Fibroids are non-cancerous growths that occur within the wall of the womb. They are present in more than 40% of women and can cause problems with fertility and menstrual cycles.
What are fibroids, what are the different types and how is diagnosis made?
Fibroids are non-cancerous growths (or tumours) that occur within the wall of the womb. They are also known as leiomyomas or myomas. Fibroid growth is dependent upon female hormones and therefore shrink after the menopause when hormone levels fall.
There are three main types of fibroids that are defined based on their location within the wall of the womb. Those that are located predominantly within the muscle of the womb are called intramural; those that grow towards the outer surface of the womb are called subserosal, and; those that grow towards the inner surface are termed submucosal. The submucosal variety cause the most symptoms.
Specific investigations for fibroids are often prompted by symptoms and signs. Pelvic examination often reveals an enlarged womb. Fibroids are most often diagnosed on ultrasound scan, which can also classify fibroids as being submucosal, intramural or subserous. For greater precision in identifying submucosal fibroids, ultrasound scan can be combined with the instillation of fluid into the cavity of the womb (known as Sonohysterography or Saline Infusion Sonography).
What problems do fibroids cause?
Fibroids cause three main types of symptoms:
- Heavy and/or painful periods. Fibroids are a common cause of very heavy periods and/or very painful periods. The submucosal variety of fibroids are most commonly associated with period problems due to their proximity to the lining of the womb where bleeding originates. Excessively heavy periods for many months can lead to a low blood count (or anaemia).
- Submucosal fibroids are strongly linked with an increased risk of miscarriage. It is believed that submucosal fibroids disrupt the inner lining of the womb where the embryo needs to implant, thereby predisposing to pregnancy loss.
- Problems due to an enlarged womb: If fibroids grow to a large size, or there are multiple fibroids present, the womb can become very enlarged. In some cases of fibroids, the womb can reach the size of an advanced pregnancy and extend above the level of the belly-button. The enlarged womb causes “pressure-effects” leading to a feeling of “heaviness” in the abdomen. It can also press on neighbouring structures such as the bladder, causing changes in urination such as the need to pass urine frequently.
What are the treatment options for fibroids?
It is important to emphasise that fibroids are very common; the mere identification of a fibroid, for instance on ultrasound scan, does not necessitate treatment unless there are symptoms that can be ascribed to fibroids. Treatment options depend on the main symptoms involved and very importantly, on the patient’s fertility plans. Treatment may include either medication (hormonal treatments) or surgery.
For patients with fibroids, hormonal treatments may be helpful and can be considered on an individual basis. Esmya (Ulipristal acetate) is a recently developed treatment that blocks the effect of progesterone to cause fibroid shrinkage. Recently, however, concerns have been raised regarding serious liver injury in a very small fraction of women using Esmya.
Surgery to remove fibroids (known as myomectomy) is a well-established form of treatment. The most problematic fibroids are the submucous variety and these can be removed using a form of minimal access surgery called hysteroscopy. Because hysteroscopy only requires operation through the neck of the womb, and does not involve cuts in the abdominal wall, hysteroscopic fibroid surgery can be performed as a day-case procedure and recovery is fast. Hysteroscopic surgery is therefore very appealing, especially for fertility-related issues such as miscarriage and in preparation for IVF.
For fibroids that cannot be reached via the womb cavity (such as intramural fibroids), surgery cannot be performed using hysteroscopy and instead requires an abdominal approach. This can be performed either via key-hole surgery (laparoscopy) or with more conventional larger incisions in the tummy known as laparotomy.
Alternative treatment options include radiologic (X-Ray) approaches such as uterine artery embolization (UAE). This treatment is performed by radiologists and involves the injection of very tiny particles into the blood stream to block the tiny blood vessels that supply the womb and fibroids. This deprives fibroids of their blood supply causing them to shrink or die. UAE is an effective treatment especially for women whose fibroids are not easily treated by surgery or for whom surgery is not safe or desired. However, it is very important to be aware that Prof Homer’s research found that UAE is not advisable for women wishing to have pregnancies in the future since it increases the risk of miscarriage.
How can I get help with treating fibroids?
Prof Homer trained and worked as a specialist in one of the UK’s largest centres for minimal access surgery on fibroids, University College London Hospitals. He is an expert in all forms of treatment for fibroids including hysteroscopic surgery. He has written in authoritative textbooks about the correct techniques that should be used for performing laparoscopic myomectomy. Prof Homer also identified that uterine artery embolization for fibroids is not appropriate for women planning future pregnancy because it increases the risk of miscarriage.