Knowing facts about Uterine Fibroids
Dr Francoise Dudu Rubgeg | Tuesday August 2, 2022 06:00
• Fibroids are a cancer: False • Fibroids only affect women in their 30s and 40s: False
• You cannot get pregnant if you have fibroids: False
• A hysterectomy is the only treatment of fibroids: False
• Once fibroids are removed, they cannot come back: False
What are uterine fibroids?
Uterine fibroids are defined as benign (non-cancerous) tumours/growths of the muscle of the uterus (womb).
These growths originate in the uterine muscle but can extend into any part of the uterus The uterus is one of the reproductive organs of a female. It has three parts, the endometrium (inner layer) which has a cavity within it, the myometrium (middle part made of muscle); and the serosa (outer layer). What causes fibroids? The exact cause is unknown. However, the following have been shown to play a role in fibroid development:
• Genetic predisposition
• Sex steroid hormone (progesterone and oestrogen)
• Growth factors (proteins in the body that cause growth)
• Abnormal uterine blood vessels
What is the prevalence of uterine fibroids? Uterine fibroids are the most common pelvic tumour in females. They are commonly seen in:
• Reproductive age group (18-40years)
• Women of African ancestry. Are there any risk factors? Yes!
• Obesity
• Nulliparity (a female that has never been pregnant)
• Hypertension
• Family history of fibroids
• Early onset of 1st menses and late menopause What are the different types of fibroids? Fibroids are classified according to which part of the womb they grow into. There are four main groups namely; submucosal, intramural, subserosal and hybrid fibroids. These can be further sub-divided into eight types as per The International Federation of Gynaecology and Obstetrics (FIGO):
• Submucosal Type 0: Fibroids inside the cavity Type 1: Less than half of the fibroid is inside the muscle, the rest extends into the cavity Type 2: More than half of the fibroid is inside the muscle, the rest extends into the cavity
• Other Type 3: Intramural: Fibroids inside the myometrium but contact the endometrium
Type 4: Intramural: Fibroids inside the myometrium and do not contact endometrium Type 5: Subserosal: Fibroid projects into the outer layer of the uterus with more than half in the muscle
Type 6: Subserosal: Fibroid projects into the outer layer of the uterus, with less than half in the muscle
Type7: Subserosal pedunculated: A stalk is attached to the outer layer of the uterus and the fibroid projects into the abdominal cavity
Type 8: Other e.g. on the cervix
• Hybrid fibroids Type 2-5: Fibroids which extend from the inner layer all the way to the outer layer of the uterus The picture below illustrates the types of fibroids.
(Photo adopted from https://www-uptodate-com) What are the symptoms? Symptoms depend on which part of the womb the fibroid is as described above. Symptoms include:
• Abnormal or heavy menses
• Pelvic pain
• Back pain
• Felling of abdominal/pelvic fullness • Dysmenorrhea (period pains)
• Constipation
• Increased urination frequency or urine retention (inability to urinate)
• Sexual dysfunction e.g. pain during sex How do fibroids affect pregnancy? If a female has fibroids and falls pregnant, the pregnancy can progress normally with no complications. A normal pregnancy may occur mainly with the type 4, 5, 6, 7 fibroids (unless these are massive or affect the placenta location), in which case some of the complications below can occur too. The other types of fibroids (type 0, 1 ,2 ,3 ,8 , 2-5) can lead to the following:
• Infertility
• Pregnancy loss
• Preterm labour
• Reduced fetus growth
• Fetal malpresentation
• Antepartum haemorrhage: bleeding during pregnancy How do we diagnose fibroids?
• The main diagnostic tool is the use of an ultrasound scan. This can be done via the vagina (transvaginal ultrasound scan) or via the abdomen (transabdominal ultrasound scan). What are the treatment options? Treatment depends on the following:
• Symptoms the patient has e.g. heavy menses, infertility, pregnancy loss
• Fertility wish (the desire to fall pregnant)
• The desire to keep womb (with or without fertility wishes)
• Presence of other illnesses which may be complicated by using medication or complicate an operation. Considering the above we then choose the most appropriate option from the below:
• Medical non-hormonal treatment: e.g. tranexamic acid and nonsteroidal anti-inflammatory drugs (e.g. ibuprofen) which both help to reduce bleeding.
• Hormonal treatment: There are several options here. These include combined hormonal contraception, progestins, mirena intrauterine devices, selective progesterone receptor modulators, antiprogestins, gonadotropin releasing hormone agonists and antagonists as well as aromatase inhibitors.
(Generally, the hormonal treatment leads to either reduced bleeding or shrinkage of the fibroids. NB: These medications do not make the fibroid “disappear”).
• Uterine artery embolization: This is a minimally invasive procedure where a catheter is passed via vessels in the pelvis to the uterus, to block blood supply to the fibroid, causing fibroid necrosis (death).
• High intensity focussed ultrasound: use of ultrasound technology to cause fibroid necrosis (death)
• Myomectomy: an operation done to remove the fibroid, leaving uterus intact. This can be done via the following routes: hysteroscopy (telescope and other tools put inside the vagina and cervix to enter the uterine cavity). Laparoscopy: a telescope and other tools inserted via the abdomen Open technique: where we make an incision on the abdomen with no use of any cameras.
• Hysterectomy: complete removal of the uterus. Summary: Uterine fibroids are common in our population. They can affect quality of life as well as pregnancy. There are different treatment options for different types and presentations of fibroids.
Please see your gynaecologist if you have any of the symptoms above or for further questions/clarifications. Warm Regards, Dr. Francoise Dudu Rubgega MBBS (UB), Mmed O&G (UP) FCOG (SA) Obstetrician and Gynaecologist