Uterine Fibroids 

Uterine fibroids are a very common condition, with 80% of women having at least one or more small fibroids.  A fibroid is an abnormal collection of solid fibrous tissue within the wall of the uterus.  They are rarely ever cystic (not to be confused with "fibrocystic changes" in the breast).  They appear as white, hard tissue that is usually surrounded by a capsule and there may be anywhere from a single fibroid to dozens of them.  They can be as small as a grain of sand to the size of a lemon to very large masses that can distort the uterus to the size of a watermelon.  Most are relatively small (fingernail size to the size of a walnut), and most fibroids are "friendly", causing few if any significant symptoms.  However, sometimes  fibroids can become very problematic. When they grow, they can cause symptoms of pressure and cramping.  The most common adverse symptom is heavy and irregular bleeding.  Rarely, they can cause significant pain. Sometimes they can cause fertility problems or make it difficult to carry a pregnancy.

Most fibroids are asymptomatic and simple observation is all that is needed. The old adage that "if it isn't  broken, don't fix it" certainly holds true in this situation.  However, if they become symptomatic, or if they grow so large that they cause pain or abdominal protrusion, intervention is needed.  The most common problem that necessitates management  is heavy and/or irregular bleeding. The heavy bleeding is often accompanied by moderate to severe cramps, clotting, and sometimes significant anemia.  Fibroids may be present for many years before troublesome symptoms are noted, and often a lady may be totally unaware of the presence of fibroids until the onset of major symptoms results in a diagnosis.

Fibroids are usually diagnosed by way of a pelvic exam.  A uterus with significant fibroids feels enlarged on pelvic exam, and it often has an irregular contour.  An ultrasound may be required to detect smaller fibroids that are buried in the wall of the uterus or that bulge into the cavity of the uterus. Other causes of heavy and/or irregular bleeding must also be ruled out.  The pelvic exam and ultrasound usually suffice in this regard, though an in office sampling of the lining of the uterus may be required if the lining appears to be abnormally thickened on ultrasound.

Conservative options for the management of fibroids:

1.	Hormonal treatment:  The treatment of fibroids depends on multiple factors, including significance of symptoms, fibroid size and/or location, and the patient's desire for fertility.  Smaller fibroids can often be managed conservatively by the use of a natural progesterone or a low dose oral contraceptive.  Should hormonal management fail, there are many remaining conservative options.
2.	Hysteriscopic myomectomy: Often a fibroid will bulge into the cavity of the uterus.  Such a fibroid can usually be removed with a simple outpatient procedure called a hysteriscopic myomectomy.  The patient is given a light general anesthesia, the cervix is dilated and a scope is inserted into the uterine cavity.  A camera is attached to the scope and the physician can visualize the fibroid.  A small instrument is used to shave off pieces of the fibroid until it has been removed down to the wall of the uterus.  This often allows the periods to return to normal, even if there are other fibroids on the uterus that can't be removed because they don't protrude into the cavity.  The patient goes home shortly after the procedure and there is usually little or no postoperative pain. She can return to work or normal activities the following day.
3.	Arterial embolization:  Most fibroids don't bulge into the uterine cavity and they might not respond to hormonal treatment.  In the past, this often meant that an operation through a large incision would be needed to remove the fibroids, or a hysterectomy might be required. Fortunately, less invasive procedures are now available.  A new method of treatment is called arterial embolization.  This is done by an interventional radiologist.  The doctor gives a local anesthetic, then cuts down to a major artery in the leg (the femoral artery) and inserts a small catheter that is then manipulated under x ray guidance into the uterine artery. Tiny pellets are then injected into the blood stream and these flow to the fibroids and block the blood supply to the fibroids.  The fibroids then shrivel and die.  Seventy per cent of the time, periods return to normal and no further intervention is needed.  This procedure can even be used for women who want to have children in the future though studies on safety are still ongoing. This management should not be used if the fibroids are too large or if they protrude significantly into the uterine cavity.
4.	Endometrial ablation:  Another conservative option, when the fibroids are not too large, involves a procedure called endometrial ablation. This is an outpatient process that can be done in a surgicenter under light general or spinal anesthesia. It can even be done in the office under local anesthesia.  A probe is placed into the uterine cavity and most of the uterine lining is destroyed by cauterization or freezing. There may be some cramping after the procedure, but it is usually easily controlled with oral pain medication.  The patient is able to return to normal activity and work within 1 to 3 days.  In 50 to 70% of patients, the periods either cease entirely or become light and regular again. Because most of the lining of the uterus is destroyed, endometrial ablation is offered only to patients who have completed childbearing.
5.	Myomectomy:  Removal of the fibroids with preservation of the uterus is another reasonable option.  In the past, this usually meant a major operation done through a large abdominal incision.  Modern techniques now allow the procedure to be done by way of outpatient surgery, utilizing  a laparascope or a small incision (mini lap). The patient can usually return to work or normal activities within 3 days to a week. This approach is often recommended for women who wish to preserve their fertility.
6.	Laparascopic hysterectomy:  Our goal is to avoid hysterectomy, and we usually can by use of the above mentioned conservative approaches (with still others currently under investigation). However,  hysterectomy may sometimes still be required.  In the past, removal of major fibroids almost always meant a hysterectomy done through a major abdominal incision.  Such surgery usually involved several days in the hospital and then 6 weeks off of work for recovery to the point that the patient could carry on most normal activity.  Complete recovery often took even longer.  Now, advances in laparascopic equipment and new techniques allow us to do most of these surgeries by way of laparascopy in the outpatient setting.  The patient experiences far less pain, the complication rate is lower, and she is usually able return to work and normal activity within 1 to 3 weeks. Very large fibroids (even those that extend up to the level of the umbilicus) can usually be handled laparascopicaly.  Commonly the cervix and ovaries are left in place, so healing is accelerated, pain is minimal, and there is usually no need to go on hormone replacement.