Fibroid

What are fibroids?

Firboids are slow-growing tumours found in the uterus. They may be found in in the outer layer (serosal), the middle layer (intramural), or in the inner layer (submucosal) of the uterine wall, and may protrude partially or wholy into the uterine cavity (pedunculated).

Fibroids are almost always benign.  

Malignant or cancer change in fibroid, called leiomyosarcoma, is rare, with estimated incidence of 0.2% of uterine fibroids. At present, there are no reliable clinical, imaging  or blood tests to distinguish between a fibroid and a leiomyosacrcoma.  The diagnosis is from histology after the fibroid or uterus has been removed.

How common are fibroids?

 It is estimated that 30 to 70% of women of childbearing age may have fibroids, making them the most common tumours of the uterus.

What are the symptoms of fibroids?

The majority of women who have fibroids do not have any abnormal symptoms. Therefore, most women are not aware of their presence and may never be troubled by them. More often than not, fibroids are  incidentally detected on routine pelvic examination, ultrasound check during antenatal screen or  for abnormal bleeding.

Symptoms which may be due to fibroids include:

  • abnormal bleeding - prolonged, heavy menstruation
  • pelvic pressure or discomfort
  • bladder symptoms - frequency, voiding difficulty
  • bowel symptoms - constipation, abdominal bloating
  • pain - backache, lef pain, rarely severe pelvic pain (due to acute torsion, degenerative changes, fibroid expulsion through the cervix)

In general, locations (submucosal, intramural, serosal), size and number of fibroids strongly determine the types and chance of developing symptoms.

What problems can fibroids cause?
  • Anemia - from heavy menstrual blood loss
  • Bladder problems - incontinence, frequency, voiding difficulty
  • Constipation
  • Pain - back, leg, abdomen
  • Infertility, recurrent miscarriage, pregnancy complications - submucosal fibroids may distort the endometrial cavity and affect sperm and egg interaction or implantation.  This may result in infertility or miscarriage.  Large / multiple intramural fibroids may increase the risk of fetal malpresentations or premature labour.
  • Malignant cancerous change - uncommon, mostly unpredictable.  Growth of fibroids after menopause should raise suspicion/concern of malignant change.
When should fibroid be treated?

Firboids may need to be treated if one or more of the above-mentioned clinical problems become troublesome.

The following tests/investigations may help your doctor decide if your fibroids require treatment:

  • Ultrasound - pelvic or transvaginal
  • Hysterosonography - where saline is instilled into the uterine cavity
  • Hysterosalpingogram - an XR imaging test after dye is instilled into the uterine cavity and the fallopian tubes
  • Hysteroscopy - using a small telescope to directly examine the uterine cavity
  • Laparoscopy - using a small telescope to examine the abdominal and pelvic cavity through a small incision at the umbilicus. Apart from assessing fibroids, this technique also checks the ovaries, the fallopian tubes and conditions such as endometriosis
What treatments are available?

For most women who are asymptomatic, a wait-see expectant management is often advised.

For women with symptomatic fibroids, the treatment options include:

  • Mirena IUD or hormonal medications (progestogens, GnRH-agonists) - help control or reduce heavy menstruation
  • Myomectomy - hysteroscopic surgery (submucosal fibroid), laparoscopic or abdominal surgery for large intra-mural or serosal firboids. Potential complications of myomectomy include bleeding, blood transfusion, hysterectomy, infection and adhesions. Where large fibroids are removed, uterine wall weakness may occur . This may mean increased risk of uterine rupture in late pregnancyor during labour. Due to this risk, elective C-section may be advised to avoid / reduce the risk of uterine rupture.
  • Hysterectomy - a permanent solution, major surgery, loss of ability to bear children, loss of menstruation. The cervix and the ovaries can be preserved. The surgery can be either by laparoscopy or abdominal surgery.
  • Uterine artery embolisation (UAE) - interventional radiologists inject small particles via cannula to block the blood vessel(s) supplying the fibroid(s). Evidence suggests UAE is effective in reducing heavy bleeding and shrinking fibroid volume. Minor complications include pain, fever, nausea, vomitting, ,malaise. Reported serious complications include serious infection (1%) and ovarian failure (4-14%).
  • Uterine artery occlusion
  • Myolysis - using laser, electric current or liquid nitrogen to destroy the fibroids.  Safety, effectiveness and outcomes are unconfirmed.
  • MRI-guided focused ultrasound - using high-frequency, high-energy ultrasound to ablate the fibroids under MRI guidance. Effectiveness and outcomes are unconfirmed.

At CARE  our specialist gyanecologists can help determine if and when your fibroids require treatment.  As we specialise in laparoscopic myomectomy, this means that most women who come to CARE can have their fibroids removed by laparoscopic surgery.

For consultation or a second opinion, feel free to make an appointment with Professor Lam. Remember to bring along all blood test and ultrasound results along.