Uterine Fibroids: Causes and Treatments
Abstract
This essay examines uterine fibroids, detailing their aetiology, diagnosis, and treatment from an allopathic perspective, alongside an overview of alternative medicinal approaches.
Uterine fibroids are the most common indication for hysterectomy, yet they predominantly affect women of reproductive age, posing a challenge for those seeking symptom relief while preserving fertility. Although conclusive evidence regarding their pathogenesis remains scarce, race is frequently cited as a significant risk factor. Despite this, diagnosis is relatively straightforward through manual examination and various imaging techniques.
While the most effective treatments are surgical, post-operative recurrence remains a concern. Consequently, there is an urgent need for less invasive therapeutic approaches, with vitamin D supplementation and herbal medicine showing promise as potential interventions.
Pathophysiology
Uterine fibroids, also referred to as leiomyomata or myomata, are benign tumours arising from the smooth muscle of the uterus (Akinyemi et al., 2004). They are largely composed of extracellular matrix, including fibronectin and other structural proteins, which contribute to their dense composition. Although benign, fibroids can significantly impact menstrual bleeding, fertility, and overall quality of life.
Given that many fibroids are asymptomatic, their true prevalence remains uncertain, as many are detected incidentally during medical imaging or procedures such as cervical screening (Divakar, 2008).
The distinction between symptomatic and asymptomatic fibroids is not well understood. Symptomatic fibroids typically present with a sensation of uterine pressure, visible abdominal distension, increased urinary frequency, menorrhagia, dysmenorrhoea, or prolonged menstrual bleeding (Khan et al., 2014). Some women also experience constipation, anaemia, or reproductive challenges (Stewart, 2001). While fibroid size and number are clinically quantifiable, no correlation has been established between fibroid burden and symptom severity (McLucas, 2008).
According to the Mayo Clinic, uterine fibroids will be diagnosed in 77–80% of women during their lifetime (Mayo Clinic, n.d.).
Aetiology
Extensive research has sought to determine the root causes of uterine fibroids, including studies on the potential impact of endocrine-disrupting chemicals during critical stages of gynaecological development. However, findings remain inconclusive (Katz et al., 2016).
Commonly recognised risk factors include reproductive age, racial background, early menarche, and high caffeine intake (Laughlin et al., 2010). Additionally, a hereditary component is evident, with distinct molecular-level patterns observed in familial cases (Okolo, 2008).
Data from the United States indicate a higher prevalence of fibroids among women of African descent compared to other racial groups. While this suggests a possible genetic component, it is important to acknowledge that race and ethnicity are not synonymous, and phenotypic classification does not necessarily equate to genetic similarity.
Notably, the majority of studies identifying an increased risk among Black women originate from Western nations with lower sunlight exposure compared to Africa. A retrospective study examining the relationship between serum vitamin D levels and fibroid prevalence found that only 10% of Black women, compared to 50% of White women, had sufficient vitamin D levels. Furthermore, women with adequate vitamin D levels had a 32% lower likelihood of developing fibroids, a pattern consistent across racial groups. Additionally, those who reported at least one hour of daily sun exposure exhibited a lower incidence of fibroids (Baird et al., 2013).
Vitamin D deficiency has been implicated in various adverse health outcomes among Black populations residing in regions with limited sunlight, and this is likely a contributing factor in the higher prevalence of fibroids in Black women (Ames et al., 2021).
Historically, a lack of genetic testing has hindered the identification of fibroid-specific genetic markers. However, a 2017 genome-wide association study using data from 23andMe identified a link between reduced expression of a particular thyroid-related gene and fibroid incidence in African American women (Hellwege et al., 2017). Additionally, women with fibroids are more likely to develop thyroid nodules, with oestrogen suspected as a common aggravating factor (Kim et al., 2010).
Recent discoveries suggest that most fibroids exhibit somatic mutations in the MED12 and HMGA2 genes, with early-stage upregulation of HMGA2 implicated in fibroid pathogenesis (Galindo et al., 2018). These genetic findings may pave the way for novel therapeutic strategies beyond traditional hormonal and surgical interventions.
Moreover, an inverse relationship between childbirth and fibroid development has been observed. While the exact mechanism remains unclear, it is hypothesised that postpartum uterine repair processes may play a role in reducing fibroid risk (Khan et al., 2014).
Diagnosis
Clinical evaluation of fibroids typically begins with pelvic palpation, particularly in patients presenting with associated symptoms. Large or multiple fibroids may cause abdominal distension resembling pregnancy.
Diagnosis is confirmed using imaging techniques such as ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) (McLucas, 2008).
Ultrasound is the most common and accessible diagnostic tool; however, degenerating fibroids may exhibit atypical sonographic features, necessitating further imaging for clarification. Additionally, distinguishing fibroids from malignant tumours such as leiomyosarcomas is crucial. Given that rapidly enlarging fibroids may be malignant, continued monitoring is recommended (Wilde & Scott-Barrett, 2009).
Treatment
Hormonal Therapies
Current treatments target the hormonal dependence of fibroid growth, as fibroids are not observed in premenarchal girls and typically regress post-menopause. Hormonal interventions include gonadotropin-releasing hormone (GnRH) agonists, which induce a hypo-oestrogenic state, leading to fibroid shrinkage. However, prolonged use is limited due to adverse effects such as osteoporosis and menopausal symptoms (Hodgson et al., 2017).
Surgical Interventions
Myomectomy, involving the surgical excision of fibroids, may be performed via vaginal, abdominal, or laparoscopic approaches. Laparoscopic myomectomy is associated with shorter recovery times and reduced risk of post-operative infections compared to open surgery (Seracchioli et al., 2003). However, recurrence rates are similar across all methods (Chittawar et al., 2014).
For women who do not wish to preserve fertility, hysterectomy remains the definitive treatment. It is the leading cause of gynaecological surgery in the United States and India (Farquhar & Steiner, 2002; Pandey et al., 2014). Despite its efficacy, hysterectomy carries risks such as cardiovascular disease, pelvic floor dysfunction, and osteoporosis (Stewart et al., 2012).
Minimally Invasive Approaches
Uterine artery embolisation (UAE) is a less invasive alternative, wherein embolic agents are injected to occlude fibroid blood supply, inducing shrinkage. This method is effective but contraindicated in cases of cervical fibroids or concurrent pregnancy (Walker & Pelage, 2002).
Alternative and Herbal Therapies
Despite anecdotal reports, evidence from clinical trials on the efficacy of herbal treatments remains limited (Liu et al., 2013). However, traditional remedies with anti-mitotic properties have been historically used for fibroid management, including Turnera diffusa, Leonarus cardiaca, and Hydrastis canadensis (Bartram, 1998). Additionally, Achillea millefolium has demonstrated haemostatic properties beneficial in cases of excessive uterine bleeding (Ali et al., 2017).
Conclusion
Given the high prevalence of uterine fibroids and their substantial impact on reproductive health, further research is warranted to elucidate their aetiology and develop less invasive treatment strategies.
Surgical interventions remain the primary approach; however, their associated risks underscore the need for non-surgical alternatives. Vitamin D supplementation, genetic research, and herbal medicine represent promising avenues for future exploration.
Increased scientific investigation into alternative therapies may yield novel approaches that could mitigate fibroid growth without resorting to major surgical procedures.
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