WHAT ARE FIBROIDS?
Uterine fibroids, also known as leiomyomas, are non-cancerous tumors of the womb or uterus. These tumors start in the myometrium(muscle) of the uterus. They occur in nearly half of all women over the age of 30 and this too may be underestimated as fibroids have been found in 77 per cent of uteri removed for reasons other than fibroids.
WHAT CAUSES FIBROIDS?
Fibroids only occur after puberty and shrink after menopause. The female sex hormones such as oestrogen and progesterone are most likely involved in tumour growth. However, other growth factors as well as some genetic factors may also be involved. Though the causes are not known , women who have never had children, or are obese are particularly at risk.
It is difficult to know if fibroids run in families as they are so common. Women who have used the combined oral contraceptive pill or other drugs as contraceptive agents are protected against developing fibroids.
ARE FIBROIDS CANCEROUS?
Fibroids are non cancerous. Cancer of fibroids (leiomyosarcoma) is very rare and begin as cancers Benign tumours do not transform to malignant ones.
- Fibroids occur in more than 25% of women over 30 years of age.
- Commonest cause for hysterectomy in women under 50 years.
- Growth of fibroids depends on oestrogen and progesterone.
- Benign fibroids do not become cancerous.
SYMPTOMS OF FIBROIDS
- Heavy Periods (Menorrhagia) - Heavy periods occur in 30 per cent of women having fibroids .Tiredness, weakness and emotional changes may occur secondary to the anaemia which results from the excessive blood loss.
- Bowel and Bladder Symptoms - Pressure caused by the fibroids may result in bowel and bladder symptoms Rarely complete blockage of urine may occur requiring a catheter to be passed.
- Lump or Bloating - Discovery of a lump in the abdomen and / or distension of the abdomen may be the fi rst change noticed. The distention may be partly due to the fibroid, which is fi rm to feel, or bowel that is pushed and distended, which feels soft.
- Sexual Discomfort or Difficulty - If the fibroid (s) expand the uterus and take up considerable space within the pelvis full vaginal penetration may be prevented. This may reduce enjoyment for the female and male.
- Pain - Menstrual. Period pain(dysmenorrhoea) may be due to stretching of the uterus, or the response of trying to expel the fibroid , creating ‘labour like’ pains.
- Pressure on neighbouring organs. Back pain, or pain in the lower abdomen, may result from pressure on the spine, pelvic bones, nerves or tissue , bowel and bladder.
COMPLICATIONS OF FIBROIDS
- Degeneration - Occasionally the blood supply to the fibroid is blocked and it undergoes degeneration resulting in swelling and release of chemicals which can cause severe pain.
- Twisting - The fibroid may grow outside the uterus and is connected to the uterus by a narrow stalk, may twist on itself and cause severe pain and tenderness.
- Infection - Rarely fibroids become infected, which usually occurs when they are protruding in the vagina or after childbirth.
- Cancer - They are very rare ,a cancerous fibroid is called ‘sarcoma’.. There may be no symptoms to distinguish a sarcoma from a simple fibroid. Sometimes a rapid increase in size may raise the suspicion of the presence of a sarcoma.
TYPES OF FIBROIDS, SYMPTOMS & PROGRESSION
Even though 25 per cent of women above the age of 30 years have fibroids, only about half experience symptoms. Fibroids may be either single or multiple and may vary from being as small as a pea to as large as a football. Their site in the womb may also vary. They may be present within the cavity of the uterus (submucosal), within the muscle of the uterus (intramural), or in the outer layer and protrude from the uterus (subserosal).
- Submucosal fibroids - Submucosal fibroids protrude inwards into the cavity of the uterus and are commonly associated with heavy bleeding and may cause infertility.
- Intramural fibroids - Intramural fibroids begin as little lumps in the muscle of the uterus that grow, making the uterus larger and distort its shape. This type of fibroid may play a role in heavy periods and pressure symptoms.
- Subserosal fibroids - Subserosal fibroids grow and protrude from the outer surface of the uterus, vary greatly in size, and may be multiple.
FIBROIDS AND INFERTILITY
Fibroids may reduce the chances of becoming pregnant in a variety of ways:
- By causing heavy periods and subsequent anaemia resulting in ill health and tiredness.
- Very large fibroids may bulge into the vagina and cause pain or discomfort during intercourse.
- Fibroids in the fundus of the uterus occasionally block the tubes preventing formation of embryos.
- Fibroids inside the cavity of the uterus may prevent implantation of the embryo.
- Multiple fibroids in the wall of the uterus reduce IVF success rates, perhaps by affecting the lining of the uterus andthe implantation of the embryo.
- Most fibroids do not need to be removed before attempting to become pregnant unless the fibroid is causing infertility.
- Fibroids in Pregnancy - Fibroids may not only make it diffi cult to get pregnant, but they may cause miscarriage, malnutrition of the foetus, abnormal position of the baby in the uterus, obstruction during labour requiring caesarean section, and bleeding after delivery of the baby.
- Most fibroids do not need to be removed before attempting pregnancy.
- Removal of fibroids before pregnancy may be required if they are large ,cause severe bleeding, grow rapidly, or protrude into the uterine cavity.
- Detection and Diagnosis - Clinical Examination: Fibroids are often diagnosed during vaginal examination by the gynaecologist at the time of a routine Pap smear/ general health checkup . Ultrasound: The best and least expensive test to diagnose the presence of fibroids .The addition of Color Doppler measures the blood fl ow and helps to determine the diff erence between fibroids, adenomyosis (endometriosis inside the uterus) and some cancers.
- Computerised tomography - CT is another method of assessing lumps and masses in the pelvis but is not as specific as ultrasound and is inferior in its ability to diff erentiate between the uterus and ovaries.
- Magnetic Resonance Imaging (MRI) - This sophisticated X ray is most the specific imaging for the female pelvis with precision, definition and accuracy . It may be helpful in distinguishing between fibroids and adenomyosis.
- Management Strategy - Management depends upon size of the fibroid, the position of the fibroid in the uterus, the age of the women, the desire to conceive, and the attitude to surgery. Symptoms of heavy bleeding, pain during periods, or pressure on the bladder, bowel and spine usually require treatment. The anemia due to the excessive bleeding can be managed by oral iron or intravenous iron sucrose therapy if oral iron not tolerated .
Fibroids which are growing in size may need treatment, as delay may increase the difficulty of surgery and lead to more extensive surgery. Most often fibroids up to 3 cm need not be treated unless they are in the cavity of the uterus.
In some circumstances it may be considered prudent to remove a fibroid even if it is not causing any symptoms, e.g. a symptom-free 7cm fibroid may be dealt with laparoscopically easily, whilst in a few years time if it doubles in size and causes symptoms the surgery is likely to be more complex.
PREVENTION OF FIBROIDS
- Weight control – reduction of obesity
- Early child-bearing
- Oral Contraceptive Pills
No Treatment may be required
- No symptoms
- Small fibroids
- After menopause
If no treatment is given regular ultrasonography should be done to monitor the growth of fibroids.
Treatment may be required
- Symptoms – heavy bleeding, pain
- Large fibroid in young women
- Rapid growth in fibroid
- Infertility related to fibroid
- Suspicion of cancerous fibroid (sarcoma)
Shrinkage of fibroids before surgery
The shrinkage effect of GnRH analogues drugs is sometimes quite dramatic but is only temporary and may not be suffi cient to overcome the ill eff ects the fibroid on fertility. They can regrow in 3 to 6 months so the drug therapy maybe useful for postponement of surgical removal.
Removal of Fibroids (Myomectomy)
Myomectomy, the surgical removal of fibroids while preserving the uterus and its child bearing function is the defi nitive treatment.
Techniques of removal
- Hysteroscopic - Telescope via birth passage
- Laparoscopic - By Small Key Hole Incisions in the abdomen
- Laparo-hysteroscopic - By a combination of Hysteroscopy & Laparoscopy
- Laparotomy - By an incision in the abdomen