Fibroid
Fibroids are benign (not cancer) tumours in the uterus. 25-30% women are diagnosed with fibroids in their lifetime. It is a slow-growing tumour which one may be unaware and may get detected only on a routine scan.
Fibroid is an abnormal growth from the muscle of the uterus. They are also called leiomyomas or myomas. Typically seen in reproductive age, but can also develop earlier of later in life.
Although common, we know very little as to why they develop. It is a disruptive growth of the muscle cells of the uterus and female hormone estrogen seems to increase their growth. For instance, pregnancy causes an increase in its size and menopause can decrease it. Fibroids can run in families. The size, shape, and location of fibroids can vary greatly. They may be on the outer side of the uterus (subserous), or in the wall of the uterus (intramural) or inside the cavity of the uterus (submucous). As they grow, they can distort the inside as well as the outside of the uterus. Sometimes fibroids grow large enough to completely fill the pelvis or abdomen.
What are their symptoms?
- Abnormal Bleeding
- Heavy bleeding- Clots may be there.
- Menstrual pain (dysmenorrhoea)
- Vaginal bleeding at times other than menstruation
- Anemia
- Pain
- Abdomen or lower back which is of recent onset (often dull, heavy and aching, but may be sharp)
- During sex
- Pressure symptoms
- Difficulty urinating or frequent urination
- Constipation, rectal pain, or difficult bowel movements
- Enlarged mass in the abdomen
- Miscarriages and infertility
WHAT ARE THE RISK FACTORS FOR FIBROID?
Age - As you age you are more likely to develop fibroids
Family History -2 to 2. 5 fold increased risk if your mother or sister has fibroids
Ethnic -African origin women have a higher tendency (2-3 times higher risk)
Some other factors which are associated with fibroids are-
Family History -2 to 2. 5 fold increased risk if your mother or sister has fibroids
Ethnic -African origin women have a higher tendency (2-3 times higher risk)
Some other factors which are associated with fibroids are-
- Early onset menstruation
- Nulliparity (no children)
- Obesity
- Endometriosis
- Infertility
- Environmental toxins (endocrine-disrupting compounds (EDC))
- Mutations to specific genes
- They continue to grow or reoccur while estrogen is present; till the age of menopause and can shrink or disappear after menopause
How do we diagnose fibroids?
Fibroids can be diagnosed on routine USG or pelvic examination. Often ultrasonography is sufficient for diagnosis. However MRI is useful as preoperative investigation when only removal of fibroids are planned. MRI not only becomes the GPS to track all fibroids for their location and size but also distinguishes them from adenomyosis which is different from fibroids. Hysteroscopy can be used to diagnose submucous fibroids.
When to treat fibroids?
Most fibroids are asymptomatic or are smal and often do not require treatment. Signs and symptoms that may indicate the need for treatment are
- Heavy or painful menstrual periods causing anaemia
- Bleeding between periods
- Sudden increase in size of fibroid
- Uncertainty whether the growth is a fibroid or cancer
- Infertility
- Pelvic pain
Perimenopausal patients with asymptomatic fibroids are often observed, as we know that with menopause the size of fibroids reduce and may not require any surgery.
How do we treat Fibroids?
What are the medical therapies for fibroids?
Some drugs can be used for temorary relief. However, there are no medicines available at present that can permanently cure fibroids. Some options are
Combined oral contraceptive pills
These can help decrease bleeding during the menstrual cycle but cannot decrease the size of the fibroid
Uripisilate
This is a new drug recently introduced in fibroid management but we do not know the long term benefits that they can provide.
Progesterone Releasing IUD (intrauterine device)
This device is inserted into the uterus. It releases small amounts of progesterone hormone (20 microgm/day). These can decrease bleeding but cannot make fibroids disappear.
NSAIDs (nonsteroidal anti-inflammatory drugs)
These provide symptomatic relief from associated pain and to some extent reduce bleeding as well but will be temporary.
Gonadotropin Releasing Hormone (GnRH) Agonists
These injections suppress the release of natural estrogen and progesterone and causes shrinkage of fibroids and thus decrease bleeding. These medications act by creating a pseudo- menopausal state . Hence while taking these injections one can have troublesome hot flashes. GnRH agonists are not a long-term management option.
What are the surgical methods to treat fibroids?
The common and permanent treatment of fibroids is surgery which could be hysterectomy (removal of uterus with the fibroids)or myomectomy (removal of fibroids while preserving the uterus for future function) This decision is taken depending on the patients age and fertility status. Because a woman keeps her uterus during myomectomy, she may still be able to have children in future. If a woman does become pregnant after a myomectomy, she may need to have a cesarean delivery. Fibroids may develop again, which are the new ones as the ones removed do not come back even after the surgery. If they do, repeat surgery is needed in 20-40% of cases. The surgical method used depends on the location and size of the fibroids as well as the skill of surgeon and technology available.
- Abdominal Myomectomy -is the surgical removal of fibroids while leaving the uterus in place. This is done via a large incision on the abdomen and requires long recovery as any open surgery does.
- Hysteroscopic Myomectomy, a method where no cuts are required and is done with help of telescope (hysteroscope). It is recommended for submucous fibroids. Hystereoscope with camera and an electric loop attachment is introduced inside the cavity of the uterus through the vagina. The fibroids are removed by shaving them off the wall of the uterus. This is an outpatient procedure and patients can go home the same day of surgery.
- Key hole surgery (Laparoscopic myomectomy) – This is a key hole surgery which is performed through small incisions on the abdomen. Fibroids are removed after making an incision on the uterus. Once removed the uterus is sutured back to its original shape. The fibroid so removed are then put in an ‘Endo Bag’ (specimen retrieval bag). This is a safe and recommended method of removing fibroids which we always use at our center to avoid accidentally spillage of tissues in abdominal cavity. For very large fibroids one of the ports is extended or a small incision is given on bikini line to remove fibroids. Patients typically go home in 24-48 hours resulting in a quicker postoperative recovery. Of course this type of surgery requires expert surgical skill.
- Uterine Artery Embolisation(UAE)-With this procedure, the blood vessels to the uterus are blocked. This helps stop the blood flow into the fibroids which causes them to shrink to a reasonable size for symptoms to reduce but cannot make fibroids disappear. This procedure is performed by interventional Radiologist. Not recommended for patients planning pregnancy in future.
- Robotic Myomectomy– DaVinci This is an advanced laparoscopic myomectomy especially recommended when you are planning future pregnancy. Enables the surgeon to do a precise and detailed operation in 3D vision with instruments that move like a human wrist. Ensures quick recovery, less blood loss and women can go home in 24 hours. The main advantage is the multilayer suturing of the uterus after removal of fibroid giving it adequate strength to support future pregnancies.
- Hysterectomy– is the removal of the uterus and is offered to older women as final treatment. The ovaries may or may not be removed. It depends on age and the woman’s desire. Hysterectomy is usually done by Laparoscopy or by Robotic assistance. Open surgery is not recommended.
FAQ FIBROIDS
There is no clear evidence that all or any fibroid can cause infertility or miscarriages. But we do know that fibroids that go inside the cavity of uterus can distort the cavity and infertility. Some fibroids which are growing in the wall of the uterus can cause problem during implantation and growth of the fetus. So there is some amount of negative impact due to the presence of fibroids with pregnancy. Evidence shows that surgically removing fibroids can improve the pregnancy rates.
Minimally invasive surgery, should be considered as valid option for all patients requiring treatment for symptomatic fibroids. Laparoscopy or Robotic surgery to remove fibroids requires advanced surgical skill. Additionally these surgeries become more challenging if they are associated with conditions like endometriosis, adhesions due to prior surgeries or adenomyosis. However, in the hands of an expert surgeon, any size, number or type of fibroid can be surgically removed with small incisions (holes)
Having a myomectomy cannot ensure or promise a pregnancy. But if fibroid is the only is the only issue then studies show that your chances of getting pregnant increase by 50-60% irrespective of the type of surgery.
Some women are advised to have a caesarean delivery if they have a myomectomy because there is a theoretical risk of uterine rupture during subsequent labor, which can be catastrophic. There is no hard core scientific evidence regarding this at the moment. One must discuss this with your treating Obstetrician who can evaluate this carefully and advise close to delivery.
Fibroids are usually benign (not cancerous). There is a rare chance (less than one in 1,000) that the fibroid may have evidence of leiomyosarcoma. Leiomyosarcoma has poor outcomes.
There are various factors that can increase a woman's risk of developing fibroids.
AGE.
Fibroids are common in women during the 30s and 40s through menopause. After menopause, fibroids usually shrink.
FAMILY HISTORY.
Having a family member especially mother or sister with fibroids increases your risk. It increases the risk about three times higher than average.
ETHNIC ORIGIN.
African-American women are more likely to develop fibroids.
OBESITY.
Women who are overweight are at higher risk for fibroids.
EATING HABITS.
Consuming a lot of red meat is linked with a higher risk of developing fibroids. Green vegetables may have protective effect on the contrary.
AGE.
Fibroids are common in women during the 30s and 40s through menopause. After menopause, fibroids usually shrink.
FAMILY HISTORY.
Having a family member especially mother or sister with fibroids increases your risk. It increases the risk about three times higher than average.
ETHNIC ORIGIN.
African-American women are more likely to develop fibroids.
OBESITY.
Women who are overweight are at higher risk for fibroids.
EATING HABITS.
Consuming a lot of red meat is linked with a higher risk of developing fibroids. Green vegetables may have protective effect on the contrary.