Much like endometriosis, fibroids are not a disease on their own in Chinese Medicine, they are grouped under the topic of Abdominal Masses, including Myomas or Uterine Leyiomyomas, flooding and trickling, infertility and painful periods. Uterine Leiomyomas are the most common gynecological neoplasm, occurring in 20%–30% of women of reproductive age and arise from an overgrowth of smooth muscle and connective tissue in the uterus.
Causes
The cause of uterine leiomyomas is unknown. Several studies have suggested that each leiomyoma arises from a single neoplastic cell within the smooth muscle of the myometrium. A genetic predisposition exists and there is evidence of an hormonal dependency includes the following:
- Both estrogen and progestin receptors are present in fibroids.
- Elevated estrogen levels may cause fibroid enlargement. During the first trimester of pregnancy, 15-30% of fibroids may enlarge then shrink after birth. Some fibroids may decrease in size during pregnancy.
- Fibroids shrink after menopause and some regrowth may occur with hormonal therapy.
- Leiomyomas occurin women of reproductive age, often enlarge during pregnancyor during oral contraceptive use, and regress after menopause.
What do they Look Like?
The size of uterine leiomyomas is variable, ranging from microscopic to large tumors that fill the abdomen. Leiomyomas may be single or, more frequently, multiple. The consistency of an individual leiomyoma varies from hard and stoney (as with a calcified leiomyoma) to soft (as with cystic degeneration), although the usual consistency is described as firm or rubbery. As leiomyomas enlarge, they may outgrow their blood supply resulting in various types of degeneration, though most histological findings of these are unrelated to symptoms.
Classification
Leiomyomas most commonly involve the myometrium of the uterine corpus but may also occur in the cervix (~8% of cases). According to their location, leiomyomas are classified as:
- Submucosal: projectinginto the endometrial canal
- Intramural: within the substanceof the myometrium
- Subserosal: beneath the serosa
This classification is of clinical significance because the symptoms and treatment vary among these subtypes of leiomyomas. Although submucosal leiomyomas are the least common, representing approximately only 5% of uterine leiomyomas, they are most commonlysymptomatic; these lesions may be associated with dysmenorrhea, menorrhagia, and infertility. In rare instances, submucosal leiomyomas may become pedunculated and protrude into the cervical canal or vagina; the prevalence of such submucosal leiomyomas is estimated to be 2.5%. Intramural leiomyomas,which are the most common, are most often asymptomatic. However,they can occasionally be associated with menorrhagia and infertility. Infertility can occur secondary to extrinsic compression ofthe fallopian tube. Menstrual irregularities are hypothesized to be secondary to the loss of symmetric uterine contractions.
Fibroids – Symptoms & Examination
It has been estimated that 20%–50% of women with leiomyomas present with symptoms such as menorrhagia, dysmenorrhea, pressure,urinary frequency, pain, infertility, or a palpable abdominal-pelvic mass. The clinical presentation is variable, dependingon the size, location, and number of tumors. The four major symptoms of leiomyomas that are appropriate indications for intervention are bleeding, pressure on adjacent organs, pain, and infertility.
- Bleeding: the most frequent symptom. It may manifest as menorrhagia or menometrorrhagia,which may result in anemia. Submucosal leiomyomas are often associated with ulceration of the overlying endometrium. Bleeding may also be caused by interference of intramural leiomyomas with normal uterine contractility, which presumably plays a role in limiting uterine bleeding during menstruation.
- Pressure on Adjacent Organs: As leiomyomas enlarge, they may produce pressure on surrounding structures. Anterior leiomyomas may cause compression of the bladder with resultant urinary frequency or incontinence. Similarly, posterior leiomyomas that impinge on the rectosigmoid may cause constipation. Intraligamentous lesions may compress the ureter along the pelvic wall, resulting in hydro-ureter or hydronephrosis.
- Pain: occurs in approximately 30% of women with uterine leiomyomas and is usually the result of acute degeneration. Red degeneration,which is most commonly observed during pregnancy, results from hemorrhagic infarction of a leiomyoma. Such degeneration may result in systemic symptoms, such as abdominal pain, low-grade fever, and leukocytosis. Pain may also occur with torsionof pedunculated subserosal leiomyomas or prolapse of pedunculated submucosal leiomyomas.
- Infertility: Leiomyomas are an infrequent primary cause of infertility. Infertility may be caused by compromise of the patency of the fallopian tube or distortion of the endometrial cavity. Intramural leiomyomas located in the cornual regions of the uterus may obstruct the interstitial portion of the tube; intraligamentous leiomyomas may also impinge sufficiently on the tubal lumen to cause tubal obstruction. Patients with submucosal leiomyomas may have an increased prevalence of early abortion resulting from faulty implantation.
Diagnosis
Imaging modality for the evaluation of uterine fibroids is ultrasonography, both transabdominal and transvaginal. MRIprovides additional information.
Treatment of Fibroids in Western Medicine
Approximately 80% of leiomyomas are asymptomatic and therefore require no treatment. For patients with symptoms, either medical or surgical treatment may be indicated. In the past, gynecological practice held that surgical intervention was necessary if the size of the uterus exceeded that of a woman at 12 weeks gestation regardless of the presence or absence of symptoms. This was done to ensure accessibility to adequately examine the ovaries and decrease the risk of additional surgery if uterine growth continued. Currently, surgery is not performed for two reasons. First, ultrasound and MRI allow evaluation of the adnexa in a uterus with fibroids. Second, with current surgical techniques,there is no increase in morbidity among women with an enlarged uterus who undergo hysterectomy. No difference in surgical morbidity exists between patients with a 20-week-sized uterus if the procedures are performed abdominally. Therefore, hysterectomy for leiomyomas should be considered only in symptomatic patients who do not desire future fertility. The reduced uterine size before hysterectomy patients with large leiomyomas may be pretreated with a gonadotropin-releasing hormone agonists (GnRH). In some cases, surgery is indicated:
- Hysterectomy: traditionally this has been the primary treatment for symptomatic leiomyoma. Leiomyomas are the most frequent nonmalignant indication for hysterectomy. Hysterectomy should be reserved forwomen who have completed childbearing and no longer wish to preserve the uterus. The surgery can be performed via the vaginal or abdominal route. In selected cases, the uterus may be removed with a laparoscopic approach.
- Myomectomy: enucleation of a leiomyoma with preservation of the uterus is indicated in women with a history of second-trimester fetal loss, anemia secondary to hypermenorrhea, or pelvic pain. Abdominal myomectomy has been associated with more significant blood loss and higher morbidity than hysterectomy. However, with the recent improvements in surgical technique, the morbidity of myomectomy is now comparable with that of hysterectomy. The risk of recurrence after myomectomy has been estimatedto be 27% after 10 years.
- New Surgical Interventions: recent developments in surgical endoscopy have, in selected cases, allowed myomectomy to be performed with minimally invasive surgical procedures. These include hysteroscopic myomectomy, laparoscopic myomectomy, and laparoscopic myoma coagulation. These procedures offer several advantages, including shorter hospitalization time, faster recovery, and cost savings per patient in hospital and surgical fees.
Other medical treatments include GnRH analogs and uterine artery embolization. Recently, therapy with gonadotropin-releasing hormone (GnRH) analogs has been advocated in the conservative treatment of various estrogen-dependent tumors such as uterine leiomyomas and endometriosis. By inhibiting normal pituitary secretion of gonadotropins, GnRH analogs can induce a reversible hypoestrogenic state, resulting in amenorrhea and a reduction in the size of hormone-responsive leiomyomas. The maximum reduction is usually achieved with 12 weeks of GnRH analog treatment. However, after cessation of treatment, there is rapid regrowth of the tumor.
Uterine artery embolization is a promising new method of treating symptomatic leiomyomas. In this procedure, both uterine arteries are selectively catheterized from a femoral artery approach and subsequently embolized with polyvinyl alcohol particles or coils. Uterine artery embolization may result in shrinkage of the uterus and leiomyomas, along with relief of menorrhagia and symptoms due to local mass effect. As a percutaneous interventional technique, this procedure may offer the advantages of avoidance of surgical risks, potential preservation of fertility, and shorter hospitalization.
Treatment in Chinese Medicine
According to Chinese Medicine, the symptoms should be treated according to syndrome differentiation. For example, if a patient has irregular uterine bleeding, the treatment principle should be to stop bleeding first and treat the fibroid second. For long term patients, strengthening Zheng Qi will help to shrink the tumor(s). Taking herbs in bolus form is the most suitable form of herbal administration for tumor treatment. Otherwise, there are other common differentiations:
| Differentiation | Qi Stagnation | Blood Stasis | SP & KI Deficiency |
| Signs | Fibroids, depression, breast distention before menses, pain and distention in abdomen, normal tongue, deep stringy taut pulse | Fibroids, stabbing abdominal pain, dark menses with clots, purplish tongue or purplish spots on tongue, deep uneven pulse | Fibroids, fatigue, cold aversion, low back ache, menorrhagia, light red puffy tongue, deep thready pulse |
| Acupuncture | RN 6, RN 4,LV14,LV3, SP 6, PC 6, KI 6 | RN 4, RN 5, SP 6, LI 4,LV3, Zi Gong Xue | UB 20, UB 23, RN 4, RN 6, SP 6, ST 40, PC 6, KI 6 |
| Herbs | Modified Xiang Ling Wan | Modified Gui Zhi Fu Ling Wan | Modified Si Jun Zi Tang + You Gui Wan |
Chinese Medicine & Post-Hysterectomy Care
Acupuncture and Chinese Medicine has been shown to help with post operative care and complications. If there is urinary retention, needle SP 6, SP 9, RN 3 and RN 4. For post operative gastrointestinal complications, needle ST 35, ST 36, ST 37, and ST 25. Ileus obstruction usually manifests as diminished bowel sounds, abdominal distention, and nausea and vomiting. Small bowel obstruction is cause by adhesions to the operative site. Early in its clinical course, a postoperative small bowel obstruction may exhibit signs and symptoms identical to those of ileus, initial conservative management as outlined for the treatment is same as the treatment of ileus. Xiao Cheng Qi Tang, Da Cheng Qi Tang or Lai Fu Zi can be used for gastrointestinal complications. For constipation, needle SJ 6 and ST 37. For post surgery pain, needle PC 6, ST 36 and SP 4 and administer Bu Zhong Yi Qi Tang or Gui Pi Tang.
Chinese Medicine, with or without Western Medicine is an excellent way of treating fibroids and managing symptoms. Our clinic offers integrated treatments which marry the Western and the Eastern for the most comprehensive treatments available today. Check us out!
Caroline Prodoehl, D.Ac.
References
Maciocia, Giovanni, 2011. Obstetrics and Gynecology in Chinese Medicine, 2nd Ed. Churchill Livingstone,Philadelphia,PA.
Wang, Yuxiang (2010). Integrated Gynecology Course Notes. TorontoSchoolof Traditional Chinese Medicine.