Uterine Fibroids

Uterine fibroids are abnormal growths made up of smooth muscle cells and other surrounding tissue that develop within the wall of the uterus. The number of fibroids can vary from being a single growth to multiple fibroids. Even the size can range from being just about microscopic to eight inches or more. The size of most fibroids ranges from being the size of a large marble to being slightly smaller than a baseball.

Uterine fibroids are the most common pelvic tumours that occur in women who are in the reproductive age. According to a study, by the age of 50 years, up to 80% of women develop uterine fibroids. In the United States, uterine fibroids are the main reason for surgical removal of the uterus (hysterectomy). In a study conducted in the European population in 2014, an estimated 21.4% of women between 30 to 60 years of age were diagnosed with fibroids. In women who have no symptoms of fibroids, the diagnosis is usually established incidentally on an ultrasound scan during routine health check-up or during investigations performed for the diagnosis of some other health condition. 20% to 50% of women with uterine fibroids are symptomatic and may wish to undergo treatment.

Fibroids are of three types depending on their location within the uterus or on the outer surface of the uterus:

• Intramural fibroids 
  These are the most common type of fibroids, developing within the muscular wall of the uterus. They may grow larger over time and may stretch the uterus.
• Subserosal fibroids 
  These fibroids develop outside the wall (serosa) of the uterus and into the pelvis. They can become very large. In fact, if they become too big, they can make your belly look protruded and big from one side.
• Submucosal fibroids
  These types of fibroids develop in the middle muscular layer (myometrium), beneath the innermost lining of the uterus and may protrude into the uterine cavity. They are uncommon as compared to the other types.

In some people, subserosal or submucosal fibroids can develop a narrow stem, which provides support to the fibroid. These are known as pedunculated fibroids.

Many women do not experience any symptoms even though they do have fibroids in the uterus. However, in other women, uterine fibroids can cause uncomfortable or sometimes painful symptoms, like:

• Bleeding between periods (known as metrorrhagia, spotting or intermenstrual bleeding).
• Heavy bleeding or painful periods.
• Anaemia i.e., a decrease in the haemoglobin or the red blood cells of the blood due to heavy bleeding during periods.
• Increased frequency of urination due to pressure caused by the fibroid pressing onto the bladder.
• A lower back pain of the dull aching type.
• Difficult bowel movements or constipation.
• A feeling of “fullness” in the belly (lower abdomen). Sometimes, this is also called “pelvic pressure.”
• Pain during sex (dyspareunia).
• Problems of the reproductive system like multiple miscarriages, early onset of labour pains during pregnancy, and infertility.
• Problems related to childbirth and pregnancy, like increased chances of requiring a caesarean section during delivery. (Read more - Pros and Cons of natural birth and C-section)

Differential diagnosis

Other health conditions that may present with symptoms similar to those of uterine fibroids are:

• Adenomyosis: an abnormal encroachment of the muscular layer of the uterus (myometrium) by the inner lining of the uterus (endometrium).
• Pregnancy
• Ectopic pregnancy: a pregnancy that occurs outside the uterine cavity, mostly in the fallopian tubes.
• Endometrial polyp: a small growth protruding from the inner lining of the uterus.
• Endometrial hyperplasia: an abnormal growth of the inner lining (endometrium) of the uterus.
• Endometriosis: tissues from the inner lining of the uterus grows at places outside the uterus.
• Endometrial cancer: cancer arising from the inner lining of the uterus.
• Ovarian cancer: a type of cancer that originates in the ovaries.
• Uterine sarcoma: cancer of the muscles of the uterus or of the tissues that support the uterus.
• Uterine carcinosarcoma: a rare type of uterine cancer.

Causes

The exact cause of fibroids is unknown. However, there are certain factors that are believed to play a role in the development of fibroids. These include:

• Hormones
  The female sex hormones can stimulate the growth of fibroids, but they do not cause fibroids. After menopause, fibroids tend to shrink.
• Heredity
  Women who have a family history of uterine fibroids are prone to develop fibroids themselves.

Risk Factors

While there are a few factors that increase the risk of developing uterine fibroids, there are also some factors that decrease the risk of developing uterine fibroids

• Factors which increase the risk of fibroids:
  • Early occurrence of first menses (before 10 years of age).
  • A family history of uterine fibroids.
  • Women more than 40 years of age.
  • A woman who has never conceived or has never given birth to a viable baby.
  • Obesity.
  • Women of African descent.
• Factors that decrease the risk of fibroids:
  • Use of oral contraceptive pills.
  • Higher the number of children a woman gives birth to, the lower is the risk.
  • Late occurrence of first menses (after 16 years of age).

There are no proven measures to prevent fibroids from developing in the uterus, as the cause is unknown. However, studies have shown that athletic women are less likely to develop fibroids than women who are not physically fit or are obese.

If your gynaecologist/health provider suspects fibroids, usually a pelvic examination will be performed to look for any obvious abnormalities. He/she may also advise further investigations to confirm the diagnosis or rule out any other possible causes. Sometimes fibroids are only discovered incidentally during routine gynaecological examinations, as they are often asymptomatic. Investigations include:

• Ultrasound scan 
  This is one of the main tests for diagnosing uterine fibroids. An ultrasound scan is a painless diagnostic procedure in which a probe is used to generate sound waves. These sound waves are then captured back and an image is created that shows the details of the inside of the body. It is of two types:
  • Abdominal scan 
    In this type, the probe is placed over your abdomen and moved gradually over it to study the uterus for the presence of fibroids.
  • Transvaginal scan
    In this type, the probe is gently inserted through your vagina into the vaginal canal and the uterus is
• Hysteroscopy
  This is a procedure wherein a small telescope (hysteroscope) is inserted into your uterus through the vagina. Hysteroscopy takes about 5 minutes only. Most women do not need anaesthesia, but if you experience pain, a local anaesthetic may be used. Hysteroscopy is mostly carried out to look for submucosal fibroids.
• Laparoscopy
  During a laparoscopy, a small incision is made on the abdominal skin and a laparoscope is inserted through that. A laparoscope is a device in which a small telescope with a camera and light source are attached at one end. Once the camera is inserted through the incision, the monitor converts the signal into a series of images that give a detailed view of the uterus. A laparoscope not only helps in looking for fibroids that develop outside the uterus but also those that grow in the muscular layer. As the procedure is performed under general anaesthesia, the person undergoing it will be asleep during the entire procedure.
• Biopsy
  Some women require biopsy, which means a small sample of the fibroid tissue will be removed by using a hysteroscope or laparoscope to be examined under a microscope.
• Hysterosalpingogram
  This is an X-ray procedure wherein a dye is injected into the uterus and the fallopian tubes so that any irregularities, as noticed by the way the dye moves in the uterine cavity, are outlined.

Treatment of uterine fibroids depends on whether the woman is symptomatic or asymptomatic:

For women without symptoms

In women without symptoms, treatment is generally not required. A regular clinical monitoring is carried out to ensure that the fibroid does not grow suddenly or increase in number.

For women with symptoms

​In women who experience symptoms, treatment depends on whether the woman is premenopausal or postmenopausal.

• Premenopausal woman
  • If the woman wishes to preserve her fertility or her uterus then she can be managed medically or surgically. Medical therapy includes drugs that temporarily make the ovaries to stop the production of estrogen, the female sex hormone.
    So, oral contraceptives (birth control pills), NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), drugs containing tranexamic acid (to reduce the amount of blood flow during menstruation) or Gonadotropin-releasing hormone (GnRH) agonists (medicines that reduce the production of sex hormones), and selective progesterone receptor modulators (SPRMs) that reduce the growth of the fibroids are usually prescribed. Surgical therapy involves removing the fibroids (myomectomy).
  • If the woman does not wish to preserve her fertility or her uterus, then the choice of procedure will be between surgically removing just the fibroids (myomectomy), cutting off the blood supply to the fibroids (uterine artery embolization) or removal of the uterus with or without removal of the fallopian tubes and the ovaries (hysterectomy with or without bilateral salpingo-oophorectomy).
• Postmenopausal woman
  In these women, either only the fibroids are removed or the uterus is removed with or without removal of the fallopian tubes and the ovaries.

Treatment for fibroids may also include:

• Iron supplements that may be needed to treat or prevent anaemia, which can occur due to heavy bleeding during periods.
• Pain relief medications like ibuprofen or naproxen for pain or cramps.
• You may have to undergo pelvic examinations and ultrasounds, once in a year, just so your doctor can keep a check on the size and the number of fibroids.

Lifestyle management

A study conducted by researchers in China reported that pre-menopausal women with a high BMI (Body Mass Index) had a higher risk of developing uterine fibroids. So, aim to maintain an ideal weight for your height by eating healthy food and by exercising regularly. 

Prognosis

Almost 75% of all fibroids are non-cancerous (benign). They usually shrink after menopause as menopause results in a drop in hormone levels. that are required for the fibroids to grow. Many women have small to medium sized uterine fibroids throughout their reproductive years that cause them little or no problems.

If you are pregnant and have fibroids or you become pregnant and have fibroids, then your doctor will carefully monitor you throughout your pregnancy until delivery. After the baby is born, a fibroid usually goes back to its original size. In most women, fibroids generally do not cause any problems. 

Complications

Complications of fibroids include:

• Extreme pain or very heavy bleeding which might need an emergency surgical treatment.
• Twisting of the uterine fibroid may also occur. When a fibroid twists, the blood vessels that feed the fibroid can be blocked. If this happens, surgery may be required.
• Anaemia (reduced number of red blood cells in the blood) can occur due to heavy bleeding.
• Urinary tract infections may also occur if the fibroid presses onto the urinary bladder. Thus, it can be difficult to empty your bladder completely and this may predispose you to develop urinary tract infections.
• In rare cases, infertility may occur.

If you are pregnant, there is a minor risk that your fibroids may cause complications:

• If the fibroid causes a blockage in the birth canal or positions the baby dangerously, a  surgery (a caesarean section) may be required.
• If the fibroid occupies too much space in the uterus, the woman may have a premature delivery. 
• Heavy bleeding may occur after the delivery.