What are uterine fibroids?

Uterine fibroid, also known as leiomyoma or myoma, is the most common tumour that can develop in the pelvis of a woman. It is a noncancerous tumour that arises from the muscles cells present in the uterus. It presents as growths or masses that bulges either inside or outside of the uterus. Fibroids do not usually undergo malignant transformation, meaning that they are not likely to become cancerous. However, it is important to distinguish between a cancerous and noncancerous mass once detected in the uterus.

Fibroid is a very common disorder among women. Around 80% of women will at some point in their life end up having fibroids. However, not everyone will have bothersome symptoms. Fibroids can be related to several problems such as heavy periods, abdominal pain and fertility problems. The prevalence of uterine fibroids increases with increasing age. Most fibroids will shrink following menopause.

There are several treatment options available to treat the problems related to fibroids as well as the fibroids themselves if too bothersome.

What are the causes of uterine fibroids?

The exact cause of uterine fibroids is unknown. It has been observed that fibroids may be responding to levels of hormones present in a woman, including estrogen and progesterone. In some cases, genetics may be contributing to the development of fibroids. Some inherited genes may be the cause. Lifestyle and reproductive factors may also play a big role in the development of uterine fibroids. The course of the condition will vary among women. In some women, the fibroids may increase in size while in others, they may shrink.

What are the risk factors for uterine fibroids?

The following factors may have an influence on the development of fibroids:

·         Race: Black women are more prone to have uterine fibroids compared to white women. Black women are also more likely to have fibroids at a younger age compared to white women.

·         Number of pregnancies: If you have had at least one previous pregnancy which lasted beyond 20 weeks of gestation, you have a lower risk of having fibroids. The higher the number of pregnancies, the lower the risk.

·         Early menarche: Having your first menses at an age younger than 10 years can increase your risk of having fibroids later in life.

·         Hormonal contraception: Long-acting progestin-only contraceptives has been shown to provide protection against having fibroids.

·         Diet: What you eat can have an impact on the development of fibroids. Increased consumption of red meats or processed foods can increase your risk of having fibroids. Consumption of green vegetables and fruits can have protective effect against fibroids.

·         Alcohol consumption: This increases the risk of having uterine fibroids.

·         Smoking: Ironically, smoking has been found to decrease the risk of having uterine fibroids.

·         Genetics: If you have close family members with the same condition, you are at increased risk of developing it later in life.

What are the symptoms of uterine fibroids?

Uterine fibroids can manifest with the following symptoms:

·         Changes in menstrual bleeding: Uterine fibroids can lead to heavy and/or prolonged menses. This is because the fibroid leads to an increase in surface area of the inner lining of your uterus. The degree by which it is increased depends on the location and size of the fibroid. This can further lead to anemia and social embarrassment.

·         Pressure or pain in the pelvis: This is closely related to big fibroids as they tend to compress on surrounding structures. Back pain can sometimes also be present.

·         Problems with the urinary and digestive system: Some people may experience symptoms such as incomplete emptying of the bladder, increased frequency of urination and rarely, complete obstruction to urine outflow. Uterine fibroids can also cause compression on the rectum leading to constipation.

·         Painful periods: Many women complain of painful menses when they have fibroids. It may also be associated with the passage of blood clots.

·         Painful sexual intercourse: This symptom depends on the location of the fibroid as not all fibroids will cause pain with sexual intercourse.

·         Infertility and complications during pregnancy: Women with uterine fibroids may have difficulty to fall pregnant. It is also associated with an increased risk of miscarriage if identified during the first trimester.

How is the diagnosis of uterine fibroids made?

Your doctor will start by asking you a series of questions to know more about your symptoms. He/she will then proceed by examining you. Your doctor will perform a pelvic examination with you. This will involve him/her inserting his/her fingers through your vagina and at the same time using his/her other hand to palpate your abdomen to feel the uterus. Your doctor may then request other tests to confirm the diagnosis:

·         Laboratory tests: There is no specific test to make the diagnosis of uterine fibroids. However, blood tests may have to be done to check if anemia is present as fibroids can be associated with heavy menstrual bleeding. A pregnancy test may also have to be done to check whether you are pregnant.

·         Pelvic ultrasound: In this procedure, sound waves emitted from a probe is used to visualize the structures present in your pelvis. This is usually the first imaging test requested if uterine fibroid is suspected.

·         Saline infusion sonogram: In this procedure, saline solution is injected into the uterus in order to make it expand. This makes it easier to get images of the lining of the uterus and fibroids.

·         Hysteroscopy: In this procedure, a special device with a camera is used to examine the inside of the uterus as well as the openings of the fallopian tubes.

·         Hysterosalpingography: This is a procedure involving the injection of a dye inside the uterus followed by taking X-ray images of the pelvis. The dye outlines the structures allowing visualisation of the pelvic organs.

How are uterine fibroids managed?

If the fibroids are not causing any bothersome symptoms, no treatment is actually required. If significant symptoms are present, treatment will have to be done. Your doctor will evaluate your case and will know best which treatment he/she should advise you. Both medical and surgical treatments are available for fibroids. These include:

·         Iron and vitamins supplements: These will have to be taken if you are found to be anaemic due to the heavy menstrual flow.

·         Nonsteroidal anti-inflammatory drugs (NSAIDs): These medications help to alleviate menstrual cramps and in some women, they may even be effective in decreasing the menstrual flow. These drugs are available over-the counter and include ibuprofen and naproxen.

·         Hormonal birth control: Pills, skin patched, shots, hormonal intrauterine devices, vaginal rings and hormonal implants can help in reducing bleeding and pain associated with menses. This can result in a correction in any coexisting anaemia.

·         Anti-fibrinolytic medications: These are non-hormonal medications that can help to stop menstrual bleeding quickly as they help in the formation of blood clots. The medication most commonly used is tranexamic acid. Some side effects associated with this medication include headache and muscle pain.

·         Gonadotropin-releasing hormone (GnRH) analogues: This class of drug includes GnRH antagonists and agonists. Both of them work by temporarily stopping the production of estrogen and progesterone. This results in a decrease in menstrual flow.

·         Myomectomy: This is a surgical procedure in which fibroids are removed. This improves bleeding as well as compressive symptoms. This does not impair the ability to have children later on. However, in some cases, the fibroid may come back after removal. Myomectomy can be done through different approaches. The best approach for you will depend on the size and exact location of the fibroid.

·         Endometrial ablation: In this procedure, the inner lining of the uterus (endometrium) is destroyed. This is done to decrease menstrual flow that may be present with fibroids. In some cases, women may completely stop to have menses. It is not recommended or not possible to fall pregnant after this treatment.

·         Uterine artery embolization: In this procedure, the artery that brings blood to the fibroids are blocked. This result in the shrinkage of the fibroid as it is cut off from its oxygen and nutrient source.

·         Hysterectomy: This is the surgery in which the whole uterus is removed. Your ovaries and cervix may be left in place given that there are no pathologies present in these organs. Unfortunately, it is impossible for you to get pregnant following this procedure.

Prognosis

 Fibroid uterus is a benign condition for which a variety of treatment options is available. Following removal of the fibroid, 15-30% of them will come back, while 10% will end up requiring hysterectomy within the next few years.

Begum, D., 2016. Effect of Fibroid on Pregnancy and Pregnancy on Fibroid Uterus. Journal of Medical Science And clinical Research,.

Stewart, E., n.d. Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history

Stewart, E., n.d. Uterine fibroids (leiomyomas): Treatment overview