The following article has been contributed by leading Harley Street Gynecologist Mahantesh Karoshi.
Uterine fibroid tumours are benign (noncancerous) growths of the uterus and may also be called myomas, leiomyomas, or just fibroids. They arise from the smooth muscle connective tissue that lines the uterus (myometrium) and can grow in any location in and around the uterus. Some women only develop one fibroid or just a few, while others may have as many as 10 or more. Their size also varies tremendously; some are so small that a microscope is needed to visualize them, while others grow as large as a watermelon.
Since not all fibroids cause symptoms, not all fibroids will be diagnosed, which means prevalence rates may be higher than current estimates. In some cases severe symptoms may develop that require urgent medical attention. The chance that fibroids will turn cancerous is quite rare. According to several studies cited only about 0.002 to 0.003 per cent of cases of leiomyomas develop into cancer (ie, uterine leiomyosarcomas).
There are 4 main types of fibroids:
- Submucosal fibroidsGrow into the cavity of the uterus.
- Intramural fibroidsGrow in the muscle wall of the uterus.
- Subserosal fibroidsGrow on the outside lining of the uterus.
- Pedunculated fibroidsGrow on a stalk off of the outside of the uterus.
HOW COMMON ARE FIBROIDS?
In fact, an estimated 1in 3 women will be diagnosed with fibroids at some point in their lives. Most of the time fibroids grow asymptomatically. However, when they are symptomatic, they can have a major impact on a woman’s quality of life. They’re usually diagnosed during childbearing years, typically between the ages 30-40. One reason diagnoses occur more commonly in this age group may be because fibroids can increase in size during pregnancies and therefore finally begin causing symptoms.
WHAT CAUSES FIBROIDS
Fibroids occur when a single uterine smooth muscle connective tissue cell replicates until a cluster of cells form a mass that is distinct from the normal muscular tissues. Doctors and researchers are still investigating what triggers this deregulated growth; however no one really knows why fibroids develop.
Some possibilities are genetic factors (fibroids tend to run in families) or hormonal causes (fibroid tissue has more oestrogen and progesterone receptors than normal uterine tissue and therefore are more sensitive to alteration of these two hormones during the menstrual cycle). Other observed tendencies include the fact that:
- fibroids do not develop before the onset of menstruation when hormonal changes occur
- fibroids will continue to grow and/or reoccur while oestrogen is present
- fibroids often grow very quickly during pregnancy when the body is producing extra oestrogen
- fibroids often shrink and/or disappear after menopause when the body stops producing oestrogen
- fibroids rarely developafter
WHAT ARE THE SIGNS AND SYMPTOMS OF FIBROIDS?
Changes in menstruation Fibroids distort the lining of the uterus and muscular wall of the uterus, which can lead to a variety of changes in menstrual cycle, including:
- Periods lasting longer than 7 days
- More frequent periods
- Heavier than normal bleeding during period (menorrhagia)
- Painful periods
- Irregular bleeding between periods
Pain As fibroids grow, they can exhaust their blood supply, causing intense pelvic pain and sometimes fever. The mass of the fibroids can also cause other painful symptoms including:
- Pelvic pain
- Abdominal pain
- Sudden or severe abdominal pain
- Pain with intercourse (dyspareunia)
- Pain during menstruation
- Lower back and thigh pain
Pressure Because the uterus is bordered in front by the bladder and behind by the rectum, larger or growing fibroids can cause pressure symptoms, including:
- Urinary frequency or difficulty with urination
- Bowel irregularities such as constipation, rectal pressure and difficulty with bowel movements
- Abdominal bloating and cramping
Pregnancy Miscarriages Fibroids can distort the uterus so a pregnancy cannot grow properly secondary to the mass of the fibroid. Also, the blood supply of the pregnancy can be diverted to a growing fibroid. In these cases, pregnancies can miscarry.
Infertility Fibroids can grow near the fallopian tubes and cervix blocking proper motility of sperm and egg through the uterus and tubes. Fibroids can also line the cavity of the uterus making it impossible for a pregnancy to properly implant in the uterus.
Anaemia and other serious symptoms Some women with fibroids lose so much blood that they develop anaemia (low blood cell count). The most common symptom of anaemia is fatigue (feeling tired or weak). Other common symptoms include dizziness, shortness of breath, chest pain, syncope (passing out), headache, cold hands and feet, sweating, fast heart rate, irregular heart beat (arrhythmia), pale skin, and fluid imbalances (electrolyte imbalance, etc.), just to name a few. These symptoms may arise because of iron deficiency and/or because woman’s heart has to work harder.
HOW ARE FIBROIDS DIAGNOSED?
Fibroids can be diagnosed multiple ways. Most commonly, fibroids are diagnosed by abdominal or pelvic exam by a doctor. Doctors may be able to feel an enlargement or an irregular contour to the uterus.
A variety of imaging modalities are used to aid in the diagnosis of fibroids, including:
- UltrasoundA probe over the abdomen or inside the vagina that can visualize the uterus and any masses within it.
- MRI(magnetic resonance imaging) This imaging technique is very sensitive in detecting the exact size and location of fibroids: however, it is very expensive.
- Outpatient hysteroscopy: A tiny telescope (<2mm) inserted into the uterus under local anaesthesia will help to identify fibroids in the cavity of the uterus
- CT-scan – Not a preferred mode of investigation, but CT scan used for other reasons can pick up fibroids in asymptomatic women.
Which fibroids need treatment?
If fibroids are causing symptoms that are affecting her day-to-day work or lifestyle or affecting organs (kidneys, bladder and or bowel function), a woman may need treatment. Serious symptoms requiring immediate medical attention are sudden or severe abdominal pain, heavy menstrual bleeding causing anaemia (low red blood cell count), any bladder or bowel symptoms, recurrent miscarriages and infertility.
is THERE A TREATMENT FOR FIBROIDS?
There are a variety of treatment options for fibroids, ranging from medical management of symptoms to definitive surgical management. As with any medical intervention, there are always risks and benefits that must be carefully considered on a case-by-case basis before choosing a treatment plan.
ARE THERE MEDICATIONS to control FIBROIDS or fibroid related symptoms?
Fibroids cannot be eliminated by medications but symptoms can be managed with certain medications:
- Combined oral contraceptive pillsThe birth control pill contains both oestrogen and progesterone hormones, which can help decrease bleeding symptoms. Some studies show that they can slow the growth of fibroids, but cannot decrease the size of the fibroid
- Progesterone Releasing IUS(Mirena) This device is inserted into the uterus and contains a small amount of progesterone hormone. This can decrease bleeding symptoms.
- Progestin pillsThese pills contain progesterone hormone, which will decrease bleeding side effects. These pills have no effect on the fibroid itself.
- Gonadotropin Releasing Hormone (GnRH) agonistsThese medications (Zoladex, Prostap etc.) suppress the release of natural oestrogen and progesterone production, which then causes shrinkage of fibroids and decrease in bleeding symptoms. These medications cause a temporary menopausal state and are often associated with hot flushes. Typically, a doctor may recommend this medication to correct anaemia from heavy bleeding and shrink the size of the fibroid prior to surgical management. GnRH agonists are not a long-term management option.
- NSAIDs(non-steroidal anti-inflammatory drugs) These are pain medications that may help with the painful symptoms of fibroids but will not effect the fibroid or any bleeding symptoms.
WHAT SURGICAL OPTIONS available for FIBROIDS?
There are a variety of surgical options. They range from minimally invasive procedures to open abdominal (laparotomy) surgeries. Some procedures are performed by a gynaecologic surgeon and others are performed by an interventional radiologist.
HERE ARE THE DETAILS:
You can have an operation called a myomectomy where just the fibroids are removed from the uterine tissue. There are different types of myomectomies:
- Hysteroscopic myomectomyA camera with an electric loop attachment is placed inside the cavity of the uterus through the vagina and the fibroids are visualized and removed by shaving them off the wall of the uterus. One should be aware that, this can only be done for submucosal fibroids that are protruding into the cavity of the uterus. This is a day case surgical procedure and patients can go home the same day of surgery with minimal side effects.
- Abdominal myomectomyA large incision is made on the abdomen to gain access to the uterus. The fibroids are removed by cutting into the uterus and taken out through the abdominal incision. The uterus is then sewn back together. Fibroids that are on the outside or in the wall of the uterus can be removed this way. Because of the large abdominal incision, patients are hospitalized for 2-4 days after surgery.
- Laparoscopic myomectomyA small camera is placed through the navel, 2-3 small 0.5-1.0cm incisions are made in the lower abdomen and the surgery is performed through these small incisions. Fibroids on the outside and in the walls of the uterus can be removed this way. They are cut into small pieces and pulled out through the small laparoscopic incisions. Because of the complex nature of laparoscopic dissection and suturing, special surgical expertise typically is required.
WILL A MYOMECTOMY INCREASE one’s CHANCES OF GETTING PREGNANT?
Pregnancy rates have been reported as high as 60% after myomectomy regardless of which type of myomectomy is performed.
WILL I HAVE TO HAVE A CESAREAN SECTION IF one GETs PREGNANT AFTER A MYOMECTOMY?
Some patients are told they have to have a caesarean delivery if they have a myomectomy is because of the theoretical risk of uterine rupture during labour. No randomized trials have been performed on this subject. There are very few case reports of uterine rupture after myomectomy, particularly with hysteroscopic and laparoscopic myomectomies. However, one should discuss this with their specialist doctor, as patients have a unique health history that must be carefully evaluated.
WHAT IS THE ROLE OF UTERINE ARTERY EMBOLIZATION IN THE TREATMENT OF FIBROIDS?
Uterine artery embolization (UAE) is an outpatient procedure performed by an interventional radiologist. A catheter is placed through the groin into the uterine artery. Small coils or pellets are used to block the uterine artery, which gives its blood supply to the uterus and fibroids. Without adequate blood supply, the fibroids shrink and symptoms of pressure and heavy bleeding can also reside. UAE is recommended for a select group of patients who are premenopausal with symptomatic fibroids within the uterine wall and where future fertility is not a primary concern. UAE is also helpful for patients for whom surgery is too risky. Although it is a relatively safe procedure, there are some severe side effects, including fever, pain, infection, necrosis of uterine tissue, premature ovarian failure, infertility, and increased risk of hospital readmission compared to other minimally invasive myomectomy procedures.
WHEN IS A HYSTERECTOMY INDICATED FOR THE TREATMENT FIBROIDS?
This is a difficult question to answer, since it depends on many factors. However, in general, many specialists will suggest hysterectomy in peri or postmenopausal patients whose health history may indicate a higher risk and whose fibroids are causing uncontrollable haemorrhaging and other severe symptoms, which haven’t responded to more conservative treatments. Hysterectomy may also be recommended for severe cases of fibroids where the risk of myomectomy seems too great or when patients have other risk factors or co-morbidities, including bleeding disorders, diabetes, and adenomyosis.