Fibroids

CONDITION

What are fibroids?

Fibroids are non-cancerous tumours of the uterus that appear during your childbearing years. They can appear on the inside or outside lining of your uterus, or within its muscular wall. Fibroids usually develop from a single smooth muscle cell that continues to grow.

Fibroids

Fibroids

What are the common names for fibroids?

Fibroids are also called myomas, fibromyomas or leiomyomas.

What is the percentage of population affected by fibroids?

Uterine fibroids are the most common type of benign growth that affects the uterus. It affects about 70% white women and more than 80% black women.

Which part of the body is affected?

The female reproductive system is made up of the following parts:

  • Vagina: opening of the reproductive system, which allows the entry of sperm
  • Cervix: narrow region that connects the vagina to the uterus
  • Uterus: womb, where a fertilised egg implants and grows to develop into a baby
  • Ovaries: organs on either side of the uterus, which release an egg each month in the prospect of a pregnancy
  • Fallopian tubes: narrow tubes that open out at the ovaries to pick up the released egg for fertilisation

The uterus is made up of three layers – The innermost layer is called the endometrium, the second layer, myometrium and the third layer, the serosa. Every month, the endometrial layer is built, and thickens in preparation to accept the fertilised egg for implantation and provide nourishment to the growing embryo, until birth. If the egg does not get fertilised, the layer of tissue that is formed sloughs off and passes out in the form of your monthly period.

How do fibroids affect you?

Uterine fibroids usually cause problems during your periods. They can be very painful, affect your fertility and cause complications during your pregnancy.

What are the different types of fibroids?

Fibroids are categorised by their location, which include:

  • Intramural: most common variety that grows in the uterine wall
  • Submucosal: grows in the uterine lining (endometrium), causing excessive menstrual bleeding and period pain
  • Subserosal: grows on the exterior wall of the uterus and sometimes appears as long stalks

What are the causes of fibroids?

Uterine fibroids may be caused by:

  • Genetic changes
  • Presence of high levels of oestrogen and progesterone hormones
  • Growth factors

Who is at risk of developing fibroids?

The risk factors for uterine fibroids are:

  • Increasing age
  • High BMI
  • High alcohol consumption
  • History of infertility

What are the signs and symptoms of fibroids?

In many cases, fibroids are asymptomatic. Symptoms may include:

  • Heavy periods
  • Lengthy periods that last more than a week
  • Painful periods
  • Spotting between periods
  • Painful intercourse
  • A sense of heaviness or pressure in the back, bowel and bladder
  • Frequent urination
  • A lump or swelling in the lower abdomen

What are the related disorders that occur with fibroids?

Uterine fibroids can be associated with anaemia, urinary problems, miscarriage, premature labour and infertility. Fibroids can prompt the growth of polyps in the uterine lining (endometrium). A polyp is a small protrusion that looks like a tiny ball on the end of a slim stalk. Endometrial polyps can also contribute to menstrual problems, such as excessive bleeding and pain.

How are fibroids diagnosed?

Fibroids can be detected using an ultrasound, where sound waves create a two-dimensional picture. The inside of the uterus can be examined with a hysteroscope, which is a thin tube passed through the cervix. A small camera may be placed at the tip of the hysteroscope, so that the interior of the uterus can be viewed on a monitor.

TREATMENT

What are the consequences of not treating fibroids?

Most uterine fibroids that do not cause any problem can be left untreated. They are benign, and may remain the same size or grow very slowly, causing no symptoms to mild signs and symptoms. As the levels of reproductive hormones drop with menopause, the fibroids usually shrink in size.

When should I consider watchful waiting of fibroids?

Close monitoring is required when your fibroids are not causing any problems and treatment is stalled for further development. In rare cases, it can rapidly grow into a tumour or to sizes that can cause significant problems, and make surgical removal difficult and risky.

What are the treatment options for fibroids?

Treatment depends on the location, size and number of fibroids and may include:

Non-surgical treatments

  • Medication: such as hormones, are used in combination to shrink the fibroids prior to surgery
  • Uterine artery embolisation (UAE): blocking the blood supply to the fibroids and in turn causing them to shrink
  • Endometrial ablation: removing the uterine lining containing the fibroid with the help of laser, heated wire loop or hot liquid in a balloon
  • MRI-guided procedures: ultrasound or laser energy passed through small needles that are inserted under the guidance of MRI

Symptoms caused by uterine fibroids usually resolve by the time you reach menopause. Hence, if you are nearing menopause you can consider controlling symptoms with home treatment and medicine.

Surgeries

  • Open surgery: required for the removal of larger fibroids
  • Laparoscopy: keyhole surgery is performed where a thin tube is inserted through the abdomen to remove the fibroids
  • Myomectomy: uterine fibroids are excised, retaining the ovaries
  • Hysterectomy: a part or all of the uterus is removed
  • Hysteroscopy: fibroids are removed via the cervix, using a hysteroscope

Am I candidate for fibroid surgery?

You may be a candidate for surgical treatment in the following cases:

  • Do not respond to conservative treatments
  • Post menopause, with growing tumours
  • Grow large enough to cause pressure on other organs, such as the bladder
  • Grow rapidly
  • Profuse bleeding that can lead to anaemia and lifestyle problems
  • Chronic abdominal pain, or pelvic or lower back pressure
  • Cause problems with regard to fertility

How do I prepare for surgery?

You will be advised to stop eating or drinking anything at least 6 hours before the procedure. Discuss all the medications that you are taking on a regular basis so that your doctor can advise you on the ones that you can safely continue and those that may need to be stopped during the time of surgery.

How is surgery for fibroids performed?

Fibroid surgery can be performed by an open or minimally invasive laparoscopic approach. While open surgery requires a large incision on your abdomen to access the fibroids, laparoscopy requires only small incisions to allow the insertion of surgical instruments and a narrow lighted tube with a camera, called a laparoscope. The scope relays images of the surgical site onto a large monitor, which can be viewed by your surgeon. There are two surgical techniques that can be followed to treat fibroids:

Myomectomy

Your surgeon will cut the fibroid into pieces using laser, cryotherapy (extreme cold) or cautery (extreme heat), and remove them through a small incision made in the abdominal wall. A larger incision is required if the fibroid is removed without being cut into pieces. In some cases, the fibroid is removed through the vagina by a process called colpotomy.

Following the excision, the defects are irrigated to control bleeding and sutured.

Hysterectomy

Your surgeon separates the uterus from the surrounding organs and blood vessels, by ligating and sealing the open ends. The uterus is then removed via the abdominal incision or vagina. Your surgeon will also remove the ovaries only if you have a risk of developing ovarian or breast cancer. Usually, the ovaries are spared.

What can I expect after surgery?

Following laparoscopic surgery, you may be able to go home after a night’s stay in the hospital. An open approach may require a longer stay. You will be prescribed pain medication to keep you comfortable and advised to move around after the surgery.

What are the pros and cons of fibroid removal surgeries?

The laparoscopic approach to fibroid treatment is associated with more advantages than open surgery. These include:

  • Less blood loss
  • Lower postoperative pain
  • Fewer complications
  • Faster recovery
  • Minimal scar formation

An added advantage of myomectomy is the ability to preserve your fertility. However, laparoscopic myomectomy may be associated with challenges in suturing the defect left after the removal of the fibroid as well as the detection and removal of small uterine fibroids, and large fibroids from difficult locations such as lower region of the uterus or junction of the cervix.

On the other hand, while you will not be able to conceive in the future after hysterectomy, the complete removal of the uterus and sometimes the ovaries as well, ensures complete cure of fibroids.

Describe the stages of recovery and care plan?

You can start exercising 4-6 weeks after surgery and have intercourse 8 weeks after surgery. Give your uterus at least three months to heal before attempting to get pregnant after myomectomy. You are advised not to lift any heavy object until 4-6 weeks after surgery.

If your ovaries are removed as well, you will be prescribed hormone therapy to avoid premature menopause and the symptoms such as hot flashes, that are associated with it.

What are the potential complications of fibroid removal surgery?

As with most surgical procedures, fibroid removal surgeries may be associated with certain complications such as:

  • Infection
  • Bleeding
  • Blood clots
  • Conversion to an open surgery
  • Hernia
  • Bowel obstruction
  • Injury to neighbouring organs (ureter, bladder, bowel or blood vessels)
  • Recurrence
  • Chances of uterine rupture during labour
  • Sometimes even death

What is the downtime of fibroid removal surgery?

You will usually be able to resume your normal work within a week. If you engage in physically demanding work, you are advised to take rest for 2 to 3 weeks.

What is the cost of fibroid removal surgery?

Any costs involved will be discussed with you prior to your surgery.

What is the likelihood of fibroid recurrence? How can it be managed?

Fibroids can recur even after surgery. This may require further surgery.

What are the lifestyle recommendations to manage fibroids?

Menstrual pain caused by fibroids can be managed with:

  • Exercise
  • Using pads instead of tampons
  • Rest
  • Heat application

What are the current research regarding fibroids?

Extensive research is being done to find better treatment options for fibroids. Some of the recent studies are listed below:

  • Yoon J, Spies JB, Caridi TM. Benign Metastasizing Leiomyomas Following Myomectomy and Uterine Artery Embolization. Cardiovasc Intervent Radiol. 2017 May 23. doi: 10.1007/s00270-017-1696-z. [Epub ahead of print]
  • Nakayama K, Tsukao M, Ishikawa M, et al. Total laparoscopic hysterectomy for large uterine cervical myoma. Mol Clin Oncol. 2017 May;6(5):655-660.
  • Vercellini P, Frattaruolo MP. Uterine fibroids: from observational epidemiology to clinical management. BJOG. 2017 May 12. doi: 10.1111/1471-0528.14730. [Epub ahead of print]