One of my favorite parts of primary care is women’s health. Contraception, cancer prevention and sexual health and wellness are all important subjects I cover with my female patients. However, the subject that elicits the most conversation and distress is that of fibroids.
Uterine fibroids or leiomyomas are benign tumors originating in the muscle or surrounding tissue in or around the walls of the uterus. They are the most common noncancerous tumors of childbearing women. These tumors vary in size and can be as large as a melon.
They occur in women usually in their 40s and Black women are more likely to be affected than white women. Heavy, painful periods are the hallmark of these pelvic masses, but some women experience no symptoms at all. Other symptoms include a feeling of pelvic fullness, infertility or frequent miscarriages, pain during intercourse, frequent urination or low back pain.
Both reproductive and environmental risk factors influence the development of fibroids. Low-fat dairy products and eating a diet rich in fruits and vegetables may decrease the risk. Whereas, having a high body mass index may increase the risk.
Women who started their periods early during puberty also have an increased risk. In contrast, women using progestin-only injectable contraceptives may have a lower risk. However, the major risk factors continue to be increasing age and Black race.
It is often during a routine pelvic examination that these fibroids are detected. A past medical history of large amounts of bleeding during menses should also raise suspicions about the likelihood of benign tumors. Differentiating between a pregnant uterus, fallopian tube mass or uterine fibroid is best achieved with ultrasonography. Ultrasound testing is relatively inexpensive, provides immediate results and is safe for an unsuspecting fetus.
Fibroid treatment can be divided into the following categories: expectant- watching/waiting, medicinal, surgical, and newer less invasive methods. Because women vary quite a bit regarding the severity of their symptoms from fibroids, treatment should be individually tailored. For some women, simply monitoring the progression of the tumor will be all the management that is needed. On the other hand, for those women whose symptoms have interfered with their employment and intimate relationships, and additionally caused embarrassment from soiled clothes, more aggressive treatment is warranted.
Treatment for fibroids has advanced since I was a child. I recall several of my aunts who suffered with fibroids and were only offered the option of a hysterectomy for treatment. If you had completed the childbearing phase of your life, this option was a viable choice. However, I have cared for many women who never had a chance to conceive due to their fibroid history.
For a subset of women, treating the painful periods with anti-inflammatory medications like ibuprofen or Naprosyn is sufficient. Women who are experiencing bladder and pelvic pressure may benefit from fibroid volume reduction with Gonadotropin Releasing Hormones (GnRH). This hormonal treatment is limited to about 3-6 months due to the vasomotor side effects.
Hysterectomy, surgical removal of the uterus, by far, is the most common procedure performed for fibroids. It is a permanent treatment and eliminates fertility as a future option. Three-fourths of women choose this method. Hysterectomy in the past was mostly done abdominally. Today it is done vaginally or laparoscopically reducing the rehabilitation time dramatically. For some women, replacing the large unattractive abdominal scars with tiny surgical incisions is an improvement from the historical procedures.
Another surgical option for treatment is a myomectomy. This procedure spares the uterus and simply removes only the fibroid. In the U.S. roughly 30,000 myomectomies are performed annually as compared to 200,000 hysterectomies. However, women should be counseled that with a myomectomy the risk of recurrence is approximately 25%.
Uterine artery embolization, an interventional radiologic procedure, is another method utilized for treatment that involves injecting particles in the arteries that supply the fibroids. Those particles adhere to the walls of the vessels and cause a clot to form, resulting in a disruption of blood supply thereby causing the fibroids to shrink. Uterine artery embolization, although slightly invasive, is an additional form of treatment for women who desire methods that spare the uterus.
Although the cause of fibroids is unknown, greater options are now available for treatment, but more research is needed to help improve the disparity that exists between Black and white women.
Denise Hooks-Anderson, M.D., FAAFP is an associate professor, SLUCare Family Medicine, and interim assistant dean of Diversity, Equity and Inclusion