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Uterine fibroids, one of the most common noncancerous gynecological conditions occurring in reproductive-age women, are estimated to affect more than 1 out of 5 women under 50 and account for 3 out of every 10 hysterectomies performed annually in the United States. A fibroid, or myoma, is a noncancerous mass of muscle and connective tissue in the uterus (womb). No one knows what causes fibroids, but scientists believe the female sex hormone estrogen may stimulate their growth.

Every year, about 175,000 American women-most of them 35 to 55-undergo hysterectomy, or surgical removal of the uterus, as treatment for fibroids. According to American College of Obstetricians and Gynecologists guidelines, a fibroid that makes a woman's uterus bigger than it would be at 12 weeks of pregnancy, even if the woman were suffering no other symptoms, is an indication for a hysterectomy.

However, the practice of routinely recommending hysterectomy for fibroids has come under increasing scrutiny from both consumer organizations and doctors concerned about the high rate of hysterectomy in the United States. By age 60, more than a third of American women have had a hysterectomy, a rate higher than in any other Western country. Blue Cross/Blue Shield of Illinois, in a study of all the hysterectomies performed in the state between 1987 and 1989, concluded that one-third were unnecessary. Most of the unnecessary surgeries, the insurer found, were performed for fibroids and other benign (noncancerous) conditions.

Fibroid Types

Fibroids are classified by their position in the uterus. Intramural fibroids, the most common type, grow inside the uterine wall. Subserous or subserosal fibroids grow outward from the uterine wall into the abdominal cavity. Submucous fibroids grow inward from the uterine wall, taking up space within the uterus itself This type of fibroid is the most likely to cause symptoms of heavy, prolonged menstrual bleeding. A fibroid can be as big as 20 centimeters (nearly 8 inches) in diameter and can weigh more than 20 pounds.
Small fibroids usually cause few if any symptoms. But, as a fibroid grows larger, it may press on the bladder and the ureters, the pair of tubes that connect the bladder to the kidneys. Pressure on the bladder can cause urinary frequency; pressure on the ureters can lead to kidney and urinary tract infections. Fibroids can sometimes be a cause of miscarriages and infertility.

A woman with a moderate-to-large fibroid may also notice a protruding stomach and a sensation of heaviness in the abdomen. For many women, the most distressing symptom is prolonged, heavy bleeding at the time of their menstrual periods, as well as spotty vaginal bleeding outside of the normal menstrual cycle. Women who lose too much blood may become anemic. Fibroids tend to grow in spurts, with periods of rapid growth punctuated by periods of no or very slow growth. As a woman approaches menopause, a fibroid may begin to grow rapidly. After menopause, however, fibroids stop growing and may start to shrink.

Options Increase

New medications and less-invasive surgeries have made more treatment options available to women whose fibroids cause them problems. A number of doctors interviewed for this article say the most important consideration in treating a fibroid should be how the patient feels about her condition and what level of intervention she is comfortable with.
The physician should look objectively at the patient's symptoms, inform her of the treatment choices, and give her the autonomy to decide what she wants to do.
There are probably hundreds of thousands of women who have fibroids on their uteruses that don't need to have anything done to them. At the other end of the spectrum, if a woman who has completed her family has a large fibroid that is causing distressing symptoms-like painful cramps, heavy menstrual bleeding, and anemia-she would be a candidate for hysterectomy."

Ovarian cancer might go undetected because the presence of a fibroid makes it difficult for the doctor to feel the ovaries during a pelvic examination. A rapidly growing fibroid may signal uterine cancer. A growing fibroid may produce more debilitating symptoms and add to the risks of surgery later on. The development of ultrasound (the use of high-frequency sound waves to produce an image of a part of the body) makes it possible to look at a woman's ovaries even when a fibroid prevents a manual examination. In any case, ovarian cancer is rare before age 50, and most hysterectomies for fibroids are done on women ages 35 to 44.
Ultrasound and magnetic resonance imaging can be used to screen for uterine cancer, also rare in women under 50.
Studies of hysterectomies done because of fibroids have not shown that removing a larger uterus poses a greater risk of surgical complications.

The development of endoscopes, lasers, and electrosurgical devices has led to new, less-invasive surgical techniques to remove fibroids. An endoscope is a thin fiber optic tube that surgeons insert into the body. It can transmit an image to a television-like screen. A laser is a device that uses a thin, intense light beam to “cut” or vaporize tissue, while electrosurgery or electorcautery devices use electricity to destroy tissue by applying heat.