What is uterine / uterus fibroid ?
Uterine fibroids (myomas, leiomyomas, or fibromyomas) are the most frequent tumors of the female genital tract: 20 to 40% of women of childbearing age have a fibroid. Fibroids range in size from very tiny to the size of an orange or larger. In some cases, they can cause the uterus to grow to the size of a five-month pregnancy or more.
Women aged between 30 and 50 are the most likely to develop fibroids. Overweight and obese women are at significantly higher risk of developing fibroids, compared to women of normal weight.
Types of uterine Fibroids
They are named according to their location within the uterus:
- Intramural fibroids are located within the wall of the uterus and are the most common type; unless large, they may be asymptomatic. They may cause heavy bleeding with clots. With time, intramural fibroids may expand inwards, causing distortion and enlargement of the uterine cavity.
- Subserosal fibroids are located on surface of the uterus and can become very large. They can cause pressure over bladder and rectum producing symptoms like urgent urination and constipation with back pain.
- Submucosal fibroids are located in the muscle beneath the endometrium of the uterus and distort the uterine cavity; even small lesion in this location may lead to bleeding and infertility.
- Cervical fibroids are located in the wall of the cervix (neck of the uterus). They may also cause infertility if obstructing the cervical canal and difficulty in normal delivery.
Symptoms of fibroids:
- Heavy, prolonged menstrual periods and unusual bleeding, sometime with clots. This might lead to anemia.
- Lower abdomen, back or leg pain
- Lower abdominal pressure or heaviness
- Bladder pressure leading to a constant urge to urinate
- Pressure on bowel, leading to constipation and bloating
- Abnormally enlarged abdomen
Diagnosis
Fibroids are usually suspected during a gynecologic examination. The presence of fibroids is most often confirmed by a lower abdomen ultrasound scan. Fibroids can also be confirmed using MRI (magnetic resonance imaging). It is a good idea to have an MRI Scan before any kind of treatment. These imaging techniques serve as a baseline examination for follow-up after uterine fibroid embolization (UFE) or any other treatment.
Picture A. Ultrasound image shows sub mucosal fibroid Picture B. MRI image shows multiple intramural fibroids.
Causes
Doctors don’t know the cause of uterine fibroids, but research and clinical experience point to these factors:
Genetic alterations: – Many fibroids contain alterations in genes that are different from those in normal uterine muscle cells.
Hormones: – Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than do normal uterine muscle cells.
Other chemicals: – Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
Complications
Although uterine fibroids usually aren’t dangerous, they can cause discomfort and may lead to complications such as anemia from heavy blood loss.
Anemia: – if the bleeding is very heavy.
Urinary tract infections: – if pressure from the fibroid prevents the bladder from fully emptying
Pregnancy and fibroids: – Fibroids usually don’t interfere with conception and pregnancy. However, it’s possible that fibroids could distort or block your fallopian tubes, or interfere with the passage of sperm from your cervix to your fallopian tubes. In other cases, treatment for fibroids during pregnancy isn’t necessary. A common complication of fibroids during pregnancy is localized pain, typically between the first and second trimesters. This is usually easily treated with pain relievers. But sometimes in presence of fibroids one may experience repeated pregnancy losses and no other cause of miscarriage can be found.
Treatment Options for Fibroids
There’s no single best approach to uterine fibroid treatment. Many treatment options exist.
Watchful waiting: Many women with uterine fibroids experience no signs or symptoms. If that’s the case for you, watchful waiting (expectant management) could be the best option. Fibroids aren’t cancerous.
Medications: They help in reducing mild symptoms but do not treat the fibroids.
Non-surgical: – A. Uterine artery embolization B. HIFU
Surgical: – A. Hysterectomy B. Myomectomy
Medications
Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids. Medications include:
(GnRH) Agonists-Releasing Hormone. Medications called GnRH agonists treat fibroids by causing your natural estrogen and progesterone levels to decrease, putting you into a temporary postmenopausal state. Many women have significant hot flashes while using this medication.
Androgens. This drug similar to male hormone testosterone may effectively stop menstruation, correct anemia. However, this drug is rarely used to treat fibroids. Unpleasant side effects, such as weight gain, feeling depressed, anxious or uneasy, acne, headaches, unwanted hair growth, and a deeper voice, make many women reluctant to take this drug.
Non – Surgical Treatment options for uterine fibroids
A.Uterine artery embolization / Uterine Fibroid embolization:
It is a minimally invasive interventional radiological procedure, which means it requires only a tiny nick in the skin. It is performed under sedation and local anesthesia – feeling no pain and usually requires a hospital stay of one night. Many women resume light activities in a few days and the majority of women are able to return to normal activities within one week.
UFE treats all uterine fibroids at the same time and is, therefore, extremely effective.
Ideal Patient for uterine fibroid embolization
- They have single or multiple fibroids
- The fibroids are symptomatic
- There is no cancer
- A desire to retain her uterus.
- Does not desire surgery.
- Poor surgical candidate (e.g., because of obesity, bleeding disorders, anemia).
The interventional Radiologist makes a small nick in the skin (less the ¼ of an inch) at groin, inserts a catheter, identifies uterine artery by using angiography with contrast media injection and then inject embolization particles (polyvinyl alcohol) that block the tiny vessels supplying all the fibroids. This blockade of blood supply to fibroids causes infarction (loss of blood supply to the fibroids) and subsequent degeneration of the fibroids and it starts reducing in size reaching half the size in few weeks. Symptoms due to the fibroids (like bleeding and pain) resolve in 85% to 95% of patients.
Uterine Artery Embolization has many Indications:-
- Single / multiple Uterine Fibroids.
- Adenomyosis.
- Failed myomectomy / recurrence of fibroids after myomectomy
- High risk patient for surgery like obesity, anemia, Chronic renal failure etc.
- Post-partum Hemorrhage
- Bleeding from Cancer of Cervix & Uterus
- Pre-operative embolization to reduce bleeding during uterine surgery.
Side effects:
- About 1% chance for infection which is typically characterized by fever and smell from vagina. It just needs antibiotics to treat.
- Mild pelvic pain will remain for 1-2 days and it is controlled very well by simple pain medication.
- Mild fever which is well controlled by paracetamol oral tablets.
- About a half percentage of the woman land-up in short term menopause. Later they may resume normal periods.
- Women those have fibroids always have risk of fertility. Despite these risks, many women have had successful pregnancies following uterine artery embolization
Pros & Cons of non-surgical treatment: It shows overall success rate of about 96-98% which is unlikely in other methods of fibroid treatment.
- It is the only method that can treat multiple fibroids in one sitting.
- The uterine artery embolization treats the fibroid and adenomyosis together.
- No surgical scar or blood loss during the procedure.
- It needs just daycare or 24 hrs hospitalization.
- Short recovery time just 1-4 Days.
Advantages of Uterine artery embolization
- It is performed under Local anesthesia. Not General anesthesia.
- Requires only a tiny nick in the skin (No surgical incision of abdomen).
- Recovery is shorter than from hysterectomy or open myomectomy.
- Virtually no adhesion formation has been found. But in surgery adhesions are common.
- All fibroids are treated at once, which is not the case with myomectomy.
- Recurrent growth of treated fibroids is uncommon.
- Uterine fibroid embolization involves virtually no blood loss or risk of blood transfusion.
- If the presenting complaint was excess vaginal bleeding, 87-90% of cases experiences resolution within 24 hours.
- Emotionally, financially and physically – embolization can have an overall advantage over other procedures for the patient as the uterus is not removed.
B. Focused ultrasound surgery: –
MRI-guided focused ultrasound surgery (FUS) is a noninvasive treatment option for uterine fibroids that preserves your uterus. This procedure is performed while you’re inside of a specially crafted MRI scanner that allows doctors to visualize your anatomy, and then locate and destroy (ablate) fibroids inside your uterus without making an incision. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids. One or two treatment sessions are done in an on- and off-again fashion, sometimes spanning several hours.
Because it’s a newer technology, researchers are learning more about the long-term safety and effectiveness of FUS. Research continues, but so far data collected show that FUS for uterine fibroids is safe and very effective.
Surgical Treatment options for uterine fibroids
A. Hysterectomy (removal of uterus)
What it is It is surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing complete uterus including cervix) or partial (removal of the uterus leaving the cervix intact). Ovaries may also be removed at the same time.
How it is done it is a major surgery and needs general anesthesia. It requires a surgical cut, the size of the scar depends on how big the uterus is. It can be abdominal, vaginal or laparoscopic.
Side effects Risk of bleeding is very common, requires blood transfusion.
Long term morbidity is relatively more under the age of 45 years believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy.
Approximately 35% of women after hysterectomy undergo another related surgery within 2 years.
Ureteral(Urinary Tube) injury is not uncommon and can range from 2.2% to 3%.
Pros & Cons of surgery – Hospital stay is 2 to 5 days or more. Time for full recovery is very long in all types of hysterectomy whether abdominal, vaginal or laparoscopic. Definition of “full recovery” means 3 to 12 months. Serious limitations in everyday activities are expected for a minimum of 4 months.
It ends your ability to bear children, and if you also elect to have your ovaries removed, it brings on menopause and the question of whether you’ll take hormone replacement therapy.
B.Myomectomy (removal of fibroid)
What it is: It is surgical removal of the fibroids, usually performed by a gynecologist. Myomectomy may be open or by laparoscopic approach. Sometimes it is done by hysteroscope. Whatever is the approach it is a major surgery.
How it is done. It needs general anesthesia and requires surgical cut in lower abdomen, the size of the scar depends on how big the fibroid is. It can be abdominal or laparoscopic.
Side effects Excessive blood loss. The uterus has a rich network of blood vessels and fibroids stimulate growth of new vessels to obtain their own blood supply. So during myomectomy, surgeons must take extra steps to avoid excessive bleeding.
Scar tissue. Incisions into the uterus to remove fibroids can lead to adhesions — bands of scar tissue that may develop after surgery. Within the uterus, adhesions may block implantation of a fertilized egg in the uterine lining and adhesions could entangle neighboring structures and lead to a blocked fallopian tube or a trapped loop of intestine.
Development of new fibroids. Myomectomy doesn’t eliminate your risk of developing more fibroids later. Instead, the very small invisible fibroid start growing at a much faster rate leading to a high rate of recurrence. If fibroids return, future treatment — a repeat myomectomy, hysterectomy or other procedure — may be necessary.
Childbirth complications. If myomectomy incision is deep it may weaken the uterine wall which may pose problem in future childbirth. Your gynecologist may recommend cesarean delivery to avoid rupture of the uterus during labor.
Pros & Cons of surgery – Hospital stay is 2 to 5 days or more. Time for full recovery is very long ie few months.
Best solution for fibroid treatment – Non surgical treatment Uterine artery embolization
Uterine artery embolization (UAE) is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the fibroids. If the procedure is done for the treatment of uterine fibroids it is also called uterine fibroid embolization (UFE). The procedure is not a surgical intervention and allows the uterus to be kept in place, relieving the patient of its symptoms with quick recovery and quick resumption of day to day activities.
Benefits of non-surgical treatment
- It is performed under Local anesthesia. Not General anesthesia.
- Requires only a tiny nick in the skin (No surgical incision of abdomen).
- Recovery is shorter than from hysterectomy or open myomectomy.
- Virtually no adhesion formation has been found. But in surgery adhesions are common.
- All fibroids are treated at once, which is not the case with myomectomy.
- Recurrent growth of treated fibroids is uncommon.
- Uterine fibroid embolization involves virtually no blood loss or risk of blood transfusion.
- If the presenting complaint was excess vaginal bleeding, 87-90% of cases experiences resolution within 24 hours.
- Emotionally, financially and physically – embolization can have an overall advantage over other procedures for the patient as the uterus is not removed.