy, i.e., when the fibroid is removed while preserving the uterus.
The symptoms caused by the presence of fibroids depend on the site of the growths and their bulk. The main symptom is abnormal loss of blood, with consequent altered menstrual flow, which can become much more abundant and last for a long time.
An intracavitary fibroma can cause significant menstrual bleeding accompanied by pain in the lower abdomen. This leads to the patients becoming anemic.
A single subserosal fibroma can reach a considerable size without causing menstrual disorders; in this case the symptoms derive from the mechanical effect of the fibroma which, when it is anterior, can compress the bladder and, when it is posterior, can compress the rectum. This compression gives rise to the symptoms of frequent urination (pollakiuria) and rectal tenesmus, a continuous sensation of having to defecate.
Pain is rare and tends to occur only if there is degeneration of muscle tissue in the center of the fibroma.
When the fibroid develops on the right or left side of the lower portion of the uterus (isthmic region), the fibroma can compress a ureter and cause pain resembling that of renal colic.
The diagnosis of uterine fibroids is based on a gynecological examination and instrumental investigations such as transvaginal ultrasound (TV US) and, in rare cases, magnetic resonance imaging. These investigations, starting with ultrasound, enable better definition of the site of the fibroma and its direction of development. Both techniques can give some information on degenerative aspects of the fibroma.
In 0.2% of cases the fibroma may have histological features of a malignant muscle-connective tissue tumor.
The management may be medical, surgical or just observation.
Hormonal type medical therapy is legitimate in women near the menopause or in those being prepared for surgery when the woman has severe anemia. In these cases, iron therapy is added.
Surgical therapy may preserve the uterus and involve only removal of the fibroid(s), or be radical with removal of the whole uterus. The choice of the type of intervention depends on the age of the patient, the desire of the woman to have children and her general medical condition. The uterus can be removed by laparoscopic or vaginal surgery; abdominal surgery may be necessary for a very large uterus. If only fibroids are to be removed, this can be done via laparoscopy or laparotomy depending on the site and volume of the fibroma(s).