Mid-Years WOMEN’S HEALTH

Understand the options when it comes to fibroids

By Ivy M. Alexander, MS, C-ANP
Adult Nurse Practitioner/Assistant Professor
Adult and Family Nurse Practitioner Specialty
Yale University School of Nursing
New Haven, CT

Approximately 576,000 women undergo hysterectomies annually in the United States. Of these, 25% to 30% are attributed to uterine fibroids.1,2 It is estimated that between 20% and 50% of the women over age 35 have fibroids,3,4 and while more than 50% are asymptomatic, others suffer from pain, dyspareunia, and abnormal bleeding.1,3-5

Uterine fibroids, also known as myomas or leiomyomas, are benign neoplasms that arise from smooth muscle in the uterus and are classified according to location. Although the exact mechanism causing fibroid development is not known, growth is affected by estrogen, epidermal growth factor, and some enzymes.1,3,5 In most women, fibroids will shrink following the natural decrease in estrogen during menopause.3,4

Although most women with fibroids are asymptomatic, many will develop symptoms over time. Fibroid size and location generally indicate what symptoms will be experienced. Symptoms generally are insidious, beginning with vague feelings of abdominal fullness and pelvic pressure.4 Pressure and discomfort typically increase as the fibroid enlarges.

Symptoms range from mild to severe and can include abdominal enlargement, constipation, gastrointestinal pressure, backache, dyspareunia, pregnancy loss, infertility, premature labor, and urinary urgency, retention, or frequency. Hydro nephrosis or hydroureter is possible if the fibroid blocks urinary drainage. Inferior vena cava compression, although rare, can result in pulmonary embolus. Abnormal bleeding, including meno metrorrhagia, metrorrhagia, or menorrhagia can occur, often resulting in anemia.1,3-5 Abdominal or pelvic pain is usually related to fibroid degeneration, occurring when the fibroid outgrows its blood supply.3,5

Diagnosis and evaluation

Most uterine fibroids are identified during the bimanual exam. Myomas are usually firm (but can be hard or soft) and not tender. They have smooth, rounded protrusions and create an irregularly enlarged uterus. The beginning work-up includes a Pap smear to evaluate for cervical cancer; a complete blood count to assess for anemia, platelet abnormality, or blood dyscrasia; and a serum beta human chorionic gonadotropin assay to exclude the possibility of pregnancy.3-5 In women who have abnormal bleeding, endometrial cancer should be excluded next using office endometrial biopsy.3,5

Transvaginal ultrasound is a useful diagnostic tool.3-5 Fibroid size and location can be evaluated and ovarian tumors can be excluded. In women with a uterine size of >12-weeks gestation, both an abdominal and transvaginal ultrasound should be ordered. Magnetic resonance imaging may be indicated if the ultrasound does not clearly show the fibroid. Renal ultrasound occasionally may be necessary to evaluate hydronephrosis, and an intravenous pyleogram is useful in the rare case of suspected ureter compression. Hysterosal pingo gram can be helpful when evaluating infertile women (although infertility solely due to myomas is uncommon), or when a submucosal fibroid is suspected. Sonohysterography can be used to distinguish the type of fibroid and to plan surgical intervention.3,5

Medical management focuses on controlling symptoms and bleeding. Pain and pressure is often reduced by nonsteroidal anti-inflammatory drugs. Hormonal therapy may reduce irregular bleeding. Fibroid size can be decreased with gonadotropin-releasing hormone (GnRH).1,3,5

GnRH decreases circulating estrogen by inhibiting pituitary gonadotropin secretion. However, women taking GnRH experience side effects that mimic perimenopausal symptoms including hot flushes, headaches, vaginal dryness, fatigue, dyspareunia, insomnia, increased lipid levels, and bone loss. Maximum fibroid shrinkage occurs in the first three months of therapy, but long-term treatment is generally not recommended due to the side effect profile.1,3,5 GnRH does provide an option for women who prefer to avoid surgery and are nearing menopause.

Surgical interventions are not indicated for asymptomatic women.1,3,6 When surgery is necessary, options include myomectomy (excision of the fibroid) and hysterectomy. Myomectomy may be a good option for a woman who wants to retain fertility. However, because fibroids occur in multiples, several surgeries may be needed over time. Surgical risk and risk for future pregnancies due to uterine scarring increase with each procedure.1,3,5 The American College of Obstetricians and Gynecologists (ACOG) in Washington, DC, cites infertility when the leiomyomata is the likely cause and a patient’s desire to retain fertility as indications for myomectomy.6

Hysterectomy is generally the treatment of choice for women who do require surgical intervention, who want to stop menstruating, and who have completed childbearing.1,3,5 Fibroid size should be reevaluated every two to three months by bimanual exam and ultrasound. If the size stabilizes, then follow-up every six months is appropriate.

References

    1. Kramer MG, Reiter RC. Hysterectomy: Indications, alternatives and predictors. Am Fam Phys 1997; 55:827-834.

    2. Samadi AR, Lee NC, Flanders D, et al. Risk factors for self-reported uterine fibroids: A case-control study. Am J Public Health 1996; 86:858-862.

    3. Garcia CR, Pfeifer SM, Wallach EE. Uterine fibroids: Treat — or ignore? Patient Care 1997; 31:48-52, 55.

    4. Robertson C. Differential diagnosis of lower abdominal pain in women of childbearing age. Lippincotts’s Primary Care Practice 1998; 2:210-229.

    5. Strickland K. Continuing education forum: The primary care management of leiomyoma-induced abnormal uterine bleeding. J Am Acad Nurse Practitioners 1996; 8:541-545.

    6. American College of Obstetricians and Gynecologists. Uterine leiomyomata. Technical Bulletin 1994; May:1-9.