There are three main categories of fibroids:
- Submucosal: when the fibroid is located in the muscle under the uterine lining or within the cavity (also called intracavitary)
- Intramural: when the fibroid is located within the uterine wall – this is the most prevalent type.
- Subsersosal: When the fibroid is located underneath the outer (serosal) surface of the uterus or protrudes outward (called peduculated). Very rarely, fibroids can disconnect from the uterus and parasitize (obtain blood supply from) other organs.
Fibroids generally grow slowly over time, but growth can be variable. Occasionally, fibroids can grow faster than their blood supply leading to spontaneous death of some cells; this is called a degenerating fibroid. When a degenerating fibroid occurs, it can lead to severe pain. In the past, rapid growth created concern that the fibroid might be cancerous (called a sarcoma), but more recent studies have shown that not to be the case.
Oftentimes, fibroids do not produce any symptoms. If that is the case, many women can live their entire lives with fibroids and never have to take any medical action. In fact, approximately 40 percent of all women have some form of fibroids by the age of 40, but only a small number experience adverse symptom from them.
Symptoms can occur when the fibroids grow too big or too numerous, causing a mass effect on surrounding organs. This kind of mass effect can lead to:
- Constipation from pressure on the colon
- Increased frequency of urination from pressure on the bladder
- Abdominal distention from the enlarged fibroid, which can give the aesthetic appearance of pregnancy
- Effects on fertility from distortion of the tubal and/or ovarian anatomy
- Generalized feeling of pelvic pressure and/or pain
In addition to the maladies from mass effect, submucosal fibroids can lead to abnormal vaginal bleeding, such as heavy menstrual periods or increased risk of miscarriage/inability to conceive. A markedly enlarged uterus from fibroids can also increase the size of the uterine cavity and produce heavy menses or even bleeding at unexpected times. In severe cases, patients risk becoming anemic from increased blood losses.
When fibroids are large enough, they can be felt upon pelvic examination. In diagnosing the fibroids, an ultra sound is used to help determine the anatomy. In some cases, an MRI will be performed. The MRI provides a clearer picture as to the location and size of the fibroids, which can help in formulating the type of surgical approach necessary.
There are multiple options for surgical treatment of troublesome fibroid cases. Today’s technology has allowed for effective and minimally invasive surgeries. These options include:
- Myomectomy by Laparoscopy: Fibroids are removed with surgical instruments inserted through several small (< 1 inch) incisions made in the abdomen, aided by a video feed from a laparoscope inserted through the navel. (See exhibit A)
- Myomectomy by Laparotomy: Fibroids are removed through an abdominal incision. In the past, this was the traditional method of removal before the advent of newer techniques and can still be the most appropriate method under certain circumstances. (See exhibit B)
- Resectoscopic Myomectomy: A scope is passed into the uterine cavity which allows the surgeon to look into the cavity and remove the offending submucosal fibroid(s). This localized approach allows for a minimally invasive approach, with the patient discharged the same day as an outpatient. (See exhibit C)
- Robotic Myomectomy: Similar to Laparoscopic, only instead of manual surgical tools, robotic instruments are inserted and controlled remotely by the surgeon.
- MRI guided High-Intensity Focus Ultrasound Ablation: The fibroid is destroyed by the use of targeted high-energy ultrasound, eliminating the need for surgery.
- Uterine Artery Embolization: A technique carried out by an interventional radiologist where a small incision is made in the groin. Under fluoroscopy, a catheter is guided into the uterine artery, and small beads are released to block (embolize) the artery. This deprives the fibroids of blood supply, causing them to shrink to half of their original size, which may be sufficient to relieve the patient’s symptoms.
Hysterectomy or Supracervical Hysterectomy: Performed laparoscopically, vaginally, by laparotomy, or by robot, this definitive procedure removes the entire uterus or the uterus above the cervix. There is no chance of recurrence of fibroids or symptoms with hysterectomy or supracervical hysterectomy, however, such treatment is usually reserved for women who have completed child bearing.