Fibroid Tumors - A Threat to Pregnancy

I don't think I have ever seen a patient who does not freeze with fear the moment her doctor uses the word tumor. As frightening as it sounds, however, I am always pleased to tell my patients that the majority of gynecological tumors are simple, benign, noncancerous growths that cause few, if any, life-threatening complications. This is especially true of fibroid tumors, the growth most often associated with fertility problems.

Composed of a solid mass of fibrous and muscular tissue, fibroids generally grow in and around the uterus, and therein lies their link to fertility. Ranging in size from a tiny seedling no bigger than a pea to melon-sized growths, fibroids are found both individually and in clusters (one patient of mine had thirty-two growing at the same time). Primarily, they interfere with conception by causing blockages in the reproductive tract.

WHERE, WHY, AND HOW FIBROID TUMORS GROW

The composition of all fibroid tumors is basically the same, and they all begin growing within the half-inch wall that surrounds your uterus. Based on the direction in which they grow, they are categorized into three types:

• Intramural fibroid. The most common type of fibroid, these remain within the wall of the uterus and are usually asymptomatic.

• Subserous fibroid. Rooted in the outer portion of the uterine wall, they push outward into the abdominal cavity and can sometimes form a stem at their base (called a pediculated fibroid). If that stem should twist (a common occurrence), it can result in pelvic pain that can be extremely severe. These fibroids can also cause pressure on the bladder, with pain prior to urination.

• Submucous fibroid. Pushing inward, these fibroids sometimes grow so large that they burst through the uterine lining and inflate the entire uterus. During the menstrual cycle, uterine contractions often attempt to push them out. This can cause severe pain and exceptionally heavy bleeding. If these growths also develop a "stem," they can dangle down into the cervix and cause pain during intercourse as well.

WHERE DO FIBROIDS COME FROM?

Studies show that 20 percent of all women between the ages of twenty and thirty-five and up to 30 percent of women over the age of thirty are the most susceptible to fibroids. I have rarely seen them in patients younger than twenty-five. Most often they begin growing when a woman is in her late twenties and early thirties and then continue throughout the childbearing years.

Because, as studies show, it is often high levels of estrogen that spark the growth of fibroid tumors, they can grow especially fast during pregnancy or if a woman is very overweight. For this same reason, I have often seen them diminish and even disappear once a woman finishes menopause and estrogen levels drop dramatically. I have rarely seen a woman develop fibroids after menopause has been completed.

In addition to estrogen, these other factors can also make you more susceptible to fibroids:

• Heredity. There is strong evidence that fibroid tumors may run in families. If your mother or a close female relative had these growths, you may be at higher risk.

• Predisposition. Some women may be born with the fibroid seedlings already implanted. When they reach adulthood, some biochemical event sparks an excess of estrogen, which in turn exacerbates fibroid growth. This is why small tumors often grow like wildfire during pregnancy, when estrogen levels are constant and high.

HOW FIBROIDS AFFECT YOUR FERTILITY

Although I have seen a few patients who were not able to conceive due to excessively large intramural fibroids, the submucous tumors seem to cause the most fertility-related problems by far. When left to grow large enough, submucous fibroids can cause problems by:

• Interfering with the development of your endometrium, causing implantation problems and increasing your risk of miscarriage.

• Blocking your fallopian tube, keeping your fertilized egg from being transported to your uterus. When this happens, the embryo can sometimes start to grow inside your tube, resulting in an ectopic (out-of-womb) pregnancy. This is always fatal for your baby and potentially life threating for you.

• Altering the position of your cervix and by so doing keep your partner's sperm from passing into your uterus. This can prevent fertilization from taking place.

• Distorting the shape of your uterus, making implantation impossible or difficult; if conception occurs, this can increase your risk of miscarriage.

In addition, because the high levels of estrogen associated with pregnancy can make even the tiniest fibroid seedlings grow extremely large, if you do conceive when fibroids are present, studies indicate you may be at a somewhat higher risk for premature labor and/or miscarriage.

HOW YOU CAN PROTECT YOUR FERTILITY

The best way to protect your fertility against the damage of fibroid tumors is early diagnosis and treatment — if possible, long before you plan to conceive. By removing fibroids prior to conception, you can be sure that your uterus is clear for a healthy implantation.

I have found that one of the simplest treatments for fibroids is medication that decreases estrogen levels and creates a kind of temporary menopause. This can encourage tumors to shrink and disintegrate, much the way they often do when you undergo menopause naturally. These medications include danozol and leuprolide acetate (the same drugs used to treat endometriosis) and a promising new drug called simply LHRH, a synthetic version of several natural hormones that suppress estrogen levels by decreasing the activity of the pituitary gland. For most of my patients these medications have posed no significant side effects or problems. However, in a few patients I have observed certain drawbacks, primarily the onset of symptoms typical of menopause, such as hot flashes and a dry vagina, as well as temporary infertility. In addition, in some patients, fibroids resume growing as soon as the drugs are withdrawn.

Because danazol can increase cholesterol levels, I believe it should not be used for more than six consecutive months, and blood cholesterol levels should be checked every few weeks during the time it is used.

THE FIBROID SURGERY THAT PRESERVES YOUR FERTILITY

Another option for treating fibroids is a myomectomy, a special type of surgery that removes only the tumors, leaving the rest of your reproductive organs intact. This is important to note, since many doctors still insist that a hysterectomy is the surgical treatment of choice for fibroid tumors. If your doctor does suggest a hysterectomy for fibroids, I urge you to resist. This procedure will completely destroy your fertility, and every day evidence continues to mount that a hysterectomy for fibroid tumors is unnecessary for the majority of women in their reproductive years.

Conversely, a myomectomy, which removes your fibroids but leaves all your other reproductive organs intact, restores your fertility and will help you avoid the other catastrophic physical and emotional complications that directly follow a hysterectomy and can continue for life. You should consider a myomectomy if your fibroid tumors are causing you extreme pain or excessive bleeding or are clearly blocking your ability to conceive.

CAN FIBROIDS DISAPPEAR ON THEIR OWN?

Sometimes — most often as a result of spontaneous changes in biochemistry For this reason I sometimes prefer a wait-and-see attitude, so long as the fibroids are not interfering with conception. If your doctor offers you this alternative, be certain not to use birth control pills during this time. The estrogen they contain can spark the growth of your tumors or at least discourage their disintegration.