Uterine Fibroids may be offered as an alternative to surgery in women who are unable or unwilling to have surgery.

Nevertheless, surgery is the preferred method of treatment as it results in a higher cure rate when compared with radiation therapy. Cure rates for surgery have been reported to be between 80% and 94% compared with 60% and 80% for radiation therapy. After surgery, the woman may, however, be offered radiation therapy as adjuvant therapy. This is sometimes done for women with spread of uterine cancer to the lymph nodes or who have other high-risk features portending a higher risk for cancer recurrence. Rarely, for young women who wish to maintain the ability to get pregnant, hormonal therapy with progestins may be a consideration, but only if the cancer is considered a very early cancer. During the consultation regarding endometrial cancer, a physician may use terms such as stage and grade to characterize the cancer. The stage of a cancer ranging from Stage I to Stage IV refers to the extent of spread of the cancer with Stage I being a cancer confined to the uterus and Stage IV indicating spread beyond lymph nodes and uterus, usually advanced spread. The grade of the cancer refers to the degree of differentiation of the cancer cells or how aggressive the cancer cells appear under the microscope. Pathologists currently grade endometrial cancers from 1 to 3 with grade 1 indicating a well-differentiated or not so aggressive appearing cancer, a grade 3 indicating a poorly differentiated or aggressive-appearing cancer, and a grade 2 in between. Important prognostic factors of endometrial cancer, meaning factors that indicate how well the cancer will respond to treatment, include the stage, grade, and status of lymph node involvement. Fortunately, uterine cancer has a high cure rate because most women with uterine cancer are diagnosed at an early stage, confined to the uterus. The overall cure rate of uterine cancer is greater than 80%. For the majority of women who are diagnosed with cancer confined to the uterus, the cure rate is greater than 90%.
SEE ALSO: Cancer, Cancer screening, Dilation and curettage, Endometriosis, Hysterectomy, Pap test, Ultrasound, Vaginal bleeding

Uterine Fibroids Uterine fibroids are the most

common of the noncancerous (benign) tumors of the uterus. The medical term that is synonymous with uterine fibroids is leiomyoma. The cause of fibroids is unknown. However, the hormone estrogen plays a dominant role, since fibroids and associated symptoms are prevalent during the reproductive years and decline during menopause. Fibroid-related symptoms resolve during the menopause and rarely occur during puberty or adolescence. The mean age group for symptoms related to fibroid tumors is between 30 and 50 years old. The incidence of uterine fibroids ranges from 10% to 50%. Factors affecting the incidence include age, race, genetics, and family history. Luckily, most women with uterine fibroids are asymptomatic. Some fibroids may undergo cancerous (malignant) transformation, but fortunately, this is rare. In fact, leiomyosarcoma (the cancerous change of fibroids) is detected in only 0.1% of women with fibroids. The uterus is normally about the size of a small lemon. There are three regions within the uterus: the inner wall (endometrium), the middle wall (myometrium), and the outer wall (serosal layers). Fibroids even though originating in the myometrium can extend to any or all of these regions. Fibroids are defined as an increase in the smooth muscle component of the uterus. Generally, those originating in the endometrium (called submucosal fibroids) or myometrium (called intramural fibroids) will result in changes within the menstrual cycle. Fibroids originating in the serosa and myometrium tend to be associated with symptoms of pressure on the bladder or the bowels. The size of fibroids can range from the size of a lentil pea to the size of a watermelon. Likewise, the weight may range from a few ounces to several pounds. Symptoms from uterine fibroids include changes in menstruation, pain, infertility, urinary pressure or urinary retention, constipation, backache, leg pain or swelling, dyspareunia (painful sexual intercourse), pregnancy-related complications, infertility, and increased abdominal girth. In the past, patients were often advised to undergo removal of all or part of the affected uterine tissue (myomectomy or hysterectomy) if the size of the uterus was greater than the size of a normal uterus at 12 weeks in pregnancy. This is no longer true. Today, the caveat is if your fibroids dont bother you, we dont bother them. Some patients can experience a range of menstrual complaints associated with fibroids. These include heavier cycles, blood clots, longer duration of menses, and irregular menstruation, constant vaginal discharge,

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Uterine Fibroids or episodic bloody/fluid (serosanguineous) discharge. Severely affected patients may decrease physical activities and miss work, due to incessant need to change sanitary pads and tampons. Patients who chronically suffer from heavier menstrual cycles may develop anemia (low blood counts) and fatigue. Other patients have symptoms related to pressure on the bladder. These include complaints of urinary frequency and urgency. Nocturia (having to urinate several times during the night) is also common. Less frequent complaints are stress urinary incontinence, acute urinary retention, urinary tract infections, and pain or difficulty urinating (dysuria). When fibroids enlarge to 1620 cm, they may put pressure on the ureters, leading to hydronephrosis (swelling of the tube connecting the kidney to the bladder). This may lead to kidney damage on rare occasions. The least common structure associated with the presence of fibroids is the bowel. Common bowelrelated complaints include severe constipation and painful bowel movements. Collectively, bulk symptoms include pelvic heaviness, feeling full, abdominal pressure, and backache. Some patients will also complain of heaviness or a sense that something is falling out of the vagina. Some may experience discomfort with intercourse. These symptoms may increase in intensity 12 weeks before the menstrual cycle and resolve after menstruation. Finally, patients with fibroids may note increasing menstrual cramps and pain (dysmenorrhea). Menstrual cramps may escalate 12 weeks before menses and be further exacerbated with the menses. The impact of fibroids on pregnancy and infertility is debatable. Luckily, most women with fibroids do not have reproductive problems. However, fibroids have been associated with premature labor and delivery, persistent breech presentation, postpartum uterine bleeding, more complicated cesarean sections, and early pregnancy-related bleeding. The location of uterine fibroids plays an important role in patients with infertility. Large submucosal fibroids obstructing the endometrial cavity can be associated with difficulty for the egg to implant in the wall of the uterus as is necessary for normal pregnancy (poor placentation), poor sperm migration, and blockage of the fallopian tubes. Likewise, intramural fibroids may impinge on the fallopian tubes or distort the interior of the uterus (endometrial cavity) making pregnancy more difficult. It is important that women experiencing recurrent miscarriages or infertility undergo a thorough evaluation. The diagnosis of uterine fibroids is often suspected by clinical history and the pelvic examination. Confirmation can be made with pelvic or transvaginal ultrasound. Patients with a normal uterine size but heavy menses may undergo specialized diagnostic procedures that help visualize the uterus better (hysteroscopy is an imaging procedure that can be done in the doctors office) to determine the presence of uterine fibroids, which line the endometrial cavity. Many factors must be considered when advising a patient with fibroids. Choice of therapy depends upon reproductive desires of the patient, age, size and number of fibroids, and desire for maintaining the uterus. Sometimes, expectant management is indicated in women who are perimenopausal. Patients with minimal complaints nearing menopause may be reassured about resolution of fibroid symptoms once menopause occurs. Some fibroid-related complaints might be simply treated with nonsteroidal medication, low-dose oral contraceptive pills, or hormone (GnRH) therapy. Luckily there are many conventional surgical procedures as well as minimally invasive techniques to treat uterine fibroids. Hysterectomy always solves fibroid-related bleeding and bulk symptoms. However, hysterectomy should rarely be advised in women wanting children. Myomectomy, which involves just the removal of uterine fibroids, should be considered in women who wish to preserve their fertility or in women opposing hysterectomy. Currently there are several methods available to perform myomectomy including procedures that take place via a small tube (hysteroscopic, laparoscopic procedures), vaginal, or by conventional exploratory laparotomy (conventional surgery). The surgical choice depends upon the size, number, and location of the fibroids. Finally, a newer form of nonsurgical therapy called uterine fibroid embolization (UFE) is a minimally invasive technique performed by a specially trained radiologist (interventional radiologist) who selectively blocks the flow of blood to the fibroid. The blocked blood flow essentially causes the fibroid to break down and resolve. Patients now have a vast array of options to treat uterine fibroids. Fortunately, most fibroids are benign. For this reason, patients should never feel rushed into making a clinical or surgical decision. Patients with symptomatic uterine fibroids should seek a compassionate and well-trained gynecologist who is knowledgeable about all fibroid options. The decision to proceed with surgery or other minimally invasive options should be made rationally.

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SEE ALSO: Dysmenorrhea, Infertility, Menstrual cycle disorders
Clark, A., Black, N., Rowe, P., et al. (1995). Indications for and outcome of total abdominal hysterectomy for benign disease: A prospective cohort study. British Journal of Obstetrics and Gynaecology, 102(8), 611620.

Suggested Reading
Bradley, L. D., Falcone, T., & Magen, A. B. (2000). Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding. Obstetrics and Gynecology Clinics of North America, 27(2), 245276.

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