Uterine Fibroids

She was holding a pelvic ultrasound report, showing a 3 cm fibroid uterus. There were so many queries in her mind; Why am I having it? Will I have babies? What will happen now? What is the treatment? Does it need urgent removal? Is it dangerous? Could it give problems in future? These are some questions which usually women ask when they are diagnosed with a fibroid, it can make you worry if you do not have appropriate knowledge.

Fibroids are a very common gynecologic problem, which can affect any age group of women. They could be of various number, shapes and sizes but the severity of problem depends on their size and area of uterus involved. This blog will provide you with the answers to above questions and will guide you about various available treatment options.

What are fibroids?
These are the most common, benign (non-cancerous) tumors of uterus, which arise from the muscle cells of uterus.

How common are fibroids?
They are seen in 20 to 25% of females, every 1 in 4 females could have them.

What is the most common affected age group?
They can occur at any age, but are most commonly seen between 30 to 40 years.

What are the risk factors?
The exact cause of fibroids formation is unknown but there are certain predisposing factors like: 

• Age more than 35 years
• Nulliparity 
• African origin
• Family history of fibroids
• Increase in Estrogen and Progesterone hormone levels 
• Pregnancy

What are the types of fibroids?
There are different types of fibroids according to the site and the involved area of uterus:

• Sub serosal fibroid: They are formed in outermost layer of uterus (serosa) making uterus size big.
• Intramural fibroid: The fibroid is in the middle muscle layer of uterus. 
• Sub mucosal fibroid: The fibroids are formed under the innermost layer (endometrial) of uterus.
• Pedunculated fibroids: The fibroids develop a stem (containing the blood vessel) which supports its growth.

How do the patients with fibroid present?
Sometimes fibroids don’t give any problem and are diagnosed accidently on a routine ultrasound, checkup, patients come with:

• Heaviness or increase in size of tummy
• Pain or discomfort lower abdomen
• Disturbed, irregular, painful, heavy menstrual cycle 
• Pressure symptoms during passing urine or bowel movement 
• Infertility
• Abortions

How could fibroids affect a normal pregnancy?
There are many asymptomatic patients whose fibroids are diagnosed in pregnancy, since they do not cause any problem so no treatment is required. They are only monitored by routine ultrasound, and minor problems like pressure and pain are treated with safe medicines. 

• Remember, fibroids could be associated with certain problems during pregnancy. 
• There is a risk of abortion if uterine cavity is distorted by a big fibroid. 
• During pregnancy the fibroids may increase in size due to more blood supply to uterus causing pressure symptoms.
• There are chances of preterm labor, malposition and malpresentations of baby requiring Caesarian delivery, and more chances of bleeding after the delivery.
• The fibroids could have degeneration after delivery of baby, causing severe abdominal pain, fever, nausea and vomiting.
• If you have fibroids and planning for a pregnancy then always see your doctor for proper monitoring and follow-up.

What are the complications of fibroids?

• Fibroids make abdominal and pelvic examination difficult, and also make pelvic surgeries difficult.
• Pedunculated fibroids with a stem could get twisted causing severe pain, nausea, vomiting and fever. 
• They can get infected if there is already infection in the area. 
• There is 1% chance of having a malignant change in a fibroid, it is suspected if there is sudden increase in size of fibroid.

What investigations help in diagnosing fibroids?

• Ultrasound tells about size, shape and location of fibroids.
• Hysteroscopy; is a fine soft tubular camera inserted in the uterus to check the inner cavity and walls of uterus and opening of tubes.
• Hysterosalpingography is X-ray with contrast, outlining the uterine cavity and tubal patency, it is usually helpful for infertile patients.
• Laparoscopy is a test performed under general anesthesia, in which a camera is inserted in abdomen to visualize the whole pelvis.

What are available treatment options?
Treatment of fibroids depends on severity of problems of fibroids, age, parity and co-existing problems:

• Medical Treatment: It includes medicines which can reduce pain and bleeding but have no effect on shrinking, size of fibroid. These are:
  • (NSAIDS) painkillers like ibuprofen
  • Antispasmodic drugs
  • Progesterone hormone loaded IUD (MIRENA)
  • Oral contraceptive pills

There are certain medicines which lower estrogen and progesterone levels and may help in decreasing size of fibroids, these are:

1. (GNRH analogues) LUPRON, hormone injections which decrease estrogen and progestogen release.
2. (GNRH antagonist) cetrolix acetate and ganirelix reduce FSH and LH hormones which then reduce estrogen and progesterone.

• Surgical Treatment: 
  • Endometrial Ablation: It’s used for pedunculated small endometrial polyps and fibroids. It’s preceded by uterine cavity examination by a camera (hysteroscope) which is followed by removal of fibroids in uterine cavity by heat or electric current.

• Myomectomy: There are certain patients with multiple, large, symptomatic fibroids who do not respond well to medical treatment and require operation, that could be removal of fibroids, called myomectomy done by an operation or through camera of laparoscope. But remember that even after operation, the fibroids can regrow and increase in size.

• Hystrectomy: Patients with age more than 45 years, who do not want to have more children, worsening condition and there is failure to respond to any treatment, there is an option of surgical removal of uterus (hystrectomy).

Minimum Invasive Procedures:
These are latest non-invasive techniques which are really beneficial, but they require proper patient selection on the basis of history and examination and expertise.

• Forced Ultrasound Surgery (FUS): Fibroid is located by an ultrasound machine and is then destroyed by high energy, high frequency ultrasound waves. There are also local treatments by electric current, laser and cryotherapy to destroy the fibroid tissue.

• Uterine Artery Embolization: A catheter is passed through a vein of limb till it reaches the blood vessel of uterus, then a certain chemical (embolizing particles) is injected to block the blood supply to fibroid, as a result the size of fibroids starts reducing.

Remember!! All fibroids do not require aggressive treatment if they are not giving problems. Just monitor them by regular medical checkups; for early detection of any change, appropriate treatment and avoiding future complications.

Dr. Ayesha Azam Khan