Having just had a number of patients with fibroids as their major cause of infertility, it’s the perfect time to talk about this frustrating and widespread problem.
First, we really do not have an accepted theory as to why or how fibroids come about. We know that they are more common in certain races (for example, as many as 40 percent of African-American women have fibroids) and can run in families, so there is most surely a genetic component. But while the researchers try to figure all that out, we practitioners are stuck with what to do about them. The answer lies in what the person with fibroids is experiencing and what she desires regarding her fertility.
Fibroids are often present with no obvious symptoms, or the symptoms can be so severe they feel as if they are ruining one's life. They can cause heavy menstrual flow and clots, and consequently severe anemia. They also can put pressure on surrounding organs like the bladder, causing a frequent urge to urinate. A fibroid can grow so big that it outgrows its own blood supply and cause severe pain as ischemia ( lack of oxygen) will do – similar to a heart attack.
With regards to pregnancy, fibroids can prevent an embryo from attaching and implanting in the wall of the uterus and also be a cause of recurrent miscarriages. As fibroids may grow during pregnancy, they can put a pregnancy at risk in its later stages by causing premature labor or even incompetence of the uterus.
Fibroids are classified by where they are attached to the uterus. From the inside out, they can be:
• Submucosal - under the endometrium or lining, often extending into the cavity (think of a boulder emerging from your lawn). Submucosal fibroids will cause increased bleeding, a failure to implant or even miscarriages.
• Intramural - in the wall of the uterus. These fibroids often cause no symptoms but can cause bleeding if close to the cavity/lining and can cause increased menstrual cramping. They also can become quite large and cause pressure or abdominal swelling. I have seen intramural fibroids compress the fallopian tube as it travels through the wall out to the ovary, possibly blocking transport of sperm and embryos.
• Subserosal - these are on the outside of the uterus and are also often without symptoms, but they can cause pressure on the bladder and abdominal swelling. Also if positioned near the side (i.e. the tubes and ovaries), they could interfere with the transport of the egg to the tube by pushing them apart.
• Pedunculated - (I know what you're thinking...Pe-what?) this means the fibroid is hanging on a stalk – think of a mushroom. These fibroids are different in that they are at risk for twisting around on their own stalk, cutting off the blood supply and possibly causing acute pain - what I call "a fibroid attack." These fibroids can get quite big and can also displace tubes and ovaries, causing infertility.
When you are attempting conception, and pregnancy is not happening easily, why not always start by removing fibroids? Fibroid removal is called "myomectomy." We think carefully before moving forward with myomectomy because the surgery can cause new problems, including scar tissue and new "plumbing issues," so we must be convinced the fibroids are an issue before moving forward to surgery.
So how should you manage fibroids? Part 2 of my blog post, coming Sept. 1, will outline what you and your doctor need to do to manage your fibroids and - if at all possible - preserve your fertility.
