Fibroids

uterine-fibroids

By Dr. Nii Adjeidu Armar

Fibroids – what are they?

They are lumps of tissue made up of fibrous tissue and uterine muscle and can distort the shape of the uterus. They originate from uterine tissue and are usually found either within the uterine muscle or they may be attached to the inside or the outside of the uterus. They are rarely found before puberty. Fibroid tumours (usually non-cancerous) are the commonest tumours of the female genital tract.

The uterus (womb) is mainly made up of muscle tissue. Fibroids, which are a mixture of muscle and fibrous tissue, are recognizable because they form lumps either attached to or within the walls of the uterus; the lumpiness is mainly due to the fibrous tiisue. An example of fibrous tissue is the whitish tissue which can usually be found attaching muscle to bone. Fibroids usually have a firm, rubbery consistency similar to that of soft potatoes.

Fibroids tend to increase the overall size of the uterus and generally, they cause problems on account of either their size and/or their position.

Size

Fibroids can grow to virtually any size; the largest on record was over 45kgs in weight. The smallest ones are barely visible to the naked eye and this can make surgery to remove them extremely difficult and time consuming. A surgeon can only remove the fibroids he/she can see.

Fibroids can grow as fast a normal pregnancy does and occasionally, they outgrow their own blood supply. When this happens, the fibroid ‘dies’ and can partly be replaced by calcium, forming a hard lump which subsequently does not change much in size. Some fibroids shrink when they die, reducing the overall size of the uterus. There may be only one or two fibroids present in a uterus of there may be several; the larger ones can easily be seen during an ultrasound scan examination.

Symptoms

Most women with fibroids are completely unaware that they have them. However, these are some of the common problems they can give rise to:

Period problems (usual bleeding): The menstrual periods can become either heavy and/or painful and occasionally, they can also cause bleeding ‘out of turn’.

Pain:

This is not a common problem with fibroids; however, a uterus enlarged by fibroids can start interfering with the normal function of neighbouring organs (e.g., the bladder or the bowel) and this comes to light when, for example, the bladder has to be emptied more frequently or there is difficulty opening or moving the bowels. Pain during intercourse can also be caused by the presence of fibroids.

Severe cramping pain during menstrual periods may be due to a fibroid sitting inside the uterine cavity; this pain has been described by some women as being similar to the pain of a miscarriage or labour pains. This type of pain is due to the uterus trying to push the fibroid out through the neck of the womb (cervix).

When fibroids ‘die’, they can cause excruciating pain, occasionally requiring hospital admission for the administration of strong pain killers for pain relief.

‘A lump in my tummy’: The enlarging uterus can increase the waistline (larger clothes become necessary) or the swelling may become unsightly. In some cases, the fibroids grow large enough to look like advanced ‘pregnancies’, causing a great deal of embarrassment if they are present for too long.

“Silent problems’: Occasionally, a large fibroid uterus can cause difficulties which are not immediately obvious as ‘fibroid associated or related problems’, e.g., swelling of the legs/feet.

“Fertility difficulties’: Some women are not aware that they have fibroids until they try to start a family. Fibroids can interfere with fertility or even give rise to complications during pregnancy, that is, if the individual is able to conceive with the fibroids in place.

 

How do I know if I have fibroids?

As long as you have past puberty or have started having periods, it is possible for you to develop fibroids. The symptoms described above should make you consider the possibility. Of course, as mentioned above, it is possible to have fibroids and have no symptoms at all.

Generally speaking, there are 2 main ways of detecting fibroids:

  1. Clinical examination
  2. Ultra-sound scan

 

Where can I have test to find out if I have fibroids?

Any gynaecologist should be able to assess your case and find out if you have fibroids. However, if you have any of the above symptoms and you are not sure of the nature of your problem then you must consult your GP or ‘general doctor’ first. S/he will probably arrange an ultrasound scan for you (usually after examining you) and see you with to discuss the findings. If s/he considers it necessary, s/he will then arrange a hospital appointment for you to see a specialist (gynaecologist).

Those most at risk

             Black women appear to be the most at risk of developing fibroids and about 85% of black women over the age of 35 probably have fibroids, although most have no symptoms (problems) and may never have any.

             Women who leave childbearing till their later years are more likely to develop them.

             Women who are overweight are more likely to develop them than women of normal weight.

The risk of developing significant fibroids is lower in:

  1. Women who have their babies at a younger age
  2. Women who do not allow themselves to become overweight
  3. Women who use hormone treatments that mimic pregnancy (progesterone treatment)

Things to consider when looking at treatment options.

Your symptoms: How are they affecting your life? Are you coping at work? Are you coping with your domestic responsibilities?

The fibroids: How many are there and how big are they? Have you completed your family? Is childbearing still an issue, or are you not sure?

You have to be able to openly discuss these points with your doctor. On the whole, most doctors will help you to come to a decision which you are entirely at peace with.

Most doctors will tell you what they consider unacceptable from a ‘general health point of view’ but the ultimate decision/choice is yours.

 

However,

             Heavy bleeding which makes you anaemic is not acceptable

             Pain/discomfort which keeps you away from work or leaves you unable to look after (for example) your children is not acceptable.

             If you have a fibroid uterus or fibroids which are causing difficulties for nearby organs (or are affecting the function of) e.g., the bladder (making frequent emptying necessary, and even disturbing your sleep); this is not acceptable.

Remember: Giving the GP or specialist an early opportunity to assess your problem is helpful for all concerned. Also, write down any advice you are given.

Fibroids are rarely life-threatening but when there is evidence that they are likely to cause serious harm, prompt action is required.

Not all fibroids cause problems

Some die naturally and disappear. Unfortunately, no doctor can predict which ones are going to die. Doctors focus their attention on the ‘problem fibroids’ whenever necessary.

Rarely, fibroids are or can become cancerous and usually, they are the large ones which can be seen to be growing rapidly. Unfortunately, doctors usually discover that they are cancerous only after they have been removed.

NOTE: Survival rates from fibroid cancers are extremely poor. The treatments available for cancerous fibroids are NOT very successful at treating or controlling such cancers.

What if I have fibroids but no immediate problems?

You should probably have a scan every 6 months or so to assess the growth rates of the fibroids (this depends on the size of your fibroids when they are discovered). Of course, if problems develop, you must let your doctor know.

Can fibroids grow back once removed?

Once removed, those taken out obviously cannot grow back but any smaller ones (possibly not seen at the time of surgery) may grow ad replace of the removed ones. This is why women often think that the operation ‘was not done properly’.

If surgery is undertaken, do remember that it is almost always possible to remove just the fibroids and to leave the uterus (womb) behind.

During surgery for fibroids, there is a risk that approximately one out of every 100 women who have such an operation will need a hysterectomy (removal of the womb) during the fibroid operation (during the operation to remove the fibroids) cannot be controlled adequately.

The treatment options:

  1. Open surgery

This is the commonest type of surgery available for fibroids at present. It is called a myomectomy (pronounced my-o-mek-tomi). This involves a full anaesthetic following which the abdomen (tummy) is opened. This usually means a ‘bikini cut’, although if the fibroids are very large, a mid-line (or vertical) incision may have to be used.

The advantage of the midline incision is that if other organs are affected by the fibroids, the surgeon will be able to extend the incision (up to the chest margins if necessary) to gain good access to deal with any such problems safely. The uterus is isolated and the fibroids are removed individually. The uterus is then repaired and replaced inside the abdomen and the wound is closed.

This can be difficult surgery, it can be awkward and it may also be time consuming. The main disadvantage of ‘open surgery’ is that adhesions or internal scarring tends to occur more readily when this approach is used.

Internal scars, or adhesions can make the internal organs ‘stick to each other’ and this can affect their function and this therefore matters a great deal, especially if fertility is a major consideration. There are now special agents (fluids or cloth-like material used during the operation) to protect any raw areas) which can be used to minimize the risk of this happening.

Heavy bleeding is the main risk associated with all forms of fibroid surgery; a blood transfusion can help to overcome this problem but for those who cannot be given blood or blood products, auto-transfusion (where the individual is given back blood collected from them before surgery) is an option. A cell-saver (where blood lost during the operation is ‘washed’ and prepared for infusion back into the patient) is another option but this is not widely available.

Full recovery from such an operation can take between 6 and 12 weeks.

 

  1. Keyhole surgery

Keyhole surgery refers to operations where a big cut to gain access for the operation is not used. A camera at the end of a long telescopic tube is used instead and the tube is passed into the abdomen (tummy) or uterus (womb) to enable the surgeon to see the inside of the abdomen or womb. The picture is displayed on a television screen called a ‘monitor’.

The telescope is called a LAPAROSCOPE (if passed into the abdomen, usually though a cut just below the belly button or ‘umbilicus’) or, if passed through the cervix (neck of the womb), it is called a HYSTERPSCOPE.

 

  1. Laparoscopy (a key-hole operation): This is performed under a full amaesthetic. Gas is blown into the belly through a fine needle and when the belly swells up (literally like a balloon), a laparoscope (a telescope about 15 inches long and just a little thicker than an ordinary pen. The surgeon is then able to see all the internal organs and to an extent, examine them.

Some (selected) fibroids can be removed this way. The surgeon uses additional instruments passed either through other very small incisions (cuts on the abdomen) or alongside the telescope to carry out the operation.

After they have been separated from the womb, a small bag is slipped into the abdomen; small fibroids can be placed inside the bag and it is then pulled out! Alternatively, a morcellator (which cuts the fibroids into little pieces) can be used to remove the fibroids. The uterus is usually repaired before the fibroids are removed, to minimize the risk of heavy blood loss whilst the fibroids are being removed.

Full recovery from this operation usually takes between 4 and 6 weeks.

 

  1. Hysteroscope: Trans-cervical resection of fibroid(s) or TCRF (a key-hole operation:

This operation is only used in cases where the offending fibroid is building into the cavity or sitting within the uterine cavity. During a full anaesthetic, the neck of the womb is stretched open long but hysteroscope (about a foot long but usually narrower than a laparoscope) is inserted into the womb to firstly, examine (inspect) the cavity and secondly, to resect (shave out) the fibroid(s).

A similar method is used to remove large endometrial polyps (growths on the lining) as well. Full recovery from this operation usually takes between 1 and 2 weeks.

 

  1. Embolization

During a light anaesthetic, tiny (fine sand-like) particles are injected into the main blood vessels supplying the fibroids. The particles block off the vessels and, having had their blood supply cut-off, the fibroids die and therefore ‘shrink’, although some are passed through the cervix ‘like a miscarriage’.

Only a few centres around the world provide this treatment regularly at the present time but it is hoped that it will become more widely available for the treatment of some types of fibroids.

The official report from N.I.C.E (National Institute for Clinical Excellence, UK.) about the ‘safety of embolization’ as a treatment for fibroids is available from http://guidance.nice.org.uk/IPG94/publicinfo/pdf/English/download.dspx

 

  1. MRI Laser treatment

External laser treatments are currently being tried. Laser beams are directed onto fibroids which have been ‘marked out’ using scanning methods. By firing the laser beam at the same spot from different angles, the fibroid receives a relatively large dose but all the other tissues receive only a small dose each. This method is in its early stages of assessment (see the following web): (http://guidance.nice.org.uk/IPG30/publicinfo/pdf/English/download.dspx) .

A major concern over all the ‘newer’ methods is that not enough is known about the effect of these treatments on subsequent fertility.

There is concern by some specialists that some of the newer methods affect the ability of the uterus to carry a pregnancy safety, until it is mature after some of these treatments.

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