About uterine fibroids


Developments in medical science, especially in the area of imaging techniques to place needles or catheters in different areas of the body to evaluate and/or treat a variety of conditions in a minimally invasive fashion, have given women different options when its comes to treating different conditions. One example is uterine fibroids.  

WHAT are uterine fibroids? Are they common? A uterine fibroid (known medically as a leiomyoma, or simply myoma) is a benign (non-cancerous) growth composed of smooth muscle and connective tissue. Fibroids are the most common benign tumours in women. Fibroid sizes can range from pea sized to bigger than a cantaloupe and can grow inside or outside the uterus.  

Fibroids of more than 9kg have been reported. Where they grow determines what type of symptoms you experience. About 40% of all women over the age of 35 have fibroids. Fertility is often affected. The bulk of hysterectomies carried out are due to fibroids. 

What are the causes of uterine fibroids?  

No one knows exactly what causes fibroids. They can appear at any age, but usually occur just before menopause. Research suggests fibroid development may be related to oestrogen levels. 

At what age will women have uterine fibroids? Why do fibroids develop at this age? 

Approximately 40% of all women over 35 have fibroids. It may be that you don’t have any symptoms. Fewer than half of the women who have fibroids never experience any symptoms at all. Most women don’t even know they have fibroids until their physician examines them during a routine pelvic exam. If you fall into this category, all you probably have to do is watch to see that they don’t grow in size. Doctors call this “expectant management”.  

What about the size of these uterine fibroids? What is the most common form of uterine fibroids found amongst Malaysian women? Why? 

Fibroid size can range from pea size to bigger than a cantaloupe and can grow inside or outside the uterus. Where they grow determines what type of symptoms you experience. Fibroids originate from the thick wall of the uterus and are categorised by the direction in which they grow: 

Intramural fibroids grow within the middle and thickest layer of the uterus (called the myometrium). They are the most common fibroids.  

Subserous fibroids grow out from the thin outer fibrous layer of the uterus (called the serosa). Subserous can be either stalk-like (pedunculated) or broad-based (sessile). These are the second most common fibroids.  

Submucous fibroids grow from the uterine wall toward and into the inner lining of the uterus (the endometrium). Submucous fibroids can also be stalk-like or broad-based. Only about 5% of fibroids are submucous.  

How many Malaysian women are currently experiencing symptoms from uterine fibroids?  

I am not sure about the exact figure as there doesn’t appear to be any studies carried out on this.  

Do uterine fibroids interfere with fertility or pregnancy? Will these become malignant later on if not treated at all? 

There are several possible effects: 

  • Fertility  

    The effect of fibroids on fertility is controversial. A 2002 analysis suggested that fibroids may account for infertility in only 1% to 2.4% of women who are having trouble conceiving. Large fibroids may cause infertility in the following ways: by impairing the uterine lining; by blocking the fallopian tubes; by distorting the shape of the uterine cavity; and by altering the position of the cervix and preventing sperm from reaching the uterus.  

    Some evidence suggests that even small fibroids may reduce the chances of pregnancy in women who are undergoing assisted reproductive techniques. Treatments to reduce fibroids may be helpful in such women, although there has been little research on this subject. 

  • Pregnancy 

    Fibroids pose some risk to a pregnancy. A caesarean section may be required in cases where multiple fibroids, particularly those located in the lower part of the uterus, block the vagina during pregnancy. Fortunately, this is a rare occurrence.  

    Multiple fibroids can also increase the risk for miscarriage. In one 2001 study, the presence of intramural fibroids halved the chances for a successful pregnancy. (The largest fibroid observed in the study was less than 3cm.)  

    Fibroids can degenerate during pregnancy, causing pain, and may cause premature labour. 

  • Uterine cancer 

    Fibroids are nearly always benign and non-cancerous, even if they have abnormal cell shapes. Cancer of the uterus nearly always develops in the lining of the uterus (endometrial cancer). Only in rare cases (a less than 0.1% incidence) does cancer develop from a malignant change in a fibroid (called leiomyosarcoma).  

    Nevertheless, rapidly enlarging fibroids in a pre-menopausal woman or even slowly enlarging fibroids in a post-menopausal woman require surgical evaluation to rule out cancer.  

    Are there any symptoms that we can look for to alert us of the presence of fibroids in the uterus?  

    Yes, there are a few. These include heavy bleeding, pelvic pain, anaemia, frequent urination, difficult or painful bowel movements, swollen or distended abdomen and difficulty getting or staying pregnant. 

    What about the type of tests that we can take to detect uterine fibroids? 

    A physician will perform a pelvic examination to check for pregnancy-related conditions and for signs of fibroids or other abnormalities, such as ovarian cysts. 

    The physician needs to have a complete history of any medical or personal conditions that might be causing heavy bleeding. He or she may need the following information: 

  • Any family history of menstrual problems or bleeding disorders (which should be suspected in teenage girls with heavy bleeding). It should be noted that, in some cases, young women with heavy bleeding from inherited conditions may not even report it if they grew up in a family where such bleeding was considered normal.  

  • Women who visit their gynaecologist with menstrual complaints, particularly heavy bleeding, pelvic pain, or both may actually have an underlying medical disorder, which must be ruled out. The pattern of the menstrual bleeding is also important.  

  • Regular use of any medications (including vitamins and over-the-counter agents). 

  • Diet history, including caffeine and alcohol intake.  

  • Past or present contraceptive use.  

  • Any recent stressful events.  

  • Sexual history. (It is very important that the patient trust the physician enough to describe any sexual activity that might be risky.)  

    Almost all women, at some stage in their reproductive life, experience heavy bleeding during a period (medically called menorrhagia). Being taller, being older, and having a higher number of pregnancies increases the chances for heavier than average bleeding. In some cases the cause of heavy bleeding is unknown, but a number of conditions can cause menorrhagia or contribute to the risk, including the following: 

  • Miscarriage 

    An isolated instance of heavy bleeding usually after the period due date may be due to a miscarriage. If the bleeding occurs at the usual time of menstruation, however, miscarriage is less likely to be a cause.  

  • Having late periods or approaching menopause 

    These events may cause occasional menorrhagia.  

  • Uterine polyps (These are small benign growths in the uterus.)  

  • Certain contraceptives (Oral contraceptives or an intrauterine device, an IUD.)  

  • Bleeding disorders 

    Bleeding disorders that impair blood clotting can cause heavy menstrual bleeding and, according to different studies, have been associated with between 10% and 17% of menorrhagia cases. Most bleeding disorders have a genetic basis and should be suspected in adolescent girls who experience heavy bleeding.  

  • Uterine cancer  

  • Pelvic infections  

  • Endometriosis  

    These are small implants of uterine tissue. They are more likely to cause pain than bleeding.  

  • Adenomyosis 

    This condition occurs when glands from the uterine lining become embedded in the uterine muscle. Its symptoms are nearly identical to fibroids (heavy bleeding and pain), and in one study fibroids were also present in 62% of cases. It is most likely to develop in middle-aged women who have had many children.  

  • Certain drugs, including anticoagulants and anti-inflammatory medications.  

    To investigate the cause of heavy menstrual bleeding, doctors may do the following:  

    A hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. Although less invasive procedures can also detect causes of abnormal uterine bleeding, hysteroscopy has the added advantage of serving as a surgical procedure for the removal of submucous fibroids. It is also quite useful in ruling out cancer. It is done in the office setting and requires no incisions.  

    Investigations such as ultrasound, sonohysterography and magnetic resonance imaging (MRI) could also be carried out. 

    When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy can be performed in the office along with an ultrasound. It is usually used with a procedure called dilation and curettage (D&C), which is particularly important to rule out uterine (endometrial) cancer. A D&C is a somewhat invasive procedure.  

    Can we prevent the occurrence/growth of uterine fibroids?  

    If you are approaching menopause (most women stop having their periods around age 51), you may not have to do much either. These oestrogen-loving growths tend to shrink as the supply of oestrogen in the body dwindles with middle age.  

    What are the methods of treatments available for women who have uterine fibroids?  

    There are a few options. These include: 

  • Drugs 

    Synthetic hormones are prescribed which can decrease the size of the uterus and the fibroid. The drugs can be prescribed alone or in conjunction with a surgical procedure to shrink fibroids prior to surgery. 

    For example, progestins are female hormones. Excessive bleeding can be controlled with this class of medications.  

    One of the newer and most promising group of drugs being used are synthetic hormones known as gonadotropin-releasing analogues (GnRH Analogues). Acting like hormones which occur naturally in the body, these “look-alikes” reduce blood flow to the uterus and in turn to individual tumours. The end result is a decrease in the overall size of both the uterus and the tumour.  

    Some physicians are prescribing GnRH agonists prior to surgery to shrink large fibroids, making it easier to remove them. In some cases, where a small fibroid is thought to be interfering with fertility, physicians will suggest a course of GnRH to shrink the fibroid in order to increase chances of conception. 

    The down side is the results are temporary. Within four to six months following the drug therapy, tumours will regrow to their original size. In addition, there are some side effects similar to those associated with menopause. GnRH agonists are generally used for six months or less to minimise the risk of osteoporosis. 

  • Myomectomy  

    This is a surgical procedure and a less “radical” approach to treating fibroids compared to a hysterectomy. Fibroids are cut away, but the uterus is preserved. This means you can still have children. Traditionally, this procedure involved an abdominal incision and several days in the hospital.  

  • Myolysis 

    This is typically used for fibroids near the uterine surface. The procedure involves using an electrical needle to destroy the blood vessels feeding the fibroids. Eventually, the fibroids shrink and occasionally may even disappear. 

  • Endometrial ablation  

    This is helpful for excessive bleeding. In this procedure, the endometrial lining (the tissue that makes up the inner lining of the uterine wall) of the uterus is destroyed. However, with this procedure, it is generally no longer possible to have children.  

  • Uterine artery embolisation  

  • Hysterectomy 

    This is surgery to remove the entire uterus. Although there is a move away from hysterectomy to treat fibroids, for a small percentage of women, it may be the best choice. You need to be certain that your doctor is recommending this procedure for the right reasons and not because he/she is unfamiliar with the newer, less invasive techniques that are now available. 

    Ten years ago, chances are your doctor would recommend treating symptomatic fibroids with major surgery – hysterectomy – to remove the entire uterus. Don’t let anyone tell you that you have no choice but to face a hysterectomy as part of being a woman or a woman with fibroids.  

    As the number of safer, less invasive treatments continue to grow, get a second and even a third opinion. You need to be convinced that a hysterectomy is absolutely the best solution for you. 

    Unfortunately, because there have been so many advances in a short period of time, not every doctor is knowledgeable about or qualified to perform these newer techniques. You really have to do your homework and learn what your options are. Then, find a doctor who feels comfortable with and does a lot of the newer techniques. 

     

  • Dr Basri Johan Jeet Abdullah is head of the Radiology Department, Faculty Of Medicine, University Of Malaya. 

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