Fibroids are growths of the muscle of the uterus (womb). Fibroids are benign (non-cancerous) and are not thought to be able to turn cancerous. Malignant (cancerous) fibroids (sarcomas) are rare, accounting to 1 in 600 to 1 in 1000 fibroids. They are more frequently associated with abnormal bleeding and pain in post-menopausal women. It can be difficult to assess if the tumour in the uterus is a benign fibroid, or a cancerous tumour.
Fibroid is a very common finding in women, with up to 40% of women having fibroids within their wombs. Most of these are small and cause no problem at all.
It is not known what causes fibroids. Fibroids appear to respond to female hormones oestrogen and progesterone. Some women have genetic and familial predisposition to fibroids. Some fibroids grow over time, they can also grow quickly over a short period of time, especially during pregnancy. Fibroids usually shrink in low hormonal state such as after menopause.
Fibroids are usually described according to the origin of their location within the uterus.
Submucosal fibroids arise from the inside wall of the uterus, often causing indentation to the internal cavity of the uterus.
Intramural fibroids arise from the deep muscle layer of the uterus itself.
Subserosal fibroids arise from the external wall of the uterus, causing protrusion to the external shape of the uterus.
Pedunculated fibroids have stalks connecting them to the external wall of the uterus.
Most women would not ever know they have fibroids as these are frequently small and do not cause any symptoms or problems. They are incidentally detected during a scan (ultrasound, CT or MRI) for other reasons.
Larger fibroid (depending on its size and location) can lead to heavy periods and pressure symptoms such as bladder pressure and frequency, bloating, bowel pressure. Fibroids which are impacting on the endometrial cavity (where embryos are implanted) can also reduce fertility.
Most fibroids do not cause any complications during pregnancy. When complications occur, pain is the most common complication, especially when it grows significantly in size.
Large fibroid especially if it is submucosal can lead to extremely heavy menstrual bleeding. Passing large blood clots during a period is a sign of very heavy bleeding. It is important to get this checked out, usually through an ultrasound scan to rule out any abnormalities within the uterus.
Fibroids are detected on medical imaging such as ultrasound or MRI.
Fibroids which are not causing any symptoms do not need to be treated or removed. They may be followed-up with serial ultrasound until menopause, when fibroids normally shrink with the reduction of hormonal supply from the ovaries.
Medical or surgical treatments are available if the fibroids lead to significant symptoms. The best treatment is chosen depending on which symptoms are to be treated, the size, number and location of fibroids, and if future pregnancy is wanted.
Medical treatments to reduce menstrual flow include non-hormonal medications such as non-steroidal anti-inflammatory drugs or anti-fibrinolytic drugs. Hormonal medications to reduce menstrual flow include the contraceptive pills, progesterone pills, implants or intra-uterine devices. While these medications may reduce menstrual flow, they do not help with the pressure symptoms of fibroids. Some of these hormonal treatments may even increase the size and bulk of the fibroids.
Other hormonal medications can be used to reduce the size of fibroids, however these medications cause medical induced menopause (during the duration of the treatment) and is not recommended as a long term treatment of fibroid. The fibroids grow larger again once the medication is stopped.
MRI guided ultrasound (MRFGUS) or uterine artery embolization (UAE) may be offered as alternatives to surgery if the fibroids are suitable for such treatments. These radiological treatments are not currently recommended for women who wish to conceive. Click on the link to our blog here discussing these options.
Surgery to remove fibroids (called myomectomy) may be offered to treat fibroid. The route of myomectomy depends on the size and location of the fibroid. Submucosal fibroid may be resected hysteroscopically, through the cervix without any cuts to the abdomen. Abdominal cuts are needed to remove any other types of fibroids (intramural or subserosal). Many fibroids may be removed through laparoscopic ‘key-hole’ surgery (laparoscopic myomectomy). Large fibroids may require a laparotomy (open surgery). Hysterectomy is another option for women who have completed their family.
Even though these operations have high success rates, any operations have associated risks. You should always discuss with your gynaecologist the available treatment options suitable for you. These treatment options are offered depending on your age, your medical condition, your fertility wishes, and personal preference.
The decision to treat fibroids within the uterus through surgical removal of the fibroids (myomectomy) or surgical removal of the entire uterus (hysterectomy) is individualised to each woman’s circumstances. The size, location and number of fibroids, together with the woman’s symptoms, age, and desire for fertility are some of the factors considered.
The goal of the treatment is to achieve the best outcome – relieve the symptoms caused by the fibroids in the most minimally invasive way, and to minimise the risks of the surgery and need for future interventions.
Most fibroids are innocent bystanders and do not need any treatment or surgical removal.
Submucosal fibroids may lead to heavy periods and decreased fertility from reduced chance of embryo implantation. These can be removed through hysteroscopic route, depending on its size. Some larger submucosal fibroids may require staged or repeated procedures to remove, while others may be too large to remove through this hysteroscopic route.
Most large symptomatic pedunculated fibroids can be removed through laparoscopic route – keyhole minimally invasive way – to allow quicker recovery.
It is a common misconception that a myomectomy is a smaller and less complicated surgery than a hysterectomy. Removal of large intramural or subserosal fibroid may be associated with more bleeding and adhesions than a hysterectomy. A laparoscopic hysterectomy can be a less surgically traumatic option in women who have completed their family, no desire for fertility, or when their age is associated with extremely low chance of successful conception and pregnancy. Hysterectomy is also a definitive treatment of fibroids with no chance of recurrence or further treatments.
Another common misconception is that hysterectomy leads to menopause. Hysterectomy is the surgical removal of uterus, but not the ovaries where the hormones are produced. Ovaries are almost always conserved, with no change in hormonal status of the woman.
Fibroids are solid tumours usually of hard rubbery consistency, while ‘keyhole’ laparoscopic surgery is performed through incisions usually measuring 1cm each. Once the myomectomy is completed, the fibroid is then placed into a special bag (that fits into the ‘key-hole’ incision) within the abdomen, before being morcellated (cutting the large fibroid into smaller pieces) within the contained bag. This allows the procedure to be performed in a minimally invasive way by an experienced gynaecologist, reducing the risks of an open surgery. It also ensures that no abnormal cells spread anywhere outside the bag even if there were unexpected malignant cells within it.
Once fibroids have been surgically removed (myomectomy), they do not grow back. However new fibroids may grow from other parts of the uterus. Up to a third of women who had a myomectomy will need a repeat procedure within 5 years as new fibroids grow. Surgical removal of uterus (hysterectomy) is a definitive treatment of fibroids with no chance of recurrence or further treatments.
If left untreated, fibroids can continue to develop and grow over time. While many smaller fibroids grow slowly and do not ever become symptomatic, some grow more quickly and large fibroids can take over the uterus and become more symptomatic. Periods may become heavier, leading to iron deficiency, anaemia and fatigue. Pressure symptoms such as bloating, urinary frequency, pressure to bladder and bowel may also worsen.
Please click here for Dr Kuswanto’s presentation to GP on Management of Fibroids.
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