Types of Fibroids

Uterine fibroids, the most prevalent benign pelvic tumor in women, are estimated to affect more than 70% of reproductive-age women. Although all uterine fibroids arise from myometrium, they are classified by their location in the uterus. Uterine fibroids fall into three major clinical categories: subserosal, submucosal, and intramural. A fourth type, pedunculated fibroids, are characterized by their structure and behavior, rather than their location. In addition to their different positions in relation to the uterus, fibroid types vary in terms of associated symptoms, as well as their potential impact on reproductive functions, including fertility.

Subserosal fibroids are located on the outer wall of the uterus and protrude into the abdominal cavity. The most common of the three types, approximately 55% of uterine fibroids can be classified as subserosal. As subserosal fibroids grow outward, they can press against surrounding organs, causing what are known as “bulk symptoms”—pelvic pain, pressure, and urinary symptoms being common examples. Large subserosal fibroids that push on the bowel, pelvic wall, or vagina can result in painful bowel movements or intercourse.

The second category, submucosal fibroids, grow on the inside of the uterus, protruding into the uterine cavity. While submucosal fibroids are the least common type, comprising only 5% of cases, they are the most likely to be symptomatic. They are typically responsible for the heavy bleeding that many fibroid patients experience; this bleeding occurs because submucosal tumors disrupt the endometrial lining of the uterus and, when particularly large, can distort or enlarge the uterine cavity.

Whereas subserosal and submucosal fibroids grow from the wall of the uterus, the third type of fibroid, intramural, grows within the muscular layers of the uterine wall. Symptoms related to intramural fibroids include heavy bleeding, pressure and pain, depending on their size and location within the uterine wall. Enlarged intramural fibroids located close to the uterine cavity can change the shape of the uterus and interfere with menstrual and reproductive functions.

By disrupting the reproductive mechanism of the uterus in certain ways, submucosal and intramural fibroids can affect a woman’s fertility; large intramural fibroids, for example, can press into the fallopian tubes, interfering with ovulation. Having fibroids inside the wall or cavity of the uterus has also been shown to decrease the chance of success with in vitro fertilization (IVF), particularly if they are larger than 5 cm.

Pain is a common symptom of uterine fibroids, though the nature and severity can vary. A particular type of fibroid is especially painful, however: pedunculated tumors, which are connected to the uterus by a thin stalk, can easily twist, causing extreme pain. As they develop, submucosal and subserosal fibroids can become pedunculated.

Fibroids don’t tend to occur singularly: In fact, the average affected uterus has 6 to 7 fibroid tumors, and they can develop in different locations simultaneously. Moreover, while the clinical classification separates fibroids into distinct types by location, in reality, most fibroid tumors are “hybrids”; for example, a fibroid that is predominantly intramural can extend past the endometrium and protrude into the uterine cavity, rendering it a hybrid of the intramural-submucosal types. As a result, multiple diagnostic methods may be required to determine the actual size and location of all existing fibroids.

SOURCES:

  1. Center for Uterine Fibroids, “What Are Fibroids”, Fibroids.net. Retrieved May 4, 2015 from http://www.fibroids.net/fibroids.html
  2. Galen, D. et. al, “Does Menstrual Bleeding Decrease After Ablation of Intramural Myomas? A Retrospective Study”, Journal of Minimally Invasive Gynecology. May 2013; Vol 20(6): 830-835
  3. “Fibroid Tumors.” [Video]. American Society for Reproductive Medicine, 21 Feb. 2012. Retrieved April 28, 2015, from https://www.youtube.com/watch?v=eSJ-ztQ97Og
  4. Wilde, S. and Scott-Barret, S. “Radiological Appearances of Uterine Fibroids”, Indian Journal of Radiology and Imaging. Aug 2009; Vol 19(3): 222–231. doi: 10.4103/0971-3026.54887
  5. Burbank, F. Fibroids, Menstruation, Childbirth, and Evolution, p. 106. Wheatmark, 2009. Tucson, AZ.

 

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“Won’t My Fibroids Go Away On Their Own?” Weighing the Wait-And-See Option

If you’ve done any Internet research on fibroids at all, you’ve probably encountered some mention of a woman’s fibroids disappearing on their own after menopause. It’s most likely a true story. Indeed, as the body’s natural production of estrogen declines in menopause, the estrogen-fueled fibroid tumors, also called leiomyomas, will follow suit—at least, in theory.

There are a number of reasons why a woman would continue to see the persistence or even growth of her fibroids after menopause: the reintroduction of estrogen with hormone replacement therapy or malignant changes in the tumor (cancer known as leiomyosarcoma) are two possible explanations for the continuation of symptoms. Hormone replacement, in particular, is commonly necessitated when a woman’s menopausal symptoms impact her quality of life, but the need isn’t foreseeable in pre-menopausal years. In such cases, fibroids that may have otherwise gone away naturally could continue to present problematic symptoms far later in life than anticipated.

Still, the natural disappearance of fibroids is a viable possibility. For many women, this raises the question, if fibroids will potentially shrink or even disappear on their own after menopause, should a pre-menopausal woman take steps to have them treated, or should she simply wait and see? The urgency for treatment typically depends on the severity of symptoms, according to Dr. Donald Galen, OB-GYN and former Surgical Director at the Reproductive Science Center of the San Francisco Bay Area.

The degree to which women experience common fibroid symptoms like heavy menstrual bleeding, pelvic pain and pressure, and urinary frequency varies substantially. For many women, fibroid symptoms are more than inconvenient: they can interfere with all aspects of her life and relationships. When symptoms are debilitating, a woman may want to consider treating her fibroids sooner, rather than later. With many available treatment options, including minimally invasive options like Acessa Procedure, treating any existing fibroids will improve her quality of life.

Women whose symptoms are less severe, on the other hand, may choose to delay treatment. “If symptoms are minimal,” Dr. Galen explains, “it is reasonable to follow these patients and as they progress in menopause…their fibroids and symptoms should progressively diminish and thus no other treatment may be needed.” Stressing the importance of the patient’s participation in the decision-making progress, he adds, “this decision is made by the woman, with counseling from her physician as to all available risks, treatments, alternatives, etc.”

Sources:

  1. Burbank, Fred. Fibroids, Menstruation, Childbirth and Evolution: The Fascinating Story of Uterine Blood Vessels. Tucson, AZ: Wheatmark, 2009. 135. Print.
  2. American Society for Reproductive Medicine, “What Are Fibroids”, Resources, ReproductiveFacts.org: 2011. Retrieved April 6 2015, from http://www.reproductivefacts.org/FACTSHEET_What_are_Fibroids/

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Fibroids’ Psychological Toll

Fibroids hurt. The pain isn’t just physical: the psychological toll that comes with symptomatic fibroids is profound. In a 2014 study on the emotional impact of fibroids, researchers at Northwestern University’s Feinberg School of Medicine surveyed 48 women who had diagnosed, symptomatic uterine fibroids. The researchers found that the majority of those women had a “significant emotional response to their fibroids, ranging from general worry and concern to fear, anxiety, sadness, and depression”. More than half of the study’s participants reported feeling as though they had no control over their fibroids, mostly due to the difficulty of managing and predicting the heavy menstrual flow that is characteristic of the condition. The majority felt disempowered and possessed a “negative self-image”. The women also frequently expressed “concern over appearing pregnant, overweight, and less attractive”. Many of them expressed that the insecurities made intimacy with a partner difficult.

Despite both the physical and emotional suffering that the condition engenders, the prevailing attitude among women with fibroids seems to be that the condition is one to simply be endured. They resign themselves to “toughing it out”. Why would they voluntarily suffer? The answer partly lies in the woman’s perception of normalcy surrounding her experience with fibroids, according to researchers. M.S. Ghant et al. discovered in their 2014 study that many of the women they surveyed had delayed seeking a diagnosis for their heavy menstrual bleeding because they believed what they were experiencing was essentially a normal burden of womanhood. Even after receiving a diagnosis of fibroids, the researchers reported, many did not seek treatment: instead, they frequently minimized their suffering and “expressed that they were ‘just dealing’ with their fibroids”.

Fear about invasive treatments and the consequences of procedures like hysterectomy are clearly major deterrents for many fibroid sufferers who would otherwise seek treatment. Fortunately, new, outpatient treatment options like the Acessa Procedure offer women with fibroids alternatives to hysterectomy and invasive surgery. Evidence suggests that treating fibroids through a minimally invasive procedure of this nature leads to improved quality of life and psychological wellbeing.

A 2013 study by Guido et al. examined the impact of fibroid treatment via radiofrequency volumetric thermal ablation (also known as Acessa Procedure) on various aspects of patient’s wellbeing. Using the participant’s responses to follow-up questionnaires at 3, 6, 12 and 24 months post-procedure, the research team measured improvements in multiple quality-of-life factors, including: Concern, Activities, Energy/Mood, Control, Sexual Function, and Self-Consciousness. They concluded that the women participants, “showed significant improvement in their symptom severity and health-related quality of life [in the first] 3 months post treatment”. Moreover, the effects seemed to last; the researchers noted that the improvements they observed, represented in the graph below, were “sustained over 2 years, accompanied by a low rate of re-intervention (4.8%)”.

As awareness of minimally invasive treatment options increases, perhaps the painful emotions like fear, anxiety, and depression that commonly precede treatment decisions will be alleviated, and “toughing it out” will no longer be perceived as necessary. Moreover, for those women who take the next step of treating, rather than enduring, their fibroids through a minimally invasive procedure, the outlook for an improved emotional, physical, and mental state is a positive one.

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SOURCES:

  1. Ghant, M.S. et al. “An altered perception of normal: a qualitative assessment of women’s experiences with symptomatic uterine fibroids”, Fertility & Sterility. Sept 2014; Vol. 102(3):255.
  2. Ghant, M.S. et al. “Beyond the physical: a qualitative assessment of the emotional burden of symptomatic uterine fibroids on women’s mental health”, Fertility & Sterility. Sept 2014; Vol. 102(3):329.
  3. Guido et al. “Radiofrequency volumetric thermal ablation of fibroids: a prospective, clinical analysis of two years’ outcome from the Halt trial”, Health and Quality of Life Outcomes 2013 11:139.

 

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