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For Women of Child-Bearing Age, What to Know About Painful Fibroids

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Fibroids are the most commonly occurring pelvic tumors, affecting as many as one in five women of reproductive age -- and as many as half of women age 35 or older. But most women with fibroids may never have symptoms or they may be so mild they never know the growths are there.

A quarter of women with fibroids experience significant problems: heavy, prolonged menstrual periods; bleeding between periods; anemia; pelvic pain or pressure; pain in the back or legs from fibroids pressing on nerves; pain during sex; bladder pressure leading to a constant urges to urinate; pressure on the bowel, causing constipation and bloating; and an abnormally enlarged abdomen.

Fibroids also have been linked to infertility. Studies have found fibroids were associated with a 5 percent reduction in pregnancy rates, 30 percent reduction in live birth rates and a 67 percent increase in miscarriage rates compared to women without fibroids.

These benign tumors are generally slow-growing balls of muscle that form in the walls of the uterus or in its cavity. They start out as normal uterus muscle cells, but then -- for reasons that aren't fully understood, though estrogen appears to play a role -- begin to grow abnormally and form benign tumors. They can be as small as a grape, or as large as a cantaloupe -- or larger.

Large fibroids can cause the uterus to grow as large as it would be during the sixth or seventh month of pregnancy. They're also called myoma, leiomyoma, leiomyomata and fibromyoma. There are three types identified by their location: subserosal fibroids develop in the outer portion of the uterus, grow outward and pose the risk of painfully pressing on other organs. Submucosal fibroids grow just under the lining of the uterus and are least common; they often cause long, heavy periods. Pedunculated uterine fibroids are fibroids that grow on a stalk of tissue and may occur inside or outside the uterus.

In general, if a woman has one fibroid, she likely has others that just haven't been found. Women who start their periods young -- earlier than age 10 -- are at greater risk, as are women with a family history of fibroids. Women who bear children are less likely to get them and women who take birth control pills are less likely to develop significant fibroids.
African American women are at greater risk, developing fibroids two to three times more often than white women. Their diagnosed fibroids also tend to be larger. A study looking at more than 1,800 women found that 78 percent of those undergoing hysterectomies were black, compared to 22 percent who were white. Fibroids, along with endometriosis and uterine prolapse, are among the most common reasons women undergo a hysterectomy.

There is some concern that more black women undergo hysterectomies due to their increased risk of fibroids and a lack of access to care and information about alternatives. The Centers for Disease Control statistics do show declining numbers of hysterectomies attributed to fibroids, which MDs hope indicates that more women are learning more about alternative treatments.

Treatments

Hysterectomy is no longer the only choice for women with fibroids. There are choices, including ones that will preserve their fertility and minimally invasive options.

One option is to simply keep an eye on the fibroids, which tend to grow slowly and may shrink with menopause. Another course of action is to treat the symptoms caused by the fibroids with contraceptives or progestin-releasing intrauterine devices, which can lighten menstrual bleeding and alleviate pain. Pain due to this condition often can be managed with over-the-counter drugs. This, of course, does not the affect the tumors.

Other medications may be used to manage fibroids, including gonadotropin-releasing hormone agonists. These medications decrease women's levels of estrogen and progesterone, putting them into a postmenopausal state. This stops their periods, shrinks fibroids and often will improve anemia. There are concerns about long-term use, as studies have shown these drugs can slash bone density and increase osteoporosis risk. For this reason, it's recommended they be used for no longer than six months. These medications may be good options, however, for women nearing menopause or to shrink fibroids before surgical removal.

A myomectomy is a surgical procedure to remove fibroids but leave the uterus intact. This can be done as an open surgery but some centers offer minimally invasive options. Depending on the size and location of the fibroids, they can be removed hysteroscopically -- through the vagina, without an abdominal incision.

They also can be removed laparoscopically, in which tiny incisions are made to accommodate a camera and surgical tools. The fibroids are freed from the uterus, cut into smaller pieces and gently suctioned out. Sometimes, these procedures are robotically assisted. Myomectomies are a great option for women who may want to bear children in the future, as it preserves their fertility. Minimally invasive approaches to these surgeries allow for less scarring, shorter recovery times and a quicker return to normal activities.

Nonsurgical options also are available. Uterine fibroid embolization is a relatively new treatment that cuts off the blood supply to fibroids, starving them and causing them to shrink. A small incision is made in the groin area and guided by x-ray and injections of contrast material to map the blood vessels, an interventional radiologist threads a catheter through the cut and into the uterine arteries. Then tiny particles are injected that block the blood flow to the fibroids. Without blood to feed their growth, the fibroids die and become scar tissue and shrink, causing symptoms to become less severe or disappear entirely.

While there have been some cases in which women have conceived after undergoing this procedure, the American Congress of Obstetricians and Gynecologists does not recommend this option for women who wish to preserve their fertility. There is insufficient evidence to ensure the procedure doesn't harm fertility and there haven't been enough studies on outcomes related to pregnancy after embolization.

Another safe and effective noninvasive option for women is focused ultrasound surgery. Guided by MRI, the doctor locates and destroys fibroids with ablation and without making an incision. High-frequency, high energy sound waves are used to target and destroy the tumors, sometimes in one or two treatment sessions. Women have had improved symptoms for up to a year after the procedure; long-term effectiveness is still under study.

These are not the only treatments for fibroids. But it's clear that for the thousands of women who have fibroids that interfere with their everyday lives, hysterectomies are not the only option and fast are becoming old-fashioned.