Uterine Fibroids

The exact etiology (cause) of uterine fibroids remains a subject of intense research, but current evidence points to a combination of genetic, hormonal, and environmental factors. Research published in the journal Human Reproduction Update suggests that fibroids develop from a single stem cell in the myometrium. Growth is heavily influenced by the hormones estrogen and progesterone, which stimulate the development of the uterine lining during each menstrual cycle. Fibroids contain more estrogen and progesterone receptors than normal uterine muscle cells do.

Non-Modifiable Risk Factors

• Age: Risk increases as women age through their 30s and 40s until menopause.
• Race: Black women are significantly more likely to develop fibroids and experience severe symptoms.
• Family History: Having a first-degree relative (mother or sister) with fibroids triples the individual risk.
• Early Menarche: Starting menstruation before age 10 is associated with a higher risk.

Modifiable Risk Factors

• Diet: A diet high in red meat and low in green vegetables and fruit has been linked to increased risk.
• Obesity: Adipose (fat) tissue produces estrogen, which can promote fibroid growth.
• Vitamin D Deficiency: Studies have shown a correlation between low Vitamin D levels and increased fibroid prevalence.
• Alcohol Consumption: Some research suggests that beer consumption, in particular, may increase risk.

According to the American College of Obstetricians and Gynecologists (ACOG, 2021), Black women are diagnosed with fibroids at a rate three times higher than white women. They also tend to have larger fibroids at the time of diagnosis and are more likely to undergo surgery.

While there is no guaranteed way to prevent fibroids, maintaining a healthy body weight and consuming a balanced diet rich in fruits and vegetables may lower the risk. Regular pelvic exams are essential for early detection, which allows for more conservative management options.

The diagnostic journey usually begins when a patient reports heavy bleeding or pelvic pressure. Because many fibroids are asymptomatic, they are often discovered incidentally during a routine gynecological examination.

During a bimanual pelvic exam, a healthcare provider may feel an irregular, firm, or enlarged uterus, which suggests the presence of fibroids.

• Ultrasound: The primary imaging tool. It uses sound waves to create a picture of the uterus and can identify the size and location of most fibroids.
• Magnetic Resonance Imaging (MRI): Provides more detail regarding the number and exact position of fibroids, which is crucial for surgical planning.
• Hysterosonography (Saline Infusion Sonogram): Sterile saline is injected into the uterine cavity to expand it, allowing for better visualization of submucosal fibroids.
• Hysterosalpingography (HSG): Often used in infertility cases to check if fibroids are blocking the fallopian tubes.
• Hysteroscopy: A small, lighted telescope is inserted through the cervix to examine the inside of the uterus.
• Laboratory Tests: A Complete Blood Count (CBC) is typically ordered to check for anemia resulting from chronic blood loss.

Healthcare providers must rule out other conditions that cause similar symptoms, such as:

• Adenomyosis: Where the uterine lining grows into the muscular wall.
• Endometriosis: Tissue similar to the uterine lining growing outside the uterus.
• Uterine Polyps: Overgrowth of the endometrial lining.
• Uterine Sarcoma: A rare form of cancer that can mimic a benign fibroid.
• Pregnancy: Which also causes uterine enlargement.

The primary goals of treatment are to alleviate symptoms (such as pain and heavy bleeding), reduce the size of the fibroids, and preserve fertility if desired by the patient.

For asymptomatic or mildly symptomatic patients, 'watchful waiting' is often the initial approach. According to ACOG guidelines (2021), medical management is typically the first intervention for symptomatic fibroids before considering surgery.

• GnRH Antagonists: These oral medications block the gonadotropin-releasing hormone, leading to a rapid decrease in estrogen and progesterone. They are used to shrink fibroids and stop heavy bleeding. Side effects may include hot flashes and bone density loss if used long-term.
• Progestin-Releasing Intrauterine Devices (IUDs): These can significantly reduce heavy bleeding but do not shrink the fibroids themselves.
• Tranexamic Acid: A non-hormonal medication taken during the menstrual cycle to reduce blood loss by helping the blood to clot more effectively.
• NSAIDs (Nonsteroidal Anti-inflammatory Drugs): Used primarily for pain management and to slightly reduce menstrual flow.
• Oral Contraceptives (Birth Control Pills): Used to regulate the menstrual cycle and manage bleeding, though they do not reduce fibroid size.

If medications fail, minimally invasive procedures may be considered:

• Uterine Artery Embolization (UAE): Small particles are injected into the arteries supplying the uterus, cutting off blood flow to the fibroids and causing them to shrink.
• MRI-Guided Focused Ultrasound Surgery (FUS): Uses high-energy ultrasound waves to destroy fibroid tissue while the patient is inside an MRI scanner.

• Myomectomy: Surgical removal of the fibroids while leaving the uterus intact. This is the preferred surgical option for those wishing to maintain fertility.
• Hysterectomy: The complete removal of the uterus. This is the only permanent cure for fibroids but results in the inability to carry a pregnancy.
• Endometrial Ablation: A procedure to destroy the lining of the uterus to reduce heavy bleeding, though it is only suitable for small fibroids.

In pregnancy, fibroids may grow due to increased hormone levels, potentially increasing the risk of placental abruption or preterm birth. Treatment during pregnancy is usually limited to pain management.

> Important: Talk to your healthcare provider about which approach is right for you.

While no diet can cure fibroids, some evidence suggests that nutritional choices impact hormone balance. A study published in the American Journal of Clinical Nutrition found that women with a high intake of fruits (especially citrus) and vegetables had a lower risk of developing fibroids. Reducing intake of high-glycemic-index foods and processed meats may help stabilize insulin levels, which can influence fibroid growth.

Regular physical activity is associated with a reduced risk of fibroids, likely because exercise helps maintain a healthy weight and reduces circulating estrogen. Aim for at least 150 minutes of moderate-intensity aerobic activity per week, as recommended by the CDC.

Chronic pain and anemia-related fatigue can disrupt sleep. Maintaining a consistent sleep schedule and using a heating pad for pelvic cramps can improve rest quality. For those with heavy nighttime bleeding, using high-absorbency menstrual products can reduce sleep interruptions.

Chronic stress may exacerbate hormonal imbalances. Evidence-based techniques such as mindfulness-based stress reduction (MBSR), progressive muscle relaxation, and yoga have been shown to help patients manage the emotional burden of chronic pelvic pain.

Some patients find relief through acupuncture or green tea extract (EGCG). A small clinical trial suggested that green tea extract might help reduce fibroid volume and improve symptom severity, though more large-scale research is needed before this can be widely recommended.

Caregivers should be aware of the significant fatigue associated with anemia. Providing emotional support and assisting with daily tasks during heavy menstrual days can greatly improve the patient's well-being.

The prognosis for uterine fibroids is generally excellent, as they are noncancerous. Most patients find significant symptom relief through medical or surgical intervention. According to the Society of Interventional Radiology, approximately 85-90% of women who undergo Uterine Artery Embolization experience significant or total relief from heavy bleeding and pain.

• Severe Anemia: Chronic heavy blood loss can lead to iron deficiency, requiring iron supplements or blood transfusions.
• Pregnancy Complications: Fibroids can increase the risk of breech birth, fetal growth restriction, and the need for a C-section.
• Infertility: Submucosal fibroids can prevent implantation or block fallopian tubes.
• Torsion: A twisted pedunculated fibroid can cause localized tissue death and infection.

Management is often a long-term process until menopause. Regular pelvic ultrasounds may be recommended to monitor the growth rate of known fibroids. For those who have had a myomectomy, new fibroids can develop over time, necessitating ongoing monitoring.

Patients are encouraged to track their menstrual cycles and symptom severity using mobile apps or journals. Joining support groups can help mitigate the feelings of isolation often associated with reproductive health issues.

Contact your healthcare provider if you notice a change in your bleeding patterns, if pelvic pain becomes constant, or if you are having difficulty becoming pregnant. Adjustments to treatment are often necessary as fibroids change in size or as a patient's reproductive goals evolve.