Uterine fibroid tumors (benign growths also called leiomyoma, leiomyomata, leiomyofibroma, myoma, or fibromyoma) are among the most common solid pelvic tumors in women of reproductive age.¹ Uterine noncancerous tumors are typically made of uterine smooth muscle and varying amounts of fibrous tissue.¹ The tumor originates from the muscle cells within the uterus, and fibrous tissue develop from the degeneration of the smooth muscle cells. The term fibroid inadequately describes the condition if one were to describe the tumor from the cell of origin, the muscle cell.¹ Therefore, the term myoma will be used for this module. This module will discuss the latest prevalence rates of myomas, the etiology, the most common symptoms, and the treatment options. Nurses can be instrumental in reassuring women and helping them understand options for treatment and management of this common pelvic tumor.

Myomas occur in 20% to 40% of women in their reproductive years^1,2 and are most commonly discovered as an incidental finding on physical examination or ultrasound. African-American women are 2 to 9 times more likely to have myomas, particularly in the 35 to 39 age range, than women of other races.² Obese women are at increased risk because of the increased circulation of endogenous estrogen from adipose tissue.² At present, reports of myomas in prepubescent girls have not surfaced, and postmenopausal women have a 70% to 90% decreased risk of myomas compared to women in their 40s and 50s because of less circulating estrogen.² The more live births women have may further reduce the incidence of myomas, but experts recommend caution regarding this information since a false correlation may occur because myomas are associated with infertility and therefore women with myomas may experience fewer pregnancies than women without myomas.² The number and size of myomas vary greatly among women.

Uterine myomas are named according to their location on the uterus. Myomas can be located immediately under the endometrial or decidual surface of the uterine cavity (submucous), just below the uterine serosa (subserous), or contained within the myometrium (intramural).³ Occasionally, a myoma grows on a stalk, called a peduncle, and can protrude from the internal os of the cervix.¹

Etiology

The etiology of myomas is not well understood. Experts believe that cytogenenic abnormalities (inherited traits) and dysregulation of growth factor contribute to the development of myomas.² Women with a family history have a 1.5- to 3.5-fold greater risk of developing myomas when compared to women without a family history of myomas.²

Myomas are estrogen dependent, and their growth is influenced by factors associated with increased levels of estrogen, I.E. obesity, and pregnancy.² Currently, experts lack evidence to determine the direct effect of hormone therapy in increasing the size of myomas.² Recent evidence shows that myomas also are influenced by progesterone, as both estrogen and progesterone receptors have been found in myomas, but other recent studies dispute this and have suggested that the growth of myomas may not be a result of these hormones, but rather of local growth factors such as epidermal growth factor and insulin-like growth factor.¹

After adolescence, oral contraceptives appear to be protective in reducing the incidence of developing myomas² and usually improve heavy bleeding for women with myomas. Smoking tends to diminish the amounts of endogenous estrogen and therefore may decrease the incidence of myomas.⁴ One study showed that patients who have a history of pelvic inflammatory disease and chlamydia infection had a higher risk of developing uterine myomas.⁴

Symptoms

Only 35%-50% of women with myomas have symptoms.³ Depending on the size, number, and location of the myoma, women may experience any, none, or all of the following symptoms:

Abnormal uterine bleeding: AUB is the most common symptom of myomas. The range of women who present with AUB with later confirmed myomas is from 10% to 69%.² However, the relative risk of having self-reported heavy bleeding is 1.5 times greater in women with confirmed myomas.² Although the bleeding pattern may vary, women most commonly experience menorrhagia, a term used to describe progressively heavier menstrual cycles that last longer than normal. Women also may experience irregular bleeding that varies from month to month, such as bleeding between periods (metrorrhagia). Submucousal myomas are most commonly associated with abnormal bleeding.³

Heavy bleeding is caused by vascular alterations within the endometrium.¹ The heavy bleeding is most likely rooted in a growth factor impairment that causes vascular dysfunction within the uterus.² One recent theory suggests that abnormal bleeding may be caused by an abnormal microvascular pattern with stasis and a change in venous drainage.⁶ AUB can cause significant hardship in social, personal, financial, and medical affairs.² Women with AUB should have an endometrial evaluation by endometrial biopsy or dilation and curettage to rule out other pathology.¹

Pain: About 30% of all women with myomas experience pelvic pain.⁴ Often the first symptom of pain may be the onset of secondary dysmenorrhea.5 Pain may also occur as chronic lower abdominal/pelvic pain, back pain, or pain with intercourse. Pain associated with myomas may be relieved by rest and analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs). The pain may result from infarction from torsion or degeneration of the myoma.³ However, one must always consider other pathologic conditions for pelvic pain, even in women with confirmed myomas, such as ectopic pregnancy, rupture or torsion of ovarian cyst, or acute pelvic inflammatory disease.¹

Pressure: Pelvic pressure tends to be a more common symptom than pelvic pain.¹ Women typically provide vague descriptions of pelvic pressure. Myomas can exert pressure on adjacent pelvic organs, resulting in urinary frequency, incontinence, urgency, and constipation.¹ In severe cases, hydronephrosis may occur as a result of ureteral compression by the myoma.⁴ Pressure most commonly occurs by the enlarging intramural or subserous myoma, which occasionally can reach massive size.⁵

Infertility: Infertility can result from submucosal myomas and/or a markedly distorted, enlarged endometrial cavity that interferes with implantation.¹ Women undergoing infertility treatment experienced a 50% reduction in pregnancy rates compared with women without myomas.¹ Women with myomas receiving infertility treatment have a 50% decreased chance of achieving pregnancy than women without myomas.¹

Diagnosis

Myomas generally are found during a clinical examination or on a sonogram. The clinician feels the enlarged uterus with a bimanual pelvic exam and the uterus may feel like a large mobile mass with irregular contour and usually has characteristically “hard” feel-feels firmer than normal pelvic organs. (The size of the enlarged uterus is often expressed in terms of gestational weeks. A patient with a uterine myoma the size of a large orange, for example, would have a uterus equal to about 10 weeks ’ gestation size.) If the myoma is pedunculated, it may be difficult to distinguish from an ovarian or adnexal mass.⁵

A pelvic ultrasound examination is the most common imaging tool used to diagnose uterine myomas and the most cost-effective for determining the size, location, and number of myomas.⁶ The myoma can be identified as an area of acoustic shadow hypoechogenicity (decreased penetration of sound) along the otherwise normal endometrium, or there may be an obvious distortion of the endometrial stripe because of the presence of the myoma. Ultrasounds usually also allow the examiner to see adjacent structures such as the ovaries and to rule out other abnormalities such as ovarian cysts or tumors. A hysterosalpingogram allows the physician to visualize the uterus and fallopian tubes by injecting a radiopaque contrast dye into the uterus through the cervix under fluoroscopy. The hysterosalpingogram allows the physician to diagnose the amount of distortion within the uterus caused by myomas and distinguish myomas from polyps.⁶

Opinions vary about the use of magnetic resonance imaging in diagnosing uterine myomas. Some believe that both the CT scan and MRI are not cost-effective and are no better than the ultrasound in the diagnosis of uterine myomas.⁵ Other sources cite MRI as the most accurate imaging method available because the MRI allows differentiation between myomas and other uterine masses by providing enhanced visualization.⁴

Another procedure, called hysteroscopy, has been developed to enhance diagnostic capabilities. This procedure allows the examiner to directly visualize the enlarged uterine cavity through a thin probe-like scope passed through the vagina and cervix into the uterus. If submucous myomas are present, they can be visualized and subsequently removed.⁵ While hysteroscopy directly visualizes inside the uterine cavity, laparoscopy is sometimes used to visualize the entire pelvis, enabling the examiner to detect subserosal or intramural myomas, which are not clearly diagnosed through clinical pelvic examination or ultrasound.⁵

Treatments

Today, women have many options to manage their myomas expectantly and/or hormonally without the need for surgery. The choice between hormone and surgical management depends on the severity of symptoms and future fertility wishes. Candid conversations about treatment options and any long-term effects need to take place in order for women to make informed choices about their health care. Nurses can provide accurate, unbiased information for women who are suffering with the symptoms of myoma(s).

Hormone management

1. Gonadotropin-releasing hormone analogues (GnRHa) facilitate a hypoestrogenism state and reduce tumor size and can be used prior to surgery to reduce the myoma size. However, if removal of the myoma is not accomplished, the myoma returns to its pretherapy size once the GnRHa therapy is stopped.¹ The use of GnRHa before surgery also reduces blood flow to the myometrium, thereby causing a reduction in blood loss with a surgical procedure. Long-term therapy, greater than six months, is not recommended because of the increase in bone loss from the prolonged hypoestrogenic state.
2. The Levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena) is a device placed into the uterus as an office procedure. The LNG-IUS slowly releases the hormone for five years. The LNG-IUS has proved helpful in reducing blood loss associated with myomas in approximately 40% of women.⁷ The uterus must not be larger than 12-week size and without distortion. The positive effect of levonorgestrel is unexplained.⁷
3. Clinically and statistically, progestational agents have been noted to halt myoma symptoms and growth. Depot medroxyprogesterone acetate (Depo Provera) significantly may reduce the risk of developing myomas.² Norethindrone (Nor-QD), medrogestone (Prothil), and medroxyprogesterone acetate (Provera) have been hypothesized to reduce myoma symptoms by causing a hypoestrogenic effect by inhibiting gonadotropin secretion and suppressing ovarian function.

Surgical management

Hysterectomy for symptomatic myomas is no longer the gold standard that it was only a decade ago. Today, women can choose from a list of options, such as a myomectomy, uterine artery embolization, and hysterectomy. Before any surgical intervention, a thorough examination needs to exclude other pathology. Women need to have a current Papanicolaou smear and evaluation of the endometrium for those women over the age of 35 years and with abnormal bleeding. Women with normal hemoglobin should consider having one to two pints of autologous blood collected about two weeks before any surgical procedure.¹ For patients who are anemic, iron stores need to be replenished. Many gynecologists prescribe GnRH analogues or progestational agents to stop uterine bleeding and add some iron supplements for up to six months to improve the hemoglobin level before surgery.¹ Surgical management of uterine myomas may be considered for the reasons listed below:¹

1. Abnormal uterine bleeding not responding to conservative treatment. Otherwise heavy periods continue and result in anemia.
2. High level of suspicion of pelvic malignancy; any suspicion of malignancy must be investigated.
3. Growth of the myoma after menopause; this would be abnormal and worrisome.
4. Infertility when there is distortion of the endometrial cavity or tubal obstruction
5. Recurrent pregnancy loss (with distortion of the endometrial cavity)
6. Pain or pressure (that interfere with quality of life)
7. Urinary tract symptoms (frequency and/or obstruction)
8. Iron deficiency anemia secondary to chronic blood loss.¹

Myomectomy: Myomectomy removes the myoma without removing the uterus. This surgical procedure is especially well suited for women who wish to preserve their fertility yet have symptoms that do not respond to medical therapies.^5,8 Myomectomy involves an abdominal incision and allows for all myomas to be removed, regardless of their number, type, or location. Pregnancy may be attempted about three months after myomectomy, and if there are uterine incisions, delivery by cesarean section is considered.⁹ After a five-year follow-up, the recurrence rate of myoma has been documented to be 10%, and about one-third of those women with recurrence will need a hysterectomy.¹

Laparoscopic myomectomy: Laparoscopic myomectomy is done using a thin illuminated scope called a laparoscope. This procedure usually involves a small incision through the umbilicus, but sometimes it is necessary to make three small incisions in the abdomen so that the myomas are visualized better and removed more easily. Pregnancy should be avoided for about 4 to 6 months following a laparoscopic myomectomy because of the disruption of the myometrium.¹ There is a recurrence rate of 62% in five years, with the symptom of heavy abnormal bleeding being the primary symptom for women who undergo a laparoscopic myomectomy.¹¹

Myolysis: Myolysis involves delivering an electrical current to the myoma through needles inserted into the abdomen at the time of laparoscopy. The electrical current causes vasoconstriction of the blood vessels and essentially stops the blood supply to the myoma, which will eventually die and shrink. This procedure is useful only for subserosal myomas in a certain size range.⁸

Hysteroscopic myomectomy: First documented in 1957, hysteroscopic myomectomy is done using a hysteroscope inserted through the cervix and into the uterus. The hysteroscopy has proven to be a successful technique for women with pedunculated submucosal and submucosal myomas with a recurrence rate of 20% after five years.¹ Postmyomectomy pregnancy rates are documented to be 25% to 85.7%.⁶ As with laparoscopic myomectomy, recovery from hysteroscopic myomectomy is shorter than from the traditional myomectomy involving an abdominal incision.¹ Complications of hemorrhage, perforation of the uterus, gas embolism, cervical lacerations, and infections have been reported.⁶

Uterine artery embolization: First documented in 1995, UAE offers women another option for myoma management. During UAE, a minimally invasive procedure, a small catheter is placed into the femoral artery and guided into the uterus. An interventional radiologist will perform the UAE and will order local anesthesia and/or conscious sedation. Once the catheter is in place, the radiologist injects tiny plastic particles the size of grains of sand through it into the artery that supplies blood to the myoma tumors. These particles cut off blood flow to the tumor and the tumor shrinks. The procedure takes about an hour. Patients who have UAE may experience abdominal cramping and pain requiring medication such as acetaminophen or an NSAID or in cases of more severe pain, narcotic analgesics. After an overnight or same-day stay in the hospital for pain management, recovery is usually short, and most women return to their usual daily routine after a week. UAE has some documented side effects and complications such as fever, severe postembolization syndrome, infection, failure to reduce the myoma, sepsis, hysterectomy and death. Ovarian failure has also been documented.¹ The Cardiovascular and Interventional Radiology Research and Education Foundation (CIRREF) has developed the Uterine Artery Embolization Fibroid Registry for Outcomes Data (FIBROID) to assess the durability, impact on fertility and quality-of-life and to obtain outcome data that allow researchers to compare UAE with other therapies for treating myomas.¹³ Initial data analysis of the FIBROID database showed researchers that women reported an improvement of their fibroid symptoms and health related quality of life.¹⁴

Hysterectomy: In the United States, approximately 600,000 hysterectomies are performed annually, with myoma as the most common indication.¹ Today, by the age of 40 about 20% of women will have a hysterectomy and by age 65 one third will have a hysterectomy.¹ Removal of the uterus is sometimes the procedure of choice for surgical treatment of uterine myomas, especially submucous myomas, as they typically are associated with heavy bleeding. Hysterectomy is used when the myomas are exceptionally large and the woman has excessive bleeding and doesn’t want or need to preserve fertility. Hysterectomy can be done through an abdominal incision or through the vagina and can involve removing the uterus alone or, as in the case of total hysterectomy, removal of the uterus, fallopian tubes, and ovaries.¹ Many women may feel that a hysterectomy may impact their sexual responses; however, recently women report an improvement on their quality of life and that the procedure does not adversely influence on sexual responses (with or without the preservation of the cervix).¹ Hysterectomy is the only treatment that permanently removes the chance of myoma recurrence.

Emerging treatments

The science of treating myomas is changing rapidly, and researchers are experimenting with such techniques as the laparoscopic radiofrequency thermal ablation¹⁵ and focused ultrasound treatment.¹⁶ By no means is this list of emerging techniques exhaustive for treating myomas.

The prevalence of uterine myomas represents a significant women’s health concern that provides many opportunities for continued research. Nurses not only can play key roles in needed research, but also can help women understand the diagnosis and treatment of this common benign pelvic tumor.