Fibroids

Posted On March 9, 2018


Fibroids

FAQ’s on Fibroids

Dr.Shobhana Mohandas. MD.DGO.FICOG.

Sun Medical Centre, Thrissur, Kerala

What are fibroids?

Fibroids are tumours found in the uterus. They are NOT cancerous by nature. Routine ultrasonography done for various symptoms show that fibroids are commonly seen in almost 40% of all women. These tumours are made of fibrous and muscle tissue and are usually seen in women who have excess of the hormone called “Estrogen” in circulation. They are usually found in the reproductive age group and may regress after the woman attains menopause. However, in the odd woman, symptomatic fibroids may be found even after menopause. There is one variety called fibrosarcoma which is cancerous by nature. But it is usually symptomatic and grows very fast. It is very, very rare and by nature cannot remain asymptomatic for long.

What are the symptoms caused by fibroids?

In many women, fibroids may remain symptom free. However, in some women, it may cause symptoms like excessive bleeding during periods, excessive pain during periods, etc.

Some patients get symptoms like increased urinary frequency, or excessive backache or pressure sensation in the pelvis.

How are fibroids diagnosed?

Symptoms of fibroid like bleeding and pain may give a clue to the doctor that the fibroid is cause.  Further, the doctor does a per vaginal examination which may reveal the uterus to be larger than normal and sometimes irregular.Confirmatory evidence is available on ultrasound examination.  Sometimes very small fibroids are seen in the cavity of the uterus, which are better delineated when fluid is passed into the uterus while scanning is done.  This is called saline sonography.  MRI, or Magnetic resonance imaging is sometimes used to pinpoint the location of the fibroid .

Why do fibroids occur?

The exact reason why fibroids occur in some women and not in others is not known.  It is known that it is a tumour occurring in patients with increased amount of the hormone called oestrogen.  Thus fibroids increase in size in pregnancy and decrease in size or disappear after menopause as oestrogen levels fall after menopause.  .  It is said to have a genetic origin also.  The incidence of fibroids is increased in women who have other blood relatives with fibroids and thus it is seen to run in families.

Who are prone to develop fibroids?

Fibroids are known to be related to the parity of the woman.   Incidence of fibroids is more  in women with no children and less in women with many children.  Research has shown that women who eat a vegetarian diet are less likely to develop fibroids than women whose diets include meat. Some studies suggest that consuming more fruits, vegetables, and low-fat dairy products could reduce the risk of developing fibroids; however, the effectiveness of changing dietary habits in slowing the growth of existing fibroids or preventing the development of new fibroids has not been conclusively established.

What are the factors that may increase the incidence of fibroids?

Obesity and increased intake of saturated fatty acids is said to increase the incidence of fibroids.  Obesity leads to increased formation of the hormone oestrogen, which leads to fibroid formation.   Eating red meat and refined rice is also known to increase the incidence of fibroids.  Women with high mental tension are also known to have increased incidence of fibroids.  Eating lot of fruits and vegetables are said to help in preventing growth of fibroids.  There is no proper research on diet in fibroids.  Eating food made with saturated fatty acids and white rice, sugar, etc are also factors that are said to be bad for fibroids.

Which are the fibroids which need attention?

A woman may go to a doctor with specific gynaecological complaints like excessive periods, excessive pain during periods,or severe pressure sensation in the back or pelvis. If fibroids are found, either on ultrasonography or even on clinical examination, in such a situation, the symptoms are likely to have been caused by the fibroids. These fibroids  require treatment.

However, today, ultrasonography is being done routinely for many indications like indigestion, mild abdominal discomfort, etc. If fibroids are seen on ultrasonography incidentally at such times, they could be ignored if it appears that the cause of the abdominal discomfort or bloating or whatever other symptom the patient has is not caused due to the presence of fibroids.  Quite often patients have very tiny fibroids in the uterus in a harmless position, but the knowledge that there is a fibroid makes the patient scared. It is best for patients to understand that these fibroids should be left alone.

Is it possible to cure fibroids with medicines?

As of now, there are a few medications which can reduce the size of the fibroids to some extent.  However, after the medications are stopped, the size of the fibroids may come back to the original size after a certain time period.   Thus, these drugs may be useful in women nearing menopause, because, during the period of medical treatment,  if the woman goes into natural menopause, the fibroids may regress for ever.  If the medicines regress the size of the fibroids of a woman who is trying to get pregnant,  the symtpoms may remain in the suppressed state for some more time.  During this period it is quite possible that she may get pregnant.  This is a long shot, though it could happen.  There are no  medicines which could permanently destroy fibroids in the reproductive age.   Sometimes in very large fibroids, giving medical treatment could reduce the size of fibroids quite a bit and then the patient could under go a simpler surgical procedure instead of a more complicated procedure that she would have otherwise needed.

Will fibroids definitely regress after menopause?

Although it is usually assumed that problems associated with fibroids resolve with the onset of the menopause, in reality fibroids can cause symptoms (including abnormal bleeding) even in the menopause.

What are the medicines used in the treatment of fibroids?

Some of the medicines used in the treatment of fibroids are:

  1. Mifepristone: Mifepristone is good at relieving heavy menstrual bleeding assossiated with fibroids, but may not reduce the average size of fibroids
  2. Ulipristal: Ulipristal blocks the progesterone receptors in the uterus leading to decreased formation of new blood vessels and new cells. Treatment with ulipristal for 3 months can reduce the size of fibroids and stop the bleeding caused by fibroids. There is no data on it’s use for more than 3 months
  3. GnRh analogues: GnRh analogues temporarily block the production of estrogen and progesterone, putting the woman in a temporary state of menopause.   They  are injections given monthly ,which can reduce the size of the fibroids,temporairily for a period of a few months. But these injections are costly . Each injection costs around Rs.5000/- They are to be administered every 28 days for a minimum of 3 injections. Many women have significant hot flashes while using Gn-RH agonists. Gn-RH agonists typically are used for no more than three to six months because symptoms return when the medication is stopped and long-term use can cause loss of bone.
  4. Tranexamic acid: This drug causes clotting of blood. The blood clots clog the small blood vessels to prevent further bleeding . This drug is used to temporarily reduce the flow of blood.

What is Progesterone releasing  Intrauterine device? Can it help in the treatment of fibroids?

It is a T shaped device , the long arm being a little short of a matchstick.  The device is placed inside the uterus.  It releases progesterone, a hormone which is released continuously.  This may prevent or reduce excessive bleeding caused by fibroids.  However, it will not reduce the size of the fibroid, which will continue to grow.  The device also provides contraception.

What is the treatment for fibroids?

The 3 modalities of treatment for fibroids are:

1.Surgery to remove the fibroids only (Myomectomy)

2.Surgery to remove the uterus along with the fibroids

3.Nonsurgical embolization/Ultrasound  therapy which will necrotize the fibroids.

What are the indications for active intervention in a case of fibroids?

Active intervention in case of fibroids is necessary only in severely symptomatic patients. In infertile patients, surgery for fibroids need be done only if fibroids are thought to be the cause of infertility.

What is myomectomy? Which are the patients who should undergo myomectomy?

Myomectomy means removal of the fibroids.  In young patients, when fibroids are causing symptoms like bleeding, pain, difficulty in micturition or defecation, fibroids have to be removed.  In patients who are infertile, if the doctor feels that fibroids need to be removed, for improving fertility, myomectomy has to be done.

What are the methods of myomectomy?

Fibroids can be removed by

a.Laparoscopic myomectomy

b.Hysteroscopic myomectomy

c.Laparotomy

Laparoscopic myomectomy: In this procedure, long instruments are introduced into the abdomen through 3 or 4 tiny holes in the abdomen. 

In the picture, a laparoscopic myomectomy is shown. The white tumour in the centre is the fibroid.  The edges of the wound have to be sutured laparoscopically.   The recovery of the patient is faster.  The tumour has to be removed with morcellation.  The size of the fibroid which can be removed laparoscopically and the number of fibroids that can be removed laparoscopically varies from centre to centre.  The author has removed fibroids up to 9 cm laparoscopically with subsequent successful pregnancies which have gone to term.  Multiple fibroids up to 6 in number has also been dealt with laparoscopically in the past in her hands.

Hysteroscopic myomectomy:Sometimes fibroids protrude into the cavity of the uterus causing heavy bleeding.  In such cases if their size is less than 5 cm, they can be removed through the hysteroscope using cautery.  There is no scar on the abdomen and no incision need to be made into the muscle of the uterus.  The patient goes home the same  day absolutely pain free.

In the picture, a fibroid protruding through the uterine cavity is seen hysteroscopically. It is being removed using cautery.

 

Myomectomy by laparotomy:

Abdomen is opened and fibroids removed . This is necessary for very large fibroids and multiple fibroids.   Recuperation will happen in one month’s time.

Will fibroids recur after myomectomy?

Women who have a propensity to develop fibroid will continue to do so even after myomectomy.  They may in due course of time develop new fibroids.  Very tiny fibroids which cannot be seen at the time of hysteroscopy or laparoscopy or even palpated at the time of laparotomy may grow and be seen as new growth of fibroids as years go by.

What are the indications for hysterectomy (removal of uterus) in a case of fibroids?

Hysterectomy as a treatment for fibroids is usually done only in patients who have completed their family. Hysterectomy is preferred in the woman in the older age group.   However, hysterectomy being a major surgery, it should be performed on a patient only if she is severely symptomatic. Certain guidelines for the performance of hysterectomy are:

  1. Very fast growth of fibroids
  2. Very large fibroids in patients who have completed their family
  3. Symptomatic women with heavy menstrual bleeding (for e.g; Bleeding more than 8-10 days in the last 2 cycles or last 40 days and Hb <10g/dL or transfusion within the last 6 months) not responding to medical therapy..
  4. Urinary retention, frequency or incontinence or difficulty evacuating stool .
  5. Severe pelvic pain for at least 6 months, interfering with daily activity.
  6. Postmenopausal women with large fibroids or fibroids which continue to grow even after menopause

In patients in the reproductive age group, who have completed their family, there may be a debate on the wisdom of removing the uterus. It is generally felt that removal of the uterus may jeopardize the blood supply to the ovaries and stop its function prematurely. This may lead to the patient getting perimenopausal symptoms like hot flashes, sweating, etc much before the actual time of biological menopause. Hysterectomy is also known to predispose to urinary symptoms later on. In view of all these factors, some doctors prefer not to remove the uterus even if the patient has completed child bearing.      Instead of removing the uterus, myomectomy, a surgery which removes only the fibroids is done. Surgery for removing only the fibroids is technically associated with more blood loss. Besides that, the tendency for formation of fibroids being inherent, the patient is also liable to have a recurrence of symptoms. Thus, weighing the pros and cons of hysterectomy vs myomectomy, a mature decision has to be taken.

What are the types of hysterectomy?

Please refer to the “hysterectomy” section of this website.

 What is the nonsurgical and permanent solution to fibroids?

Non surgical treatments for fibroids are;

1.Uterine artery embolization

2.MRI guided focused ultrasound surgery(FUS)

Uterine artery embolization:  Through a small prick in the groin area, the main vessel supplying the lower limb, viz, the femoral artery is cannulated. The cannula is then guided into the uterine artery, the main blood vessel supplying blood to the uterus. Some particles are injected into this main vessel to block it and thus the uterus is deprived of it’s main supply of blood. This causes the fibroids to degenerate and undergo necrosis. The uterus does not atrophy as alternate channels of blood supply take over and supply enough blood to the uterus to keep it functioning, but not enough to allow fibroids to grow. The procedure can be done in any center with an angiography machine. It requires specialized skills in radiology. The patient may get abdominal cramps after the procedure and can be discharged from the hospital in a day or two. At present, the procedure is not recommended for women who have not completed childbearing.

Uterine Fibroid Embolisation has certain risks related with it:The embolic fluid might accumulate in the wrong place that might block the oxygen supply in that place. It is difficult of predict if the uterine wall is weakened by Uterine Fibroid Embolisation. Hence it is recommended to use contraception for six months after the procedure and to undergo Cesarean section to not allow extra pressure on the uterine walls which might otherwise occur during a normal delivery.

 

MRI guided focused ultrasound surgery:

It is a noninvasive treatment option for uterine fibroids that preserves the uterus, requires no incision and is done on an outpatient basis in very select centres.     It is performed inside an MRI scanner equipped with a high-energy ultrasound transducer for treatment.  The images on the MRI machine is used to locate the fibroid and the ultrasound transducer focuses sound waves(sonications) into the fibroid to heat and destroy small areas of fibroid tissue.  It can be done only for select cases.

What If I Become Pregnant and Have Fibroids?
Asymptomatic small or medium sized fibroids alone are unlikely to present significant risk to pregnancy. However, fibroids may increase in size as a result of increased levels of hormones and blood flow to the uterus during pregnancy. The growth of fibroids may cause discomfort, feelings of pressure, or pain. There may be degeneration in the fibroid during pregnancy , rarely.  Pain has to be constantly managed in patients who go through pregnancy.  The pain is severe in some patients, but it is manageable with medical help .  Generally the vast majority of women who have fibroids with pregnancy carry to term , though incidence of certain complications are higher in these patients.

 

 

 

Questions and Answers compiled by

Dr.Shobhana Mohandas.MD.DGO.FICOG

Consultant gynaecologist, Sun Medical centre,Thrissur, Kerala

E-mail: shobhanamohandas@gmail.com


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