Fibroids Diagnosis and Treatment

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When a woman experiences symptoms, such as pain, excessive menstrual bleeding or a frequent need to urinate the first point of action should be to visit a gynaecologist who uses various methods to examine whether these signs of discomfort are attributable to fibroids.

After a series of questions (anamnesis), the gynaecologist usually carries out a palpation (physical) examination and conducts an ultrasound. Should these first checks not lead to a definite diagnosis, further examinations will be required.

Methods of Diagnosing Fibroids

Anamnesis (medical history)

Your doctor asks a set of questions regarding pre-existing conditions, your current state of mind, ailments and discomforts that could be related to fibroids. The questions aim at determining the severity of your symptoms with regards to pain, irregular bleeding, bowl & bladder problems.

Palpation (physical examination)

Palpation is a physical assessment by a physician. It’s the process of palpating or feeling your abdomen and pelvis to find typical signs of fibroids, such as a firm palpable uterine mass, a distended abdomen or other irregularities. This process typically helps to detect large myomas on the front and backside of the uterus. However, smaller fibroids are difficult to diagnose through simple palpation. This examination generally does not cause you any pain. Discomfort may be felt if other sources of inflammation  are present, such as infection or endometriosis.

Ultrasound

The diagnosis of fibroids can be confirmed by conducting an ultrasound examination, typically via vaginal ultrasonography. A properly done ultrasound can provide very accurate information about the type, size and location of fibroids.

MRI

Magnetic Resonance Imaging is not always necessary, but can be very useful when the diagnosis is not clear and to help differentiate fibroids from malignant uterine tumours.

Diagnostic Hysteroscopy

A diagnostic hysteroscopy may be helpful for a more precise assessment of submucosal fibroids which grow towards the internal layer or mucosa of the uterus and protrude into the uterine cavity. A hysteroscopy is performed with a hysteroscope consisting of a long and thin optical lens attached to a camera. To provide better vision for the gynaecologist, the uterine cavity has to be stretched by means of carbon dioxide gas or a liquid solution. The hysteroscope is inserted through the vagina into the natural opening of the cervix and does not require incisions or cuts. Hence, the procedure bears minimal risks for the patient and doesn’t usually cause any pain afterwards.

Treatment of Fibroids

Fibroids are non-cancerous tumors and the need for treatment depends on many factors. Myomas tend to grow slowly during the reproductive years of a woman, but also tend to shrink after menopause. Treatment of fibroids is not always necessary. If you only observe mild symptoms and no discomfort, your gynaecologist may recommend regular examination every 6-12 months to observe any changes and to reassess the condition regularly.

Medical Treatment of Fibroids

There are several medical treatment options available. Medication can be used to mitigate symptoms. Pain killer, for example, can be prescribed if you experience pain and pressure symptoms. Bleeding symptoms, on the other hand, require hormone-based medication which targets hormone levels to regulate the menstrual cycle.

Progesterone

High levels of estrogen combined with insufficient levels of progesterone typically cause fibroids to grow. Progesterone based medication helps to gain back a healthy hormone balance and therefore can mitigate the growth of fibroids. In some cases progesterone also helps to shrink the size of myomas. Besides curbing growth, it also alleviates pain symptoms and helps control heavy bleeding.

GnRh analogues

GnRh analogues are synthetic hormones which reduce the production of estrogen in the ovaries, inducing a state of artificial menopause. GnRh analogues are used to diminish the growth of fibroids and in some cases can achieve a reduction of up to 40% in size. The hormones are typically injected into the muscle tissue once a month. Due to known side-effects, prolonged treatment with GnRh analogues is not recommended. The duration of this therapy is typically limited to 3-4 months. Often, GnRh analogues are prescribed in conjunction with a planned surgery and are intended to reduce the size of fibroids. It has the potential benefit of making an operation easier, diminishing intra-operative bleeding, and making a myomectomy or a laparoscopic hysterectomy possible where it previously would not have been.

Surgical Treatment of Fibroids

Endometrial Ablation

Endometrial ablation is a minimally-invasive surgery to treat prolonged or excessive bleeding (Menorrhagia) which can be caused by fibroids. During an endometrial ablation, the lining of the uterus (endometrium) is destroyed by means of thermal energy. While it does not treat the fibroid itself, an endometrial ablation reduces, or in some cases completely stops the excessive bleeding caused by the fibroids. If you have plans to have a baby in the future, you shouldn’t have an endometrial ablation as it makes it impossible to carry a healthy pregnancy.

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Uterine Artery Embolization

This procedure is a minimally invasive intervention to control uterine fibroid symptoms. Uterine artery embolization – also called fibroid embolization, is done through interventionist radiology. A catheter (flexible tube) is inserted through the femoral artery and advanced through X-ray guidance near the uterus. Embolic agents (small particles) are injected into the uterine arteries to starve the fibroids of their blood supply which then causes them to shrink and die. 

The success rate of reducing heavy bleeding caused by fibroids, is remarkably high. However, it also depends on factors such as the woman’s age as well as the number and size of the fibroids. Due to possible complications, uterine artery embolization is not suitable for extremely large fibroids. The procedure should also be avoided if you are pregnant, have pelvic cancer or suffer from chronic pelvic infection.

Temporary side effects after surgery are common but resolve after a few days or weeks and typically include pain, bleeding and vaginal discharge and nausea.

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MRI guided Focused Ultrasound (MRgFUS)

Using ultrasonic pulses to destroy fibroid cells, MRI guided Focused Ultrasound (MRgFUs), also called focused ultrasound fibroid ablation, is a procedure to reduce the size of the fibroids.

As the name suggests, the MRI guides a beam of ultrasound energy which delivers a series of precise ultrasonic pulses to heat up and destroy the fibroids right at the core without damaging the adjacent healthy tissue.

While this procedure typically eases troublesome symptoms, such as heavy bleeding, pelvic pain and other ailments, it does not remove the fibroids and risk of future growth.

To determine eligibility for MRgFUS, an MRI is necessary to determine the number of fibroids, the size and their position within the uterus.

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Myomectomy

A myomectomy, sometimes called fibroidectomy, is a surgical procedure to remove one or more fibroids. As opposed to a hysterectomy, the uterus and fertility is preserved. There are a few different ways to perform a myomectomy: 

Hysteroscopic myomectomy – An instrument called hysteroscopic resectoscope is guided into the uterine cavity through the vagina and cervix to provide vision inside the uterine cavity.

Laparoscopic myomectomy – small surgical incisions (around 5 mm) through umbilicus (naval) to access the abdominal and pelvic cavities.

Laparotomic myomectomy – an incision similar to the one done for a caesarean section is performed to gain access to the abdominal cavity.

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Hysterectomy

A hysterectomy is a surgical procedure to remove the uterus. It is only required in case of very large fibroids, large number of fibroids and/ or when other medical treatments have failed to alleviate symptoms of discomfort and pain. While fertility is not preserved, a hysterectomy is the most successful treatment of fibroids. It completely resolves bleeding and pressure symptoms caused by fibroids.

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Hysteroscopic Resection of Fibroid

Another surgical procedure which preserves fertility is a hysteroscopic resection of fibroids. This procedure is typically considered to remove fibroids growing inside the uterus (submucosal fibroids). The hysteroscope which has a long thin optical lens attached, is used to provide vision inside the uterine cavity. No surgical incisions are necessary because the hysteroscope can be inserted through the vagina and guided through the cervix opening. Using a small cutting device which is inserted through the hysteroscopy the fibroid is removed in small fragments.

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