Uterine Growths

Illustration of the female reproductive system

Uterine growths are tissue enlargements of the female womb (uterus). Uterine growth can be caused by either harmless or dangerous conditions. Growths are sometimes referred to medically as masses or tumors. An example of a harmless (benign or non-cancerous) growth, which does not pose a threat, is a polyp of the cervix. Some growths, such as uterine fibroids, are benign, but they can still cause some annoying problems, such as bleeding. Dangerous growths of the uterus include cancerous (malignant) tumors.

While the majority of uterine growths are benign, cancers of the uterus do occur. This article will discuss the benign conditions that cause uterine growths or masses. Benign growths, or non-cancerous, growths include uterine fibroids, adenomyosis, and uterine polyps.

Anatomy

The uterus (or womb) is a hollow, pear-shaped organ that is located in a woman's pelvis between the bladder and the rectum. The narrow, lower portion of the uterus is the cervix; the broader, upper part is known as the corpus. The cervix forms the transition between the uterus and the vagina. The vagina, or birth canal, connects the uterus to the outside of the body.

What are uterine fibroids? 

Uterine fibroids are benign masses that grow in the uterus for unclear reasons. Uterine fibroids are commonly called by the shorter name, "fibroids." The medical term for a fibroid is leiomyoma, which refers to the proliferation of abnormal growth of smooth muscle tissue. Uterine fibroids arise from the tissue in the muscle layer of the wall of the uterus, called the myometrium. They are not usually cancerous.

The reason why some women develop fibroids is not yet understood. Family history may play a role since there is often a history of fibroids developing in women of the same family. For poorly understood reasons, fibroids are more common in African American women (who have a two- to threefold increased risk) than in white Americans or Asian women. Fibroids are most common between the ages of 35 to 49. In addition, women who are overweight have an increased risk of fibroids. Most women with fibroids probably go through life not even knowing they have them because fibroids are often found incidentally during diagnostic or therapeutic procedures.

Most women with uterine fibroids have no symptoms. However, fibroids can cause several symptoms depending on their size, location within the uterus, and how close they are to adjacent pelvic organs. Large fibroids can cause:

• Bleeding
• Pressure
• Pelvic pain
• Pressure on the bladder with frequent or even obstructed urination
• Pain during intercourse
• Reproductive difficulties such as infertility, miscarriage, or premature labor
• Pressure on the rectum with pain during defecation

Abnormal uterine bleeding is the most common symptom of a fibroid. If the tumors are near the uterine lining or interfere with the blood flow to the lining, they can cause heavy periods, painful periods, prolonged periods, or spotting between menses. Uterine fibroids that are deteriorating can sometimes cause severe, localized pain.

Picture of Uterine Fibroids

If uterine fibroids are benign, why are they the reason for so many hysterectomies (surgeries performed to remove the uterus)?

The main answer is that uterine fibroids can cause bleeding. This bleeding can sometimes be significant and lead to anemia. Fibroids can also lead to complications as discussed in the next section. Fortunately, there are also many nonsurgical means available to treat fibroids.

Fibroids are diagnosed by performing a manual pelvic examination (bimanual examination) and confirmed by ultrasound. Ultrasound is harmless and does not involve radiation exposure. This test is similar to the one performed on pregnant women to view the developing fetus inside the uterus. Rarely, more complex imaging is used, but only in cases wherein the doctor cannot determine the exact nature of the mass found on the physical exam or ultrasound.

Reasons for surgical removal of uterine fibroids

Some of the reasons for surgical removal of uterine fibroids include:

1. If there is still concern that the uterine growth could be cancer: In these cases, the doctor is not certain that the growth is a benign fibroid. Unusually rapid growth is a sign that uterine growth may be cancerous. The growth must be removed and examined by a pathologist for signs of more dangerous conditions.
2. If another pelvic surgery is already being done: There are other reasons for pelvic surgery, such as ovarian disease.
3. If all medical treatments have failed to stop bleeding or other complications.

Surgery for uterine fibroids 

There are three major categories of surgery for fibroids.

1. Hysterectomy: Removal of the uterus is called a hysterectomy. Fibroids are the most common reason that hysterectomies are performed in the United States. Advantages are that: (1) the fibroids never return (the only "cure" for fibroids); (2) the woman will never have another menstrual period (which some, but not all women, find to be an advantage); and (3) contraception is no longer a concern. It is easy to understand, therefore, that the best candidates for hysterectomy have already finished their childbearing.
2. Myomectomy (Local Resection): This surgery involves the removal of the fibroids themselves without removal of the whole uterus. Myomectomy is not permanent in the sense that fibroids can grow back after the procedure. The fibroids grow back in about 25% to 50% of women, and about 10% of women will need a second surgery. Although myomectomy is a sure temporary measure, it is less guaranteed to be a permanent solution. Thus, this procedure is often used to "buy time" if the woman is planning to become pregnant in the next few years. The advantages of this surgery are that it preserves the uterus for childbearing and involves less extensive surgery, which implies less extensive recovery periods. Certainly, in the short term, bleeding tends to be much improved after myomectomy (in about 80% of women).
3. Embolization: Another technique for treating fibroids is known as uterine artery embolization (UAE). This technique uses small beads of a compound called polyvinyl alcohol, which is injected through a catheter into the arteries that supply the fibroid. These beads obstruct the blood supply to the fibroid and starve it of blood and oxygen. Uterine artery occlusion (UAO), which involves clamping the involved uterine arteries as opposed to injecting the polyvinyl alcohol beads, has also been used as a way to interrupt blood supply to the fibroid.
4. Other Procedures: Some treatments have involved boring holes into the fibroid with laser fibers, freezing probes (cryosurgery), and other destructive techniques that do not remove the tissue but try to destroy it in place.

Complications of uterine fibroid surgery

It might seem very appealing to a woman to just have the uterus removed, however, as with any surgery, complications can include a risk (though extremely low) of dying or having complications from the general anesthesia. There are also risks of bleeding and infection, although these risks are fairly low. However, a hysterectomy is a more significant procedure than many women realize in that it does require substantial recovery time.

What other medical treatments are available for uterine fibroids?

It is important to remember that fibroids only require treatment if they cause bleeding or pain. There are several medical treatments available for fibroids. Birth control pills (oral contraceptives) can provide many benefits for women with fibroids. They decrease the amount of uterine bleeding by about 50% and decrease cramping pain during menstruation. They also may decrease the risk of fibroids.

Other medical treatments include the use of drugs that turn off the production of estrogen from the ovaries (GnRH analogs). These medications are given for three to six months. When successful, they can shrink the fibroids by as much as 50%.

Mifepristone (RU-486) is an antiprogestin drug that can shrink fibroids to an extent comparable to treatment with the GnRH analogs. This drug, sometimes known as the "morning-after pill," is also used to terminate early pregnancy. Treatment with mifepristone also reduces the bleeding associated with fibroids, but this treatment can be associated with adverse side effects such as overgrowth (hyperplasia) of the endometrium (uterine lining).

Danazol is an androgenic steroid hormone that has been used to reduce bleeding in women with fibroids since this drug causes menstruation to cease. However, danazol does not appear to shrink the size of fibroids.

Letrozole, an aromatase inhibitor blocks the conversion of testosterone to estrogen and is used to treat some women with breast cancer. Preliminary studies have shown a potential role for aromatase inhibitors in the management of fibroids, but more research is needed.

The administration of raloxifene (a drug used to prevent and treat osteoporosis in postmenopausal women) has been shown to decrease the size of fibroids in postmenopausal women, but the results of this therapy in premenopausal women have been conflicting.

Fibroids themselves do not require treatment, but women with fibroids can develop complications as a result of fibroids, including bleeding and pelvic pain (as discussed previously). It is because of symptoms that doctors may suggest treatment for a fibroid. Only 20% to 50% of women with fibroids have symptoms due to the condition, primarily bleeding or pelvic pressure.

In addition to bleeding and pelvic pressure, fibroids can cause recurrent miscarriage, infertility, premature labor, and labor complications. However, a substantial majority of women with fibroids can have successful pregnancies unless the uterine cavity is unusually distorted.

Picture of Adenomyosis

Adenomyosis is the growth of uterine tissue from one particular layer of the uterus (the endometrial glands from the lining tissue of the uterus) into the "wrong" layer (the muscle layer, called the myometrium). It is a benign condition, but it can enlarge the uterus, clinically appearing as a growth. Adenomyosis is similar to endometriosis, which is the growth of cells similar to those that form the inside of the uterus (endometrial cells), in a location outside of the uterus. In adenomyosis, the abnormal growth of endometrial cells occurs within the muscular layer of the uterus itself rather than outside the uterus.

The cause of adenomyosis is not well understood. Some researchers believe that previous surgeries on the uterus (including Cesarean births) can cause the endometrial (uterine lining) cells to spread and grow in an abnormal location (the muscular layer of the uterine wall). Another possibility is that adenomyosis arises from tissues in the uterine wall itself that may have been deposited there during the development of the uterus.

Adenomyosis is more common after childbirth.

What are the symptoms of adenomyosis?

Adenomyosis may not produce any symptoms, although some women may experience:

• Excessive bleeding
• Painful menstrual periods
• Bleeding between periods
• Painful intercourse

How is adenomyosis diagnosed?

The true diagnosis of adenomyosis is only possible with an actual microscopic examination of uterine tissue. This means that it is ultimately diagnosed after a hysterectomy. Sometimes the results of a physical examination and/or ultrasound examination may suggest the presence of adenomyosis.

How is adenomyosis treated? 

Pain medications are used to relieve the cramping pain of adenomyosis. Currently, the only effective treatment for adenomyosis is a hysterectomy, meaning the removal of the uterus. This requires a recovery period and carries the risk of surgery and anesthesia, as described previously. The decision as to whether or not to have a hysterectomy depends on the severity of the symptoms and the overall health of the patient. Controlling the menstrual cycle through hormonal contraception (the pill) or the use of other hormones may provide some symptom relief.

Picture of Uterine Polyps

Polyps of the uterus are benign overgrowths, or bulges, of the normal tissue lining the uterus into the uterine cavity. Polyps may also be found in the uterine cervix. Polyps are usually attached to the underlying tissue by a base or stalk, and they vary in size. Polyps only rarely contain cancerous cells. They are most common in women in their 40s and are rare in women under 20 years of age.

What are the symptoms of uterine polyps and what do they look like?

Uterine polyps may not produce any symptoms. However, some women may experience:

• Irregular vaginal bleeding
• Bleeding after intercourse
• Heavy menstrual bleeding

How are uterine polyps diagnosed and treated?

Sometimes, the polyps stick out through the opening of the cervix so that they are visible during a speculum exam, such as during a Pap smear. Diagnosis is by ultrasound or examination under a microscope of the tissue removed during uterine sampling. A diagnosis can also be made by hysteroscopy, the insertion of a scope that allows visualization of the uterine cavity from the inside. It is often possible to remove polyps during this procedure. Curettage, a procedure in which the lining of the uterus is removed, can be used to cure endometrial polyps in most cases.