By Doctor Sumayya Ebrahim
Fibroids are the commonest benign or non cancerous gynaecological tumours that occur on the uterus. They are also called uterine myomas or leiomyomata. They originate from the muscle layer of this organ.
As many as 1 in 5 women may have fibroids during their childbearing years (from menstruation to menopause), although presentation occurs most commonly towards the end of this time.
No hereditary factors have been identified, but they are commoner in women of colour.
Obesity is associated with an increased risk of developing fibroids while cigarette smoking is associated with a decreased risk.
Women who have fibroids have fewer full term pregnancies and generally have fewer children than their counterparts without this problem, but it is not clear whether fibroids are a cause or consequence of small family size.
The cause is generally unknown. They do seem to be hormonally dependent though. The hormone estrogen has been linked to their growth. As long as menstruation occurs, fibroids will probably continue to grow, usually slowly, whilst they tend to shrink after menopause.
LOCATION AND SIZE
Fibroids can be microscopic in size, i.e. not visible to the naked eye or they can grow to be very large, weighing several hundred grams. They can occur as a single entity or be numerous. They are described by their location in the uterus. (see figure 1)
-myometrial -in the muscle wall of the uterus
-submucosal -just under the lining
-subserosal -just under the outside covering of the uterus
-pedunculated –occurs on a long stalk on the outside of the uterus or inside the cavity of
Often they can be asymptomatic and are detected on routine gynaecological examination. The commoner symptoms are:
- Menorrhagia (heavy bleeding): this can be associated with the passing of blood clots. If persistent, iron deficient anaemia can result. Less commonly there can be bleeding in-between periods as well.
- Pelvic Pain and Pressure:
Abdominal fullness or constipation: this is usually associated with large fibroids. If
large enough, they can exert pressure on surrounding pelvic organs like the
bladder or rectum, resulting in urinary frequency and retention or difficulty
Pain: Fibroids do not usually give rise to pain. If they do, the nature of pain may vary. In some instances, it is chronic backache, intermittent cramp like pelvic pain or increasing discomfort and cramps with a period. Deep pain with intercourse can also be present. When fibroids undergo complications such as torsion (twisting on a stalk) or a process called degeneration, acute pain may result.
- Subfertility: It is estimated that infertility is the major presenting factor in around
27% of women with fibroids. However, when compared with other causes of
infertility, they are relatively uncommon, being implicated in only approximately
3% of couples.
It is probable that a delay in child-bearing whether voluntary or involuntary, may predispose towards the development of fibroids and it is thus mandatory to investigate both partners fully to exclude other factors which may be contributing towards their subfertility.
Many women with fibroids do get pregnant and may well carry a pregnancy to full term without any complications. These pregnancies however, have to be carefully monitored.
HOW IS THE DIAGNOSIS MADE?
Clues to the presence of fibroids are provided by the symptoms of the patient. Pelvic examination by a general practitioner or gynaecologist usually reveals an enlarged uterus that may be irregularly shaped or lumpy. In obese women the diagnosis could be difficult.
Physical examination is usually reliable. If further clarity is required, a transvaginal or pelvic ultrasound may be done to confirm the diagnose. In rare instances pelvic MRI (Magnetic Resonance Imaging) is used. This is extremely expensive and often not necessary.
Fibroids have been mistaken for:
- ovarian tumours
- inflammation of fallopian tubes
- Uterine Adenomyosis ( a condition in which the uterine lining grows into the muscle wall of the uterus)Very occasionally in the event of abnormal bleeding, an endometrial biopsy may need to be performed to rule out cancer.HOW ARE FIBROIDS TREATED?
- Because fibroids are very rarely cancerous and usually slow growing, the decision made regarding an appropriate treatment option should not be rushed. The option chosen is usually done with careful consideration of the following factors:
- Need for future childbearing
- Severity of signs and symptoms
- How close the patient is to menopause.
- Patient’s feelings about surgery
- Overall general healthThere is no single best approach. In most instances, the best action to take after discussing fibroids is simply to be aware that they are present. EXPECTANT MANAGEMENT In general, medications for uterine fibroids treat symptoms like heavy bleeding, pain and pressure. They do not eliminate them. Certain medications that target menstrual hormones may shrink them.. Birth control pills (oral contraceptives): help to control heavy periods. cramps. This also can reduce bleeding by approximately 10%. Long-term usage. Cyclokapron: This medication affects the blood clotting pathway. It tends to reduce the . Iron supplements: prevents and treats anaemia that results from heavy periods. fibroids distorting the inner uterine cavity. It relieves pain and bleeding in the long-term,. Androgen (Danazol): This is a synthetic hormone-like drug similar to testosterone that and reduce uterine size. It is rarely used because of unpleasant side effects viz weight deeper voice. medication targets the pituitary gland in the brain and sets in motion certain hormonal levels drop, menstruation stops, fibroids shrink and anaemia often improves. It is not create a menopause state with all the attendant complications. fibroid size or to control symptoms in women close to the menopause. With this with the return of menstrual cycles, regrowth occurs.SURGERY OPTIONS:
- medication a reduction of 50% can be expected in fibroid size. Once stopped, however
- They are used only in special instances, mainly to achieve pre-surgical reduction in
- recommended that these drugs be used long-term (i.e. more than six months), as they
- events that stop normal ovarian function. Consequently, Estrogen and Progestrone
- . Gonadotropin-releasing hormone (Gn-RH) agonists (Synarel, Zoladex): This
- gain, mood swings, acne, headaches, excessive body hair growth and creation of a
- can stop menstruation and hence correct anemia. It can even shrink fibroid tumours
- but has no effect on elimination or shrinkage of fibroids.
- . Progestin-releasing intra-uterine device (Mirena IUD): This is used if there are no
- amount of bleeding or shorten the length of the period. It is used only during the period.
- however is associated with gastritis (inflammation of stomach lining) or peptic ulcers.
- . Non-steroidal anti-inflammatory drugs (NSAIDS) such as, Ibuprofen is used to control
- Medications include:
- This is also called “watchful waiting”. In the absence of symptoms they can be monitored at routine gynaecological examination. Very rarely do they become cancerous.
- Hysterectomy: (Removal of the uterus)
This option is the only proven permanent solution. The drawbacks are that it involves major surgery and permanently removes the ability to bear children. Removal of the ovaries during this procedure (usually not necessary) in a woman who is not menopausal, will create an immediate surgical menopause that may necessitate the introduction of hormone replacement therapy.
This option involves removal of fibroids only, with preservation of the uterus. There is always a risk, however, that fibroids re-grow. There are several ways that a myomectomy can be performed:
- a) Abdominal myomectomy: usually for large, multiple fibroids. An open abdominal approach is used.
- b) Laparoscopic myomectomy: for smaller and fewer fibroids: during this procedure, narrow instruments are inserted through small abdominal wall incisions to facilitate removal of the fibroids. Visualisation during the procedure is via a small camera attached to one of the instruments.
- c) Hysteroscopic Myomectomy: an option for fibroids located within the uterine cavity. A long slender instrument (hysteroscope) is passed through the vagina into the uterus and the fibroid is removed.
- Other procedures:
Myolysis: using a laparoscopic procedure, an electric current or laser is used to
vaporize or destroy the fibroids and to shrink the blood vessels that feed them. A similar procedure using liquid nitrogen to freeze them (cryomyolysis) can be used. The safety, efficacy and recurence risks of myolysis and cryomyolysis have yet to be determined.
Endometrial Ablation: This treatment, performed with special instruments inserted into the uterus, uses either heat, microwave energy or electric current to destroy the lining of the uterus. It will reduce blood loss but will not help with shrinking or destroying fibroids that are located in the uterine wall or surface.
Uterine artery embolisation: This technique is performed by an interventional radiologist. In this procedure, small particles are injected into the blood vessels feeding the fibroids to cut off blood flow and hence to cause them to shrink. The advantages over surgery involve no incision, and shorter recovery time.
NEWER EXPERIMENTAL OPTIONS:
MRI guided focused ultrasound surgery: This is a highly specialized technique with promising results, but its long-term effectiveness is unknown. Hence it is not widely available. During this procedure the patient is positioned within a specially crafted MRI scanner that allows visualisation of anatomy. Fibroids are located, targeted and destroyed using focused high-frequency, high energy sound waves. No incision is made.
Information is widely available in magazines and on the internet on alternative treatment options. These range from dietary recommendations to enzymes or herbal preparations. More research is required in these areas to determine their true efficacy.
FIBROIDS AND PREGNANCY: Points to note
- During pregnancy under the influence of hormones, existing fibroids may grow. They usually return to their original size around six weeks after the baby is delivered.
- Most women are able to carry babies to full term. Some end up with a preterm or premature delivery because there is insufficient room in the uterus.
- Caesarian section may be necessary because fibroids can occasionally obstruct the birth canal or result in the baby being positioned too incorrectly for natural birth.
- Heavy bleeding immediately after birth can be a complication of fibroids.