A fibroid is one of the most common benign tumors of the female reproductive organs, originating from muscle tissue (mainly from smooth muscle cells) and the connective tissue of the uterus. Leiomyoma, fibroid, and fibromyoma are other terms for uterine fibroids.
It’s challenging to accurately assess the prevalence of this condition, as fibroids can be asymptomatic, and women, especially in remote areas with limited access to healthcare, may not always consult a doctor. According to various studies, uterine fibroids occur in 40-70% of women.
The size of fibroids can range from small grains to large masses that can deform and enlarge the uterus. Uterine fibroids can be singular or multiple.
The growth patterns of uterine fibroids vary—they can grow slowly, rapidly, or remain unchanged. Some fibroids may grow significantly, while others can shrink on their own.
According to the latest classification by the International Federation of Gynecology and Obstetrics (FIGO), there are 9 subtypes based on the location of the nodule:
- Types 0-2 are characterized by submucosal nodules, meaning they are located under the mucous membrane and are often associated with bleeding.
- Types 3-5 are primarily intramural, meaning they are located within the thickness of the uterine muscle layer.
- Type 6 consists of nodules that are more than 50% subserosal (under the peritoneum).
- Type 7 refers to subserosal nodules located on a stalk.
- Type 8 encompasses other nodules (such as intraligamentary or cervical).
There is also a hybrid fibroid type that affects all layers of the uterus (endometrium, myometrium, and serous membrane).
Causes of uterine fibroids
The exact causes of fibroids remain unknown, but research is ongoing. The primary causes identified include:
- Hormones: Fibroids are typically hormone-dependent tumors. They contain more estrogen and progesterone receptors than normal uterine muscle cells. Experimental research confirms that the growth of these tumors is stimulated by estradiol and other estrogens. Clinical data also indicate that progesterone plays a significant role in the development of fibroids, although, unlike estradiol, it inhibits this process. Progesterone receptors control the proliferation of tumor cells. After menopause, due to the reduction in hormone production, fibroids tend to shrink.
- Genetic Changes: Studies of the myometrial cells in women with fibroids often reveal genetic mutations that are absent in normal myometrial cells. It is likely that these mutated genes trigger the pathological cell division that leads to fibroid formation.
- Excessive Production of Growth Factors: Substances that are crucial for regulating various cellular processes, such as insulin-like growth factor, may influence the growth of fibroids.
Risk factors for developing uterine fibroids
The risk factors for uterine fibroids include:
- Race and ethnicity: Women of African descent are 3 to 9 times more likely to develop this condition compared to women of European descent.
- Age: Uterine fibroids are most commonly diagnosed in women aged 30 to 40 years (with an average detection age of 32.8 years ± 6 months), and less frequently in women under 30.
- Pregnancy and childbirth history: The risk of uterine fibroids is higher in women who have never given birth, as well as in those who experience their first pregnancy and childbirth after the age of 30. A history of pregnancy terminations increases the risk of fibroids, while the risk decreases proportionally with the number of full-term pregnancies.
- Early onset of menstruation.
- Obesity and excess body weight.
- Diet: Excessive consumption of red meat is likely to increase the risk of fibroid development.
Uterine fibroids – symptoms and signs
Possible symptoms of uterine fibroids include:
- Heavy, painful, or prolonged menstrual periods;
- Bleeding between periods;
- Pelvic pain and a sensation of pressure and heaviness in the lower abdomen. The pain may be constant, dull, sharp, or cramp-like during menstruation, depending on the location and size of the fibroid;
- Bloating or enlargement of the lower abdomen;
- Constipation/diarrhea;
- Frequent urination or urinary problems;
- Pain during intercourse;
- Lower back pain;
- Reproductive issues (such as difficulty conceiving);
- Fatigue and weakness (as a possible sign of anemia due to bleeding).
All symptoms of uterine fibroids are non-specific and may indicate the presence of other conditions. To confirm the diagnosis, the following are necessary:
- Gynecological examination on a chair;
- Transabdominal and transvaginal ultrasound of the pelvic organs;
- Sometimes, hysteroscopy, CT, or MRI may be required.
Often, patients with fibroids have no complaints, and there are no objective or subjective clinical symptoms. The fibroid is often detected during a bimanual gynecological examination or ultrasound performed as part of a screening or for another reason. A blood test may indicate anemia (reduced hemoglobin, hematocrit, red blood cells, and red cell indices).
Treatment of uterine fibroids – approaches and methods
There is no single best approach to treating uterine fibroids in different women. Treatment should be personalized based on symptoms, the location and size of the fibroids, age, the presence of coexisting conditions, and reproductive plans.
Treatment of uterine fibroids can be managed through either medical or surgical methods.
In asymptomatic women with small, stable fibroids, a watchful waiting approach may be chosen, involving regular monitoring without immediate intervention.
Medical therapy
Medical therapy for uterine fibroids aims to reduce the size of fibroids and manage menorrhagia (excessive menstrual bleeding). While it does not eliminate fibroids, it can help shrink them. The following methods are commonly used:
- Levonorgestrel-releasing intrauterine system (LNG IUS): The LNG IUS significantly reduces menstrual blood loss in women with fibroids and may slightly decrease the size of the fibroids in some cases.
- Combined oral contraceptives (COCs): There is no evidence that COCs cause the growth of fibroids, so they may be used to reduce menstrual bleeding and prevent the development of fibroids.
- Gonadotropin-releasing hormone (GnRH) agonists: These drugs work by blocking the synthesis of estrogen and progesterone, putting the woman into a state of “temporary menopause.” During treatment, the size of fibroids can be expected to reduce by up to 50% of their initial volume within three months. GnRH agonists are usually used for no longer than three to six months, as symptoms often return after stopping the medication, and prolonged use can lead to bone loss.
- GnRH agonists are particularly useful before planning surgical treatment, as they help reduce the size of fibroids and alleviate anemia often associated with chronic blood loss.
- Non-steroidal anti-inflammatory drugs (NSAIDs): Although NSAIDs are not hormonal treatments, they can effectively relieve pain related to fibroids. However, they do not reduce fibroid-related bleeding or affect fibroid growth.
The options for conservative treatment of uterine fibroids are limited, as symptomatic therapy does not address the underlying disease mechanism, and hormonal treatments may have side effects.
Surgical treatment
Surgical intervention is indicated for large fibroids, rapid growth, submucosal location (submucosal nodules), heavy menstrual bleeding, and impairment of adjacent organ functions. Surgery is also necessary if the fibroid has a thin pedicle and there is a significant risk of torsion, or if torsion has already occurred (in which case emergency surgery is performed). Additionally, surgical treatment is required if there are signs of compromised blood supply to the fibroid (ischemia).
Indications for surgical treatment of uterine fibroids also include their association with other uterine and adnexal pathologies that require surgical intervention, as well as infertility caused by the fibroids. Surgery is recommended in cases of reproductive dysfunction and infertility when no other causes are identified.
Surgical methods for treating uterine fibroids include:
- Laparoscopic myomectomy: During a myomectomy, the surgeon removes the fibroid while preserving the uterus. Laparoscopic myomectomy is recommended for patients with single subserosal or interstitial fibroids. Micro-surgical instruments are introduced through 3-4 small incisions in the abdominal wall. The fibroid is cut and extracted, followed by suturing. Compared to other myomectomy methods, this approach is the least invasive, with minimal blood loss, lower risk of surgical complications, and complete recovery typically occurring within 15 days (according to Mais et al.).
- Hysteroscopic myomectomy: This procedure is performed when the fibroid is located inside the uterus (submucosal). The surgeon accesses and removes the fibroid using instruments introduced through the vagina and cervix into the uterine cavity.
- Laparoscopic hysterectomy: This minimally invasive surgery aims to remove the uterus. Since the procedure is performed through small abdominal incisions, it is associated with easier recovery, better cosmetic outcomes, and minimal risk of complications.
- Laparotomic myomectomy: For multiple fibroids with varying locations, very large fibroids, or deeply situated fibroids, an open abdominal surgery may be recommended for their removal.
- Laparotomic hysterectomy: This involves the removal of the uterus through an open incision in the abdominal wall. It does not offer advantages over laparoscopic or vaginal approaches and is necessary for patients with very large tumors.
- Vaginal hysterectomy: This procedure involves removing the uterus through the vagina. For this approach to be feasible, several conditions must be met: adequate vaginal capacity and uterine mobility, small size and weight of the tumor, absence of significant adhesions in the pelvic cavity, and no need for additional surgeries on the uterine adnexa and/or abdominal organs.
For any procedure that does not involve complete removal of the uterus, there is a risk of fibroid recurrence.
Non-invasive treatment methods
HIFU ablation (High-intensity focused ultrasound) is a non-invasive treatment option for uterine fibroids that preserves the uterus, requires no incisions, and is performed on an outpatient basis. High-intensity focused ultrasound waves penetrate through all layers of the abdominal wall and create a powerful coagulative necrosis of the fibroid. This procedure is performed without cuts, pain, or blood loss.
As a cutting-edge technology, researchers are continuing to learn more about its long-term safety and efficacy.
Possible complications of uterine fibroids
Uterine fibroids can lead to:
- Iron-deficiency anemia: Reduced productivity and overall health deterioration due to heavy and prolonged menstrual or intermenstrual bleeding.
- Ureteral compression: Disruption of urine flow, leading to inflammatory processes in the urinary tract and kidneys, which may be complicated by urinary tract infections.
- Fertility issues: Problems with conception and pregnancy maintenance. The presence of fibroids in the uterine cavity can lead to uterine deformation, delayed fetal development, placental attachment anomalies, and other pregnancy complications such as miscarriage, preterm labor, and weakened uterine contractions during childbirth.
- Associated conditions: Approximately 20% of patients with pathological uterine bleeding due to fibroids may also experience adenomyosis or other endometrial dysfunctions.
Is pregnancy possible after treatment for uterine fibroids
Hysterectomy (removal of the uterus) will make future pregnancies impossible. Additionally, uterine artery embolization may not be the best treatment option for women with reproductive plans.
It is essential to thoroughly discuss the risks and benefits of each treatment method with your doctor if you wish to preserve your ability to conceive. Before deciding on a treatment plan for fibroids, a complete fertility assessment is recommended if you have reproductive plans.
If treatment for fibroids is necessary and you want to preserve your fertility, myomectomy is generally the treatment of choice. However, all treatment methods come with their own risks and benefits.
Women who have undergone organ-preserving treatments for uterine fibroids typically require additional preparation when planning a pregnancy. They also need more careful monitoring by an obstetrician-gynecologist during pregnancy.
What to avoid with uterine fibroids
- Avoid excessive consumption of fast food, red meat, processed meats, and high-fat dairy products. Studies suggest that consuming these foods may influence the growth of fibroids. The same applies to alcohol.
- Limit sugar intake. Research indicates that a diet high in sugar may be associated with an increased risk of fibroids.
- Do not smoke. Experts believe that smoking can exacerbate menstrual pain by reducing the oxygen supply to the pelvic area.
- Maintain physical activity. Regular exercise is important for overall health and well-being.
- Heat and physical therapy, massage, and UV radiation: There is no proven evidence that these treatments influence the growth of fibroids. Therefore, recommendations to avoid saunas, steam rooms, tanning beds, or beaches lack scientific support.
Preventive advice from Doctors
Since the exact cause of uterine fibroids is not fully understood, preventive methods have not been established. Avoiding stress, engaging in moderate physical activity, maintaining a balanced diet, controlling weight and blood pressure, and preventing and promptly treating urinary tract infections and inflammatory pelvic diseases can help reduce some risk factors, although they do not guarantee 100% prevention of fibroids.
Fibroids often have a prolonged asymptomatic course or present with nonspecific symptoms. Therefore, it is advisable to undergo annual preventive gynecological examinations to detect fibroids at an early stage and prevent complications. If you experience prolonged menstrual bleeding, increased discharge, pain, or other related symptoms, it is important to consult a doctor immediately.
The ICSI Clinic in Kyiv invites you to undergo diagnosis and treatment of uterine fibroids. The clinic utilizes modern, proven treatment methods, and each patient’s treatment plan is developed individually, taking into account various factors. The experience and qualifications of the doctors, along with advanced diagnostic equipment, ensure early detection of fibroids. Surgeries are performed by highly skilled surgeons using state-of-the-art equipment.