Rehan Salim MD MRCOG
Consultant Gynaecologist & Subspecialist in Reproductive Medicine
Wolfson Fertility Centre - Hammersmith Hospital
What are Fibroids?
Fibroids are benign (non-cancerous) lumps in the muscle wall of the uterus that can change the shape or size of the uterus (womb) and sometimes the cervix. They are also called leiomyomas or myomas that originate from the smooth muscle layer (myometrium) of the uterus.
Fibroids can vary in size, they may grow slowly or rapidly, or they may stay the same size for a long period. Some fibroids go through growth spurts, and some may shrink on their own. Fibroids don't spread to other parts of the body, except in very rare circumstances.
Fibroids can be asymptomatic, most of the time women with fibroids are unaware of having them since they are often without symptoms.
Where can Fibroids grow?
Fibroids are named according to the location where they found in the uterus.
Intramural fibroids- the most common type, they develop within the muscle tissue of the uterine wall
Subserosal fibroids- grow on the outside wall of the womb
Submucosal fibroids- grow from the inner wall into the middle of the womb
Pedunculated fibroids- grow from the outside of the womb and are attached to it by a narrow stalk or other nearby organs
How do fibroids cause infertility?
It is not entirely clear how fibroids affect fertility. However, large fibroids in the muscle wall of the uterus and fibroids that distort the cavity of the uterus (submucous) have been shown to reduce the chances of successful fertility treatment. It is possible fibroids affect fertility by creating an abnormal environment in the uterine cavity or causing changes to the blood supply of the lining of the uterus.
Who can have Fibroids?
Fibroids are more commoner in overweight women, and women who have never had children previously. Fibroids are foundin 20% of women during reproductive years. however women of African descent have been known to have a higher incidence of fibroid formation, which could be up to 80%.
What are the causes of Fibroids?
The exact reasons why some women develop fibroids is unknown. However, there is some indication that a combination of genetic, hormonal and environmental factors may play a role.
What are the symptoms of Fibroids?
Some fibroids, even the large ones may be asymptomatic. However, when women do experience symptoms, the most common are the following:
Heavy bleeding during period- excessively heavy or prolonged menstruation
Bladder problem- the most common bladder problem symptom is the need to urinate frequently. The cause of these symptoms are by fibroids pressing against the bladder, reducing its capacity for holding urine or blocking the drainage of urine.
Pelvic cramping or pain with periods
Pain during intercourse
Constipation – this happens if a fibroid is pressing on the bowel
Bloating or fullness in the belly or pelvis
How are fibroids diagnosed?
Most women with fibroids have no symptoms, so they often go undetected. At times, fibroids are found during a routine gynaecological visit with a pelvic examination. A pelvic exam allows the doctor to feel the size and shape of the womb.
If the doctor thinks you may have fibroids after performing the exam, there are several tests that can confirm the diagnosis.
Vaginal Ultrasound- Uses ultrasound waves to create a picture of the womb, and can confirm the presence of fibroids.
CT scan/ Magnetic Resonance Imaging (MRI)- Uses a large special magnet to take pictures of the body, and will give a reportable, detailed picture of the number, size and exact location of the fibroid. Not all women with fibroids need an MRI.
Hysteroscopy- Uses a long, thin camera (= hysteroscope) that is inserted through the vagina into the uterine cavity to examine and visualise the inside of the womb.
What are the treatment options for fibroids?
Fibroids usually do not require treatment because most patients with fibroids do not have symptoms. Women with fibroids should have regular checkups to determine if the fibroids are changing in size, to track worsening symptoms and if planning to get pregnant.
The type of treatment for women who have fibroid(s) depends on the age, general health, symptoms, type of fibroid. If there is a desire to conceive, pregnancy or a wish to preserve fertility.
Treatment options may vary. The management of uterine fibroids will depend upon the findings (size and location of the fibroid), the severity of the symptoms and our consultant′s recommendations. The scientific knowledge, whether asymptomatic fibroids do have a negative impact on fertility, is still very limited.
If treatment is required, are there alternates to surgery?
Fibroids are affected by the estrogen level in our blood. So, medical management does provide relief but does not improve fertility. Also, medication may cause certain undesirable side-effects.
Some medications used to treat fibroids and their associated side-effects are:
Gonadotropin-releasing-hormone (GnRH) analogs- hot flashes, vaginal dryness, mood changes, and osteoporosis
Birth control pills- breast tenderness, risk of thrombosis
Progestins- bloating, abnormal bleeding
Androgens- unwanted hair growth
Alternative approaches to herbal and homeopathic therapies have not been shown to improve symptoms associated with fibroids.
When is surgery considered?
In the contect of fertility, removal of fibroids needs to be carefully considered with all the factors. It is possible that removal of fibroids will improve chances of fertility treatment and natural conception but this does vary depending on individual circumstances.
If future fertility is desired, what surgical options are available?
If a woman plans to get pregnant in the future, the only surgical option is a myomectomy, i.e. the surgical removal of the fibroids. The size and location of the fibroids are used to determine the appropriate surgical technique in most cases.
How is a myomectomy performed? Is there a minimally invasive approach?
A myomectomy (described below) can be of various types, depending on the location and size of the fibroids. All myomectomies carry the risk of scarring and adhesions, which can affect future fertility. Each also carries the risk of excessive bleeding, which may require a hysterectomy.
Abdominal myomectomy (Laparotomy)
This approach is used to remove fibroids or tumors that are on the outer surface of the uterus and surrounding organs. The surgeon accesses these through an incision in the abdomen. This surgery usually requires a 24 to 72-hour hospital stay and 4-6 weeks of recovery.
A Laparoscopic myomectomy is a simple, minimally invasive procedure, where a laparoscope is used to remove fibroids through a small 5-10 mm incisions in the abdomen, and via the navel. Women can go home the same day or within 24 hours. Recovery time is usually two to seven days.
This procedure is the best approach for fibroids that are present inside the uterine cavity. In this procedure, a telescope-like instrument is inserted through the cervix. Then, fluid is used to fill up the uterus to expand the walls. Thus allows for better access and visualisation. Then, via a hysteroscope, surgical instruments are inserted to remove submucous fibroids.
Women who choose this procedure generally, go home the same day of surgery and can get back to their routine within a few days.
This procedure is not linked to serious complications. But, there is a risk of damage or scarring to the inside cavity of the uterus, electrolyte imbalance (changes in the minerals in the blood system) and puncturing of the uterus and bleeding.
What is the chance after a myomectomy that the uterine fibroids will return?
This risk of recurrence after a myomectomy is about 30% over a period of 10 years. Patients who have had multiple fibroids are more likely to experience recurrence as compared to patients with singular or isolated fibroids.