UTERINE FIBROIDS (MYOMAS): SPECIAL CASE
Lena’s main problem with fibroids was painful, heavy, dot-laden bleeding which occurred for eight or more days each month. After almost a year of putting up with this, she felt frustrated about the situation and was determined to do something about it. When a friend mentioned the possibility of a hysterectomy, she had strong reservations. She wanted to have a child, and her doctor agreed that a myomectomy (the surgical removal of fibroids from the uterus) was appropriate in her case. This was carried out successfully, leaving her uterus intact. Some years later, by which time Lena had given birth to a child, the fibroids recurred. This time they were even more troublesome causing pain and severe haemorrhoids as well as heavy bleeding. An internal examination revealed that the fibroids were more extensive and intrusive than they had been previously and Lena decided on a hysterectomy.
Before a diagnosis of fibroids is confirmed, other possible reasons for a mass in the abdomen should be excluded; for example, pregnancy or cancer of the cervix, endometrium or ovaries. To rule out pregnancy in a premenopausal woman, a sample of blood or urine is tested and a result obtained within minutes. To exclude cancer, several diagnostic procedures may be necessary. These include a Pap smear; a colposcopy, which entails viewing the cervix with a magnifying instrument called a colposcope, with or without removing a small sample of tissue (a biopsy) for subsequent examination; dilatation and curettage, in which the cervix is stretched or dilated and an instrument is inserted to scrape away most of the uterine lining; an ultrasound examination conducted via the vagina which produces an image of the uterus and other internal structures; and laparoscope a pelvic examination using a laparoscope (a tubular instrument with a light at one end and an eyepiece at the other) inserted through a small incision in the abdominal wall. Before committing to a diagnosis a doctor may also want to exclude other situations in which similar symptoms can occur, such as endometriosis, a pregnancy in a Fallopian tube, irregular placement of the uterus, bladder cancer, and ascites, which is an accumulation of fluid in the abdomen.
Doctors do not usually recommend removing fibroids if they are not causing problems, and it is estimated that this is the situation for most women who have them. In these women, fibroids tend to be diagnosed during a routine check-up, usually causing suspicion because the uterus is larger than expected but there is no evidence of pregnancy. If a doctor feels a firm, irregularly shaped mass when conducting an abdominal examination, the likelihood is that one or more fibroids are present.
When suggestions are made about removing fibroids that are not producing symptoms, this may be because of concerns that their further growth could make later removal difficult, or could result in serious complications by pressing on nearby organs. Of course doctors do not have crystal balls and predicting which patients will experience a worsening of their symptoms requires a good deal of guesswork. If this is the reason given for hysterectomy, it should be closely questioned. It is reasonable to remove symptomless fibroids if they are blocking the cervix, protruding into the uterine cavity or closing off the Fallopian tubes. Recent estimates suggest that fibroids are involved in about one in fifty cases of infertility in Australian couples.
The cause or causes of fibroids are uncertain although it is clear that stimulation of the myometrium by oestrogen promotes their growth and development. When oestrogen levels are high, as occurs during the reproductive years in general and pregnancy in particular, fibroids tend to increase in size. When oestrogen levels fall, for example after menopause, fibroids tend to shrink. During the past decade, further valuable insights have emerged. Studies of large population groups show that fibroids are much more common in women from certain racial groups. Black women in the US, for example, are three to nine times more likely to develop fibroids than comparable White women. Suspicion has fallen on genetic factors and pelvic infections, but it has also been suggested that a predisposition to fibroid formation occurs in obese women with above-average levels of blood glucose and growth hormone. Oestrogen and growth hormone are synergistic, meaning that their combined effect is greater than the effect of either hormone acting alone. Women on the Pill and those who smoke cigarettes seem to be less likely to develop fibroids.
*10\198\4*
