MYOMA A benign growth of smooth muscle in the wall of the uterus Description of myoma: A Myoma is a solid tumor made

of fibrous tissue, hence it is often called a 'fibroid' tumor. Myomas vary in size and number, are most often slow-growing and usually cause no symptoms. Myomas that do not produce symptoms do not need to be treated. Approximately 25% of myomas will cause symptoms and need medical treatment. Myomas may grow as a single nodule or in clusters and may range in size from 1 mm to more than 20 cm in diameter. Myomas are the most frequently diagnosed tumor of the female pelvis and the most common reason for a woman to have a hysterectomy. Although they are often referred to as tumors, they are not cancerous. The cause of myomas has not actually been determined, but most myomas develop in women during their reproductive years. Myomas do not develop before the body begins producing estrogen. Myomas tend to grow very quickly during pregnancy when the body is producing extra estrogen. Once menopause has begun, myomas generally stop growing and can begin to shrink due to the loss of estrogen.
Uterine fibroids (also referred to as myoma, leiomyoma, leiomyomata, and fibromyoma) are benign (non-cancerous) tumors that grow within the muscle tissue of the uterus. Between 2050% of women of childbearing age have uterine fibroids. While many women do not experience any problems, symptoms can be severe enough to require treatment.

Fibroids range in size from very small (coin sized) to larger than a melon. A very large uterine fibroid can cause the uterus to expand to the size of a six or seven-month pregnancy. There can either be one dominant fibroid or a cluster of many small fibroids. Causes of Uterine Fibroid or Myoma

No one knows what exactly causes fibroids but their growth appears to depend on increases estrogen hormone levels. Because of this fibroids enlarge during estrogen (hormonal) replacement therapy and pregnancy. Also oral contraceptives are know to cause fibroids.

Symptoms of Uterine Fibroids or Myomas

Patients of fibroid or myoma may not have any symptoms and doctor discovering the uterine fibroids on physical examination or ultrasonography. Excessive, heavy, irregular or prolonged bleeding. Uterine heaviness. Pain in lower abdomen in general. Painful sexual intercourse. Bloating. Infertility. Abdominal lump. Urinary frequency. Bowel pressure with constant urging for stool.

Complications of Uterine Fibroids or Myomas

Anemia due to excessive heavy bleeding. Interference with growth of fetus during pregnancy. Could cause problem during delivery. Severe bleeding or infection.

What are Uterine Fibroids or Myomas? Uterine fibroid or myoma is a non-cancerous i.e. benign growth in the uterus. They are also called fibromyoma, myofibroma and fibroleiomyoma. Fibroids vary in size, usually grow slowly, and may occur in the wall of the uterus or inside the cavity, in the cervix (the part below the uterus) or at times even on the outer side of uterus. They are usually made up of muscular or fibrous tissue of the uterus and blood vessels. Uterine fibroids or myomas are extremely common occuring in 20 to 25% of women by age of 40 and 50% of women in general and are the most common cause of major surgery in women. They usually develop in women between 30 and 50 years of age

Treatment

If fibroids become symptomatic enough, they can be removed surgically. The most common surgical approach is to perform an abdominal myomectomy. An incision is made in the lower abdomen into the abdominal cavity, and the fibroids are removed from the uterus and the uterus stitched closed. If the uterus is no longer necessary (the woman is finished having her family) and the woman desires her uterus removed, a hysterectomy (removal of the uterus) can be performed. (A hysterectomy is removal of the uterus and cervix, not removal of the ovaries. Therefore, a woman who has a hysterectomy does not necessarily go through menopause.) If a submucous fibroid is diagnosed, then the removal of the fibroid can be performed through the cervix. This is called a hysteroscopic myomectomy. Because the instrument goes through the cervix, there is no cutting. It is usually a same-day procedure, which means you come in on the day of the procedure and go home the same day, with a minimal recovery period. If you are very anemic or the fibroids are very large, you may be treated before surgery with a medication called Depot Lupron. This medication puts you into a temporary menopause, thus decreasing your estrogen levels and causing the fibroids to shrink. Unfortunately, this medication does not shrink the fibroids permanently, so it can not be used as a permanent solution. The DOs Keep your follow-up appointments so that your doctor can check your fibroids regularly. Take your iron supplement if one has been recommended. This will prevent anemia. It is also helpful to eat a diet rich in iron in addition to the iron supplement. If your period cramps are uncomfortable, overthe-counter ibuprofen can be very effective in relieving the cramps. Over-the-counter ibuprofen comes in 200milligram tablets. You can start with 2 tablets every 4 hours. However, if this does not relieve the cramps enough, you can take 3 tablets (600 milligrams) every 6 hours or 4 tablets (800 milligrams) every 8 hours. You should always take ibuprofen with some food on your stomach to avoid stomach irritation. (Obviously, you should not take ibuprofen if you have an allergy to it, have been told you should not take it or any aspirin-like products, or have a history of ulcer or gastritis.)

The DONTs If you take birth control pills, you and your doctor may want to consider another birth control method because the estrogen in the birth control pills sometimes stimulate the fibroids to grow more quickly.

What are fibroids?

Fibroids are muscular tumors that grow in the wall of the uterus (womb). Another medical term for fibroids is "leiomyoma" (leye-oh-meye-OH-muh) or just "myoma". Fibroids are almost always benign (not cancerous). Fibroids can grow as a single tumor, or there can be many of them in the uterus. They can be as small as an apple seed or as big as a grapefruit. In unusual cases they can become very large.

Why should women know about fibroids?

About 20 percent to 80 percent of women develop fibroids by the time they reach age 50. Fibroids are most common in women in their 40s and early 50s. Not all women with fibroids have symptoms. Women who do have symptoms often find fibroids hard to live with. Some have pain and heavy menstrual bleeding. Fibroids also can put pressure on the bladder, causing frequent urination, or the rectum, causing rectal pressure. Should the fibroids get very large, they can cause the abdomen (stomach area) to enlarge, making a woman look pregnant.

Who gets fibroids?

There are factors that can increase a woman's risk of developing fibroids.

Age. Fibroids become more common as women age, especially during the 30s and 40s through menopause. After menopause, fibroids usually shrink. Family history. Having a family member with fibroids increases your risk. If a woman's mother had fibroids, her risk of having them is about three times higher than average. Ethnic origin. African-American women are more likely to develop fibroids than white women. Obesity. Women who are overweight are at higher risk for fibroids. For very heavy women, the risk is two to three times greater than average. Eating habits. Eating a lot of red meat (e.g., beef) and ham is linked with a higher risk of fibroids. Eating plenty of green vegetables seems to protect women from developing fibroids.

Where can fibroids grow?

Most fibroids grow in the wall of the uterus. Doctors put them into three groups based on where they grow:

Submucosal (sub-myoo-KOH-zuhl) fibroids grow into the uterine cavity. Intramural (ihn-truh-MYOOR-uhl) fibroids grow within the wall of the uterus. Subserosal (sub-suh-ROH-zuhl) fibroids grow on the outside of the uterus.

Some fibroids grow on stalks that grow out from the surface of the uterus or into the cavity of the uterus. They might look like mushrooms. These are called pedunculated (pih-DUHN-kyoo-lay-ted) fibroids.

What are the symptoms of fibroids?

Most fibroids do not cause any symptoms, but some women with fibroids can have:

Heavy bleeding (which can be heavy enough to cause anemia) or painful periods Feeling of fullness in the pelvic area (lower stomach area) Enlargement of the lower abdomen Frequent urination Pain during sex Lower back pain Complications during pregnancy and labor, including a six-time greater risk of cesarean section Reproductive problems, such as infertility, which is very rare

What causes fibroids?

No one knows for sure what causes fibroids. Researchers think that more than one factor could play a role. These factors could be:

Hormonal (affected by estrogen and progesterone levels) Genetic (runs in families)

Because no one knows for sure what causes fibroids, we also don't know what causes them to grow or shrink. We do know that they are under hormonal control both estrogen and progesterone. They grow rapidly during pregnancy, when hormone levels are high. They shrink when anti-hormone medication is used. They also stop growing or shrink once a woman reaches menopause.

Can fibroids turn into cancer?

Fibroids are almost always benign (not cancerous). Rarely (less than one in 1,000) a cancerous fibroid will occur. This is called leiomyosarcoma (leye-oh-meye-oh-sarKOH-muh). Doctors think that these cancers do not arise from an already-existing fibroid. Having fibroids does not increase the risk of developing a cancerous fibroid. Having fibroids also does not increase a woman's chances of getting other forms of cancer in the uterus.

What if I become pregnant and have fibroids?

Women who have fibroids are more likely to have problems during pregnancy and delivery. This doesn't mean there will be problems. Most women with fibroids have normal pregnancies. The most common problems seen in women with fibroids are:

Cesarean section. The risk of needing a c-section is six times greater for women with fibroids. Baby is breech. The baby is not positioned well for vaginal delivery. Labor fails to progress. Placental abruption. The placenta breaks away from the wall of the uterus before delivery. When this happens, the fetus does not get enough oxygen. Preterm delivery.

Talk to your obstetrician if you have fibroids and become pregnant. All obstetricians have experience dealing with fibroids and pregnancy. Most women who have fibroids and become pregnant do not need to see an OB who deals with high-risk pregnancies.

How do I know for sure that I have fibroids?

Your doctor may find that you have fibroids when you see her or him for a regular pelvic exam to check your uterus, ovaries, and vagina. The doctor can feel the fibroid with her or his fingers during an ordinary pelvic exam, as a (usually painless) lump or mass on the uterus. Often, a doctor will describe how small or how large the fibroids are by comparing their size to the size your uterus would be if you were pregnant. For example, you may be told that your fibroids have made your uterus the size it would be if you were 16 weeks pregnant. Or the fibroid might be compared to fruits, nuts, or a ball, such as a grape or an orange, an acorn or a walnut, or a golf ball or a volleyball. Your doctor can do imaging tests to confirm that you have fibroids. These are tests that create a "picture" of the inside of your body without surgery. These tests might include:

Ultrasound Uses sound waves to produce the picture. The ultrasound probe can be placed on the abdomen or it can be placed inside the vagina to make the picture. Magnetic resonance imaging (MRI) Uses magnets and radio waves to produce the picture X-rays Uses a form of radiation to see into the body and produce the picture Cat scan (CT) Takes many X-ray pictures of the body from different angles for a more complete image Hysterosalpingogram (hiss-tur-oh-sal-PIN-juh-gram) (HSG) or sonohysterogram (soh-noh-HISS-tur-oh-gram) An HSG involves injecting xray dye into the uterus and taking x-ray pictures. A sonohysterogram involves injecting water into the uterus and making ultrasound pictures.

You might also need surgery to know for sure if you have fibroids. There are two types of surgery to do this:

Laparoscopy (lap-ar-OSS-koh-pee) The doctor inserts a long, thin scope into a tiny incision made in or near the navel. The scope has a bright light and a camera. This allows the doctor to view the uterus and other organs on a monitor during the procedure. Pictures also can be made. Hysteroscopy (hiss-tur-OSS-koh-pee) The doctor passes a long, thin scope with a light through the vagina and cervix into the uterus. No incision is needed. The doctor can look inside the uterus for fibroids and other problems, such as polyps. A camera also can be used with the scope.

What questions should I ask my doctor if I have fibroids?

How many fibroids do I have? What size is my fibroid(s)? Where is my fibroid(s) located (outer surface, inner surface, or in the wall of the uterus)? Can I expect the fibroid(s) to grow larger? How rapidly have they grown (if they were known about already)? How will I know if the fibroid(s) is growing larger? What problems can the fibroid(s) cause? What tests or imaging studies are best for keeping track of the growth of my fibroids? What are my treatment options if my fibroid(s) becomes a problem? What are your views on treating fibroids with a hysterectomy versus other types of treatments?

A second opinion is always a good idea if your doctor has not answered your questions completely or does not seem to be meeting your needs.

How are fibroids treated?

Most women with fibroids do not have any symptoms. For women who do have symptoms, there are treatments that can help. Talk with your doctor about the best way to treat your fibroids. She or he will consider many things before helping you choose a treatment. Some of these things include:

Whether or not you are having symptoms from the fibroids If you might want to become pregnant in the future The size of the fibroids The location of the fibroids Your age and how close to menopause you might be

If you have fibroids but do not have any symptoms, you may not need treatment. Your doctor will check during your regular exams to see if they have grown. Medications If you have fibroids and have mild symptoms, your doctor may suggest taking medication. Over-the-counter drugs such as ibuprofen or acetaminophen can be used for mild pain. If you have heavy bleeding during your period, taking an iron supplement can keep you from getting anemia or correct it if you already are anemic. Several drugs commonly used for birth control can be prescribed to help control symptoms of fibroids. Low-dose birth control pills do not make fibroids grow and can help control heavy bleeding. The same is true of progesterone-like injections (e.g., DepoProvera). An IUD (intrauterine device) called Mirena contains a small amount of

progesterone-like medication, which can be used to control heavy bleeding as well as for birth control. Other drugs used to treat fibroids are "gonadotropin releasing hormone agonists" (GnRHa). The one most commonly used is Lupron. These drugs, given by injection, nasal spray, or implanted, can shrink your fibroids. Sometimes they are used before surgery to make fibroids easier to remove. Side effects of GnRHas can include hot flashes, depression, not being able to sleep, decreased sex drive, and joint pain. Most women tolerate GnRHas quite well. Most women do not get a period when taking GnRHas. This can be a big relief to women who have heavy bleeding. It also allows women with anemia to recover to a normal blood count. GnRHas can cause bone thinning, so their use is generally limited to six months or less. These drugs also are very expensive, and some insurance companies will cover only some or none of the cost. GnRHas offer temporary relief from the symptoms of fibroids; once you stop taking the drugs, the fibroids often grow back quickly. Surgery If you have fibroids with moderate or severe symptoms, surgery may be the best way to treat them. Here are the options:

Myomectomy (meye-oh-MEK-tuh-mee) Surgery to remove fibroids without taking out the healthy tissue of the uterus. It is best for women who wish to have children after treatment for their fibroids or who wish to keep their uterus for other reasons. You can become pregnant after myomectomy. But if your fibroids were imbedded deeply in the uterus, you might need a cesarean section to deliver. Myomectomy can be performed in many ways. It can be major surgery (involving cutting into the abdomen) or performed with laparoscopy or hysteroscopy. The type of surgery that can be done depends on the type, size, and location of the fibroids. After myomectomy new fibroids can grow and cause trouble later. All of the possible risks of surgery are true for myomectomy. The risks depend on how extensive the surgery is. Hysterectomy (hiss-tur-EK-tuh-mee) Surgery to remove the uterus. This surgery is the only sure way to cure uterine fibroids. Fibroids are the most common reason that hysterectomy is performed. This surgery is used when a woman's fibroids are large, if she has heavy bleeding, is either near or past menopause, or does not want children. If the fibroids are large, a woman may need a hysterectomy that involves cutting into the abdomen to remove the uterus. If the fibroids are smaller, the doctor may be able to reach the uterus through the vagina, instead of making a cut in the abdomen. In some cases hysterectomy can be performed through the laparoscope. Removal of the ovaries and the cervix at the time of hysterectomy is usually optional. Women whose ovaries are not removed do not go into menopause at the time of hysterectomy. Hysterectomy is a major surgery. Although hysterectomy is usually quite safe, it does carry a significant risk of complications. Recovery from hysterectomy usually takes several weeks.

Endometrial Ablation (en-doh-MEE-tree-uhl uh-BLAY-shuhn) The lining of the uterus is removed or destroyed to control very heavy bleeding. This can be done with laser, wire loops, boiling water, electric current, microwaves, freezing, and other methods. This procedure usually is considered minor surgery. It can be done on an outpatient basis or even in a doctor's office. Complications can occur, but are uncommon with most of the methods. Most people recover quickly. About half of women who have this procedure have no more menstrual bleeding. About three in 10 women have much lighter bleeding. But, a woman cannot have children after this surgery. Myolysis (meye-OL-uh-siss) A needle is inserted into the fibroids, usually guided by laparoscopy, and electric current or freezing is used to destroy the fibroids. Uterine Fibroid Embolization (UFE), or Uterine Artery Embolization (UAE) A thin tube is thread into the blood vessels that supply blood to the fibroid. Then, tiny plastic or gel particles are injected into the blood vessels. This blocks the blood supply to the fibroid, causing it to shrink. UFE can be an outpatient or inpatient procedure. Complications, including early menopause, are uncommon but can occur. Studies suggest fibroids are not likely to grow back after UFE, but more long-term research is needed. Not all fibroids can be treated with UFE. The best candidates for UFE are women who: o Have fibroids that are causing heavy bleeding o Have fibroids that are causing pain or pressing on the bladder or rectum o Don't want to have a hysterectomy o Don't want to have children in the future

Are other treatments being developed for uterine fibroids?

Yes. Researchers are looking into other ways to treat uterine fibroids. The following methods are not yet standard treatments; so your doctor may not offer them or health insurance may not cover them.

MRI-guided ultrasound surgery shrinks fibroids using a high-intensity ultrasound beam. The MRI scanner helps the doctor locate the fibroid, and the ultrasound sends out very hot sound waves to destroy the fibroid. The ExAblate 2000 System is a medical device that uses this method to destroy uterine fibroids. Some health care providers use lasers to remove a fibroid or to cut off the blood supply to the fibroid, making it shrink. Mifepristone, and other anti-hormonal drugs being developed, could provide symptom relief without bone-thinning side effects. These are promising treatments, but none are yet available or FDA approved. Other medications are being studied for treatment of fibroids.

Uterine leiomyomas, or fibroids, are benign tumors of the uterus composed of smooth muscle and connective tissue. Fibroids are very common, present in at least onequarter of women by the age of 40. Fibroids are classified by anatomic location as intramural (within the myometrium), submucosal (underlying the endometrium), or subserosal (underlying the uterine serosa). There is no identifiable cause of uterine fibroids. However, estrogen is necessary for their growth, as many grow during pregnancy and then recede at menopause. Further, higher parity and oral contraceptive use have been shown to decrease the risk of fibroid formation. Most uterine fibroid cases are asymptomatic. However, symptoms may include uterine bleeding, resulting in prolonged or heavy menstrual flow and possibly anemia; dysmenorrhea; urinary frequency and urgency; constipation, dyspareunia; and abdominal tenderness. Complications of pregnancy are more common in women with fibroids, including miscarriage, placental abruption, and premature labor. Risk Factors African American women are up to 3 times more likely to have fibroids compared with white women, and often have more severe disease at a younger age.1 Age. Fibroids occur during the reproductive years, most commonly becoming clinically apparent during the fourth and fifth decades of life. They do not occur in prepubescent girls and usually shrink at menopause. Genetics. Monozygotic twins have a 2 to 3 times greater risk of fibroids than dizygotic twins when one twin is affected.2 Pregnancy. Parity appears to decrease the risk of fibroids. Oral contraceptive pills. Although these appear to be protective, the Nurses Health Study showed an increased risk in women who used oral contraceptive pills at ages 13 to 16. Lowdose oral contraceptives and menopausal hormone therapy are not contraindicated in women with fibroids. Some evidence suggests that cigarette smoking may decrease the risk of fibroids. Of course, the health risks of smoking far outweigh this potential benefit. Diagnosis Fibroids may be suspected from the patient history, and a bimanual pelvic exam often confirms the diagnosis. The uterus is generally enlarged, mobile, and asymmetric.

Extremely large fibroids may cause a palpable uterus on abdominal exam. Findings can be confirmed by imaging studies. Transvaginal ultrasound can be used to detect and localize fibroids. However, for women with large uteri or more than 4 fibroids, it is less precise than MRI.4 Sonohysterography can better characterize submucosal fibroids than transvaginal ultrasound. Pelvic MRI best localizes all types of fibroids, accurately assesses their size, and distinguishes fibroids from other growths (eg, adenomyomas, leiomyosarcomas). However, expense should be taken into consideration. Hysterosalpingography is best reserved for fertility evaluations. It defines the contour of the endometrium and patency of the fallopian tubes. Hysteroscopy provides direct visualization inside the uterus and can diagnose submucosal fibroids. Treatment Most uterine fibroids are asymptomatic and need not be treated. Intervention depends upon a number of factors, including age (women approaching menopause may not require therapy as fibroids typically regress spontaneously), fertility concerns, and the location and size of the fibroids. Surgery Surgical interventions are generally the most effective therapy for fibroids. Myomectomy, via hysteroscopy, laparoscopy, or laparotomy, preserves childbearing potential but is at least as difficult for the surgeon and patient as hysterectomy. Hysteroscopy is best for submucosal fibroids. Laparotomy may be indicated for large or multiple fibroids. Hysterectomy is a definitive treatment that offers clear symptomatic improvement in approximately 90% of fibroid patients who undergo it. The primary indication for hysterectomy is uncontrollable bleeding. Other options for women who do not desire pregnancy include endometrial ablation via hysteroscopic myomectomy, cryotherapy, uterine artery embolization, or magnetic resonanceguided ultrasonic ablation. Pharmacologic Interventions

Oral contraceptives or progestins (norethindrone acetate, levonorgestrelcontaining intrauterine device) are the simplest treatments for abnormal bleeding associated with fibroids. These treatments can be continued until menopause in women who are not interested in pregnancy. Gonadotropinreleasing hormone (GnRH) analogs (eg, leuprolide) can shrink fibroids prior to surgical removal. Symptoms will sometimes return with discontinuation of the therapy. GnRH analogs are generally not recommended for longterm medical management due to cost. GnRH antagonists, mifepristone, asoprisnil, and androgens are under investigation for future use in treating fibroids. Acute pain can be treated with nonsteroidal antiinflammatory drugs (NSAIDs). COX2 inhibitors appear to benefit postmenopausal women,5 but further trials are needed to establish their effect for premenopausal women. However, potential cardiac and other risks of COX2 inhibitors must be considered. Nutritional Considerations Evidence for a direct effect of diet on fibroid risk or progression is very limited. However, the production of certain growth factors (insulinlike growth factor I, epidermal growth factor) is a risk factor for fibroid growth,6 and evidence indicates that these may be the effectors of estrogen and progesteronemediated fibroid growth.7 Diets low in fat and high in fiber (eg, vegetarian diets) have the ability to modulate blood hormone concentration and activity8 and reduce levels of growth factors.9 These effects may underlie the results of studies that have found higher risk for fibroids in women who eat red meat more often than do others, and who are overweight, as described below. However, this does not necessarily mean that a diet change, even if effective, will alleviate symptoms rapidly enough to obviate the need for other treatments. Epidemiologic studies indicate that the following factors are associated with increased risk of fibroids: Red meat consumption. Available evidence suggests that women who eat more than one serving per day of red meat have a 70% greater risk for uterine myoma, compared with women who eat the least. Women who eat more than one serving per day of green vegetables have a 50% lower risk.10 However, this study should be repeated by other independent investigators before diet is assumed to be effective for preventing or treating fibroids. Weight gain. A greater number of women with fibroids are obese, compared with the general population.11 In the Black Womens Health Study, the relationship between fibroids and obesity appeared to be Jshaped. Compared with the thinnest women (body mass index [BMI] <20 kg/m2), risk appears to increase gradually in women with a

BMI of 20 to 22.4 (34% increased risk), to a maximum risk in women with a BMI of 27.5 to 29.9 (47% increased risk), before falling in the most obese group (20% increased risk).12 Alcohol. Alcohol appears to increase the risk for fibroids. This risk is positively correlated with the number of years of alcohol intake and specifically with beer consumption. Compared with women who abstained from alcohol, those who had one or more drinks of beer per day had more than a 50% increased risk for leiomyomata.13