Fibroids

What are fibroids

Uterine fibroids are benign (not cancer) growths in the uterus. They occur in about 20-25% of all women. Most women who have fibroids are not aware of them because the growths can remain small and not cause symptoms. In other women they can cause problems because of their size, number, and location.

Fibroids are most common in women aged 30-40, but they can occur at any age. They are also called leiomyomas or myomas.

Although uterine fibroids are quite common, little is known about what causes them. They develop from the cells that make up the muscle of the uterus. The female hormone estrogen seems to increase their growth. The levels of estrogen in the body can rise or fall based on natural events. For instance, pregnancy causes an increase in estrogen and menopause causes a decrease. Medications also may cause a change in estrogen levels. Fibroids occur more often in black women than in white women.

The size, shape, and location of fibroids can vary greatly. Fibroids can range in size from small, pea-sized growths to large ones that may be more than 15cm wide. They may appear inside the uterus on its outer surface (subserous), within its wall (intramural), or under the endometrium protruding into the uterine cavity (submucosal).

Some of them if they grow, may distort the inside as well as the outside of the uterus. A very large fibroid may cause swelling of the abdomen. This can make it hard to do a thorough pelvic exam.

A woman may have only one fibroid or many of varying sizes. Whether they will occur singly or in groups, is hard to predict. They may remain very small for a long time, suddenly grow rapidly, or grow slowly over a number of years. Because it is hard to predict their growth, fibroids can be hard to treat.

Symptoms

Most fibroids, even large ones, produce no symptoms at all. When symptoms occur, they often include:

Changes in menstruation. Periods may become heavier, last longer and come more frequent. Menstrual pains (cramps) may be present and anemia may be the result of blood loss.

Pain. Patients may experience a low dull pressure in the abdomen. The pain may also focus at the lower back. The pain can vary in severity and occasionally it may become sharp.

Some patients may experience pain during intercourse.

Pressure symptoms. If fibroids are large and press the bladder, then patients may experience frequency and difficulty in urination. Similarly, if fibroids press the bowel, patients may complain for constipation, rectal pain, or difficult bowel movements.

Miscarriages and infertility. When other causes of miscarriage and infertility have been excluded, fibroids may be considered that contribute to some extent, to these problems.

Complications

Most fibroids do not cause problems and women may pass their whole life with no symptoms.

However if a fibroid is attached to the uterus by a stem, it may twist. This can cause pain, nausea, or fever.

Fibroids may also become infected. In most cases, this happens only when there is an infection already in the area.

In very rare cases, very rapid growth of the fibroid and other symptoms may signal cancer.

Fibroids also may cause infertility. Other factors should be explored before fibroids are called the cause of a couple's infertility. When fibroids are thought to be a cause, many women are able to become pregnant after they are treated.

Pregnancy and fibroids

A number of pregnant women have uterine fibroids which will not cause any problems for them or their babies.

However during pregnancy, fibroids may increase in size. Growth of fibroids may cause discomfort, feelings of pressure, or pain. Fibroids decrease in size after pregnancy in most cases.

Although fibroids do not usually causes serious problems to pregnant women, the risk of certain complications of pregnancy increase comparing to women who do not have fibroids. These complications are:

• Miscarriage (in which the pregnancy ends before 20 weeks)

• Preterm labour

• Unstable lie (in which the baby is in a position other than head down)

Usually no treatment of fibroids are needed during pregnancy. If a patient has symptoms such as pain or discomfort, rest will be recommended. Sometimes a pregnant woman with fibroids will need to stay in the hospital for some time because of pain, bleeding, or threatened preterm labor. Sometimes a fibroid can be in the way of the fetus when exiting the uterus. In most cases, even a large fibroid will move out of the fetus's way as the uterus expands during pregnancy. Rarely, a large fibroid can block the opening of the uterus or keep the baby from passing into the birth canal. In this case, a cesarean delivery is required. Women with large fibroids may have more blood loss after delivery.

Patients who have had a myomectomy before pregnancy, may need a Cesarean section, depending on the extent of the operation.

Diagnosis

During a routine pelvic examination, the doctor may suspect the presence of fibroids if their size is significant. Other times they can be diagnosed when investigations are performed for other medical conditions.

There is a number of investigations that may give information about fibroids:

• Pelvic Ultrasound: can give useful information about the number, the size and the location of fibroids.

• Hysteroscopy: This permits the doctor to see some fibroids inside the uterine cavity which may be the cause of heavy periods or even infertility.

• Hysterosalpingography (HSG): is a special X-ray test which may detect abnormal changes in the size and shape of the uterus and fallopian tubes.

• Laparoscopy: helps the doctor to see the inside of the abdomen. The doctor can see fibroids on the outside of the uterus and some inside the uterine wall with the laparoscope.

Imaging tests, such as magnetic resonance imaging (MRI) and computed tomography (CT) scans, may be used if there is need for more clarification.

Some of these tests may be helpful in checking on the growth of the fibroid over time.

Treatment

Fibroids that do not cause symptoms, are small, or occur in a woman approaching menopause, often do not require treatment.

Patients with fibroids should have regular checkups. If troubled with symptoms, they should consult a doctor sooner.

If a patient can not put up with the symptoms and the discomfort, then surgical treatment should be considered.

There is no medical treatment that can be used in order to shrink fibroids. Fibroids can only be treated effectively by removing them with surgery. Drugs, such as gonadotropin-releasing

hormone (GnRH) agonists, can only be used to shrink fibroids temporarily before surgery and they can not be used for long-term as they may have serious side-effects.

The fibroids may be removed with myomectomy or hysterectomy. The choice of treatment depends on patient’s age and wishes.

Myomectomy

Myomectomy is the surgical removal of fibroids from the wall of the womb which is then repaired and the womb left in place. Because a woman keeps her uterus, she may still be able to have children. If a woman does become pregnant after a myomectomy, she may need to have a Cesarean delivery. Sometimes, though, a myomectomy causes internal scarring that can lead to infertility.

Myomectomy is a major operation and sometimes it is impossible for every fibroid to be removed (as some may be too small to be discovered). Therefore fibroids may develop again, even after the procedure. If they do, more surgery is needed in 20-40% of cases.

Fibroids may be removed through an incision in the abdomen (laparotomy), or by laparoscopic surgery. With this method the fibroids can be removed through 3 or 4 small cuts on the abdomen of one inch size. The method used depends on the location and size of the fibroids.

Hysteroscopic surgery can also be used to remove fibroids that protrude into the cavity of the uterus. The fibroids may be removed with a resectoscope, a tiny wire loop that uses electric power and can be inserted through the hysteroscope. Although it cannot remove fibroids deep in the walls of the uterus, it often can control the bleeding these fibroids cause. This type of treatment is often done with pain relief, but you may not need to stay in the hospital.

Hysterectomy

Hysterectomy is the removal of the uterus including the cervix through a low ‘bikini line’ abdominal incision or, less commonly, through the vagina. The ovaries may or may not be removed. Hysterectomy may be needed if:

• Pain or abnormal bleeding persists

• Fibroids are very large

• Myomectomy in the past failed to remove all the fibroids.

• A woman no longer wants children

If hysterectomy is considered, other problems, such as diseases of the endometrium should be ruled out.