Fibroids

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Fibroids are one of the most common gynaecological problems. They affect 20-25% of women worldwide and about 3-5 % of women will require surgical removal.

The main symptoms include:

  • Heavy periods (menorrhagia) / Abnormal uterine bleeding (AUB) is the most common symptom and can be severe enough to cause iron deficiency anaemia.
  • Pelvic pain (pressure symptoms): Large fibroids at particular locations can cause these symptoms. Painful periods or painful intercourse may also be associated with the presence of fibroids.
  • Sub-fertility (difficulty achieving pregnancy): Fibroids that distort the uterine cavity can result in difficulty falling pregnant and increase the risk of miscarriage. Pregnancies complicated by fibroids can result in fetal growth restriction, abruption, slow labor and postpartum haemorrhage.

Treatment will be tailored to your symptoms and needs.

Women will notice a relief of fibroid related symptoms at the time of menopause. This is because fibroids shrink with waning hormone levels in menopause.

Pathology

Fibroids (also known as leiomyomas) are benign smooth muscle tumors of the uterus. Fibroids are classified according to their location as:

  • Sub-serosal (originate from the outer surface of the uterus)
  • Intra-mural (originate within the uterine muscle wall)
  • Sub-mucosal (grow into the uterine cavity)

A sarcoma is a malignant transformation of a fibroid. Fortunately, sarcomas are very rare.

Risk Factors for fibroids

  • Early first menstruation
  • Family history
  • Hypertension
  • Obesity
  • Consumption of red meat
  • Protective factors
    • Smoking
    • Long acting progesterone

Diagnosis

Diagnosis is based on pelvic examination and imaging.

Findings of an enlarged uterus, mobile (unless it is very large), irregular contours are suggestive of uterine fibroids.

Other imaging techniques include saline hysterosonogram (HSG) and MRI.

There has been recent controversy regarding extraction of the fibroids following a myomectomy (removal of fibroid). It is feared that an occult malignancy in the fibroid may spread it in the peritoneal cavity. At AEVAFEM, we use the latest methods to extract the specimen, such as in bag morcellation to minimise this risk.

Treatment

Expectant management can be offered to patients who are:

  • Asymptomatic
  • Decline medical or surgical management
  • Follow up: Re-evaluate if an increase in size of fibroid, development of new symptoms such as menorrhagia, pelvic pressure and or anaemia.

Risks of expectant management

  • Development of new symptoms
  • Increase in size & number of fibroids
  • Very rarely can lead to development of sarcoma

Medical therapy

Good quality data on effective medical therapies is lacking. However, it is prudent to offer medical therapy to patients before considering surgical options.

It provides adequate symptom relief in some women where bleeding is the dominant or the only symptom. 75% of women get some improvement over one year of therapy, but long-term failure rates are high. Over 60% of women who have symptomatic fibroids and are treated with medical therapy will need surgery within two years. Medical therapy cannot be offered to post- menopausal women.

The various available options are:

  • Combined Oral Contraceptive Pills (COCP)
  • Progesterone only pills (POP), Progestin Implants & Injections
  • Mirena
  • GnRH agonist or antagonists
  • Anti-progestins and progesterone receptor inhibitors – Mifepristone
  • Raloxifene – selective estrogen receptor modulators (SERMs)
  • Danazol / Gestrinone

Surgical options:

Myomectomy

  • Involves surgically removing the fibroids.
  • Procedure of choice in women who have not completed childbearing or decline hysterectomy.
  • Abdominal / Laparoscopic / Robotic Assisted removal of fibroids is the standard option.
    • Robotic Surgery is seen to be the best surgical option for the future. It offers 3D visualisation of the surgical field, wristed movements offering better suturing of the uterine defect, thereby improving the surgical technique. This results in better outcomes for patient recovery and future pregnancies.
  • Hysteroscopic resection involves removal of fibroids within the uterus by passing an instrument through the cervix.

Hysterectomy

30% – 50% of hysterectomies are done for fibroid uteri.

Beneficial in women who have:

  • Completed childbearing
  • Have concomitant disease (endometriosis, adenomyosis, etc.)
  • Failed medical or minimally invasive therapy
  • Choice of surgical procedure (Laparoscopic / Robotic Assisted / Abdominal Hysterectomy) depends on patient’s individual circumstances.
    • Laparoscopic and Robotic-Assisted Hysterectomy are associated with less morbidity than laparotomy.

Endometrial ablation

  • Helpful only in a small percentage of women with symptoms of heavy bleeding who have a regular intrauterine cavity which is not distorted due to the presence of fibroids.
  • The disadvantage is that the fibroids are still persistant

 

Benefits of surgical procedures:

  • Definitive procedure
  • Resolution of symptoms due to size
  • Procedure of choice in patients with infertility or pregnancy loss due to fibroids

Intervention radiology

  • Uterine artery embolisation
  • MRI-guided focused ultrasound

At AEVAFEM (as specialists in advanced gynaecological care) we receive many referrals for second opinions. If you have been diagnosed with fibroids and want to know about your treatment options, we will take the time to discuss these with you and offer a solution that is tailored to your needs and expectations.