Definition of Cancer
Women are more prone to breast, uterine and
Cancer is disease of regulation of tissue growth. In this
disease, the cells of the body display uncontrolled
growth, invasion that intrudes and destroys adjacent
tissues and spreads to other body locations. In order for
a normal cell to transform into a cancer cell, genes
which regulate cell growth and differentiation must be
altered.
Theories about Cancer
1. Cellular transformation and Derangement
theory. In this theory, exposure of normal cells
to some etiologic agent may transform normal
cells into cancer cells.
2. Failure of the Immune Response Theory. This
theory conceptualizes that all individuals possess
cancer cells but these cancer cells are NOT
recognized by the immune system. Thus, cancer
cells undergo destruction. Failure of the immune
response system to kill or destroy the cancer
cells leads to cancer.
Etiologic Factors or Carcinogens
• Viruses or Oncogenic Viruses. Prolonged and
recurrent viral infections may lead to the
breakdown of the immune system. The
overwhelmed immune system may fail to
destroy the cancer cells present in the body. The
human papillomavirus (HPV) are particularly
common cancer-causing virus which is well-
known for causing genital warts and all cases of
cervical cancer.
• Chemical carcinogens. These chemicals cause
cell mutation or alter the cell enzymes and
proteins.
Industrial Compounds
1. Vinyl chloride – plastic manufacture, asbestos
factories, construction works
2. Polycyclic aromatic hydrocarbons
3. Fertilizers
4. Weed killers
5. Dyes – analine dyes (most commonly found in
beauty shops and used at homes), hair bleach
6. Drugs – cytotoxic drugs, tar nicotine in tobacco,
alcohol
Hormones
1. Estrogen
2. Diethystilbesterol (DES)
Foods, preservatives
1. Nitrites in bacon or smoked meat
2. Talc (polished rice, salami and chewing gum)
3. Food sweeteners
4. Nitrosomines (rubber baby nipples)
5. Aflatoxins (mold in nuts, grains, milk, cheese
and peanut butter)
6. Polycyclic hydrocarbons
• Physical agents
Radiation
1. From x-rays or radioactive isotopes
2. From sunlight or UV rays
Physical irritation or trauma
1. Pipe smoking
2. Multiple deliveries
• Genetics
Risk Factors
1. Older individuals
2.
cervical cancer
3. Men are more prone prostate and lung cancer
4. Urban dwellers
5. Chemical factory workers
6. Farmers
7. Personnel of radiology department
8. Family history
9. Obesity
10. Stress
Pathophysiology of Cancer
A healthy cell becomes a cancer cell by undergoing the
following processes:
1. Proto-oncogenes are changed to oncogenes.
Proto-oncogenes are genes that are coded to
maintain normal cell growth. In cases of a
developing cancer, oncogene takes its place.
Oncogene is a gene that makes cells grow and
divide rapidly.
2. Cancer cell grows and divides rapidly.
3. Alteration of the tumor suppression genes takes
place.
4. DNA repair genes are altered and turned off.
Uterine fibroids
Leiomyoma; Fibromyoma; Myoma; Fibroids
Uterine fibroids are noncancerous (benign) tumors that
develop in the uterus (womb), a female reproductive
organ.
Causes, incidence, and risk factors
Uterine fibroids are the most common pelvic tumor. As
many as 1 in 5 women may have fibroids during their
childbearing years (the time after starting menstruation
for the first time and before menopause).
Fibroids usually affect women over age 30. They are
rare in women under 20, and often shrink and cause no
symptoms in women who have gone through
menopause. They are more common in African
Americans than Caucasians.
The cause of uterine fibroid tumors is unknown.
However, fibroid growth seems to depend on the
hormone estrogen. As long as a woman with fibroids is
menstruating, a fibroid will probably continue to grow,
usually slowly.
Fibroids can be so tiny that you need a microscope to
see them. However, they can grow very large. They may
fill the entire uterus, and may weigh several pounds.
Although it is possible for just one fibroid to develop,
usually there are more than one.
Fibroids are often described by their location in the
uterus:
• Myometrial -- in the muscle wall of the uterus
• Submucosal -- just under the surface of the
uterine lining
• Subserosal -- just under the outside covering of
the uterus
• Pendunculated -- occurring on a long stalk on
the outside of the uterus or inside the cavity of
the uterus
Symptoms
More common symptoms of uterine fibroids are:
• Abdominal fullness, gas, or constipation
• Bleeding between periods
• Increase in urinary frequency
 • Heavy menstrual bleeding (menorrhagia),
sometimes with the passage of blood clots
• Menstrual periods that may last longer than
normal
• Pelvic cramping or pain with periods
• Sensation of fullness or pressure in lower
abdomen
• Pain during intercourse
Note: There are often no symptoms.
Signs and tests
A pelvic examination may show an irregularly shaped,
lumpy, or enlarged uterus. Frequently, this diagnosis is
reliable. In some cases, it is difficult to diagnose fibroids,
especially in obese women. Fibroid tumors have been
mistaken for:
• Pregnancy
• Ovarian tumors
• Inflammation of the fallopian tubes
• Uterine adenomyosis (a condition in which the
uterine lining grows into the muscle wall of the
uterus)
A transvaginal ultrasound or pelvic ultrasound may be
done to confirm the diagnosis of fibroids. Sometimes, a
pelvic MRI is used to confirm the diagnosis.
An endometrial biopsy (biopsy of the uterine lining) or
laparoscopy may be needed to rule out cancer.
Treatment
Treatment depends on various factors, including:
• Age
• General health
• Severity of symptoms
• Type of fibroids
• Whether you are pregnant
• If you want children in the future
Some women may just need pelvic exams or
ultrasounds every once in a while to monitor the fibroid's
growth.
Treatment for the symptoms of fibroids may include:
• Birth control pills (oral contraceptives) to help
control heavy periods
• Intrauterine devices (IUDs) that release the
hormone progestin to help reduce heavy
bleeding and pain
• Iron supplements to prevent or treat anemia due
to heavy periods
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
such as ibuprofen or naprosyn for cramps or
pain
Hormonal therapy (gonadotropin releasing hormone
(GnRH) agonists or Depo Leuprolide injections) may be
used to help shrink the fibroids. This therapy is used
only for a short period of time, either before surgery to
remove a fibroid or when a woman is expected to reach
menopause soon. Side effects include hot flashes and
vaginal dryness.
Surgery and procedures used to treat fibroids include:
• Hysteroscopic resection of fibroids: Women who
have fibroids growing inside the uterine cavity
may need this outpatient procedure. In this
procedure, a small camera and instruments are
inserted through the cervix into the uterus to
remove the fibroid tumors.
• Uterine artery embolization: This procedure
stops the blood supply to the fibroid, causing it
to die and shrink. Women who may want to
become pregnant in the future should discuss
this procedure with their health care provider.
• Myomectomy: This surgery removes the fibroids.
It is often the chosen treatment for women who
want to have children, because it usually can
preserve fertility. More fibroids can develop after
a myomectomy.
• Hysterectomy: This invasive surgery may be an
option if medicines do not work and other
surgeries and procedures are not an option.
Support Groups
National Uterine Fibroid Foundation - www.nuff.org
Expectations (prognosis)
Some women with fibroids have no symptoms and may
not need treatment.
During a pregnancy, existing fibroids may grow due to
the increased blood flow and estrogen levels. The
fibroids usually return to their original size after the
baby is delivered.
Complications
Fibroids may cause pregnancy complications, although
the risk is thought to be small:
• Most women are able to carry their babies to
term, but some end up delivering prematurely
because there is not enough room in the uterus.
• Some pregnant women with fibroids may need a
cesarean section because fibroids can
occasionally block the birth canal or cause the
baby to be positioned wrong.
• Some pregnant women with fibroids have heavy
bleeding immediately after giving birth.
Other complications of fibroids include:
• Severe pain or excessively heavy bleeding that
may require emergency surgery
• A pedunculated fibroid can become twisted and
cause a kink in the blood vessels feeding the
tumor (this type of fibroid may need surgery)
• Anemia (which may be severe if the bleeding is
very heavy)
• Urinary tract infections, if pressure from the
fibroid prevents the bladder from fully emptying
• Cancerous changes called leiomyosarcoma (in
rare cases)
• Infertility (rarely)
Calling your health care provider
Call your health care provider if:
• You have gradual changes in your menstrual
pattern, including a heavier flow, increased
cramping, or bleeding between periods
• Fullness or heaviness develops in your lower
abdomen
A uterine fibroid (also uterine leiomyoma,[1]
myoma, fibromyoma, leiofibromyoma,
fibroleiomyoma, and fibroma) (the plural of myoma is
myomas or myomata) is a benign (non-cancerous)
tumor that originates from the smooth muscle layer
(myometrium) and the accompanying connective tissue
of the uterus.
Fibroids are the most common benign tumors in females
and typically found during the middle and later
reproductive years. While most fibroids are
asymptomatic, they can grow and cause heavy and
painful menstruation, painful sexual intercourse, and
urinary frequency and urgency. Some fibroids may
interfere with pregnancy although this appears to be
very rare.[2]
In the US, symptoms caused by uterine fibroids are a
very frequent indication for hysterectomy.[3] Fibroids are
often multiple and if the uterus contains too many
leiomyomatas to count, it is referred to as diffuse
uterine leiomyomatosis. The malignant version of a
fibroid is extremely uncommon and termed a
leiomyosarcoma.
• the uterus. With further growth, some lesions may
Prevalence
A relatively large submucosal leiomyoma; it fills out the
major part of the endometrial cavity
About 20–40% of women will be diagnosed with
leiomyoma but only a fraction of those will cause
problems or require treatment.[3]
The condition is about twice as common in black women
as white women.[4][5]
Leiomyoma are more common in overweight women
(perhaps because of increased estrogen from adipose
aromatase activity).[6] Fibroids are dependent on
estrogen and progesterone to grow and therefore
relevant only during the reproductive years, they are
expected to shrink after menopause.
Pathology and histology
Leiomyomas grossly appear as round, well circumscribed
(but not encapsulated), solid nodules that are white or
tan, and show whorled appearance on histological
section. The size varies, from microscopic to lesions of
considerable size. Typically lesions the size of a
grapefruit or bigger are felt by the patient herself
through the abdominal wall.
Microscopically, tumor cells resemble normal cells
(elongated, spindle-shaped, with a cigar-shaped
nucleus) and form bundles with different directions
(whorled). These cells are uniform in size and shape,
with scarce mitoses. There are three benign variants:
bizarre (atypical); cellular; and mitotically active.
Location
Growth and location are the main factors that determine
if a fibroid leads to symptoms and problems.[3] A
small lesion can be symptomatic if located within
the uterine cavity while a large lesion on the
outside of the uterus may go unnoticed.
Different locations are classified as follows:
• Intramural Fibroids are located within the wall
of the uterus and are the most common type;
unless large, they may be asymptomatic.
Intramural fibroids begin as small nodules in the
muscular wall of the uterus. With time,
intramural fibroids may expand inwards, causing
distortion and elongation of the uterine cavity.
• Subserosal fibroids are located underneath
the mucosal (peritoneal) surface of the uterus
and can become very large. They can also grow
out in a papillary manner to become
pedunculated fibroids. These pedunculated
growths can actually detach from the uterus to
become a parasitic leiomyoma.
• Submucosal fibroids are located in the muscle
beneath the endometrium of the uterus and
distort the uterine cavity; even small lesion in
this location may lead to bleeding and infertility.
A pedunculated lesion within the cavity is
termed an intracavitary fibroid and can be
passed through the cervix.
• Cervical fibroids are located in the wall of the
cervix (neck of the uterus). Rarely fibroids are
found in the supporting structures (round
ligament, broad ligament, or uterosacral
ligament) of the uterus that also contain smooth
muscle tissue.
Fibroids may be single or multiple. Most fibroids start in
an intramural location, that is the layer of the muscle of
develop towards the outside of the uterus or towards the
internal cavity. Secondary changes that may develop
within fibroids are hemorrhage, necrosis, calcification,
and cystic changes.
Aetiology and pathogenesis
Fibroids are monoclonal tumors, approximately 40 to
50% show karyotypically detectable chromosomal
abnormalities. When multiple fibroids are present they
will usually have mostly unrelated genetic defects. Exact
aetiology is not nearly understood, current working
hypothesis is that genetic predispositions, prenatal
hormone exposure and the effects of hormones, growth
factors and xenoestrogens cause fibroid growth. Known
risk factors are African-American descent, nulliparity,
obesity, polycystic ovary syndrome, diabetes and
hypertension.[7]
Fibroid growth is strongly dependent on estrogen and
progesterone. Although both estrogen and progesterone
are usually regarded as growth promoting they will also
cause growth restriction in some circumstances.
Paradoxically fibroids will rarely grow during pregnancy
despite very high steroid hormone levels and pregnancy
appears to exert a certain protective effect.[2] This
protective effect might be partially mediated by an
interaction estrogen and the oxytocin receptor.[8]
It is believed that estrogen and progesterone have both
mitogenic effect on leiomyoma cells and also act by
influencing (directly and indirectly) a large number of
growth factors, cytokines and apoptotic factors as well
as other hormones. Furthermore the actions of estrogen
and progesterone are modulated by the cross-talk
between estrogen, progesterone and prolactin signalling
which controls the expression of the respective nuclear
receptors. It is believed that estrogen is growth
promoting by up-regulating IGF-1, EGFR, TGF-beta1,
TGF-beta3 and PDGF, promotes aberrant survival of
leiomyoma cells by down-regulating p53, increasing
expression of the anti-apoptotic factor PCP4 and
antagonizing PPAR-gamma signalling. Progesterone is
thought to promote the growth of leiomyoma through
up-regulating EGF, TGF-beta1 and TGF-beta3, and the
survival through up-regulating Bcl-2 expression and
down-regulating TNF-alpha. Progesterone is believed to
counteract growth by downregulating IGF-1.[9][10][11]
Expression of transforming growth interacting factor
(TGIF) is increased in leiomyoma compared with
myometrium.[12] TGIF is a potential repressor of TGF-β
pathways in myometrial cells.[12]
Whereas in premenopausal fibroids the ER-beta, ER-
alpha and progesterone receptors are found
overexpressed, in the rare postmenopausal fibroids only
ER-beta was found significantly overexpressed.[13] Most
studies found that polymorphisms in ER and PR gene
encodings are not correlated with incidence of fibroids in
Caucasian populations [14][15] however a special ER-alpha
genotype was found correlated with incidence and size
of fibroids. The higher prevalence of this genotype in
black women may also explain the high incidence of
fibroids in this group.[16]
Uterine leiomyoma was more sensitive than normal
myometrium to PPAR-gamma receptor activation
resulting in reduced survival and apoptosis of leiomyoma
cells. The mechanism is thought to involve negative
cross-talk between ER and PPAR signaling pathways.
Several PPAR-gamma ligands were considered as
potential treatment.[17] PPAR-gamma agonists may also
counteract leiomyoma growth by several other
mechanisms of action such as TGF-beta3 expression
inhibition.[18]
Hypertension is significantly correlated with fibroids.
Although a causal relationships is not at all clear the
hypothesis has been formulated that atherosclerotic
injury to uterine blood vessels and the resulting
inflammatory state may play a role. Furthermore
endocrine factors related to blood pressure such as
angiotensin II are suspected to cause fibroid
proliferation via angiotensin II type 1 receptor.[19][20]
Aromatase and 17beta-hydroxysteroid dehydrogenase
are aberrantly expressed in fibroids, indicating that
fibroids can convert circulating androstenedione into
estradiol.[21] Similar mechanism of action has been
elucidated in endometriosis and other endometrial
diseases.[22] Aromatase inhibotors are currently
considered for treatment, at certain doses they would
completely inhibit estrogen production in the fibroid
while not largely affecting ovarian production of
estrogen (and thus systemic levels of it). Aromatase
overexpression is particularly pronounced in Afro-
American women [23]
Genetic and hereditary causes are being considered and
several epidemiologic findings indicate considerable
genetic influence especially for early onset cases. First
degree relatives have a 2.5-fold risk, and nearly 6-fold
risk when considering early onset cases. Monozygotic
twins have double concordance rate for hysterectomy
compared to dizygotic twins.[24]
Like keloids, fibroids have disregulated production of
extracellular matrix. Recent studies suggest that this
production may represent an abnormal response to
ischemic and mechanical tissue stress.[25] Several factors
indicate significant involvement of extracellular signaling
pathways such as ERK1 and ERK2, which in fibroids are
prominently influenced by hormones.[26] Paradoxically
and unlike most other conditions involving significant
fibrosis the Cyr61 gene has been found downregulated
in fibroids.[27]
Cyr61 is also known for its role as tumor suppressing
factor and in angiogenesis. Hence fibroids are one of the
very few tumors with reduced vascular density.[27]
Symptoms
Generally, symptoms relate to the location of the lesion
and its size (mass effect). Important symptoms include
abnormal gynecologic hemorrhage, heavy or painful
periods, abdominal discomfort or bloating, painful
defecation, back ache, urinary frequency or retention,
and in some cases, infertility.[28] There may also be pain
during intercourse, depending on the location of the
fibroid. During pregnancy they may be the cause of
miscarriage, bleeding, premature labor, or interference
with the position of the fetus.
Fibroids, particularly when small, may be entirely
asymptomatic. The U.S. Department of Health & Human
Services states that "Fibroids are almost always benign
(not cancerous). Rarely (less than one in 1,000) a
cancerous fibroid will occur. This is called
leiomyosarcoma. Doctors think that these cancers do
not arise from an already-existing fibroid. Having
fibroids does not increase the risk of developing a
cancerous fibroid. Having fibroids also does not increase
a woman's chances of getting other forms of cancer in
the uterus."[29]
While fibroids are common, they are not a typical cause
for infertility accounting for about 3% of reasons why a
woman may not have a child.[30] Typically in such cases
a fibroid is located in a submucosal position and it is
thought that this location may interfere with the function
of the lining and the ability of the embryo to implant.[30]
Also larger fibroids may distort or block the fallopian
tubes.
Diagnosis
While a bimanual examination typically can identify the
presence of larger fibroids, gynecologic ultrasonography
(ultrasound) has evolved as the standard tool to
evaluate the uterus for fibroids. Sonography will depict
the fibroids as focal masses with a heterogeneous
texture, which usually cause shadowing of the
ultrasound beam. The location can be determined and
dimensions of the lesion measured. Also magnetic
resonance imaging (MRI) can be used to define the
depiction of the size and location of the fibroids within
the uterus.
Imaging modalities cannot clearly distinguish between
the benign uterine leiomyoma and the malignant uterine
leiomyosarcoma, however, the latter is quite rare.
However fast growth or unexpected growth such as
enlargement of a lesion after the menopause raise the
level of suspicion that the lesion might be a sarcoma.
Also, with advanced malignant lesions there may be
evidence of local invasion. A more recent study has
suggested that diagnostic capabilities using MRI have
improved the ability to detect sarcomatous lesions.[31]
Biopsy is rarely performed and if performed, is rarely
diagnostic. Should there be an uncertain diagnosis after
ultrasounds and MRI imaging, surgery is generally
indicated.
Other imaging techniques that may be helpful
specifically in the evaluation of lesions that affect the
uterine cavity are hysterosalpingography or
sonohysterography.
Coexisting disorders
Fibroids that lead to heavy vaginal bleeding lead to
anemia and iron deficiency. Due to pressure effects
gastrointestinal problems are possible such as
constipation and bloatedness. Compression of the ureter
may lead to hydronephrosis. Fibroids may also present
alongside endometriosis, which itself may cause
infertility. Adenomyosis may be mistaken for or coexist
with fibroids.
In very rare cases, malignant (cancerous) growths,
leiomyosarcoma, of the myometrium can develop.[32]
Treatment
Most fibroids do not require treatment unless they are
causing symptoms. After menopause fibroids shrink and
it is unusual for fibroids to cause problems.
Symptomatic uterine fibroids can be treated by:
• medication to control symptoms
• medication aimed at shrinking tumours
• ultrasound fibroid destruction
• various surgically aided methods to reduce blood
supply of fibroids
• myomectomy or radio frequency ablation
• hysterectomy
Herbal treatment
Most frequently used herbal treatments are Vitex agnus-
castus, Yarrow and Capsella bursa-pastoris. There is no
clinical evidence supporting their use in the treatment of
fibroids, however for Vitex[33] and Yarrow[citation needed]there
is evidence that they can reduce menstrual bleeding and
PMS symptoms.
Medication
A number of medications are in use to control symptoms
caused by fibroids. NSAIDs can be used to reduce
painful menses. Oral contraceptive pills are prescribed to
reduce uterine bleeding and cramps.[30] Anemia may
have to be treated with iron supplementation.
Levonorgestrel intrauterine devices are highly effective
in limiting menstrual blood flow. Side effects are
typically very moderate because the levonorgestrel (a
progestin) is released in low concentration locally. While
most Levongestrel-IUD studies concentrated on
treatment of women without fibroids a few reported very
good results specifically for women with fibroids
including a substantial regression of fibroids.[34] One
reported problem is that women with large fibroids had
more frequently spontaneous expulsion of the IUD,
however many of those asked for reinsertion of the
device indicating a high rate of satisfaction despite the
expulsion.[35][36]
Danazol is an effective treatment to shrink fibroids and
control symptoms. Its use is limited by unpleasant side
effects. Mechanism of action is thought to be
antiestrogenic effects. Recent experience indicates that
safety and side effect profile can be improved by more
cautious dosing.[35]
Dostinex in a moderate and well tolerated dosis has
been shown in 2 studies to shrink fibroids effectively.
Mechanism of action is completely unclear.[35][37]
Gonadotropin-releasing hormone analogs cause
temporary regression of fibroids by decreasing estrogen
levels. Because of the limitations and side effects of this
medication it is rarely recommended other than for
preoperative use to shrink the size of the fibroids and
uterus before surgery. Its is typically used for a
maximum of 6 months or shorter because after longer
use they could cause osteoporosis and other typically
postmenopausal complications. The main side effects are
transient postmenopausal symptoms. In many cases the
fibroids will regrow after cessation of treatment,
however significant benefits may persists for much
longer time in some cases. Several variations are
possible, such as GnRH agonists with add-back regimens
intended to decrease the adverse effects of estrogen
deficiency. Several add-back regimes are possible,
tibolone, raloxifene, progestogens alone, estrogen alone,
and combined estrogens and progestogens.[35]
Aromatase inhibitors have been used experimentally to
reduce fibroids. The effect is believed to be due partially
by lowering systemic estrogen levels and partially by
inhibiting locally overexpressed aromatase in fibroids.[35]
Experience from experimental aromatase inhibitor
treatment of endometriosis indicates that aromatase
inhibitors might be particularly useful in combination
with a progestogenic ovulation inhibitor.
Progesterone antagonists have been shown in small
studies to decrease the size of uterine fibroids.
Mifepristone was effective in a placebo-controlled pilot
study.[38][39]Selective progesterone receptor modulators,
such as Progenta, have been under investigation.
The selective progesterone receptor modulator Asoprisnil
is currently tested with very promising results as a
possible use as a treatment for fibroids - the hope is
that it will provide the advantages of progesterone
antangonitst without their adverse effects.[35]
The long term safety of progesterone antagonists as well
as selective progesterone receptor modulators has yet to
be established.[40][41]
Magnetic Resonance-Guided Focused Ultrasound
Magnetic Resonance guided Focused Ultrasound
(MRgFUS), is a non-invasive intervention (requiring no
incision) that uses high intensity focused ultrasound
(HIFU) waves to ablate (destroy) tissue in combination
with Magnetic Resonance Imaging (MRI), which guides
and monitors the treatment. This technique was
approved by the FDA in 2004. Ultrasound is a form of
energy that passes through skin, muscle, fat and other
soft tissue. High intensity focused ultrasound energy,
focused on a small target volume (tumor), provides a
therapeutic effect by raising the tissue temperature of
the target (tumor) high enough to destroy it. This is
similar to the manner in which sunlight focused by a
magnifying glass can create sufficient heat to start a
fire. The use of heat to destroy tissue is called thermal
ablation. Treatments consist of multiple exoposures of
focused energy or sonications. MRgFUS uses a Magnetic
Resonance Imaging (MRI) scanner to identify tissues in
the body and plan the treatment. During the procedure,
delivery of focused ultrasound energy is guided and
controlled using MR thermal imaging. • MR imaging
provides a three-dimensional view of the target tissue,
allowing for precise focusing of ultrasound energy within
a desired volume. • Additionally, the MR imaging
provides quantitative, real-time, thermal images of the
treated area. This allows the physician to ensure that
the temperature generated during each cycle of
ultrasound energy is sufficient to cause thermal ablation
within the desired tissue and if not, to adapt the
parameters. The advantage and value of MR guidance
ensures safe and accurate treatment. [42] • Patients who
have symptomatic fibroids, who desire a non-invasive
treatment option and who do not have contraindictions
for MRI are candidates for MRgFUS. About 60% of
patients qualify. It is an outpatient procedure and takes
one to three hours depending on the size of the fibroids.
It is safe and effective.[43] For patients who have a total
fibroid volume of more than 500cc, they may be
pretreated for 3 months with a gonadotropin-releasing
hormone (GnRH) analogue (e.g. leuprorelin) to reduce
leiomyoma size and subsequently, improve thermal
ablation efficacy.[44] Fibroid characteristics (T2
hypointensity, smaller size, intramural location, fewer
number) are important predictor of treatment success.
[45][46][47][48]
Symptomatic improvement is sustained for
two plus years.[49] Need for additional treatment varies
from 16-20% and is largely dependent on the amount of
fibroid that can be safely ablated; the higher the ablated
volume, the lower the re-treatment rate.[50] • In
comparison to available treatment options, the cost
effectiveness of MRgFUS in the U.S. and U.K. has been
found to be reasonable and comparable to alternative
treatments (hysterectomy, pharmacotherapy, uterine
artery embolization).[51][52] • The largest hurdle for
patients who desire MRgFUS is insurance coverage. Most
insurers will not cover MRgFUS even though there is a
large body of evidence to support its efficacy and safety.
The most likely reason is because there are no
randomized trial between MRgFUS and UAE. A multi-
center trial is underway to investigate the efficacy of
MRgFUS vs. UAE.
Uterine artery embolization
Uterine artery embolization (UAE): Using
interventional radiology techniques, the interventional
radiologist occludes both uterine arteries, thus reducing
blood supply to the fibroid.[53] A small catheter (1 mm in
diameter) is inserted into the femoral artery at the level
of the groin under local anesthesia. Under imaging
guidance, the interventional radiologist will enter
selectively into both uterine arteries and inject small
(500 µm) particles that will block the blood supply to the
fibroids. A patient will usually recover from the
procedure within a few days. The UAE procedure should
result in limited blood supply to the fibroids which
should prevent them from further growth, heavy
bleeding and possibly shrink them.
A retrospective cohort study showed that UAE has much
fewer serious adverse effects than hysterectomy (odds
ratio 0.25) and similar rates of satisfaction. In this
study, 86% of women treated with UAE would
recommend the treatment to a friend compared to 70%
of those treated by hysterectomy.[54]
Uterine artery ligation
Uterine artery ligation, sometimes also laparoscopic
occlusion of uterine arteries are minimaly invasive
methods to limit blood supply of the uterus by a small
surgery that can be performed transvaginally or
laparoscopically. The principal mechanism of action may
be similar like in UAE. This is a relatively new method
which demonstrated similar efficacy similar like UAE but
is easier to perform and for this reason fewer side
effects are expected.[55][56][57] UAE currently appears
much more effective than this method in direct
comparison.Cite error: Invalid <ref> tag; invalid
names, e.g. too many; see the help page
Radio frequency ablation
Radiofrequency ablation: One of the newest
minimally invasive treatments for fibroids is
radiofrequency ablation.[58] In this technique the fibroid
is shrunk by inserting a needle-like device into the
fibroid through the abdomen and heating it with radio-
frequency (RF) electrical energy to cause necrosis of
cells. The treatment is a potential option for women who
have fibroids, have completed child-bearing and want to
avoid a hysterectomy.
Surgery
It is possible to remove multiple fibroids during a
myomectomy. Although a myomectomy cannot prevent
the recurrence of fibroids at a later date, such surgery is
increasingly recommended, especially in the case of
women who have not completed bearing children or who
express an explicit desire to retain the uterus. There are
three different types of myomectomy:
• In a hysteroscopic myomectomy, the fibroid is
removed by the use of a resectoscope, an
endoscopic instrument that can use high-
frequency electrical energy to cut tissue.
Hysteroscopic myomectomies can be done as an
outpatient procedure, with either local or general
anesthesia used. Hysteroscopic myomectomy is
most often recommended for submucosal
fibroids. A French study collected results from
235 patients suffering from submucous myomas
who were treated with hysteroscopic
myomectomies; in none of these cases was the
fibroid greater than 5 cm.[59]
• A laparoscopic myomectomy requires a small
incision near the navel. The physician then
inserts a laparoscope into the uterus and uses
surgical instruments to remove the fibroids.
Studies have suggested that laparoscopic
myomectomy leads to lower morbidity rates and
faster recovery than does laparotomic
myomectomy.[60] As with hysteroscopic
myomectomy, laparoscopic myomectomy is not
generally used on very large fibroids. A study of
laparoscopic myomectomies conducted between
January 1990 and October 1998 examined 106
cases of laparoscopic myomectomy, in which the
fibroids were intramural or subserous and
ranged in size from 3 to 10 cm.[61]
• A laparotomic myomectomy (also known as an
open or abdominal myomectomy) is the most
invasive surgical procedure to remove fibroids.
The physician makes an incision in the
abdominal wall and removes the fibroid from the
uterus. A particularly extensive laparotomic
procedure may necessitate that any future births
be conducted by Caesarean section.[30] Recovery
time from a laparatomic procedure is generally
expected to be four to six weeks.
Hysterectomy is the classical method of treating fibroids.
Although it is now recommended only as last option it is
still the leading cause of hysterectomies in the US.
Endometrial ablation
Endometrial ablation can be used if the fibroids are
only within the uterus and not intramural and relatively
small. High failure and recurrence rates are expected in
the presence of larger or intramural fibroids.
Other
The use of vitex herbal medicine lacks supporting
evidence.
Malignancy
About 1 out of 1000 lesions[30] are or become malignant,
typically as a leiomyosarcoma on histology. A sign that a
lesion may be malignant is growth after menopause.[30]
There is no consensus among pathologists regarding the
transformation of Leiomyoma into a sarcoma. Most
pathologists believe that a Leiomyosarcoma is a de novo
disease[citation needed].
Metastasis
There are a number of rare conditions in which fibroids
metastasize. They still grow in a benign fashion, but can
be dangerous depending on their location.[62]
• In leiomyoma with vascular invasion, an
ordinary-appearing fibroid invades into a vessel
but there is no risk of recurrence.
• In Intravenous leiomyomatosis, leiomyomata
grow in veins with uterine fibroids as their
source. Cardiac involvement can be fatal.
• In benign metastasizing leiomyoma,
leiomyomata grow in more distant sites such as
the lungs and lymph nodes. The source is not
entirely clear. Pulmonary involvement can be
fatal.
• In disseminated intraperitoneal
leiomyomatosis, leiomyomata grow diffusely
on the peritoneal and omental surfaces, with
uterine fibroids as their source. This can
simulate a malignant tumor but behaves
benignly.

What are Common symptoms of uterine myoma (fibroids)?

• Pain in the back of the legs

• Pelvic pain or pressure
• Very heavy and prolonged menstrual periods
• Pressure on the bowel which may lead to
constipation and/or bloating
• An enlarged abdomen (this may be mistaken
for weight gain or pregnancy)
• Pain during sexual intercourse
• Pressure on the bladder which results in: a
perpetual need to urinate, incontinence, or the
inability to empty the bladder