A Text-book of Diseases of Women

by Charles B. Penrose

Fibroid tumors are found both in multiparous and in nulliparous women—much more frequently in the latter than in the former. Single women and sterile married women are especially predisposed to this disease. There are two probable causes for this difference. The unceasing congestions of menstruation favor the development of the neoplasm; and, when once started, its further growth is not checked by the retrograde changes that accompany involution of the uterus, and that sometimes cause the disappearance of even large fibroids.

Fibroid tumors are essentially growths of the menstrual life of the woman. They usually first appear after the thirtieth year, and they continue to grow until the menopause. The size of the tumor and the severity of all the symptoms progressively increase during the active sexual period of life. It is very unusual for favorable retrograde changes or permanent amelioration of symptoms to occur during this period. In a woman with fibroid tumor of the uterus the menopause is delayed for five to fifteen years beyond the normal time. This is an important fact to be remembered in connection with the prognosis and the treatment of any case.

At the menopause, in the majority of cases, the growth of the tumor is arrested, and the retrograde changes that affect the genital apparatus involve also the fibroid tumor, and atrophy of the neoplasm, with marked diminution in size, and in some cases its complete disappearance, may take place. The tumor becomes quiescent, and the woman may finish her life in comparative comfort. This, however, is by no means always the case. The fibroid sometimes continues to grow after the menopause, and the suffering is sometimes so unbearable that the woman is finally driven to operation.

In some cases the tumor has developed entirely after the menopause has been reached.

At each menstrual period there is usually a decided increase in the size of the tumor and in the severity of the symptoms. And at these periods, in the case of a submucous or an interstitial fibroid, the cervical canal becomes more patulous.

Symptoms.—The chief symptom of fibroid tumor of the uterus is hemorrhage. This symptom is present in the great majority of fibroids of all kinds. It is not, however, universally present. I have removed tumors the size of the adult head, composed of interstitial and subperitoneal fibroids, from women who had never suffered with even slight menorrhagia. The hemorrhage appears in the form of menorrhagia or metrorrhagia. It may be an increase in the regular menstrual bleeding. It may appear as a periodical bleeding occurring every two weeks—a phenomenon that occurs in other diseases of the uterus and the endometrium. It may appear as a show of blood or a slight hemorrhage, after unwonted effort, between the regular menstrual periods. This may occur after straining at stool, coitus, or even emotional disturbance. And, finally, it may appear as a continuous bleeding from the uterus.

The cause of these hemorrhages is to be found in the increased area of the endometrium accompanying the uterine enlargement, and in the diseased condition of the endometrium.

The hemorrhage is not usually alarming in amount, and it may be somewhat controlled by rest in bed and the administration of ergot or other drugs. In some cases, however, it produces the most profound anemia, and in others, especially in the uterine polyp, the woman may literally bleed to death.

The symptom of hemorrhage is independent of the size of the tumor, but depends upon the position of the fibroid. As a rule, the hemorrhage is most severe with the uterine polyp, less severe with the submucous and the interstitial tumors, and least with the subperitoneal variety. In some cases, when the mucous membrane overlying a submucous tumor ruptures, the hemorrhage may come directly from venous sinuses in the capsule.

The hemorrhage also depends upon the variety of the growth. The edematous fibroid and the soft myoma appear always to be accompanied by profuse bleeding. In some cases the hemorrhage may occur periodically or continuously in old women who have passed the menopause, and in whom there had been no bleeding for several years. This has been observed in the small submucous fibroids which, after a period of quiescence, have gradually become polypoid, or which have undergone suppuration and disintegration. The hemorrhage, the offensive odor of the discharge, and the age and the history of the patient are very likely to lead to the diagnosis of cancer.