Fibroids

What are fibroids?

A fibroid is a non-cancerous (benign) growth of the womb. They are also called uterine myomas or leiomyomas. They are common and usually cause no symptoms. However, they can sometimes cause symptoms and need treatment.

Their size can vary. They can occur anywhere in the womb and are named according to where they grow, for example submucous, intramural, subserous and pedunculated. At least 1 in 4 women develop one or more symptomatic fibroids in their lifetime. They usually develop in women aged 30-50. Fibroids are more common in women of Afro-Caribbean origin.

What causes fibroids?

The exact cause of fibroids is unknown. However, they are linked to the hormone oestrogen. Fibroids tend to shrink after menopause, when the level of oestrogen is low. Fibroids are more common in women of Afro-Caribbean origin.

What are symptoms and problems caused by the fibroids?

Many women who have fibroids, do not get any symptoms and they are not aware that they have them. Sometimes one is found during a routine examination by a doctor or by chance during a scan which is done for another reason.

Symptoms may include:

Heavy or more painful periods: Fibroids do not disturb the menstrual cycle but cause heavy bleeding and sometimes with more pain.

Bloating or swelling: If a fibroid is large you may have discomfort or swelling in the lower tummy (abdomen). Some women experience lower back pain due to the fibroids.

Bladder or bowel symptoms: Occasionally, a fibroid may press on the bladder which lies in front of the womb (uterus). You may then pass urine more often than usual. Rarely, pressure on the bowel (which lies behind the womb) may cause constipation.

Pain during sexual intercourse: If the fibroids grow near to the vagina or neck of the womb (cervix) then this can cause pain or discomfort during sexual intercourse.

Miscarriage or subfertility: If the fibroids grow into the cavity of the womb they can affect the fertility. Very rarely, fibroids can be the cause of miscarriage.

Problems during pregnancy: In the vast majority of women fibroids do not cause any problems in pregnancy. Occasionally, it may cause pain because of degeneration. The fibroids can be associated with increased complications in pregnancy.

How are fibroids diagnosed?

Large fibroids can be felt during an abdominal or internal examination by a doctor. Investigations like an ultrasound scan or an MRI is done to confirm the diagnosis and to map out the fibroids.

What are the treatment options for fibroids?

The treatment has to be individualised depending upon the wishes of the woman, desire for fertility, size, location and symptoms of the fibroids.

Conservative option or Observation. If the fibroids are not causing any symptoms, then treatment is not usually needed. Many women choose not to have treatment, if they have mild symptoms. After menopause, fibroids often shrink and symptoms tend to get less.

Medical Treatment. This is not very effective in large fibroids. The medical options are usually NSAIDs- Mefenamic acid and Ibuprofen, which help to control the heavy bleeding and pain. The Tranexamic acid and hormonal pills also help to control the heavy bleeding.

Medication to shrink the fibroids. Some women are given a gonadotrophin-releasing hormone (GnRH) analogue. It can cause symptoms like going through menopause. It may also increase the risk of ‘thinning’ of the bones (osteoporosis). Therefore, this treatment is given for a maximum of six months or before surgery to shrink the fibroids and reduce the vascularity.

Esmya (ulipristal acetate), is another treatment option, to be used before surgery for fibroids. Esmya can be given intermittently up to 4 courses, to women with heavy menstrual bleeding and fibroids of 3 cm or more in diameter.

Surgery and other operative treatments. Depending upon the desire for fertility and the size, location and symptoms of the fibroids, there are different surgical options available to remove and treat fibroids.

Non-hysterectomy options:

Hysteroscopy and resection of fibroids: Fibroids, which are towards the cavity of the womb, can be removed easily using a hysteroscope.

Endometrial ablation: This procedure involves treatment of the lining of the womb for the women with heavy bleeding. This option is suitable for small fibroids. This can be done by different methods.

Uterine artery embolization: There is a good chance of success with this procedure but one in three women will need further treatment. Current evidence on uterine artery embolization (UAE) for fibroids shows that the procedure is efficacious for symptom relief in the short and medium term for a substantial proportion of patients. There are no major safety concerns. (See https://www.rcr.ac.uk/)

MRI-guided focused ultrasound (MRgFUS): Current evidence on the efficacy of magnetic resonance image (MRI)-guided transcutaneous focused ultrasound for uterine fibroids in the short term is adequate. This is available in selected centres only

Myomectomy: This is considered especially in women who may wish to have children in the future or want to retain the uterus. In this operation, the fibroids are removed and the womb is left. This can be done in different ways like laparoscopic, abdominal and hysteroscopically. It is fairly common for a fibroid to recur after a myomectomy.

Hysterectomy: Hysterectomy is the removal of the womb. This can be done in different ways like key hole(Laparoscopic), abdominal and vaginal route.

Other techniques/ options: MRI-guided laser ablation is a newer technique. Complementary therapies for fibroids have not been shown to be effective.