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  Q: I have a fibroid uterus approximately the size of a 16 wk pregnancy. This appears to be caused by many small fibroids, the largest of which is 4 cm. I have no symptoms, but am concerned that if they grow larger I may lose the opportunity to have them treated by Embolization. What should I do? 

A: This is an extremely practical question for those who would like to avoid hysterectomy, and are trying to make a sound decision based upon what MAY happen in the future. However, the reality is that it is very difficult to predict WHAT and WHEN with total accuracy.

It is my hope that the following discussion might help you understand the problems in making these predictions.

  • Generally speaking, if a uterine fibroid condition is without symptoms - it is usually unnecessary to treat it by any method: UAE, myomectomy, hysterectomy or any other. The old saying
    "If it's not broke, don't fix it!" still holds.

But let's consider the "gray area" the questioner posed:

  • Given fibroids which do not now have symptoms - when might symptoms start, and is there anyway to predict this before size makes embolization a less effective option?

Some Facts to Consider

First: The issue of "size".

It is generally felt that a uterine size equivalent to that of a 5 month pregnancy (top of uterus is at level of the navel) responds less well to embolization than one that is smaller. What is not known is whether this is equally true if this size is caused by

      (1) One or two really large fibroids each greater than 10 cm in diameter, or by

      (2) Multiple small fibroids, each less than 10 cm in diameter.

In our experience, multiple fibroids - if less than 10 cm in diameter - seem to respond better than multiple fibroids over 10 cm. The question arises: Is there a larger "Window of Opportunity" for multiple small fibroids versus several large ones - each creating the same size of uterine enlargement?

We suspect there is, but at this time there are no studies to confirm the impression.

Second: The significance of "fibroid growth."

Fibroid growth rates can be erratic. However, what is clear is that:

  • Estrogen plays a part in the process. For example, with the drop (or stop) of estrogen in the menopause, fibroids tend to decrease in size. Or when a temporary Artificial Menopause is induced by the drug LUPRON, the same thing happens.
  • Yet, many women in the menopause, on estrogen replacement, do not necessarily experience growth of their fibroids. Thus there are exceptions to the rule of "estrogen grows fibroids".
  • Finally, many women with normal estrogen levels who are still menstruating can have an increase in fibroids at one time - only to find that the growth stops later on. Steady progressive growth of fibroids is not always observed.

The reason for this variation in growth from estrogen stimulation is not clear. One could speculate there may be an upper limit to fibroid size based on the quantity of its original blood supply. Hence growth beyond this point might require:

  • some sort of increase in the original blood supply, or
  • an extensive collateral blood supply (in other words - extra blood vessels which grow in through the outer surface of the fibroid to supplement its original supply. Such a thing - if it happens at all - might take many years to happen.)

But regardless of reason why fibroids grow or stop growing - there is a practical problem: the rate of growth in a fibroid is hard to predict.

Having said all this, we are left with the fact that although they are imperfect markers, still the only tools we have to predict "when things might get worse" are fibroid symptoms, and fibroid size.

Thus, until something better comes along, it remains for you and your gynecologist to carefully track both entities for significant change. Decisions to intervene or not to intervene must still be based on whether both markers remain stable, or are changing.

  • Symptoms: Be very conscious of any increase in symptoms of decreasing bladder capacity, constipation, pressure in the low abdomen, pain on sexual relations, increasing menstrual flow to the point of excessive blood loss, or others.

    Remember, however, that all of these changes are really rather non-specific and can occur from many different causes (well beyond fibroids alone). You need your gynecologist's opinion to be certain they are really fibroid related, and not caused by something else with a totally different method of treatment.
  • Fibroid Size: Some objective measurement of fibroid size should be used that can compare size changes from year to year.

    A rough estimation uses the number of "finger breadths" the uterus is above the pubic bone, or is below the navel.

    Your gynecologist can often give you a more accurate estimate by measuring fibroid dimensions with Ultra-sound.

    Probably the best technique to use is MRI - but the reality is that the technology is very expensive and may not be covered by insurance for this indication.

To try to answer the initial question, a simple model is proposed:

  • If nothing changes - the "Window of Opportunity" is probably not going to be compromised.
  • If size or symptoms continue to increase as documented by your gynecologist, and there are no other reasons why this is happening - then you are on notice that there is a strong possibility the fibroids will continue to grow and cause symptoms.

Once the second model is detected, your gynecologist may recommend some sort of solution for your fibroid problem. At this point, Uterine Embolization is one of the possible methods of treatment.

C Forcade, MD
09/12/98

 

© 1998 Carlos Forcade, MD
(888) 666-2002