UTERINE FIBROIDS

What Are Fibroids?

Uterine fibroids are usually round tumours or lumps in the muscular wall of the uterus or womb.  They are also referred to myomas or leiomyomas.  They are almost always benign particularly before the onset of the menopause.  They tend to grow under the influence of oestrogen up until the menopause and should stay the same size or shrink after the menopause.  They vary in size from small seeds to very large tumours that can occupy the entire pelvic and abdominal cavity.  At least 20% of women will develop fibroids by the age of 50.

What Symptoms Do They Cause?

Many uterine fibroids cause no symptoms at all.  They can be associated with pain, often heavy and abnormal menstrual bleeding.  They can also be associated with pressure effects on the bladder causing frequency of urination, difficulty emptying the bladder and on the bowel causing rectal pressure and difficulty emptying the bowel.  Sometimes they are felt by the patient as a mobile lump in the lower abdomen causing lower abdominal distension, or they may cause pain during intercourse and lower back pain.  They may be associated with fertility, recurrent miscarriage and complications during pregnancy and labour.

Fibroids are almost always benign and the risk of cancer which is called leiomyosarcoma, less than 1 in 1000.

How Are Fibroids Diagnosed And What Investigations Are Necessary? 

Most fibroids are diagnosed by abdominal or pelvic examination and also by medical imaging and in particular pelvic ultrasound.  Sometimes tests like a CT scan or MRI of the pelvis and abdomen may be necessary to accurately outline the position and texture of the fibroids.  They may also be diagnosed by coincidental Laparoscopy of the pelvic cavity or Hysteroscopy of the cavity of the womb.

What Are My Treatment Options?

Most uterine and fibroids are simply monitored particularly if they are small and not associated with any symptoms that are interfering with quality of life.  Fibroids that are causing symptoms will need to be reduced in size or removed.  Some medications like the pill can control the symptoms of the fibroid temporarily.  Other medications like Lupron (Leuprorelin) which is called a Gonadotropin Releasing Hormone Agonists (GnRH-A), can in fact shrink the fibroid down to a smaller size to make surgery technically easier.  The latter drug can only be used for a short periods of time and are associated with symptoms of the menopause.  Non-surgical options to eliminate or reduce the size of the fibroids include uterine fibroid embolization or uterine artery embolization where a small tubal catheter is fed through blood vessels in the groin to the blood vessels in the uterus that supply the fibroid.  Tiny plastic or gel particles are injected to block these vessels causing them to shrink.  Newer treatments include radio frequency ablation and Focused ultrasound treatment for uterine fibroids which involves a high intensity Focused energy beam which is used to destroy the fibroid. These new methods are not used often as the success rates and complications are still not well documented and they are not freely available. Symptomatic uterine fibroids are more often treated with surgery and in 2016 this is mostly minimally invasive surgery not open surgery. This has the advantage of less pain, shorter hospital stay and much faster recovery to normal activities and full time work.

The types of surgery that you should discuss with your doctor include:

    1. Hysteroscopic myomectomy with removal of the fibroid performed through the cervix in an operation that is similar to a D&C (usually day surgery).

 

    1. Laparoscopic myomectomy where the fibroid is removed during keyhole surgery.  The hole in the myometrium is stitched laparoscopically.  The fibroid fragments are usually removed after morcellation or cutting of the hard fibroids into pieces.  This is often done with an electromechanical instrument like a “cookie cutter”.  The fibroids are then placed in a plastic endoscopic pouch like a large sandwich cliplock bag and removed (usually day surgery or overnight surgery).

 

    1. Open myomectomy with an incision like a Caesarean section scar or a midline incision.  This is rarely used these days (usually 3-5 day stay).

 

    1. Laparoscopic myolysis where a needle is inserted into the fibroid under vision and electric current or freezing is used to destroy the fibroid itself.(rarely used)

 

    1. Patients whose child bearing days are over usually look to have the fibroids removed with the uterus. Once again this is almost always done as a Laparoscopic or Robotic hysterectomy. This operation is safer and has less complications than simply removing the fibroids alone.  This is because the uterus is removed neatly from its blood supplies intact with the fibroids rather than leaving a large raw defect in the muscle wall of the uterus which has to be sutured.  This runs the risk of bleeding, infection and adhesion formation in the future and the need  for further surgery in the future which can be much more complicated and require further time off work and away from the family.

 

Conclusion.

Most significant fibroids will need to be removed.  If child bearing is still a consideration, then the fibroids are removed from the uterus.  If child bearing days are over, the fibroids are usually removed at keyhole Hysterectomy.  The modern way to perform all of this surgery is using the most minimally invasive technique possible and this is either Laparoscopic or Robotic.  It is very uncommon to require an old fashioned open laparotomy operation.  To achieve the removal of these large amounts of tissue through the small keyhole ports, it is necessary to cut the fibroid into small pieces or morcellate it.  This is usually done with a power morcellator.  Breaking the uterine tissue into small pieces can spread an undiagnosed cancer to other parts of the body which may make the immediate prognosis of the cancer worse although these types of cancers are very aggressive and have a poor prognosis under any circumstances.

As the risk of cancer in a fibroid is less than 1 in 1000 and screening tests will help to reduce this risk further, the patient and her doctor need to balance the very low risk of undiagnosed cancer against the huge advantages of minimally invasive surgery.  Techniques are now developed to remove the even very large tumours in endoscopic pouches which eliminate the risk of spillage.  Please discuss any of these issues with your doctor prior to surgery.