Uterine Fibroids Can Wreak Reproductive Havoc. What Are They?
Uterine Fibroids Can Wreak Reproductive Havoc. What Are They?
These benign tumors can affect women in their procreative prime, but they are more treatable than ever.
By Hilda Hutcherson
April 17, 2020
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This story was originally published on June 20, 2019 in NYT Parenting.
I was just a few months pregnant with my daughter when I had a routine ultrasound exam. I lay back, got gelled up and watched the screen, waiting for the image of my baby to appear. A layperson may not have noticed the white mass visible in the wall of my uterus, but I’m an obstetrician and it was unmistakable: a tumor the same size as my 3-month fetus. I recognized it as a fibroid, a benign mass, but I was concerned that, as my pregnancy progressed, it could cause problems. Fortunately, the fibroid didn’t grow, my pregnancy progressed normally and my daughter was born on her due date, healthy and thriving.
Mine was an ideal outcome, but that’s not always the case for expectant moms who are living with fibroids. While most pregnant women with fibroids experience no issues, some may experience difficulty conceiving, early pregnancy loss, preterm labor, low birth weight infants and increased risk of cesarean delivery. When one of my patients had experienced three pregnancy losses prior to our first visit, a complete workup revealed multiple fibroids as the most likely culprit. After successful surgery to remove more than 20 fibroids, she conceived and delivered a 7-pound baby boy by cesarean.
What are fibroids?
Fibroid tumors (also known as leiomyomas or myomas) are firm, white, round growths that are about the texture of solid rubber balls. Fibroids are described by their location in or on the uterus. They may grow on the inside (submucosal) or outside surfaces of the uterus (subserosal), within the musculature of the uterine wall (intramural) or on stalk-like growths on the outside of the uterus (pedunculated). Some are as small as baby peas; others may grow as large as a 9-month pregnancy. You may have only one or multiples of different sizes. Though fibroids are not cancerous, they can be a significant detriment to a woman’s reproductive health, causing problems such as anemia, infertility and pregnancy complications.
While we don’t really know what causes fibroids, we do know that they thrive on estrogen and progesterone, so they tend to be most problematic during the reproductive years when those hormones are at their highest levels. Once you hit menopause and your hormone levels decrease, fibroids don’t grow and usually start to shrink.
Fibroids are the most common benign tumor in women. They tend to increase in occurrence with age, affecting about 70 percent of white women and more than 80 percent of black women by age 50. Fibroids also tend to run in families: You’re twice as likely to have them if your mother or sisters do. The exact genetic link is still a mystery.
How will you know if you have them?
If your fibroids are small or on the inside of your uterus, and are not causing problems like heavy periods, you may never know you have them. But your ob-gyn can detect larger fibroids during a routine pelvic exam because they can make the uterus — which is typically about the size and shape of a pear — larger and bumpy. The most common fibroid symptom is heavy menstrual bleeding. Other symptoms can include pelvic pain or pressure, painful periods or pain during sex. Because the tumors may press against other organs, you might feel constipated or have the urge to urinate more frequently.
Who gets them?
As a gynecologist, I have diagnosed hundreds of women with fibroids. They’re a particular issue among black women, where they tend to grow faster, larger and more abundantly than they do in white women; and they can cause more severe symptoms, including intense period pain and heavy bleeding. Whereas most white women may not develop fibroids until their mid-30s, some black women start getting fibroids in their early- to mid-20s. That means they may be dealing with the tumors — and the fertility problems they can cause — throughout their prime childbearing years.
Will fibroids affect my fertility?
The majority of women who have fibroids won’t have infertility or pregnancy complications, but a small percentage of women may experience difficulty conceiving. Fibroids can block the fallopian tubes or cervical canal, making it more difficult to get pregnant. Tumors that grow inside the cavity of the uterus may interfere with implantation of a fertilized egg. Removing the fibroids can improve fertility and pregnancy outcomes. However, your doctor should be certain that the fibroids, and not other issues, are the cause of your infertility before going ahead with surgery.
Though most women are able to conceive despite having fibroids, tumors inside the uterus or within the walls of the uterus that are particularly large may sometimes cause problems with the pregnancy — such as miscarriage, preterm labor and delivery, or low birth weight — and lead to increased cesarean sections
What’s the best treatment?
Most women with fibroids never require treatment. If they’re not bothering you and aren’t interfering with other bodily functions, don’t bother them. They don’t need to be treated or removed, even if they’re fairly large. Your gynecologist or other health care provider will check them yearly during your routine exam. And obviously if you start having symptoms, that conversation may change. If you’re approaching menopause, you may be able to stick it out until your periods stop.
If you’re experiencing discomfort, pain or other symptoms, however, you may want to consider treatment. Years ago, the only option was hysterectomy — surgically removing the uterus. Fortunately, there are several more viable treatment options available today. Your choice will depend on your age; symptoms; and the location, number and size of the tumors, as well as your future pregnancy plans.
The first step is to get an ultrasonogram to confirm the presence of fibroids and estimate how many you have and where they are located on or in the uterus. Not every single fibroid will be detected, but the more significant ones will be mapped and measured. Some practitioners recommend an M.R.I. (magnetic resonance imaging) for a clearer picture.
Can medication help?
Heavy periods and cramping may be treated with birth control pills, non-steroidal anti-inflammatory drugs like ibuprofen or progestin-releasing I.U.D.s. These can make periods lighter and decrease menstrual cramping. These drugs may reduce your pain, but not the size of your fibroids.
Other types of drugs — such as gonadotropin-releasing hormone agonists — can shrink tumors by decreasing the hormone producing activity of your ovaries, lowering your estrogen levels. When fibroids are deprived of estrogen, their growth slows. But these medications should be used for only a limited amount of time because they cause menopausal symptoms like hot flashes and bone loss. They are generally used for several months to shrink fibroids before surgery.
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What if drugs are off the table?
Consider other minimally invasive options. Uterine artery embolization, for instance, can block blood supply to the fibroids by injecting tiny plastic pellets into the vessels that supply blood to the fibroid. When fibroids are starved of adequate blood supply, they can’t grow and decrease in size. U.A.E. may also make periods lighter. Though it’s not foolproof: Up to 30 percent of women will need further surgery for symptoms after U.A.E. And it’s not first-line therapy for women who want to get pregnant.
Another alternative is an M.R.I.-guided focused ultrasound, which delivers high-intensity ultrasound waves to the fibroid through your abdomen. The ultrasound generates heat within the fibroid, causing cells to die and the fibroid to shrink. Because the waves are targeted, they won’t damage the rest of the uterus.
What are my surgical options?
You can remove the fibroids with a myomectomy, a type of surgery that leaves the uterus intact. This can be done laparoscopically — via a small incision using a camera — or with a more traditional surgery that involves a larger abdominal incision. If your fibroids are inside the uterine cavity, a third surgical option would be to insert a thin, lighted tube through the cervix so the fibroids can be shaved away.
All of these surgical methods preserve fertility, and studies suggest that women who have children after myomectomies are less likely to have their fibroids return than women who don’t. But removing the tumors isn’t a permanent fix. Studies have found a 40 to 50 percent risk that fibroids will grow back after five years. With that in mind, I usually recommend when possible that women delay surgery until a few months before they plan to conceive so, hopefully, the tumors won’t have time to grow back.
Another way to get rid of fibroids for good is to remove the entire uterus. In fact, hysterectomy — which involves making a small incision and using a laparoscope, or a large abdominal incision, and removing the uterus through it — is still the most common surgical treatment for fibroids: More than 200,000 women receive a hysterectomy for fibroids every year. Black women are twice as likely to undergo hysterectomy, and at an earlier age, than other women. While the surgery is a definitive treatment (fibroids have nowhere to grow), there are many potential side effects, including menopausal symptoms, pain, infection, urinary incontinence, prolapse of the vagina and sexual dysfunction. And, of course, this option is off the table if you want to deliver children.
Can fibroids be prevented?
Though the jury is still out, some studies suggest that your diet and lifestyle may affect your risk of fibroids. Obesity may increase fibroid risk by increasing your estrogen hormones. A few studies have suggested that diets rich in caffeine and alcohol may increase fibroid risk. Others have shown that adequate vitamin D levels, which are often low in black women, may be important in preventing fibroids. Recent studies suggest that psychosocial stress and inactive lifestyle may increase risk.
These links are not definitive, so don’t beat yourself up for your past diet and lifestyle if you’re diagnosed with fibroids. Of course, being at a healthy weight, eating lots of fruit and vegetables, avoiding high caffeine intake, exercising regularly and reducing stress may or may not decrease fibroids, but you’ll probably feel better.
Hilda Hutcherson is an obstetrician-gynecologist, senior associate dean and professor of obstetrics and gynecology at Columbia University Vagelos College of Physicians and Surgeons.