Fibroids affect up to 40% of women over the age of 35. They are non-cancerous tumours that grow in the uterus and range in diameter from the size of a pea to the size of a grapefruit. The most common fibroids are intramural (growing within the muscular wall of the uterus). Subserosal fibroids grow just under the outer layer of the uterus and submucosal fibroids grow under the inner layer of the uterus known as endometrium. Fibroids, even large ones, may cause no symptoms in some women. However, most women present with one or more of the following:
• Irregular vaginal bleeding or an increase in menstrual bleeding (menorrhagia), sometimes with blood clots.
• A pelvic mass.
• Pressure on the bladder, which may cause frequent urination and a feeling of a sense of urgency to urinate.
• Pressure on the rectum, resulting in constipation.
• Pelvic pressure, "feeling full" in the lower abdomen and lower abdominal pain.
• Increase in size around the waist and change in abdominal contour.
Why do fibroids occur?
Fibroids are stimulated by the hormone oestrogen, which is produced naturally in the body. These growths can present from the beginning of reproductive age and shrink after the menopause. Women from an African and Afro-Caribbean ethnic background women have a higher prevalence of fibroids as compared to Caucasian women.
Treatment of Fibroids
Before planning the most appropriate treatment, some diagnostic tests may be arranged. A transvaginal or pelvic ultrasound scan is very useful to identify the number, size and position of the fibroids. Sometime a hysteroscopy may also be planned to further investigate the presence of fibroids distorting the uterine cavity.
Very small fibroids (3 cm or less) and fibroids not indenting the inner layer of the uterus are unlikely to cause a great deal of symptoms. Therefore, it is not necessary to remove them as the risk of complications outweighs the potential benefits. Sometimes it might be appropriate to treat the symptoms only, but this very much depends on other factors such age, history of subfertility and miscarriage.
Gonadotrophin Releasing Hormone (GnRH) analogues can be given for a period of a few months to treat symptoms while awaiting surgery. They will result in shrinking the size of fibroids. When given in a continuous dose, GnRH analogues prevent the ovary from producing oestrogens and induce a state similar to the menopause. They are usually given as monthly long acting injections. Menopausal side effects include mood swings, hot flushes and night sweats.
Surgery for fibroids is not without risks. It is therefore important to discuss the pros and cons carefully. Myomectomy is the surgical removal of fibroids. This can be accomplished through hysteroscopy, laparoscopy or an open procedure which involves an incision in the abdomen. The surgical approach depends on the size and location of the fibroids. Myomectomy is normally carried out in women who wish to conserve their uterus and to improve their fertility and pregnancy potential.
Hysterectomy is the surgical removal of the uterus and fibroids. Depending on the size of the fibroids, hysterectomy can be performed either through the vagina or an open incision in the abdomen or with 'keyhole' surgery (laparoscopy). The risk of hysterectomy at the time of myomectomy is approximately 1%.
Uterine Artery Embolisation
Uterine artery embolisation induces clotting of the arterial blood supply to the fibroid. The procedure is done by inserting a catheter (small tube) into an artery of the leg (the femoral artery), using a special x-ray video to trace the arterial blood supply to the uterus, then clotting the artery with tiny plastic or gelatin sponge particles the size of grains of sand. This material blocks blood flow to the fibroid and shrinks it. This method may prove to be a good option for women who do not want surgery or for those that may not be good candidates for surgery. It is not advisable to carry out this procedure on women planning to conceive either naturally or through assisted conception treatment.