FIBROIDS

Fibroids are non-cancerous growths in the uterus. They are common and may not cause symptoms in many women. However, they can sometimes cause heavy periods, abdominal swelling and urinary problems. Treatment is available if symptoms occur.

What are fibroids?


A fibroid is a benign (non-cancerous) growth of the womb (uterus). They are also called uterine myomas, fibromyomas or leiomyomas. Their size can vary. Some are the same size as a pea and some can be as big as a melon. Fibroids can increase in size, decrease in size. They can occur anywhere in the uterus and are named according to where they grow:

  • Intramural fibroids are located within the muscular wall of the uterus. This is the most common place for fibroids to form.

  • Subserous fibroids grow from the outside wall of the uterus into the pelvis.

  • Submucous fibroids grow from the inner wall into the middle of the uterus (inside the uterine cavity beneath the lining of the uterus).

  • Pedunculated fibroids grow from the outside wall of the uterus and are attached to it by a narrow stalk.

How common are fibroids?

Fibroids are the most common growths arising from the female pelvis, occurring in at least 20-40 percent of women. Most fibroids are accidentally detected on scan done for some other pathology They are usually seen in women between 30 to 50 years of age.

Increased risk

  • 40 years or older

  • Black race

  • Family history of uterine fibroid tumors( if mother or sister has fibroids)

  • Nulliparity (No children)

  • Obesity

What causes fibroids?

A fibroid is like an overgrowth of smooth muscle cells. (The womb is mainly made of smooth muscle.) It is not clear why they develop. Fibroids are sensitive to oestrogen, the hormone that is made in the ovary. Fibroids tend to swell when levels of oestrogen are high - for example, during pregnancy. They also shrink when oestrogen levels are low - after the menopause. This shrinkage of the fibroids after the menopause may be delayed if you take hormone replacement therapy (HRT).

What symptoms and problems are caused by fibroids?

Almost 50 percent of women with fibroids do not have any symptoms. They are accidentally detected by routine examination by a gynecologist or by ultrasound(scan) for some other problem.
The symptoms depend on size and number of fibroids.

  1. Menstrual problems:-

    1. Heavy bleeding during menses or prolonged bleeding during menses (menorrhagia). Closer the fibroid to the uterine cavity, heavier the bleeding. Sometimes small submucous(just below uterine lining) fibroids will cause very heavy bleeding, but large subserous(on the surface of uterus) fibroids may not cause any menstrual problems at all.

    2. Painful periods (Dysmenorrhea).

    3. Frequent periods ( Polymenorrhea).

    4. Postmenopausal bleeding. After menopause, some women with fibroids may suddenly get bleeding

  2. Pressure symptoms - Due to pressure on surrounding organs

    1. Bladder pressure may cause increase urgency and frequency of urination

    2. Bowel pressure by very large fibroids will cause constipation

    3. Very large fibroids may block the venous blood flow and cause swelling of legs

    4. Abdominal swelling - Mostly seen in big size fibroids, specially in thin women

    5. Pain. - Pain is not a very common symptom, unless there are additional associated problems like pelvic infection, endometriosis. Big fibroids can cause vague abdominal discomfort.

Do Fibroids cause infertility( problem in conceiving).?

  • Fibroids generally will not cause a problem in conceiving. If a woman has infertility (cannot conceive) and is found to have fibroids, one should examine other causes of infertility and carry out other investigations first. Even if a woman fails to conceive, removal of a small subserous fibroid is not justified

  • Removal of a fibroid in an infertile patient should be considered only for significant fibroids( cavity distorting/large intramural) and that too after investigating all other causes of fibroids.

What problems can fibroids cause during Pregnancy?

Majority of fibroids do not cause any complications. Some of the complications which large fibroids and submucous fibroids cause are:

During Pregnancy:

  1. Abortions( specially submucous and large intramural fibroids)

  2. Premature delivery

  3. Small birth weight baby

  4. Bleeding during pregnancy, specially if placenta is near fibroid

  5. Red degeneration of fibroid, associated with severe pain and fever

During Delivery:

  1. Malposition and malpresentation of baby( Breech, transverse lie)

  2. Obstruction of labour-Large Cervical or lower segment fibroids

  3. Prolonged and dysfunctional labour which does not progress

  4. Heavy bleeding after delivery of baby and placenta(PPH)

  5. Failure of placenta to separate(Retained placenta)

  6. Infection after delivery

If you have a fibroid in pregnancy, do not worry. Just follow your doctor's advice. There is no need to panic. One need not remove a fibroid if you are attempting a pregnancy solely because of the fear of the complications of pregnancy.

Do all fibroids increase in size during pregnancy?

Some Fibroids increase in size during pregnancy, probably under the influence of the hormone estrogen, whose levels are very high in pregnancy. It is difficult to predict which fibroid would increase. Some may remain the same and some may even flatten and reduce in size.

How are fibroids diagnosed?

Fibroids are usually diagnosed by

  1. Internal (Vaginal examination) by a gynecologist

  2. Ultrasonography (scan).

Rarely, CT scan or MRI may be required, specially if any additional information is necessary, or if the scan is not very conclusive.

Do all fibroids need to be treated?

The mere presence of a fibroid does not require treatment. Only if the fibroid causes any symptoms, or if the size of the fibroid is very big so as to cause pressure symptoms, then treatment is warranted.

What are the treatment options for fibroids?

Observation
If your fibroids are not causing any symptoms then treatment is not usually needed. Your doctor may advise you to have a repeat scan and clinical examination to assess the growth and size of your fibroids.
Many women choose not to have treatment if they have symptoms that are not too bad. After menopause, fibroids often shrink and symptoms tend to go or ease. You can change your mind and consider treatment if symptoms get worse.

Medication to improve symptoms
There are no medications to make the fibroids disappear.
The following medicines are used to treat heavy periods and pain during periods, whatever the cause, including heavy periods that are caused by fibroids. These medicines may not work so well if your fibroids are large. However, one or more of the following may be worth a try if your symptoms are not very severe and the fibroids are small:

  • Tranexamic acid is taken 3-4 times a day, for the duration of each period. It works by reducing the breakdown of blood clots in the womb.

  • Anti-inflammatory medicines such as ibuprofen and mefenamic acid. These also help to ease period pain. They are taken for a few days at the time of your period. They work by reducing the high level of a chemical (prostaglandin) in the lining of the womb. Prostaglandin seems to contribute to heavy and painful periods.

  • The contraceptive pill (low dose pills) may help you to have lighter periods and can often help with period pain too.

  • Levonorgestrel intrauterine system (LNG-IUS) is similar to the coil that is used for contraception. It is inserted into the womb and slowly releases a regular small amount of progestogen hormone called levonorgestrel. It works by making the lining of the womb very thin, so bleeding is lighter. However it can sometimes be difficult to insert into the womb in women with fibroids.
    Medication to shrink the fibroids

Some women are given a gonadotrophin-releasing hormone (GnRH) analogue. This is a hormone medicine that causes you to have a very low level of oestrogen in your body. Fibroids shrink if the level of oestrogen falls. This can improve heavy periods and pressure symptoms due to fibroids. However, a low oestrogen level can cause symptoms similar to going through the menopause (hot flushes, etc). It may also increase the risk of osteoporosis. Therefore this treatment is given for a maximum of six months. Also, GnRh analogues are very expensive.
Other medications have also been tried to shrink the fibroids. These include Mifepristone, Gestrinone, Danazol.

These medications will not make the fibroids disappear. But they will reduce the size of the fibroids by 25-40% after 3 to 6 months of treatment. Also, these medications specially GnRH analogues are very expensive. Once the medications are stopped, some fibroids regrow to their original size within 6 months of discontinuation
Medical Treatment is used in

  1. Adjunct to surgical management to reduce size of fibroids, blood flow to uterus

  2. To delay surgery if patient is temporary unfit due to anemia

  3. In perimenopausal patients( those nearing menopause)

Surgery and other operative treatments

There are several different operations available to remove and treat fibroids.

Hysterectomy (Removal of the uterus).

This is the traditional and most common treatment for fibroids which cause symptoms. A hysterectomy may be a good option for women who have completed their family.
This can be done by making a bikini scar in the lower abdomen (Open Hysterectomy) or by Key hole surgery (Laparoscopically). Or, if the fibroids are small enough, the womb can be removed through the vagina so there are no scars (vaginal hysterectomy). The type of hysterectomy depends on the size of fibroids, number of fibroids, location of fibroids and the expertise of the surgeon. Laparoscopic Hysterectomy needs good surgical expertise, expensive equipment and hence is more costly then open hysterectomy. An open hysterectomy with a small incision can be a very good option.

Myomectomy

This is a possible alternative, especially in women who may wish to have children in the future. In this operation, the fibroids are removed and the womb is left. This procedure is not always possible. This operation can be done through an incision (cut) in the abdomen(open myomectomy), via keyhole surgery (laparoscopically) or through the vagina (hysteroscopically). The type of operation depends on the size, number and position of the fibroids. Recurrence of the fibroid is fairly common after a myomectomy. There is a risk of very heavy bleeding with this operation. Your surgeon should advise you that a hysterectomy may be needed if that situation arose.

Uterine artery embolisation

This procedure is done by a specially trained radiologist (X-ray doctor) rather than a surgeon. This procedure requires specialized centres and cannot be done in all hospitals. This procedure is an alternative to those who do not wish to do a hysterectomy. The effect of this procedure on future fertility is not fully known and hence not offered to those who want to conceive. It is best suitable for those patients with symptomatic fibroids who do not want fertility but want their menstrual function to continue (those who do not want to remove the uterus and those who do not want to conceive). It involves putting a catheter (a thin flexible tube) into an artery (blood vessel) in the leg. It is guided, using X-ray pictures, to an artery in the womb that supplies the fibroid. Once there, a substance that blocks the artery is injected through the catheter. As the artery supplying the fibroid becomes blocked it means the fibroid loses its blood supply and so the fibroid shrinks. The complete process of fibroid shrinkage takes about 6-9 months but most women notice a marked improvement in their symptoms within three months. There is a good chance of success with this procedure but it does not work in every case.

  1. Women without symptoms-------------------------observation, follow up

  2. Symptomatic women who do not----------------- Hysterectomy
    want fertility ,uterus preservation

  3. Symptomatic women who want -------------- Myomectomy
    Fertility and uterus conservation

  4. Symptomatic women who do not want---------- Uterine artery embolisation
    Fertility but want uterus conservation

If you have a fibroid, kindly discuss your treatment options with your gynecologist.
If you have any queries about fibroid uterus, you can write to me on my email or this website. I would be glad to respond as early as possible to solve them.