Healthcast 632 - Fibroids are the most common cause of hysterectomy. But what are they?

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The most common cause of hysterectomy in women are benign masses that grow within the uterine wall. They occur in 4 out of 5 women, and they can be small and asymptomatic, or they can grow large and cause pain, uterine bleeding, pelvic pressure, urinary incontinence and pregnancy complications.

Uterine Fibroids are "the most common tumor in women world-wide".

Although benign, uterine fibroids are associated with significant morbidity; they are the primary indication for hysterectomy, and a major source of gynecologic and reproductive dysfunction, ranging from menorrhagia and pelvic pain to infertility, recurrent miscarriage, and preterm labor.

Fibroids are also referred to as "leiomyomas", "myomas", "fibroid tumors", and sometimes slangily referred to as "fireballs". They are in fact "ball-like" in shape and when we inspect them at hysterectomy, they are made up of swirling muscle cells that are laid down in concentric circles.

Gynecologists find fibroids when we examine a patient at their yearly visit by feeling an enlarged irregular uterus. The fibroids are within the wall of the uterus and often cause heavy uterine bleeding. Where the fibroids are, within the wall of the uterus, determines whether they are more likely to cause bleeding or not. Placement up against the uterine cavity ("submucosal") increases risk of bleeding, and placement in the middle and surface of the uterine wall ("subserosal") decreases risk of severe bleeding.

At BioBalance Health LLC we require every patient who comes to us who still has a uterus to have a formal abdominal and vaginal ultrasound to diagnose fibroids and other uterine abnormalities, before we will give them estradiol pellets. Testosterone doesn't have a negative effect on fibroids so we can still put a woman on testosterone with fibroids. Otherwise, we have the risk of fibroid growth in our consents, and we discuss this issue when a patient's ultrasound shows significant fibroids.

What causes a woman to be more likely to have fibroids during her reproductive years?

Triggers for Fibroid Development

· Race

· Genetics/ family history

· Diet

· Early Age at First Period

· Toxins in the environment especially in early life

· Obesity

· Advancing age

· Vitamin D deficiency

· Hypertension

· Pregnancy suppresses the growth of fibroids

Race: Both Black and Hispanic women are the most likely to develop fibroids and experience enough symptoms to cause the need for a hysterectomy. Black women are 3X as likely as white women to have fibroids, and they are more likely to have very large fibroids. In some circumstances fibroids can prevent pregnancy and cause recurrent miscarriages and preterm labor. 60% of African American women aged 35-49 years reported uterine fibroids, whereas 80% of those aged ≥ 50 have uterine fi-broids.

Genetics/Family History: If a woman has a mother or sister with fibroids, then that woman has twice the risk compared to a woman without a family history of fibroids. "Uterine fibroid-linked mutations in MED12" are the most common mutation we have found, however a mutation in the COMP pathway is also found to be associated with fibroids.

Diet: A diet with high intake of meat, fat and alcohol increases a woman's risk of developing fibroids. A diet deficient in fresh fruit and vegetables also increases the risk of fibroid appearance and growth. Smoking is highly associated with fibroid growth.

Early age of Menarche is a risk for developing fibroids, which increases the years a woman is exposed to estrogens.

Toxins from the environment, and from alcohol increases the development of fibroids. Cleanses might help rid your body of toxins that might methylate your genes and stimulate fibroid growth.

Obesity and Being overweight: Body fat increases the estrone estrogens in the circulation, which stimulates fibroids to grow.

Advancing age until Menopause: When women enter their late 40s their ovaries decrease ovulation and the uterus is exposed to estrogen without progesterone, which causes fibroids to grow. After menopause, some fibroids shrink while others stay the same. When women take HRT their fibroids may be stimulated again, however because it is not cyclic, it is less likely to stimulate fibroid growth.

Hormone Replacement Therapy can increase the size of fibroids:

HRT is only one of the factors that causes growth of fibroids in menopausal women. If estrogen is balanced with progesterone (not progestins) growth is less likely. Testosterone has no effect on fibroids so replacing testosterone is not a factor for Fibroid growth. At BioBalance we have medicated pellets that combine Testosterone with Anastrazole which suppress the growth of fibroids. We use these on our patient who have known fibroids, if they are willing to undergo treatment with this

Vitamin D deficiency

The role of Vitamin D in development of fibroids is being researched at this time, however an adequate Vitamin D blood level is needed to help prevent Fibroid growth.

"Approximately 80% of African American women have vitamin D deficiency, compared with only 20% of Caucasian women". This is one of the factors in Race being a factor in the development of fibroids.

Hypertension

Increased diastolic blood pressure is associated with a higher risk of uterine fibroids, regardless of use of antihypertensive drugs. Women suffering from hypertension are 5 times more likely to develop uterine fibroids.

Not Having Babies (Low parity)

Having had one or more babies (parity) is protective, and the more babies a woman has the less likely she is to have fibroids

What are the Symptoms of Uterine Fibroids?

Fibroids are benign uterine tumors, so patients are not at risk of dying of cancer, but women with fibroids often have quality of life issues, found in the symptoms listed above, that lead them to the final treatment for fibroids, a hysterectomy (removal of the uterus). So can we prevent these masses from occurring, growing and producing symptoms?

How Do You Know You Have Fibroids?

The growth of fibroids is generally slow and is accompanied by slowly worsening symptoms.

When there are many fibroids, large fibroids or submucosal fibroids patients seek help for their symptoms which include:

· Heavy uterine bleeding which can be severe leading to anemia

· Pelvic pain and pressure

· Large mass effect that puts pressure on the bladder and colon causing dysfunction of those organs like stress incontinence, and constipation.

· Painful intercourse

· Multiple Miscarriages

· Preterm labor

· Weight gain

What is the Diagnostic Process that Confirms Fibroids

When I was practicing OBGYN, and a women came into my office for a GYN exam and I felt.

The uterus was enlarged and irregular, it triggered me to do three tests to see if it was a fibroid, ovarian mass, pregnancy or other abdominal tumor. I would first order a rapid pregnancy test. Then I'd order blood work to see if my patient was anemic from heavy bleeding, and If the pregnancy test was negative, then I would order an abdominal and transvaginal ultrasound to get a picture of what I was feeling on exam. If I found a fibroid uterus, then I would have a discussion with my patient to see how severe her symptoms were. I would also tell her how big the uterus. The size of a fibroid uterus does matter. If it is greater than 16 pregnancy week size, it is likely putting undue pressure on the other organs in the abdomen. The speed of growth is also a factor because if the uterus grew quickly, then it has a tiny chance of being a malignant sarcoma. The risk of this is < 1%, however fast growth of a fibroid uterus is an indication to do a hysterectomy.

If the uterus is greater than 12 weeks size an ultrasound cannot adequately measure the uterus or reveal the inside of all of it so an MRI of the pelvis and abdomen is in order before surgery.

What Type of Treatment Can Shrink or Remove Symptoms of Fibroids?

The options for control of Fibroid Symptoms with Medications/Supplements include:

· Progestins or Progesterone without cycling

· Birth Control Pills

· Lupron and other drugs in that class (this puts the patient into a temporary menopause).

· Anastrazole (Arimidex®) which stops the conversion of testosterone into estrone and estradiol.

· Stop Estrogen replacement, or. Lower the dose of estrogen if you are menopausal.

· Treatment of inflammation (High CRP)

· Vitamin D supplementation

· Probiotics

· Supplemental vitamins and minerals

These are the first treatments doctors use to lessen the symptoms of fibroids unless bleeding is so severe that it becomes an emergency and then invasive treatments are used.

· Uterine Artery Embolization is done by a radiologist and puts a "plug" in the fibroid's blood supply and then slowly the fibroid shrinks and dies. The only problem is that once you have had one fibroid, you can always make more. This may be a delaying process to allow a patient to make more red blood cells before a definitive surgery.

· Myomectomy is a procedure done under anesthesia, and it preserves the uterus while removing one or more fibroids. This procedure makes the uterus more fragile and puts it at risk of uterine rupture if a woman gets pregnant and goes through labor. Therefore, myomectomies are usually followed by a C-section for delivery to avoid the risks.

This procedure cannot be done on all fibroid uteruses. The doctor must determine if it is possible to preserve the uterus, since many fibroids invade the whole uterus.

· Hysterectomy is the one procedure that guarantees that uterine fibroids will not return.

After childbearing is complete a woman doesn't need her uterus for anything. It is simply there to bear children and does not secrete hormones or provide any other function. A Hysterectomy is done under anesthesia and removes the uterus that contains the fibroids. If the cervix is not involved with fibroids and there is no history of cervical cancer, a supracervical hysterectomy can be done, preserving the cervix and the nerves that stimulate deep orgasms.

The Newest Research on Fibroids:

Knowing this information should make it easier for you to understand your doctors' findings and what is ahead of you. I hope you can understand the risk factors and the possible treatments available to you.

References:

"Comprehensive Review of Uterine Fibroids…."Endocrine Reviews,2021, Vol. 43, No. 4, 678-719

https://doi.org/10.1210/endrev/bnab039