Uterine fibroids, also known as uterine leiomyomas or uterine myomata, are fibrous (and non-cancerous) tumours of the uterus which affect 20-25 per cent of women past the age of 35. They vary greatly in size, number and position, some growing to vast sizes and causing pressure symptoms, others remaining small and discrete. A fibroid is comprised of dense muscular fibres arranged in circular layers and encapsulated in a layer of compressed smooth muscle cells. The blood supply reaches the fibroid via vessels which traverse the outer capsule, the tumour itself having relatively few blood vessels within its structure.

Fibroids may cause few symptoms; occasionally quite large ones are discovered because of a routine examination or ultrasound scan for another reason. In fact, fibroids which are not interfering with fertility or causing unwanted symptoms require no surgery or drugs, medical, natural or otherwise, to shrink or remove them. Regular monitoring is advisable, and some general measures to moderate the effects of oestrogen are useful to contain growth and reduce the risk of additional fibroids.

Large fibroids, those that are pedunculated (growing on a stem), and those that grow rapidly should be monitored closely. A rapidly growing fibroid can be associated with an increased risk of a uterine sarcoma, which is an aggressive type of tumour. Often doctors suggest that a fibroid that is growing quickly be removed before any abnormalities develop.

Symptoms

The most common symptom associated with fibroids is heavy bleeding. Larger fibroids are also associated with urinary frequency, pressure symptoms, heaviness and congestion in the lower abdomen. Some women have a heavy feeling, sometimes described as a sensation ‘as though everything might fall out’ before or during the period. Very large fibroids may cause abdominal enlargement and the woman may look as if she is in the early stages of pregnancy. Sometimes fibroids will cause a miscarriage or infertility and, rarely, pregnant women may go into labour too early because of fibroids. Fibroids are also associated with an increased risk of post-partum haemorrhage.

Many women have no symptoms at all and only become aware of the presence of fibroids when they are detected during a pelvic ultrasound. Very occasionally, fibroids can be associated with pain because of obstruction to the blood supply, torsion of a pedunculated fibroid or infection. Another uncommon, although potentially serious, complication associated with fibroids is obstruction producing urinary retention, or dilatation of the ureters or renal pelvis. Constipation can also result from the obstructive effects of fibroids.

Types of fibroids and their locations

Fibroids can be described according to their location in relation to the uterus; or according to their type.

Location

Intra-uterine or sub-mucosal fibroids

These fibroids are found within the uterine cavity and are sometimes called ‘sub-mucosal’ because they are situated below or within the endometrial lining. These fibroids can be removed via a hysteroscope if they are less than 5-6 cm in diameter. They are frequently associated with heavy menstruation, even if rather small, and can extend through the cervix if they are pedunculated. Problems with fertility may occur because the endometrium around the fibroid does not undergo normal hormonal change. Implantation can be affected and the miscarriage rate is often higher.

Myometrial or intramural fibroids

These are fibroids found within the muscle wall of the uterus (the myometrium). They can occur at any location within the uterine muscle and vary considerably in size. Symptoms are usually excessive bleeding at menstruation and, if large enough, pressure may be exerted on adjacent organs. Rarely, pressure on a ureter (the tube between the kidney and bladder) may cause a back-flow of urine, causing structural abnormalities of the kidney and ureter and abnormal renal function. These fibroids can adversely affect fertility if they grow into and distort the uterine cavity.

Extra-uterine or sub-serous fibroids

As their name suggests, these fibroids are attached to the outside of the uterus. They are sometimes called ‘sub-serous’ because of their positioning under the serous outer lining of the uterus. They can also cause pressure symptoms or be associated with excessive bleeding. Some are found around or on the Fallopian tubes and may interfere with fertility. Sub-serous fibroids are often pedunculated (see following).

Type

Fibroids are of two main types. They can be discrete, fibrous and encapsulated tumours, which are usually roughly spherical in shape; or pedunculated tumours attached to the uterine cavity or the outside of the uterus by a stem or pedicle.

The latter variety can cause problems because of the (fairly rare) tendency to twist on the pedicle (called torsion). If this occurs the blood supply to the fibroid can be cut off, and death of the fibroid tissue will occur. This is associated with extreme pain and increased pressure symptoms as the fibroid swells in its capsule and presses on adjacent organs. Immediate surgery may be needed.

What makes a fibroid grow?

It is not known why muscular fibres start to arrange themselves in the spherical form that is typical of fibroids. What is known, however, is that their growth is dependent upon the presence of oestrogen: they rarely develop before menarche and will almost always shrink after menopause. Women with other conditions which are associated with oestrogen over-activity, such as endometrial hyperplasia and endometriosis, have a greater risk of fibroids, adding weight to the theory that they are somehow reliant on, or caused by, oestrogen levels.

Downgrading the effect of oestrogen is one of the requirements of a successful treatment. Natural therapists treat fibroids as conditions associated with ‘relative oestrogen excess'; and doctors use drugs which will temporarily cause a menopausal state, or suggest surgical removal.

Fibroids have also been found to contain larger amounts of DDT than other uterine tissue. The significance of this is not clear, but DDT has oestrogen-like effects and may be responsible for the tissue changes seen in these women.

Factors which affect the incidence of fibroids

Pregnancy

Pregnancy seems to reduce the risk of fibroids developing. With each successive pregnancy, the rate at which fibroids develop reduces; women who have had five full-term pregnancies have only one-quarter the risk of women who have had none.

Coffee

Coffee may increase the likelihood of developing uterine fibroids. Researchers from the company Nestle gave mice the equivalent of two to three cups of instant coffee per day. They had a slightly higher incidence of fibroids than control mice, but the significance of this for women is not clear.

Hypertension

Some studies have revealed an association between fibroids and high blood pressure, suggesting that fibroids and hypertension share the same pathogenic features.

Perineal talcum powder

The use of talcum powder may increase fibroid incidence for unknown reasons.

Obesity

Obesity is associated with an increased risk of fibroids, possibly because of the relative over-abundance of oestrogen seen in overweight women compared to normal weight or thin women. Peripheral conversion of androgens to oestrone is responsible for the elevated oestrogen levels.

Use of oral contraceptives

Studies which have investigated the Pill and fibroid incidence have been inconclusive, with some studies showing a reduced incidence; one study showing a slightly increased rate (not statistically significant); and two others finding no change.

Smoking

Smokers tend to develop fibroids less often. In one study, current smokers were shown to have a 40 per cent lower incidence of fibroids than non-smokers.

Diagnosis

A fibroid could be suspected if the following signs and symptoms are present:

• Heavy bleeding at the time of menstruation.

• Dragging, congestive pain in the lower abdomen at the time of menstruation and premenstrually.

• An enlarged and bulky uterus discovered during a pelvic examination by the doctor.

• A lower abdominal mass discovered by the woman or her doctor.

An ultrasound scan is used to diagnose uterine fibroids. They will show up as masses in or attached to the uterus: their number, size and position can often be precisely determined. An ultrasound is also frequently used to monitor the size and growth rate of fibroids. Some doctors will also want to perform a laparoscopy to absolutely establish that the pelvic mass visible with the ultrasound is a fibroid. This is particularly the case if the ovaries cannot be clearly seen, as ovarian cysts or cancer can sometimes be mistaken for uterine fibroids.

The medical approach

There are three main options for the management of fibroids.

• Observe, but do not treat.

• Surgical intervention — either removal involving a hysterectomy or a myomectomy (see ‘Drugs and surgery’), or with a newer sugical procedure called uterine artery embolisation. This procedure is performed laparoscopically and involves the occlusion of the blood supply to the fibroid. The aim is to completely deprive the fibroid of arterial blood so that it atrophies. Successful outcomes have been achieved in as many as 80-90 per cent of women treated.

• Drugs to reduce the size of fibroids prior to surgery. These drugs have two different effects, but the overall aim is to reduce the level of oestrogen. The drugs used are Danazol, to produce a predominance of androgens and suppression of oestrogens; and GnRH agonists, which induce a medical menopause.

The natural therapist’s approach

The treatment of fibroids aims to:

• regulate excess bleeding

• reduce ‘relative oestrogen excess’

• contain or reduce the size of the fibroid.

Abnormal bleeding

It is often surprisingly easy to reduce the excessive bleeding associated with fibroids and this may be all that is required. Women who have passed their child-bearing years, those with small fibroids, or those women for whom surgery is not an option may find that this simple approach to managing the fibroids is satisfactory.

All of the herbs mentioned in the treatment of functional menorrhagia, especially Alchemilla vulgaris, but also Trillium erectum, Equisetum arvense, Achillea millefolium, Panax notoginseng, Capsella bursapastoris and Hydrastis canadensis, are appropriate. Anti-haemorragics are usually combined with one or more of the uterine tonic herbs to improve the uterine tone and try to normalise uterine function.

Of the nutrients, the bioflavonoids are the most useful for bleeding associated with fibroids. Iron is recommended for anaemia or low serum ferritin, and may also improve bleeding.

Relative oestrogen excess

It is possible to contain or reduce the growth-promoting effects of oestrogen. The main way this is achieved herbally is via competitive inhibition. Other methods, many without scientific trials to verify their efficacy, are also used. Considering the number of women who develop fibroids, the research on treatment and prevention is disappointingly sparse.

In one of the few trials using medicinal herbs to treat fibroids, the herbs Paeonia lactiflora and P. suffruticosa, Poria cocos, Cinnamomum cassia and Prunus persica were given to 110 pre-menopausal women with uterine fibroids. Ninety per cent experienced an improvement of their symptoms, and in 60 per cent of cases the fibroids were reduced in size. The same formula, known as Cinnamon and Hoelen Combination, also reduced adenomyosis, another oestrogen-dependent condition, in mice.

It is important to regulate relative oestrogen excess because women who have the tendency to grow fibroids can do so again after the fibroid has been removed or adequately treated, or may continue to produce multiple fibroids if the hormonal imbalance is not corrected.

All conditions related to relative oestrogen excess seem to respond to the same sorts of treatment and the principles for improving oestrogen clearance are discussed in ‘Maintaining hormonal balance’.

Other fibroid treatments

Herbs used to treat fibroids and reduce their size are Calendula officinalis, Thuja occidentalism Ruta graveolens and Turnera diffusa. Vitamin E is believed to reduce fibroid size, but the reasons for this are unclear.

Self care

Uterine fibroids are related to relative oestrogen excess. The self-care strategies to reduce this imbalance are discussed in ‘Endometriosis and adenomyosis’.

Preventing anaemia is also important and information on iron can be found below.

The Importance Of Iron

Iron and iron-deficiency anaemia

Iron requirements for women are around 80 per cent higher than for men because of menstruation and child-bearing. It is estimated that iron deficiency is the commonest nutritional disease worldwide and that more than half of all women consume less than the recommended amount of 10-15 mg daily.

Those at most risk for developing iron deficiency are:

  • pregnant women
  • women with heavy menstrual loss
  • children
  • vegetarians
  • frequent dieters
  • those who are on strict exclusion diets
  • those with low gastric acid levels such as occurs after stomach surgery and with ageing
  • those who do not have access to good quality food e.g. due to poverty and famine

Iron deficiency vs anaemia

Iron is stored in the body in places other than in the red blood cells. These include the liver, bone marrow, spleen, muscles and in the serum. A test for anaemia will determine whether there is a depletion of iron stored in the red blood cells (the haemoglobin level), but not whether iron stores elsewhere in the body are at sufficient levels.

It is now known that the symptoms of iron deficiency can exist before the red blood cells become depleted of iron and that a considerable number of people are iron deficient even though their haemoglobin is normal. For this reason, many doctors now order a blood test to check both iron stores (in the serum) and haemoglobin levels.

Symptoms of anaemia and iron deficiency

Many of the symptoms of anaemia are related to the inability of the red blood cells to carry oxygen around the body because they lack iron. These include:

• poor stamina

• shortness of breath on exertion

• unreasonable limb fatigue

• dizziness

Other symptoms seem to be related iron deficiency. These might include:

• a red sore tongue and cracks in the corners of the mouth

• concave fingernails

• reduced resistance to infection, particularly in children

• also in children, a failure to thrive, slow learning and poor appetite

• poor digestion caused by low gastric acid levels. Iron deficiency can be both a cause of decreased production of gastric acid and can be itself caused by low gastric acid.

Improving iron absorption

Apart from increasing the amount of available iron in the diet, there are a number of other ways to increase iron levels.

• Eat vitamin C-rich foods, particularly when consuming foods high in iron.

• Add acidic dressings, such as lemon juice and vinegar, to iron-rich foods. This is a common Southern Mediterranean practice, where there is a high incidence of inherited anaemia and the traditional diet contains little red meat.

• Eat bitter vegetables or fruit before or during the meal to increase the flow of gastric acid which will in turn improve the absorption of minerals. Alcoholic aperitifs, grapefruit, Swedish bitters and bitter green vegetables can all be used. Bitter vegetables are best because they usually contain iron as well as stimulate its absorption.

• When low gastric acid levels are accompanied by iron deficiency, taking iron may improve both.

• Avoid tea (especially black tea) or coffee until the iron deficiency improves. The tannin in tea binds with iron, making it difficult to absorb. Coffee also reduces absorption, especially if taken with or after a meal, but not when taken more than one hour before eating. Don’t take iron tablets with a cup of tea or coffee.

Detecting low iron stores

Iron deficiency should be suspected if the symptoms described above are apparent, and should respond to a low-dose iron supplement. Iron should not be taken unnecessarily as it will accumulate in the body and may become toxic. If symptoms do not respond, iron studies which evaluate serum iron levels and a full blood examination that evaluates haemoglobin and red blood cell status can help to differentiate between iron deficiency anaemia, anaemia association with blood loss, or anaemia from other causes, such as vitamin B12 or folate deficiency.

Table Sources of iron (mg per 100 g)

RDA 10-15 mg/day
Meat, fish and eggs
eggs 2.0 light chicken meat 0.6
beef, lean 3.4 cod 0.4
lamb, lean 2.7 sardines 2.4
pork, lean 1.3 mussels 7.7
dark chicken meat 1.9 oysters 6.0
Grains
wheatgerm 10.0 whole wheat bread 2.5
wheat bran 12.9 All Bran™ 12.0
whole wheat flour 4.0 Special K™ 20.0
raw oatmeal 4.1 Weetbix™ 7.6
soya flour 9.1 rye biscuits 3.7
white bread 1.7    
Legumes and vegetables
haricot beans 2.5 spring onions 1.2
broccoli tops 1.0 parsley, raw 8.0
leeks 2.0 peas 1.2
lentils 2.4 potatoes, jacket 0.6
lettuce 0.9 spinach 3.4
mushrooms, raw 1.0 silver beet 3.0
Fruits
apricots, fresh 0.4 peaches, dried 6.8
apricots, dried 4.1 prunes 2.9
avocado 1.5 prunes, stewed 1.4
currants 1.8 raisins 1.6
figs, dried 4.2 raspberries 1.2
dates 1.6 sultanas 1.8
Other
almonds 4.2 walnuts 2.4
brazil nuts 2.8 curry powder 75.0
hazel nuts I.I yeast 20.0
peanuts 2.0    
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