What are fibroids?
Fibroids are essentially benign muscle tumor forming within the wall of the uterus. They are mostly benign (non-cancerous) but can become malignant (cancerous) in around 1:1000 cases. Some are small and cause no problems but fibroids can also grow quite large to cause symptoms. It affects 25%-40% of all women before the age of 50 years. Most but not all women have shrinkage of fibroids after menopause.
Early menarche, nulliparity, obesity as well as a familial predisposition increase the risk of fibroids. The risk factors point to the possibility that an oversupply of oestrogens possibly drive the growth of fibroids.
Oral contraceptive pill (OCP) does not cause fibroids to grow .
What problems can they cause?
The most common problems are heavy painful periods, pressure symptoms (urinary and bowel symptoms) abdominal swelling, painful intercourse, infertility.
Malignant transformation (turning into a cancer) although uncommon (1:1000) is a serious problem and may not be obvious on conventional testing such as imaging. Any increase in fibroid size after the menopause should be regarded as suspicious.
- Pelvic exam – a bimanual pelvic/vaginal/rectal examination is helpful to determine size and mobility of the pelvic mass.
- An ultrasound is the first step to determine pelvic symptoms. Ultrasound is inexpensive and allows small fibroids to be easily outlined. Very large fibroids should be investigated by MRI scan (preferred).
- MRI scans – Women who wish to have a myomectomy (removal of fibroids, preservation of uterus) for fertility reasons should have an MRI prior to treatment. MRI scanning also is the imaging method of choice to diagnose adenomyosis, which is a common condition associated with fibroids.
What treatment is available?
Observation – Many fibroids do not cause symptoms and can simply be observed.
Medical Treatment – There is a general lack of good quality data on the medical treatment of fibroids. It is generally accepted that medical treatment provides initial symptom relief in a large number of women, but treatment failures after a year (recurrence of symptoms) are very common. A US study from 2006 suggested that 6 of 10 women who were randomly assigned to medical therapy required surgery by two years.
- Oral contraceptives (OC): Experts are divided whether combined pills are effective
- Hormone-releasing IUD (Mirena): Releases progestins at a very low rate into the uterus and is mainly used to treat women with heavy menstrual bleeding. There are no good quality studies available for the treatment of fibroids. However, some gynaecologists believe that it provides good symptomatic relief. Fibroids that grow into the uterine cavity should not be treated with Mirena.
- Hormone injections (Depoprovera) are widely given to women with fibroids for symptom control to stop bleeding. Whether progestins are effective on the fibroids or have a beneficial effect on the endometrium is unknown. Long-term progestin use can lead to diabetes, weight gain and thromboembolic complications.
- GnRH agonists, antagonists: not recommended to treat fibroids; require frequent injections and render patients menopausal, causing enormous risks and possible complications. Rapid regrowth of fibroids can occur once injections are stopped.
- Tranexamic acid: Approved for symptomatic treatment of heavy menstrual bleeding. Can be used in combination with Progestins to stop very heavy bleeding for a short time.
Surgery – Conservative surgery in the form of myomectomy is when the fibroid is excised and the uterus is conserved allowing further fertility. This can be performed laparoscopically depending on the size and position of the fibroid(s). There is a risk of uterine rupture during pregnancy following laparoscopic myomectomy.
Where fertility is not an issue and fibroids are causing problems a hysterectomy (with or without the ovaries depending on age and patient wishes) may also be an option (either laparoscopically or open depending on size of the uterus).
- Post or perimenopausal women with significant and long-standing symptoms who desire definitive symptom control
- Women who failed previous conservative treatments
- Women with fibroids and additional conditions that would be eliminated by hysterectomy (e.g. adenomyosis, history of breast cancer, increased risk of uterine or ovarian cancer)
Uterine artery Embolisation – This is performed by an interventional radiologist and involves injecting a substance designed to cut of the blood supply to the fibroid and is generally not recommended if patients wish to proceed to pregnancy in the future.