Uterine leiomyomas, or fibroids, are common non-cancerous growths within the uterus. These benign tumors are often discovered in women during their reproductive years and are generally not associated with an increased risk of uterine cancer. Intramural leiomyomas are a specific type, classified by their location within the uterine wall.
Understanding Intramural Leiomyomas
Intramural leiomyomas are a type of uterine fibroid that grows within the muscular wall of the uterus, known as the myometrium. These fibroids can vary significantly in size, ranging from microscopic to quite large, and may appear as single or multiple formations. Their position within the uterine muscle can cause the uterus to enlarge.
Unlike subserosal fibroids on the outer surface or submucosal fibroids protruding into the uterine cavity, intramural fibroids are embedded within the muscle. This internal location influences the symptoms they cause. Intramural fibroids are considered the most common type of uterine fibroid, occurring in up to 70% of women by age 50.
Recognizing the Symptoms
Symptoms of intramural leiomyomas can vary widely depending on their size, number, and location within the uterine wall. Smaller fibroids may not cause noticeable symptoms, while larger ones can lead to discomfort. One common symptom is heavy or prolonged menstrual bleeding (menorrhagia), which can sometimes lead to anemia due to blood loss.
Intramural fibroids can also cause pelvic pain or a feeling of pressure. This discomfort might be more pronounced during menstruation or intercourse. Depending on their position (e.g., anterior or posterior), these fibroids can press on nearby organs, leading to symptoms like frequent urination, difficulty emptying the bladder, or constipation. Backache can also occur, particularly if fibroids are on the back wall of the uterus.
Diagnosis and Evaluation
Intramural leiomyomas are often identified during routine gynecological examinations or through imaging. A physical examination, including a pelvic exam, is an initial step in identifying abnormalities. Patient history, detailing symptoms, guides the diagnostic process.
The primary imaging tool for diagnosing intramural fibroids is ultrasound. Both transabdominal and transvaginal ultrasound are commonly used. Transvaginal ultrasound often provides superior detail for pelvic structures. For a more comprehensive evaluation, particularly to determine the number, size, and location of fibroids, Magnetic Resonance Imaging (MRI) is often utilized. MRI offers higher resolution images than ultrasound and helps differentiate fibroids from other conditions.
Treatment Approaches
Treatment for intramural leiomyomas is tailored to the individual, considering fibroid size, number, symptom severity, and fertility desires. For asymptomatic or mildly symptomatic cases, a “watchful waiting” approach may be recommended, involving periodic ultrasound monitoring.
Medical treatments manage symptoms and include hormonal therapies. Oral contraceptives or hormone-releasing intrauterine devices (IUDs) regulate menstrual bleeding and reduce cramping. Gonadotropin-releasing hormone (GnRH) agonists, such as leuprolide acetate, temporarily shrink fibroids by reducing estrogen and progesterone levels, often used before surgery to reduce fibroid size. Iron supplements may also be prescribed to address anemia from heavy bleeding.
Minimally invasive procedures offer alternatives to surgery. Uterine artery embolization (UAE) involves injecting particles into the blood vessels supplying the fibroids, cutting off their blood flow and causing them to shrink. Radiofrequency ablation (RFA), including Acessa or Sonata, uses heat to destroy fibroid tissue. These procedures reduce symptoms while preserving the uterus.
Surgical options are considered when other treatments are ineffective or for specific patient needs. Myomectomy removes fibroids while preserving the uterus, often preferred by women desiring fertility. This can be performed through abdominal incision, laparoscopically, or hysteroscopically. Hysterectomy, the complete removal of the uterus, eliminates fibroids and is considered when childbearing is complete or for severe, recurrent symptoms.
Impact on Fertility and Pregnancy
Intramural leiomyomas can influence fertility and pregnancy outcomes due to their location within the uterine wall. Large or numerous fibroids may distort the uterine cavity, affecting embryo implantation. They can also interfere with sperm and egg interaction or embryo migration. While many women with intramural fibroids achieve successful pregnancies, their presence is a consideration for those planning to conceive.
During pregnancy, intramural fibroids may increase complication risks, including miscarriage, preterm labor, or fetal malpresentation. Larger fibroids might outgrow their blood supply, leading to pain. They can also affect the mode of delivery, with a higher likelihood of requiring a cesarean section. Careful monitoring of fibroids and pregnancy is often part of management.