What are fibroids? - For this page with References .....
Fibroids (medically known as leiomyomas) are tumours developing in the muscle of the uterus. They are the commonest tumours in women and they are generally benign. Some have found that they may be present in 50% of women. The exact cause of Fibroids is unknown. They are more common in women of Afro-Caribbean origin. Fibroids tend to grow during reproductive years and to become smaller after the menopause indicating that the sex hormones (oestrogens and progestogen) must be implicated.
Some Fibroids distort the cavity of the uterus (submucosal Figure 23.1) resulting in menstrual disturbance. Occasionally, these submucous Fibroids can be squeezed out to appear at the cervix. Other Fibroids migrate to the outer surface of the uterus (subserous) and may press on other pelvic structures such as the bladder. Small Fibroids do not generally require treatment although it is probably wise to assess them at intervals to check that they are not growing.
Fibroids - by position in the Uterus.
What symptoms can be associated with fibroids?
- The majority of Fibroids are small and cause no problems. Fibroids may be present in 50% of women so that the fact that they co-exist with a symptom such as pelvic pain does not necessarily prove cause and effect (Q4.3).
- Heavy periods are often associated with Fibroids. In one study, 30% of women presenting with heavy periods had Fibroids seen on hysteroscopy (Q 24.8). There was, however, no difference in the incidence of Fibroids in the group with heavy periods and another group who did not have heavy periods. Many women who present with heavy periods are found to have Fibroids but proof that the Fibroids are the cause of the problem is lacking. There have been very few studies to confirm that removing Fibroids reduces heavy periods.
- Bleeding between periods (intermenstrual bleeding IMB) can be related to a submucous fibroid (Figure 23.1).
How can Fibroids be diagnosed?
The diagnosis depends on the story, clinical findings and investigations. The doctor can usually feel the Fibroids when examining the uterus. If they are on the side of the uterus they need to be distinguished from a tumour of the ovary. Ultrasound is helpful in confirming the nature of the swelling. When there is intermenstrual bleeding, hysteroscopy is indicated to see if there is any abnormality within the uterine cavity such as a submucous fibroid or polyp.
How can Fibroids be treated?
In general treatment is only required if the Fibroids are causing symptoms. The fact that Fibroids are found during routine examination does not generally mean that action is indicated although you may wish to have check ups for reassurance that the Fibroids are not enlarging unduly. When there are small Fibroids and heavy periods, medical treatment should still be considered before resorting to surgery.
If fibroids become particularly large they may require surgical removal.Gynaecologists generally assess the size of the uterus by comparing it to the size expected during a pregnancy. As an approximate guide, if the uterine size is larger than 18 weeks size, surgery is probably indicated. In younger women who wish to retain their fertility, the Fibroids can be shelled out of the uterus (myomectomy). If fertility is not a re quisite, hysterectomy (hysterectomy) is likely to be the preferred operation. It has been estimated that once in every hundred myomectomies uncontrollable bleeding occurs and in such circumstances hysterectomy becomes necessary as a life-saving procedure.
GnRH analogues (gonadotrophins) reduce oestrogen and progesterone levels and they are frequently used to reduce the size of the Fibroids pre-operatively. On average, Fibroids will be reduced by about a third of their size after three months and perhaps by a half after six months. GnRH analogues can be used by themselves for a maximum of six months as there is a risk of bone thinning (osteoporosis) and the oestrogen protection against arterial disease would also be lost (23). If myomectomy is not performed the Fibroids rapidly return to their pre-treatment size. There has been recent suggestion that GnRH analogues could be continued for more than six months provided oestrogen is replaced in the form of HRT (HRT-Add-Back); early studies indicate that the oestrogen replacement does not reduce the benefits of the GnRH on fibroid size. GnRH analogues are expensive, precluding long-term use unless there are exceptional circumstances. When Fibroids are associated with heavy periods, GnRH analogues for a few months pre-operatively will provide two advantages: In addition to shrinking the size of the Fibroids, they should stop the periods, allowing anaemia to be corrected thus reducing the likely requirement for blood transfusion.
Uterine artery embolisation is a new treatment for Fibroids. The uterine arteries provide about 50% of the blood supply to the uterus. A fine catheter is introduced into an artery in the right groin. Poly Vinyl Alcohol particles are placed into the uterine arteries, under x-ray control, with the objective of starving the blood supply to the Fibroids. The starved Fibroids should then disappear or become smaller. After the procedure there may be pain and for three or four weeks there may be bleeding. Patients usually stay in hospital for a couple of days and may return to work after two weeks.
A retrospective follow-up cohort study included all patients described in a 2006 publication who had uterine artery embolisation.
Assessment was focused on comparing symptoms and quality of life in long-term follow-up.
The analysis was based on questionnaires completed by 39 patients.
The median follow-up period was 7 years.
Uterine fibroid embolization led to a reduction
- of bleeding symptoms in 89.7% of the patients,
- pain in 78.9%, bulk-related symptoms in 89.5%,
- fatigue in 76.9%,
- limitations of social life in 92.9%,
- and depression in 78.6%.
The median impairment scores for bleeding and pain decreased significantly from 7 to 0 and from 5 to 0 (both p < 0.001).
The general quality-of-life index increased significantly from 4.5 to 9 (p < 0.001). In the long term, there was no significant difference in parameters assessed compared with the midterm follow-up findings. Six patients (15.4%) underwent hysterectomy an average of 32.1 months after intervention. Thirty-two patients (82.1%) continued to be satisfied with the intervention, and 30 patients (76.9%) answered that they would recommend uterine fibroid embolization to other patients.
Magnetic Resonance Guided Ultrasound (MRgUS) is a new treatment option. It is non-invasive.
Data from the Royal Surrey County Hospital trial of 30 patients have achieved successful ongoing pregnancies with no obvious problems to date. Success rates of 85% are being achieved. A few patients stop seeing their periods. The main complication of fibroid embolisation is infection requiring hysterectomy in about 1% of cases.
Twenty patients have become pregnant following fibroid embolisation with no obvious problems to date. Deaths from fibroid embolisation (1:2500) are uncommon and appear to be less than for hysterectomy (1:1600). Fibroid embolisation is still undergoing trials to determine its benefits and risks.
Uterine Artery Embolisation is associated with less complications than hysterectomy. About 1 in 4 women having UAE require further treatment. Both treatments are safe and effective over the medium term. The choice of treatment is a matter of personal preference. UAE is cheaper than hysterectomy even allowing for repeat procedures. UAE is cost effective for those women who prefer uterine conservation.0704 The long-term results of uterine artery embolisation are awaited.
Minimal access surgery is an option in the treatment of Fibroids. The laparoscopic route is applicable to sub-serous Fibroids and hysteroscopy for sub-mucosal Fibroids.
MRI-guided focused ultrasound treatment of uterine Fibroids is a further new minimally invasive technique. Research into its place and value is being assessed.
Temporary uterine artery occlusion for treatment of menorrhagia and uterine Fibroids using an incisionless Doppler-guided transvaginal clamp provides a relatively simple means to treat Fibroids. This technique is under development.0604
This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT. I do hope that you find the answers to your women's health questions in the patient information and medical advice provided. The aim of this web site is to provide a general
guide and it is not intended as a substitute for a consultation
with an appropriate specialist in respect of individual care and
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided. David Viniker retired from active clinical practice in 2012.
In 1999, he setup this website - www.2womenshealth.com - to provide detailed information many of his patients requested. The website attracts thousands of visitors every day from around the world.
If you would like advice on how to make more from your website and achieve top page positioning on Google for your keywords, or please visit his website Keyword SEO PRO to learn about his keyword difficulty tool or email him on email@example.com. He would also be happy to assist you with the develpment of your small business website design in London. He enjoys writing articles on a variety of subjects for example recently on advertising with letterbox leaflets, wedding entertainment and loft conversions in Essex.
- Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.
The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.