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Gynaecological Problems 

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Fibroids 

Uterine fibroids also known as myomas, leyomiomas or fibromas are benign tumours that grow within the uterine walls and originate from the smooth muscle cells which make up the uterus.
 
Tumours in general develop when a specific cell of the human body multiplies itself more than it should forming a mass of tissue. In broad terms, liver tumours are made of liver cells, brain tumours are made of brain cells, and so on. Fibroids are made of uterine muscular cells.

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Benign tumours eventually stop growing and do not spread to other areas of the body as opposed to malignant tumours or cancer that never stop growing and invade other organs.
 
Fibroids are benign tumours and are almost always limited to the uterus.
Fibroids mostly appear as round, well circumscribed, pale white to pink nodules that vary greatly in size from a few millimetres to large masses.
 
It is not completely clear why fibroids appear in the first place, but they have oestrogen receptors and grow in response to oestrogen stimulation. They are very rare before puberty and after menopause, periods when the ovarian oestrogen production is low.
 
Incidence
Fibroids are present in about 30 to 50% of women of reproductive age. They are symptomatic in about half of those. During their lifetime, one in four to one in five women will see a doctor because of symptoms caused by fibroids.
 
Symptoms
Most fibroids do not cause any symptoms initially and about half of them never will.
 
Depending on the size and position within the uterus, fibroids can cause heavy bleeding or pressure/pain symptoms.
 
The most common form of abnormal bleeding is periods that become very heavy and last for many days. Any form of irregular, increased bleeding in women in their 30s and 40s could be caused by fibroids.
 
Fibroids don't usually cause severe pain and normally do not require pain killers.
 
Fibroids are not usually associated with infertility but can cause miscarriages.
Classification
According to their position within the uterine wall, fibroids are classified as:
  • Subserosal - near the outer layer or serosa of the uterus.
  • Submucous - near the internal layer or mucosa of the uterus and protruding into the uterine cavity.
  • Intramural - predominantly within thewidth of the uterine muscle or myometrium
  • Pedunculated - fibroids that grow on a stalk either to the outside of the uterus or inside the uterine cavity
 
This classification is not perfect and is limited by the fact that most fibroids are big enough to fall into at least two and sometimes three categories, but it helps clinicians make the diagnose and plan treatment.
 
Diagnosis
The diagnose is suspected on clinical symptoms. Physical examination in the form of an internal examination done by a gynaecologist reveals an enlarged and sometimes irregular uterus.
 
Ultrasound is the most common diagnostic test and is very sensitive and accurate to show the presence of fibroids. Ultrasound can measure the size of fibroids and indicate their position within the uterus.
 
In selected cases when the ultrasound is not conclusive or a more a precise diagnosis is necessary, the doctor may order an MRI (Magnetic Resonance Imaging) a Hysteroscopy or a Laparoscopy.
 
Treatment
Treatment may vary according to symptoms, type and size of fibroids, rate of growth, desire for future fertility and personal preference.
Possible options are:
 
Conservative treatment
Asymptomatic fibroids usually don't require any treatment. They can be monitored for growth by periodical visits to the doctor and ultrasound exams. If consecutive examinations don't show significant change and the woman remains asymptomatic, there is no need for surgery or other treatment.
 
Medical treatment
Medication can be used to treat symptoms caused by fibroids. The most common are bleeding which usually responds to hormone based medication, most commonly progesterone and pain which can be treated with regular pain killers.
 
Endometrial ablation is the destruction of the endometrial layer of the uterine cavity using some form of thermal energy (please see the page on Endometrial Ablation under Minimally Invasive Surgery for more details). There is a limit on the size of the uterus and position of fibroids as to which patients can have a successful ablation. In selected cases it is a good way to avoid more aggressive surgery. It is not recommended for women who still plan to have children.
 
Arterial Embolisation
This is a procedure done through interventionist radiology. A catheter is inserted through the femoral artery and is guided to the uterus. Small particles are then injected into the arteries feeding the fibroid and occluding them. Starved of their blood supply, the fibroid cells die and the fibroid stops growing.
 
MRI guided Focused Ultrasound (MRgFUS)
This is another way of destroying fibroid cells to try to make it shrink and stop growing. The MRI is used to find the precise position of the fibroid. A beam of ultrasound energy is then directed to the core of the fibroid. The increase in temperature destroys the cells.
 
Myomectomy is an operation where incisions are made on the uterus to completely remove one or more fibroids. It is mostly recommended for women who have an indication for surgical treatment because of their symptoms and who want to preserve the uterus for future fertility. It can be done through an open incision or through laparoscopy (please see Myomectomy under Minimally Invasive Surgery).
 
Hysterectomy is the removal of the whole uterus, including the fibroids. Only a small proportion of women with fibroids these days will require a hysterectomy. The indications for a hysterectomy include fibroids of large size or when many are present, cases where medical treatment to control symptoms failed and always in women who have completed their family or do not desire further fertility. A laparoscopic hysterectomy when feasible is the preferred option given its lower surgical trauma and prompter recovery (please see Hysterectomy under Minimally Invasive Surgery).
 
Hysteroscopic Resection of Fibroid
When the fibroid is submucosal, i.e., most of the nodule is growing inside the uterine cavity, it is possible to remove it using a hysteroscope. The hysteroscope is an instrument that goes inside the uterus from below, through the natural opening of the cervix. This procedure does not require any incisions to the abdomen or to the uterus itself. It is a day procedure and has excellent results. It is limited by the size and position of the fibroid. As a general rule it is possible when more than 50% of the fibroid is inside the uterine cavity and when the maximum diameter is less than 5 cm.
 
FAQ
 
Do all fibroids need treatment?
No, only the ones that cause symptoms, mainly heavy bleeding or pressure symptoms. Fibroids found incidentally on physical examination or ultrasound do not need to be treated.
 
I have fibroids, do I need a hysterectomy?
Not necessarily. A hysterectomy is usually the last resort. It may be required in case where less invasive options fail to control symptoms or when fibroids are too big or growing too fast. Even then, women who still want to preserve their fertility can avoid a hysterectomy by having a myomectomy which preserves the uterus.
 
I have fibroids, can I fall pregnant?
Most likely yes. Each case is different, but most fibroids do not cause infertility and most pregnancies in fibroid uteruses tend to develop well. There can be problems and complications and close ante-natal care by an obstetrician is recommended. Some fibroids can cause miscarriages. If you are having trouble falling pregnant or fell pregnant and miscarried and the fibroids seem to be the cause, a myomectomy should be considered.
 
I have fibroids and never had symptoms. I now have this terrible pain. What is happening?
In some cases fibroids can suffer degeneration or necrosis. This usually happens when the fibroid grows too quickly and the blood supply doesn't form at the same speed. Without enough blood to nourish and support the fibroid cells some of them die. This is a rare situation, but it is very acute and you should look for medical attention straight away. It is somewhat more frequent during pregnancy as some fibroids can experience significant growth stimulated by the pregnancy hormones.
 
If I have a hysterectomy, will I have a big cut on my stomach?
No, in most cases it is possible to do a laparoscopic hysterectomy using 4 little incisions less than 1 cm each.
 
Can I fall pregnant after a myomectomy?
Although it is not possible to guarantee until you try, the whole point of having a myomectomy is to preserve fertility. In the absence of other problems or complications you should be able to have a normal pregnancy.
 
Can I have a normal delivery after a myomectomy?
It depends on the position of the fibroid and the size of the incision made on the uterus. Fibroids that require surgery are usually large and imbedded into the uterine wall. Therefore, most women who had a myomectomy end up with a uterine incision and a scar. If this is the case, they should not labour and have a caesarean section. In some cases of either mostly subserosal fibroids (growing outside the uterus) or mostly submucosal fibroids (growing inside the uterine cavity) large incisions are not necessary and labour followed by vaginal delivery is possible. The best way is to ask for the advice and recommendation of the surgeon who performed the myomectomy.
 
Can fibroids become cancer?
No. It was thought in the past that fibroids could become malignant, but the theory most accepted at present is that the malignant tumour grew side by side and independent from the fibroid. Also, in some cases a tumour is removed thinking it was a fibroid but then the pathology shows it is actually cancer.
 
In general, if the history, examination and ultrasound suggest it is a fibroid, cancer is found in only about 1/500 cases.
 
Can fibroids come back?
Fibroids that have been removed through a myomectomy do not come back. Nevertheless, a uterus that grew fibroids once is prone to developing new ones. Recurrence rates vary depending on which study one reads, but are believed to be around 20 to 40%. Factors influencing the chance of recurrence include number of fibroids and age at the time of treatment.
 
After a hysterectomy there are no recurrences.
 
What are medications that shrink fibroids?
Many have been tried, the one with best results are the GnRh analogues (Leuprolide, Goserelin, Nafarelin,etc). GnRh analogues are medications that block the ovarian function inducing a state of artificial menopause. Fibroids have been shown to decrease up to 40% in size with the use of GnRh analogues. Unfortunately there are two problems. Firstly the fibroids tend to grow back as soon as the medication is discontinued and second GnRh analogues are not recommended for prolonged use because of their side effects. Currently, the use of GnRh analogues for fibroids is limited to 3 to 4 months prior to surgery. Reducing the size of fibroids prior to surgery has the potential benefits of making it easier, reducing intra-operative bleeding and making a myomectomy or a laparoscopic hysterectomy possible where it previously wasn't the case.
 
Can I use alternative treatments to reduce my fibroids?
Alternative therapies such as Vitamins, Dietary Supplements, Acupuncture, Chinese Herbs, etc have not been shown to decrease the size or to remove fibroids. In some cases they help with controlling symptoms by reducing bleeding or pain symptoms.
 
There are no well conducted scientific studies testing those therapies and most of the evidence is anecdotal.
 
By and large all the miracle cures offered over the internet for a small cost do not work. If they sound too good to be true, they probably are. If in doubt, ask a doctor or look for solid evidence in the international medical literature.