Fibroids

What Are Fibroids?

The womb (uterus) is made up of three layers. The inner core is the lining of the womb (endometrium) that sheds with a period. This is surrounded by a thick muscular layer (myometrium) and then a thin outer layer (serosal).

Fibroids are overgrown bundles of muscle fibres. They are the most common condition affecting the female reproductive system, found in almost half of all women. They are nearly always benign (non-cancerous). Thankfully, cancerous changes are exceedingly rare. They are the main cause for hysterectomies in women before the menopause. However, most women who have them will suffer no symptoms at all and will not even know they have them. They are usually only problematic if they are causing discomfort, pain (with periods or intercourse) or prolonged and excessive vaginal bleeding. They may also be linked to miscarriages and not getting pregnant. They can grow and become very painful during pregnancy.

The problems that fibroids cause are linked to their size and where in the womb they are growing. Fibroids mainly grow within the wall of the womb (intramural, subserosal). They can grow out on stalks into the pelvis (pedunculated) to press on the bowel or bladder. They can grow into the area normally occupied by the lining of the womb (submucosal). Here they are often associated with heavy, prolonged and painful periods or bleeding between periods. There are usually a number of fibroids present, and in rare cases they can grow extremely large.

What Causes Fibroids?

It is not known what causes fibroids. They grow because chemical hormones produced from the ovary (oestrogen and progesterone) feed them. They tend to grow very slowly over a number of years, except when oestrogen levels are boosted, for example during pregnancy, when their growth will speed up. After pregnancy they will shrink back to their original size, and after menopause they will continue to shrink. Women of Afro-Caribbean origin, women who have never been pregnant and women with a family history are more likely to develop fibroids. There is nothing you can do to prevent them.

What Are The Symptoms?

Most women do not have any symptoms and most cases are found during a routine gynaecological examination or scan. Those women who do have symptoms are likely to have heavy periods, with sudden bleeding during the second or third day. This can lead to anaemia and tiredness.

The periods may begin to last for more days and there can be bleeding between periods. Pains may occur with periods and intercourse, there can be lower backache or even sharp pains, especially during pregnancy. If the fibroids are pressing on the bowel you may have constipation or it can hurt when the bowels open. If the bladder is affected you may have difficulty passing urine or you might go to the toilet more often and pass smaller amounts. Fibroids can also affect pregnancy in a number of ways:

• If they intrude into the womb conditions may not be right for a fertilised egg to implant, causing infertility (fibroids are implicated in about 10% of infertility cases)
• Fibroids can increase the chance of miscarriage or premature labour
• Fibroids that obstruct the lower womb can cause difficulties during labour

How are fibroids diagnosed?

Many cases are picked up by your doctor when a routine gynaecological examination such as with a smear reveals that your womb is enlarged, irregularly shaped or lumpy. To confirm the diagnosis and rule out other possible causes, you will be referred to a gynaecologist. They may use an ultrasound scan to determine the position and exact size of the fibroid(s). You may also be sent for a body scan (MRI scan) if it is considered necessary.

Treatment Options

The treatment depends on the severity of your symptoms and other factors such as your age, lifestyle and whether you want to have children.

If you have no symptoms or minor symptoms no treatment is necessary. You may be advised just to have regular check-ups to keep an eye on how fast the fibroids are growing. This usually involves scans at least 6 months apart to check for any growth.

You may be advised to have treatment if you are anaemic or the fibroids are blocking the drainage of urine from a kidney. You may not know that these things are happening to you so a blood test and scan are normally done.

Some doctors may advise that you have even the small fibroids treated especially if you are young and thinking of having children in the future. If you intend to have children you may also be advised to try for them soon to avoid possible complications if the fibroids grow.

Medical Treatment
Drugs like the Mirena coil may be useful to treat heavy periods and help with some of the pains, but they do not shrink the fibroids. You may also be given iron to treat any anaemia. If your symptoms are minor and you are close to the menopause these may work well. Once you have reached the menopause the fibroids will shrink and normally stop causing problems.

Drugs may be used to make you menopausal. These drugs - GnRH analogues (like Goserelin (Zoladex) and Prostap) reduce the oestrogen and progesterone hormone levels, and it is thought that this then causes the fibroids to shrink, but this may not be the whole picture. The fibroids shrink by up to 30-50% generally within 3 months; reducing the overall size of the womb and they may stop your bleeding. However, their long term use is limited because of their side-effects: headaches, vaginal dryness and hot flushes. It is important not to become pregnant while taking them. You should be advised to use a non-hormonal form of contraception such as condoms or a diaphragm. Once you stop taking them periods normally return within 4-8 weeks and the fibroids return to their original size, but for about two thirds of women they may remain symptom free for up to a year afterwards. These drugs may be ideal if you are approaching the menopause and have no desire to get pregnant. They can be given with HRT to reduce their side effects after the first 3 months use, and can be used for long periods of time. They may be given for a short period of time before surgery, especially before a hysterectomy. They can reduce the size of the womb making it possible to avoid open surgery.

GnRH antagonists like Ganirelix are a similar type of drug and small studies have suggested they can rapidly shrink fibroids, they also have similar menopausal side effects. Some other drugs have also been tested in small studies and have been shown to shrink the size of the womb, but they are also not without side effects. These include Mifepristone, which stops the hormone progesterone working. They can cause potentially cancerous changes in the womb lining in about 10% of women and commonly cause hot flushes. Aromatase inhibitors may also show promise.

Uterine Artery Embolisation (UAE)
This is a very effective treatment for certain women with fibroids. In this procedure a small tube is placed into a blood vessel in the groin. This tube is then moved through that blood vessel until it reaches the blood supply of the fibroid. A special chemical is injected through the tube which blocks the blood supply to the fibroid and causes it to “die”. This avoids the need for surgery and is done under local anaesthetic, although it can take a long time and is painful. It produces good results with up to 90% of women experiencing relief from their symptoms. It avoids the need for hysterectomy and is useful to treat multiple and large fibroids. It is not recommended for women wishing to try and get pregnant and at the present time we do not know if it can harm the ovaries. Rarely, infections can develop after the procedure and a hysterectomy could be required.

It is possible to block the blood supply with surgery – uterine artery occlusion but this requires surgery with its risks. A specially designed clamp is currently being tested that is inserted through the vaginal to block the blood supply to the fibroids using ultrasound. Early results look promising.

Magnetic Resonance Imaging(MRI) – Guided Focused Ultrasound
Ultrasound energy can be focused to create heat in a small area. If this is directed at one point cell death occurs. This is being widely used in the USA, but at present is only available at St Mary’s Hospital in London in the UK. Using MRI ultrasound can then be focused on a fibroid to try and partially destroy it. Like UAE it is not recommended for women who wish to get pregnant at a later time. It is safe but can cause superficial skin burns.

Surgical Treatment
If the symptoms are problematic or severe, surgery is the main treatment. The type of procedure carried out will depend on a number of factors, such as your age, the desire for children and the size and number of fibroids.

Myolysis

This operation involves destroying the blood supply to the fibroid by “drilling” a hole into the centre with either laser energy or an electric current. It is normally done with key-hole surgery and the risks are similar to those for UAE. It can cause fibroids to shrink by about half but is associated with significant scar tissue (adhesion) formation. Hence, not many surgeons recommend it.

Younger women, especially those who still want to have children, should be advised to opt for less radical surgery to have the fibroids removed - a myomectomy. If the fibroid is growing in the centre or “cavity” of the womb, it can be removed by inserting a fine telescope-like instrument through the neck of the womb into the womb. The fibroid can then be cut away relatively simply (hysteroscopic resection). For large fibroids this operation may need to be repeated after a few months. In the long-term (after 8 years) about 1 in 4 women will have needed further treatment. The resection of fibroids in this way increases the chances of pregnancy in infertile women. It is also effective in reducing bleeding. If fertility is not an issue the rest of the lining of the womb could be destroyed at the same time to further reduce bleeding from heavy periods (endometrial resection).

If the fibroids are growing outside the centre of the womb then they have to be removed through the tummy preferably with key-hole surgery (laparoscopic myomectomy). This procedure is carried out under general anaesthetic. For larger or more numerous fibroids, or ones that may be touching the lining of the womb; open surgery (laparotomy) may be required, where a cut is made in the tummy and all the fibroids are removed, no matter where they are located (open myomectomy). Compared to the laparoscopic approach it is more painful, requires a longer stay in hospital and takes longer to recover from.

A myomectomy leaves all reproductive organs intact enabling you to have children in the future. However, with a myomectomy, there is no guarantee that all the symptoms will stop and fibroids can still re-grow. Any surgery has a risk of complications, the commonest risk with this is bleeding that may require a blood transfusion. If the operation results in bleeding that cannot be controlled, the surgeon may have to resort to a hysterectomy (see below). However, the chances of this are small. The surgery is often more complex than a hysterectomy and can take longer. There is also a significant risk of developing scar tissue (adhesions) afterwards that can cause further problems. If you have had a myomectomy a Caesarean section may be recommended if you become pregnant.

Fibroids are one of the commonest reasons for hysterectomies to be performed, accounting for about a third of them. The only way to guarantee that all symptoms stop and the fibroids will not re-grow is to have a hysterectomy. This is a more radical procedure where the entire womb is removed. The ovaries are left to continue naturally producing hormones such as oestrogen, which helps protect your bones and is involved in other important functions in your body.

If the ovaries are removed you will need to discuss your thoughts on Hormone Replacement Therapy (HRT) with your doctor. A hysterectomy is a major operation that can have a severe impact on your body as it involves major surgery and means that you can never have children in the future. However, most women who have it done are very satisfied. It is preferable that the operation is performed vaginally or with the assistance of key-hole surgery (laparoscopically).

The reason for this is a much quicker return to normal activities. It is also likely that drugs may be given first to shrink the fibroids and to try and reduce the likelihood of cutting your tummy open. A relatively new approach is a laparoscopic sub-total hysterectomy where the neck of the womb and the ovaries are left behind. This can be done as a day case operation and patients who have had it done can be back to work within 1-2 weeks.