Gynaecologist Perth | With a special interest in fibroids
FibroidsCauses, Symptoms and treatment
What are fibroids?
Fibroids, or leiomyoma, are benign growths of the muscle of the uterus.
The uterus is mostly a large, smooth muscle. The muscle tissue can develop fibroids via cell division.
A single muscle cell will change and start an uncontrolled division of the cells, forming a ball of cells form and slowly increases in size. As it grows, it pushes on surrounding tissue and compresses the uterus to produce a distinct division between the fibroid and the normal uterus. The border makes surgical removal easier.
Who gets fibroids?
Fibroids are very common. Over 70% of women will develop them. They typically occur during the 30s to 40s and are seen more frequently in some racial groups, particularly Africans. In this group, they often occur at a younger age.
Fibroids defy good science. They occur in variable numbers, along with variable ages, sizes, locations, and symptoms.
That makes it difficult to compare treatments, as it is almost impossible to create groups of similar situations. These differences don’t allow randomised controlled trials of therapy, and so, most treatments are largely empirical and based on the individual's situation.
As a simple rule of thumb, a large fibroid is worse than a small one, and a fibroid located closer to the inside of the uterus is more likely to be a problem. If they are located on the outside, far from the inside lining, they are not important at all.
NoneFibroids are very common and may cause no symptoms at all. If they happen to be found either at a routine clinical examination or, more commonly, during an ultrasound, it is unlikely to be important — especially if the investigation was done for something unrelated.
Fibroids and bleeding can be related. They are more likely to cause heavy periods if they are located within or very close to the inside lining of the uterus.
Relatively small fibroids inside the uterus are more likely to cause problems than larger ones in the wall of the uterus. Growths on the outside of the uterus will usually not affect periods at all.
Fibroids can grow to a very large size. The normal uterus is around 50 grams. I have removed a uterus that weighed over two kilograms, most of that weight being a large fibroid.
The bigger a uterine fibroid, the greater the likelihood that it will produce pressure symptoms, particularly bladder pressure. It can fill the pelvis and push back against the bladder, making it difficult to empty.
Fibroids and fertility problems
This can be a complex issue, and I am happy to give you guidance relevant to your specific situation. The location and size of the growth is critical to the decision.
Fibroids and pregnancy
Fibroids are usually not important in pregnancy. Associated with the high levels of oestrogen, they will grow during this time. However, while breastfeeding after birth, your oestrogen state is low and they will shrink again.
They may occasionally cause pain during the growth state during pregnancy. Depending on where they are located, they can interfere with the potential to labour normally. For example, uncommonly it may be the cause of a transverse lie.
The cause of fibroids is unknown. There is clearly a genetic basis, and several genes have been associated with an increased chance of developing them.
What begins the abnormal growth is unknown, but continued growth is strongly influenced by oestrogen. They will grow rapidly in pregnancy and shrink afterwards. After menopause, when oestrogen is no longer produced, they will shrink. Bigger fibroids will shrink less than smaller ones.
If they are not causing problems, no treatment is required. Depending on age, location and size, surveillance with an ultrasound every year or two may be recommended.
There is a new medical treatment available. It is effective, but is new and looks to have potentially serious side effects, so it may not stay on the market.
Some implant medications (Zoladex) suppress the menstrual cycle, making you temporarily menopausal. Hence, your oestrogen levels drop, which can shrink fibroids over time. They will regrow when the treatment stops, so this is only useful to reduce their size before surgery.
The blood supply to the fibroid can be blocked by feeding a catheter through the artery that supplies the uterus and releasing small pellets to block the vessel.
This method has been around for some time but is not popular. Interventional radiologists are positive in promoting the option, but gynaecology surgeons are less keen. It suits few situations, and after embolisation it is painful for weeks as the growth dies from the loss of blood supply.
There are several methods of removing fibroids:
- Hysteroscopic: This is suitable for growths inside the uterus, and those very close to the inside of the uterus. A telescope is introduced through the cervix and the growth is cut away in very small pieces. It is a low-impact surgery.
- Laparoscopic: The operation is performed through keyhole incisions in the abdominal wall. This really only suits smaller fibroids and those closer to the outside of the uterus, and so, one has to question the need to remove them at all.
- Open myomectomy: Larger growths are better removed through an open operation, that makes a large wound on the abdomen below the belly button. This has a slower recovery than any other operation because of the wound, but it is safer regarding the potential to bleed. It may also be more effective at achieving strength in the scar in the uterus, which is important for future pregnancies.
- Hysterectomy: This is the removal of the uterus, and is the definitive management of fibroids. There are a number of ways to perform a hysterectomy. Fibroids are not a contraindication to doing the operation vaginally. I have removed a uterus that weighed over a kilogram vaginally from a belly dancer who wished to avoid an abdominal wound of any type.
Essentially, the only reason to remove fibroids is to maintain fertility. If fertility is not an issue, hysterectomy is the better surgical treatment.