What are fibroids?
Fibroids are slow-growing tumours found in the uterus. It is estimated that 30 to 70% of women of childbearing age may have fibroids, making them the most common tumours of the uterus.
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.
Where do fibroids occur?
Fibroids may be located in in the outer layer (serosal), the middle layer (intramural), or protrude partially or fully into the cavity of the uterus (submucosal). When a fibroid is attached to the uterus via a pedicle, it is referred to as a pedunculated fibroid. This can be located in the serosal layer or the submucosal layer of the uterine wall.
Do fibroids cause symptoms?
The majority of women who have fibroids do not have any abnormal symptoms and hence may never know that they have fibroids . Often fibroids are incidentally detected during routine pelvic examination as an enlarged uterus, or during ultrasound examination as part of routine antenatal screen.
What problems can fibroids cause?
A variety of symptoms or problems may arise in 10 to 20% of women who have fibroids. In general, the types and the chance of symptoms depend on the location (submucosal, intramural, serosal), the size, the number and the blood supply of the fibroid(s). Women who have fibroids may have one or more of the following symptoms:
- Heavy menstrual blood loss
- Painful periods
- Anemia – from iron deficiency
- Bladder problems – frequency, voiding difficulty, incontinence
- Constipation – large fibroids may occupy most of the pelvic space and compress the rectum
- Pain – back, leg, abdomen
- Recurrent miscarriage- submucosal fibroids may distort the endometrial cavity and affect sperm and egg interaction which may result in infertility . Embryo implantation onto the fibroid may result in poor blood suppply and risk of miscarriage.
- Pregnancy complications – large / multiple intramural fibroids may increase the risk of fetal malpresentations or premature labour. Sometimes, fibroid can undergo degeneration during pregancy resulting in abdominal and pelvic pain
- Malignant cancerous change – this is very uncommon and is almost always unpredictable. Growth of fibroids is generally slow in the premenopause. Fibroids may often stop growing or shrink to a smaller size after the menopause. Growth or enlargement of fibroids after the menopause may raise suspicion of malignant change.
When should fibroid be treated?
Fibroids 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 or Dr Jessica Lowe. Remember to bring along all blood test and ultrasound results along.
A detailed CARE Update on Fibroid management is available here CARE Update on Uterine Fibroid