Fibroids are benign (not cancer) tumours in the uterus. They occur in about 25-50% of all women. This is a slow growing tumour which one maybe unaware ofand may get detected only on routine scan. This growth is from the muscle of the uterus. They are also called leiomyomas or myomas. They are often diagnosed during childbearing years, typically between the ages 30-40, but can also develop earlier of later in life.
Although fibroids are quite common, we know very little as to why they develop. It is a disruptive grwoth of the muscle cells of the uterus and scientists are still not sure why they develop. The female hormone estrogen seems to increase their growth. For instance, pregnancy causes an increase in estrogen and menopause causes a decrease. It could also be genetics as we see that fibroids run in families. The size, shape, and location of fibroids can vary greatly. They may be on the outer side of the uterus(subserous), or in the wall of the uterus(intramural) or inside the cavity of the uterus(submucous). As they grow, they can distort the inside as well as the outside of the uterus. Sometimes fibroids grow large enough to completely fill the pelvis or abdomen.
What are their symptoms?
Most fibroids, even large ones, produce no symptoms at all. Some of the symptoms that may require treatment are
- Abnormal Bleeding
- Heavy bleeding- Clots may be there.
- Menstrual pain (dysmenorrhoea)
- Vaginal bleeding at times other than menstruation
- Abdomen or lower back which is of recent onset (often dull, heavy and aching, but may be sharp)
- During sex
- Pressure symptoms
- Difficulty urinating or frequent urination
- Constipation, rectal pain, or difficult bowel movements
- Enlarged mass in the abdomen
- Miscarriages and infertility
WHAT ARE THE RISK FACTORS FOR FIBROID?
Age - As you age you are more likely to develop fibroids
Family History -2 to 2. 5 fold increased risk if your mother or sister has fibroids
Ethnic -African origin women have higher tendency (2-3 times higher risk)
Some other factors which are associated with fibroids are-
- Early onset menstruation
- Nulliparity (no children)
- Environmental toxins (endocrine-disrupting compounds (EDC))
- Mutations to specific genes
- They continue to grow or reoccur while estrogen is present; till the age of menopause and can shrink or disappear after menopause
How do we diagnose fibroids?
Fibroids may be diagnosed on routine USG or pelvic examination. Often ultrasonography is sufficient for diagnosis. However MRI is useful as preoperative investigation when only removal of fibroids are planned. Mri not only becomes the GPS to track all fibroids for their location and size but also distiguishes them from adenomyosis which is different from fibroids. Hysteroscopy can be used to diagnose submucous fibroids.
When to treat fibroids?
Fibroids that are asymptomatic or are small often do not require treatment. Signs and symptoms that may indicate the need for treatment are
- Heavy or painful menstrual periodscausing anaemia
- Bleeding between periods
- Sudden increase in sizeof fibroid
- Uncertainty whether the growth is a fibroid or another type of tumor
- Pelvic pain
Perimenopausal patients with asymptomatic fibroids are often observed, as we know that with menopause the size of fibroids reduce and may not require any surgery.
How do we treat Fibroids?
What are the medical therapies for fibroids?
Some drugs can be used for temorary relief. However, there are no medicines available at present that can permanently cure fibroids. Some options are
- Combined oral contraceptive pills These can help decrease bleeding during the menstrual cycle but cannot decrease the size of the fibroid
- Progesterone Releasing IUD (intrauterine device) This device is inserted into the uterus. It releases small amounts of progesterone hormone (20 mg/day). These can decrease bleeding but no effect on the fibroid itself.
- Gonadotropin Releasing Hormone (GnRH) Agonists Theseinjections that suppress the release of natural estrogen and progesterone and causes shrinkage of fibroids and thus decrease bleeding. These medications act by mimicing menopausal state and one can have troublesome hot flashes. GnRH agonists are not a long-term management option.
- NSAIDs (nonsteroidal anti-inflammatory drugs) These provide symtomatic relief from associated pain and to some extent reduce bleeding as well but will not effect the fibroid or any bleeding symptoms.
- Uripisilate- This is a new drug recently intoduced in fibroid management but we do not know the long trem benefits that they can provide.
What are the surgical methods to treat fibroids? The common and permanent treatment of fibroids is surgery which could be hysterectomy (removal of uterus with the fibroids)or myomectomy (removal of fibroids while preserving the uterus for future function)depending on the patients age and fertility status. Because a woman keeps her uterusduring myomectomy, she may still be able to have childrenin future. If a woman does become pregnant after a myomectomy, she may need to have a cesarean delivery. Fibroids may develop again, which are the new ones ofcourse as the ones removed do not come back even after the procedure. If they do, repeat surgery is needed in 20-40% of cases. The method used depends on the location and size of the fibroidsas well as the skill of surgeon and technology available.
- AbdominalMyomectomy -is the surgical removal of fibroids while leaving the uterus in place. This is done via a large incision on the abdomen and requires long recovery as any open surgery does.
- Hysteroscopic Myomectomy, a method where no cuts are required and is done with help of telescope (hysteroscope) inserted into uterus via vagina. It is recommended for submucous fibroids. Hystereoscope with camera and an electric loop attachment is introduced inside the cavity of the uterus through the vagina. The fibroids are removed by shaving them off the wall of the uterus. This is an outpatient procedure and patients can go home the same day of surgery.
- Key hole surgery(Laparoscopic assisted myomectomy). - This is a key hole surgery in which is performed using a telescope. Fibroids are removed after making an incision on the uterus. Once removed the uterus is sutured back to its original shape. The fibroid so removed are then put in an 'Endo Bag' (specimen retrieval bag). This is a safe and recommended method of removing fibroids which we always use at our center to avoid accidentally spillage of tissues in abdominal cavity. For very large fibroids one of the ports is extended or a small incision is given on bikini line to remove fibroids. Patients typically go home in 24-48 hours resulting in a quicker postoperative recovery. Ofcourse this type of surgery requires expert surgical skill.
- Uterine Artery Embolisation(UAE)-With this procedure, the blood vessels to the uterus are blocked. This helps stop the blood flow into the fibroids which causes them to shrink to a reasonble size for symptoms to reduce. This procedure usually is performedby interventional Radiologist. This again however is not a permanent cure and there is no pathological specimen to confirm that the tumour we dealt with was indeed fibroid. . Not recommended for patients who wish to become pregnant late. UAE is also helpful for patients for whom surgery is too risky. But some potential moderate to severe side effects and complications have been reoprted with UAE. These could be fever, pain, infection, necrosis of uterine tissue and vulva, premature ovarian failure acusing infertility as compared to myomectomy.
- Robotic Assisted Laparoscopic Myomectomy-DaVinci RoboticThis technology is recommended world over for removal of fibroids in young women. This is specially useful for women who want to conceive and deliver in future. Enables the surgeon to do a precise and detailed operationin 3D vision with wristed instruments. Being aminimally invasive approach, there is quick recovery, less blood loss and women can go home in 24 hours. The main advantage is the multilayer suturing of the uterus after removal of fibroid giving it adequate strength to support future pregnancies.
- Hysterectomy- is the removal of the uterusand is offered to older women as final treatment. The ovaries may or may not be removed. It depends on age and the woman's desire. Hysterectomy is usually done by Laparoscopy or by Robotic assistanceunless the fibroids are extremely big
Do fibroids cause infertility or recurrent miscarriages?
There is no clear evidence that all fibroids can cause infertility or miscarriages. But we do know that fibroids that go inside the cavity of uterus can distort the cavity and cause problems. Some fibroids which are growing in the wall of the uterus can cause problem implantation and growth of the fetus. So there is some amount of negative impact due to the presence of fibroids with pregnancy. Evidence shows that surgically removing fibroids can improve the pregnancy rates.
CAN ALL FIBROIDS BE TREATED BY MINIMALLY INVASIVE SURGERY?
Minimally invasive surgery, should be considered as valid options for all patients requiring treatment for symptomatic fibroids. Removing fibroids by minimally invasively surgery requires advanced surgical skill and includes techniques, like hysteroscopy, laparoscopy and robotic-assisted surgery. Still so many open surgeries are performed each year merely for removing fibroids suggests that only few surgeons are able to treat this by minimally invasively surgery. Additionally these surgeries become more challenging if they are associated with conditions like endometriosis, adhesions due to prior surgeries or adenomyosis. However, in the hands of an expert minimally invasive surgeon, any size, number or type of fibroid can be treated with minimally invasive either for myomectomy or hysterectomy.
Will having myomectomy ensure a pregnancy?
Having a myomectomy cannot ensure or promise a pregnancy. But if fibroid is the only is the only issue then studies show that your chances of getting pregnant increase by 50-60% irrespective of the type of surgery.
Do I need caesarean section if I get pregnant after myomectomy?
Some women are advised to have a caesarean delivery if they have a myomectomy because there is a theoretical risk of uterine rupture during subsequent labour, which can be catastrophic. There is no hard core scientific evidence regarding this at the moment. One must discuss this with your treating Obstetrician who can evaluate this carefully and advise close to delivery.
Can Fibroids Turn Into Cancer?
Fibroids are usually benign (not cancerous). There is a rare chance (less than one in 1,000) that the fibroid may have evidence of leiomyosarcoma. Leiomyosarcoma has poor outcomes.
Who are at Risk for developing Uterine Fibroids?
There are various factors that can increase a woman's risk of developing fibroids.
- Age. Fibroids are common in women during the 30s and 40s through menopause. After menopause, fibroids usually shrink.
- Family history. Having a family member especially mother or sister with fibroids increases your risk. It increases the risk about three times higher than average.
- Ethnic origin. African-American women are more likely to develop fibroids.
- Obesity. Women who are overweight are at higher risk for fibroids.
- Eating habits. Consuming a lot of red meat is linked with a higher risk of developing fibroids. Green vegetables may have protective effect on the contrary.
Was invited to operate at Raipur Medical College at the FOGSI North Zone Yuva Congress. Dr Rooma Sinha demonstrated urogynecological surgeries for the delegates and later also gave lecture on setting standards for caesarean Section.