Table of Contents
What is fibroid?
Uterine Fibroid (also called Leiomyoma uteri –which means smooth muscles tumor of the uterus) is a tumor that grows in the uterus (womb) of a woman. It is also called Uterine Fibroid. It is not a cancer (malignant tumor); hence it grows slowly but can get very large when not treated. Fibroid starts as a small mass in the muscles of the womb and slowly grows into a big mass.
Uterine fibroid affects women of African origin twice more than it affects other races. It does not occur before puberty but occurs mostly in women within the age range of 30 to 49 years who are in their reproductive ages. It is a neoplasm that can occur singly or in multiple locations in the uterus. Uterine fibroid is a very common tumor in women (some women may have it but may not show symptoms) and can affect their fertility.
Risk factors and Causes of Uterine fibroid
- Low parity (number of pregnancies)
- Obesity (overweight women)
- Positive family history of fibroids
- Early age of first menstrual period
- Consumption of beef and red meat
- Early use of Oral contraceptive pills (OCP)
Prevention of Uterine fibroid
- Consumption of Vegetables is associated with reduction in the risk of having Uterine fibroids
- Prolonged use of oral contraceptive pills
- Increased number of pregnancies
Symptoms of Uterine fibroid
- Pressure symptoms, caused by pressure exerted on other organs by the growing mass
- Infertility and reproductive abnormalities
- Disturbances of the menstrual cycle such as increased bleeding and painful menstruation
- Initial painless and bulging abdomen which may or may not be painful as the mass increases in size and becomes big
- As it increases, pain increases too with pain occurring sometimes during menstrual bleeding or even during intercourse
- In a woman at menopause who comes with fibroids and pain, it might have transformed to a malignant tumor (leiomyosarcoma)
Pressure Symptoms of Uterine fibroid
- Urinary retention (obstruction): because of the compression of the urinary bladder by the fibroid
- Rectal obstruction leading to difficulty in passing stool
- Urinary frequency: increased in the number of times you pass urine a day (frequent urination)
- Constipation: this is caused by obstruction of the gastrointestinal tract leading to compaction of the stool
- Urinary urgency: the feel of an urgent need to pass urine
- Pain due to torsion or degeneration
Disturbances of monthly period
- Increased or heavy bleeding: you may feel weak as a result of losing much blood. This leads to a condition known as Anemia
- Bleeding between periods or bleeding between cycles: as the fibroid gets bigger in size, it may bring about abnormal bleeding which often comes after the normal menstrual bleeding (in between cycles).
Reproductive complicationscaused by Uterine fibroid
- Infertility: one of the effects of fibroid is infertility. The inability to give birth or become pregnant can cause Uterine fibroid and also, the fibroid in turn can cause infertility.
- Miscarriage: this occurs because babies lie in the womb which has been occupied by the growing fibroid; this leads to frequent miscarriage. A woman who keeps having miscarriages without any obvious cause should be evaluated for Uterine fibroids whether there is the presence of a prominent mass or not.
- Preterm labor: the presence of fibroid during pregnancy may cause labor to start before the baby has reached term (9 months)
- Abnormal lie and presentation: the baby lies in the mothers womb in an abnormal position which makes it difficult to deliver
- Abruptio placenta: fibroids may cause the placenta to detach and may cause serious complications in the baby if not treated immediately
- Premature rupture of membrane (PROM): this will lead to infections
- Retained placenta
- Postpartum hemorrhage: bleeding occurring after child birth
- Placenta previa: presence of fibroids may cause the placenta to be abnormally placed and may lie at the lower aspect of the uterus which can cause a woman to bleed during pregnancy
Types of Uterine fibroids
- Submucous fibroids
- Pedunculated (like it is hanging on a stalk)
- Cervical fibroids
- Intra-ligamentary fibroids: lies in the broad ligament of the uterus
- Pedunculated submucous
- Subserous fibroids
Locations of different types of fibroids
- Intramural fibroids: this type of fibroid develops within the walls of the uterus
- Submucosal fibroids develop from myometrial cells just below the endometrial layer of the uterus. Submucous fibroids often distort the uterine cavity by protruding into the cavity and are mostly associated with heavy menstrual bleeding (menorrhagia). This needs to be removed to increase the pregnancy rate in women undergoing In-Vitro fertilization (IVF)
- Subserous fibroids develop below the serous layer of the uterus
Physical Signs on examination of a woman with Uterine fibroid
- Pale looking due to heavy bleeding
- Presence of a firm swelling in the lower abdomen that may become painful to touch especially when it becomes infected
- Irregular shape of the uterus (womb)
Diagnosis of Uterine Fibroid
- Fibroid is mainly diagnosed by history and Clinical examination
- Use of ultrasound scan
- Use of hysterosalpingogram (HSG)
- By Magnetic resonance imaging (MRI)
Complications of Uterine fibroids
- Excessive production of red blood cells leading to a condition called polycythemia. This condition predisposes to thrombosis that may cause stroke or organ failure. This is a rare complication that is known as myomatous erythrocytosis syndrome
- Red degeneration
- Fibroids may change to malignant (cancerous) tumors; but this occurs in about 1 in 200 women. This is also rare. There should be suspicion of a malignant change when the fibroids are rapidly growing in size
Red degeneration of fibroids
This occurs in about 3 out of 100 women having fibroid and symptoms include severe abdominal pain, vomiting and fever. It is mostly associated with pregnancy because hormones released during pregnancy helps it to grow. It occurs also in women taking contraceptive pills.
Treatment of Uterine fibroids
Majority of fibroids do not show signs (asymptomatic) and may not require treatment. Fibroid treatment depends on whether it is showing signs and symptoms or not; if it is showing symptoms such as the ones listed above, then treatment will be dependent on the size of the fibroid, the age of the woman, her plans of becoming pregnant in the future and the location of the fibroid in the womb.
Fibroid treatment can be medical treatment, which involves use of drugs or it could be surgical treatment which has to do with removing the fibroid.
Medical treatment of Fibroid
- Gonadotropin releasing Hormones (GnRH) agonists such as Leuprolide acetate depo. Use of GnRH agonist can reduce the size of the fibroids by half after using it for 3 months
- Mifepristone (RU-486)
- Tranexamic acid is used for reducing the heavy bleeding (menorrhagia)
- Non-Steroidal Anti-Iinflammatory drugs (NSAIDs)
- Oral contraceptive pills (OCP)
- Danazol-19-nortesttosterone derivative
Medical treatment does not completely treat fibroids but reduces the size of the tumor and temporary relieves the symptoms. Regrowth of the fibroids occur about 12 weeks after the medical treatment with GnRH is stopped. Sometimes, medical treatment is started before the definitive surgical treatment in order to reduce the size of the tumor before removal. Medical treatment should not be done for a long period of terms as the drugs are not without side effects such as weight gain, osteoporosis (softening of bones), hot flushes, voice changes (which may be permanent), growing of hair as that of a man (hirsutism) and bloating.
Surgical treatment of Uterine fibroids
- Conservative surgery
- Radical surgery
Conservative surgery of uterine fibroid
- Abdominal myomectomy
- Vaginal myomectomy
- Laparoscopic myomectomy
- Devascularization procedure (Uterine artery embolization): this involves catheterization of the uterine artery through the femoral artery in order to occlude the uterine artery by injecting polyvinyl alcohol
- Laparascopic myolysis using laser, cryotherapy, bipolar needles or cautery to destroy the fibroid together with its blood supply
Myomectomy is the surgical removal of fibroids. In conservative surgery, the fertility of the woman is preserved and only the affected parts of the uterus are removed. The type of surgery done is dependent on the size of the fibroids. For large sized fibroids, abdominal myomectomy is done; for smaller sized fibroids, vaginal myomectomy is done. Other forms of myomectomy such as Laparoscopic myomectomy are done when the fibroids are very small. If fertility is not desired in a woman with abnormal uterine bleeding, then concomitant endometrial ablation or resection resolves the abnormal bleeding better than myomectomy alone.
Radical surgery for fibroids
To prevent recurrence of fibroid, the only definitive treatment is total removal of the womb known as total hysterectomy. This procedure is only done if the woman has passed the age of reproduction (after menopause) or if she has completed her family size and does not want to give birth again and the fibroid is big with complications. It should be done with the consent of the woman.
Uterine fibroid occurring in Pregnancy
The hormones released during pregnancy helps fibroid to grow and enlarge and can caused miscarriage.
A woman with fibroid in pregnancy may have to deliver by caesarean section; removal of fibroid during a C-section is dangerous and should only be done when there are strong reasons to do it.
Differential diagnosis of fibroids
These refer to other tumors, diseases or conditions that may have similar symptoms as fibroids. They include:
- Ovarian masses
- Tubo-ovarian abscess
- Endolymphatic stromal myosis
- Endometrial cancer
- Congenital anomalies
- Myometrial hypertrophy
- Uterine polyps
- Uterine sarcomas
- Dysfunctional uterine bleeding