What are Fibroids?

Fibroids are almost always non-cancerous tumors formed either inside, outside, or in the wall lining of the uterus. There may be a single fibroid nodule or a cluster.  Fibroids can grow to be as small as a seed and asymptomatic (absence of symptoms)  or as large as a watermelon causing discomfort and pain – and everything in between. Their growth often corresponds to escalations of estrogen and progesterone levels and people can have multiple fibroids of varying sizes simultaneously. 

The 3 major types of fibroids include:

• Subserosal fibroids are the most common, growing on the outer wall of the uterus projecting out and into the pelvic cavity and as they grow, can possibly affect other organs.  Because of this, small subserosal fibroids are less prone to cause significant symptoms, commonly do not require treatment and are simply monitored with regular ultrasounds.  However larger subserosal fibroids can become symptomatic with:
• Heavy menstrual bleeding
• Pressure symptoms with nearby organs, usually the bladder with increased urinary frequency and rectum, difficult bowel movements/constipation
• May cause bloating, pain and cramping, or the pelvis and lower abdomen feel ‘full’.

• Intramural fibroids develop and grow within the muscular wall of the uterus. Depending on their size and position, can produce all the usual fibroid symptoms once they become larger:
• Heavy bleeding or extended periods
• Bleeding between menstrual cycle
• Pressure symptoms
• Infertility and miscarriages
• Pain in the pelvis or lower back

• Submucosal fibroids are located within the uterine cavity. These fibroids tend to be symptomatic at smaller sizes, with the main symptom being irregular and/or heavy. Submucosal fibroids are more prone to affect fertility, both by making it difficult to get pregnant and by increasing the risk of miscarriages. Most solitary submucous fibroids can be removed through a non-invasive surgery, called a hysteroscopy. A hysteroscopy is a surgical procedure in which a camera is inserted through the cervix into the uterine cavity and the fibroid can be removed surgically. 

What’s is endometriosis?

The endometrium is the layer of tissue lining the uterus that is shed with each menstrual cycle.  Endometriosis is similar tissue to the endometrium, but this abnormal tissue is located outside the uterus and can implant on organs such as the bladder, fallopian tubes, ovaries, and large intestines.  

It is not known what causes endometriosis, but there is a growing amount of evidence that it is from genetic, or embryological origins, and not retrograde menstruation.  

Endometriosis can become symptomatic in early as adolescence (teenage years) with the lesions and scar tissue progressing over time, impacting the entire reproductive system, including the fallopian tubes and ovaries.

A more comprehensive discussion of endometriosis can be found on my page on Bowel Endometriosis as well as my page on Bladder Endometriosis.

Symptoms of Endometriosis & Fibroids

Since both conditions affect the reproductive tract, endometriosis and fibroids can cause similar symptoms, the severity of which in each case can range from asymptomatic (no symptoms) to severe.

Shared Symptoms

• Pain during sex and pelvic pain
• Urinary symptoms, such as urgency and frequency
• Bowel symptoms, such as rectal pressure and constipation
• Lower back pain
• Infertility (more frequently associated with endometriosis than with fibroids)
• Heavy and painful menstruation with occasional bleeding between cycles

Distinct Symptoms

The symptoms caused by endometriosis and fibroids can also vary which is why a medical diagnosis is required to learn which disorder a person may have, even if experiencing specific or distinct symptoms of one condition.

Symptoms of endometriosis:

• Severe menstrual cramp pain
• Pain during bladder or bowel movements
• Chronic pelvic pain
• Deep vaginal pain with sex
• Stomach pain
• Bleeding or spotting between periods
• Gastrointestinal symptoms like bloating, diarrhea, nausea, and constipation, especially during menstruation

Symptoms of fibroids include:

• Menstrual bleeding severe enough to cause anemia (insufficient oxygen-rich blood).
• The pelvis and lower abdomen feels ‘full’
• Swollen or enlarged lower abdomen
• Frequent urination & pelvic pressure
• Difficulties during labor and delivery, such as being at a higher risk for cesarean section. 

Diagnostic Testing for Endometriosis vs. Fibroids

Overlapping symptoms and the potential for the simultaneous presence of both conditions make getting a diagnosis challenging. Reviewing symptoms, medical history, imaging studies, and pelvic exam can aid in a diagnosis. Some tests that can help lead to a differentiating between endometriosis and fibroids are:

• Transvaginal and/or Trans-abdominal ultrasound: This noninvasive test enables the inspection of the uterus, ovaries, and other internal pelvic region structures via sound waves. 
• Sonohysterography (also known as ‘sonohysterogram’ or ‘saline infusion sonogram’): This application of ultrasound uses a thin, flexible catheter to place saline solution through the cervix into the uterus – thereby enabling visual examination of the cavity of the uterus, which can diagnose a submucosal fibroid.
• Magnetic resonance imaging (MRI) applies radio waves and strong magnets to provide a detailed view of a fibroids’ size, location, and quantity. A MRI can also evaluate other pelvic organs, such as the uterus, ovaries, fallopian tubes, bladder and bowel. Sometimes, a MRI can pick up on adenomyosis, or endometriosis of the uterus. If there is deeply-infiltrating endometriosis involving other structures or surrounding organs, many times a MRI can detect this as well.  
• Hysteroscopy: This procedure involves inserting a small camera through the cervix into the uterine cavity to evaluate the inside of the uterus, which can often times rule out and treat submucosal fibroids. 

While imaging tests can be helpful in uncovering evidence of endometriosis, they don’t provide sufficient information for a definitive diagnosis. For example, flat and small endometrial lesions can be missed with ultrasounds and it also can’t discern if tissue growth is in fact endometrial in origin.  Having said that, ultrasound can rule out fibroids, which would indicate endometriosis as the probable diagnosis of the tissue of scrutiny. 

Surgery to Diagnose Endometriosis 

Definitive diagnosis of endometriosis requires a surgical procedure, such as a laparoscopy and biopsy of the tissue.  Laparoscopy offers the advantage of it being only small incisions and that diagnosis can be confirmed and often treatment carried out in the same surgery.  Laparoscopic surgery aims to excise the endometriosis lesions and repair any damage to organs or other structures caused by endometriosis.

During this minimally invasive procedure, small incisions in the abdomen enable a small camera, called a laparoscope, to be inserted to view the abdominopelvic cavity and inspect for endometriosis lesions, inflammation, and scar tissue.  The diseased tissue can then be excised and sent to the pathology laboratory to be examined under a microscope. This is how one gets a definitive diagnosis for endometriosis.

Endometriosis & Fibroids, Variations in Treatment 

It’s important to know that severity of symptoms for either endometriosis or fibroids may not correlate to the severity of the pathology or disease.   Some patients may have no symptoms and only find out that they have endometriosis, fibroids, or both when they’re having difficulties in getting pregnant. In such circumstances, treatment can be helpful in facilitate successful conception and pregnancy.

Treatment for endometriosis requires excision of the endometriosis and disease. Left untreated, endometriosis can spread to the to the bladder, bowels and reproductive tract affecting the ovaries and fallopian tubes. Symptoms can be managed with medications or conservative, nonsurgical options. 

Management for endometriosis include:

• Hormonal suppression, such as birth control pills (combined or progesterone-only), patches, vaginal rings, progesterone injections, progestin intrauterine devices, are considered a first-line management strategy to minimize hormonal fluctuations, which can cause a decrease in endometriosis symptoms.  
• Non-steroidal anti-inflammatories and non-opioid medication: Medications can help decrease the inflammatory response, therefore decreasing overall pain.
• Pelvic floor physical therapy: this can help with pelvic floor dysfunction, which many patients who have endometriosis suffer from, after being in pain for many years. Pelvic floor physical therapy can help retrain the pelvic floor muscles to decrease muscle strain and spasms that often result from being in chronic pelvic pain. 
• Physiatry or Physical Medicine and Rehabilitation: This can help pelvic pain with trigger point injections, suppositories and other non-invasive therapies that can help decrease inflammation and muscle spasms. Oral medication can sometimes help to decrease an overactive or central nervous system.
• Laparoscopy: A surgical procedure which is the gold standard for diagnosing and treating endometriosis by excision (or removal) of all endometriosis lesions. 

Treatments for fibroids include:

Management for fibroid symptoms, such as heavy bleeding and pain are similar to those used for management of endometriosis symptoms. Unlike management for endometriosis, certain medications may slow the growth of fibroids, therefore providing relief from symptoms. 

An additional medication that may be used for symptomatic fibroids are gonadotropin-releasing hormone (GnRH) agonists, which may be used prior to surgery to shrink a fibroid to make surgical removal easier. Some newer medications called gonadotropin-releasing hormone antagonists, may also help temporarily stop menstruation in those with iron-deficiency anemia because of the fibroids. 

Fibroids interfering with conception or causing severe symptoms are generally surgically removed, called a myomectomy. Depending on the size, location, number of fibroids, and future fertility goals this can be accomplished through different surgical approaches:

• Hysteroscopic myomectomy: This procedure is indicated for submucosal fibroids, or fibroids inside the uterine cavity. This involves inserting a small camera through the cervix into the uterine cavity to directly visualize the submucosal fibroid. The fibroid then can be removed hysteroscopically.
• Laparoscopic myomectomy: This procedure can remove fibroids laparoscopically, or minimally-invasively. Generally, this is the preferred method for fibroids that are limited in size, quantity, and for patients who are pre-menopausal. 
• Abdominal myomectomy: This is when a larger incision is made, which can be similar to a c-section incision, and the fibroids are removed through the larger incision. This is the preferred route for extremely large fibroids and/or numerous fibroids. 

Other options for symptomatic fibroids, depending on fertility goals include:  

• Uterine artery embolization: This procedure blocks the fibroids’ blood supply, causing them to shrink. Pregnancy is not advisable after an uterine artery embolization. 
• Radiofrequency ablation: This procedure uses heat to shrink the fibroids, one by one.  Pregnancy can be achieved after this procedure
• Hysterectomy: This involves the removal of the entire uterus which is the only 100% guaranteed cure for fibroids, however it eliminates the possibility of future pregnancy.