What is a fibroid?
A fibroid (leiomyoma or just myoma) is a non-cancerous growth of the muscle that forms the walls of the uterus. With an estimated lifetime risk of about 70%, most women will have a fibroid at some point in their life. For the majority of women (more than 60%) these do not cause symptoms and therefore treatment is not required. There are a number of symptoms that fibroids can cause including:
- Abnormal bleeding: Fibroids cause heavy menstrual bleeding for some women. This is the case particularly if the fibroid is located within the uterine cavity, just under the lining of the uterus or endometrium. This is called a submucous myoma. For many women this may mean that they experience clots and flooding, sometimes restricting their activity at the time of their period in case they have an accident. Low iron levels (anaemia) may result and cause generalised fatigue.
- Pressure symptoms: Fibroids can get very large, and some women can appear to be pregnant due to the size of the mass. As a result there are pressure effects on the other organs in the area, namely the bladder in front of the uterus and the bowel behind it. Women may experience an increased frequency or urgency to urinate, or the fibroid may block the flow of urine causing incomplete emptying of the bladder, and in more severe cases inability to urinate at all – a condition which is very painful! If this happens, presenting to the emergency department of your local hospital for review is the best strategy. A tube will be inserted in your bladder to help you pass urine (catheter) until the fibroid can be treated, usually requiring surgery. Pressure on the bowel can result in constipation and difficulty passing stool.
- Pain: Most fibroids don’t cause pain, however there are some occasions where pain can be a symptom. Sometimes a fibroid can be located on the outer edge of the uterus, perhaps on a stalk. If these fibroids grow rapidly they can run out of their blood supply and undergo a process called degeneration where the tissue inside the fibroid dies. Alternatively, due to their effect on menstrual flow, fibroids may cause pain at the time of your period.
- Infertility: Current evidence demonstrates that fibroids inside the uterus (submucous myomas) can have a negative effect on fertility due to failure of implantation of the embryo. For this reason, these types of fibroids are recommended to be removed before you embark on trying for a pregnancy. Fibroids inside the wall of the uterus (intramural myomas) or on the outside of the uterus (subserosal myomas) are much less likely to have an effect on fertility and so are not removed routinely unless you have other symptoms. Sometimes, if you have been trying for a pregnancy for a number of years without success, your doctor may recommend removal of these types of fibroids to see if it improves your chances. There are cons associated with this type of surgery however, so speak to your Alana Gynaecologist for more information.
How are fibroids diagnosed?
Fibroids are diagnosed with ultrasound which may be performed for the symptoms described above, or may be an incidental finding on an ultrasound which is performed for a different indication. Magnetic Resonance Imaging (MRI) can also be used to image fibroids, however in Australia MRI is not covered by Medicare for this indication and as a result is very expensive. Ultrasound can give us almost as much information for considerably less cost, so this is the imaging modality of choice.
How are fibroids treated?
Treatment for fibroids can range from medical treatment of symptoms, to surgery or even radiological treatment and depends on a number of factors.
Medical treatments: Common medical treatments include the oral contraceptive pill, other hormonal treatment like progesterone releasing intrauterine devices (IUDs) or medications to help stop the bleeding (tranexamic acid). Other medical treatments may be used over short periods of time to try to reduce the size of the fibroids temporarily by inducing a menopausal state. These medications have side effects and can only be used for 3-6 months as there are risks associated with prolonged use. These medications may be used to decrease the size of fibroids prior to surgical treatment.
Surgical treatments: Surgical treatments may be performed through the uterus (hysteroscopy – for submucous myomas), keyhole surgery (laparoscopy) or open abdominal surgery (laparotomy). The type of operation depends on your fibroid, its size and location.
Radiological treatments: Radiological treatments include a procedure called uterine artery embolisation, where a thin tube is inserted into the blood vessels of the groin and threaded up to the arteries that supply the uterus. Small chips of foam are then injected to block the blood supply to the uterus and therefore the fibroid. Although the fibroid is not removed, this treatment can decrease the size of the fibroid by up to 60% which can result in improvement in symptoms of bleeding or pressure effects. This treatment is not suitable for all types of fibroids such as submucous myomas due to the risk of infection.
There are limitations to all of the above treatment options, and it is important to find the best treatment strategy for your situation. Medical treatments can have side effects and are not suitable for treating pressure symptoms or fertility related problems of fibroids. Surgical treatments have risks which include infection, bleeding, damage to other organs like the bladder or bowel, development of clots in the legs or lungs. These major complications are uncommon but risk can depend on a number of factors including age, other medical conditions and previous surgery. Additionally removal of fibroids results in scarring of the uterus which can lead to complications in pregnancy such as uterine rupture where the scar comes apart. Your gynaecologist may recommend that you have a caesarean delivery to help minimise this risk in a future pregnancy.
Laparoscopy has both benefits and limitations in the removal of fibroids. Keyhole surgery means that your stay in hospital and recovery are much shorter than if the same procedure were performed through a laparotomy or open incision. The downside is that the fibroid tissue needs to be broken down into smaller pieces for removal through the ports. This process is called morcellation and the specific risks associated with this are covered in more detail in our blog.
Fibroids can seem like mountains at times, but there is help and treatment available. Come and see your Alana Gynaecologist for more advice.