Also known as uterine myomas or leiomyomas. It is the most commonly seen tumors of the female reproductive system. The cause of fibroids is not clearly known, but it is believed that each tumor develops from an abnormal muscle cell in the uterus which multiplies rapidly due to the influence of estrogen.
Who Are at Risk?
- Pre-menopause. Women who are approaching menopause are at the greatest risk for fibroids because of their long exposure to estrogen.
- Heredity. If your mother or sister had fibroids, you’re at increased risk of developing them.
- Race. Black women are highly likely to have fibroids than women in other racial groups.
- Age. The risk is higher among those in their 40’s to 50’s compared to women in their 20’s-30s’s.
Signs and Symptoms
Some women who have fibroids have no symptoms, or they only experience mild ones, while others suffer severe, disruptive symptoms.
Those affected may have varying symptoms. Here are the common ones you need to look out for:
Heavy or prolonged vaginal bleeding Pelvic Discomfort Pelvic Pain Bladder problems- frequent urination Low Back Pain Rectal Pressure/ constipation Discomfort or Pain with Sexual Intercourse Increasing abdominal girth
Fibroids can be diagnosed through the following:
- Ultrasound- The most common and convenient non-invasive way to locate and characterize fibroids.
- Magnetic Resonance Imaging (MRI) – More expensive than an ultrasound, it may give more information in cases of diagnostic uncertainty.
- Hysterosalpingography – This procedure uses a dye to highlight the uterine cavity and fallopian tubes in an X-ray. This is recommended if there is a concern about fibroids in the uterine cavity impacting fertility. It can also be used to rule out any obstruction in the fallopian tubes.
- Hysterosonography – This is also called a saline infusion sonogram because it uses a sterile saline solution to expand the uterine cavity to make it easier to get images of fibroids in the cavity.
- Hysteroscopy – It involves the use of a small lighted device called a hysteroscope that is inserted into your cervix to your uterus. This allows visual examination of the cervical canal and interior of the uterus and at the same setting may allow for removal of fibroids protruding into the cavity in a procedure called transcervical resection of myoma (TCRM).
- Endometrial Biopsy – A procedure in which a sample of your uterine lining tissue is obtained and examined to make a diagnosis. This may be recommended to rule out abnormal cellular changes in the lining that causes heavy disordered bleeding as the presentation can be similar.
- Blood test – A full blood count can rule out anemia due to chronic blood loss.
PROCEDURES TARGETED FOR FIBROIDS
- Hysterectomy – This procedure involves the surgical removal of the entire uterus. It may also be possible to remove the uterus laparoscopically if the size of the uterus permits so.
- Myomectomy– This procedure removes the fibroids while leaving the uterus intact to enable future pregnancies.
In a laparoscopic (key-hole) approach, small and slender instruments are inserted through small incisions in the abdomen to remove the fibroids in the uterus. By a process called morcellation, the fibroids are broken into small pieces so that it can be removed through the same incision. A key-hole approach enables faster recovery.
- Uterine artery embolization – This procedure cuts of the blood flow of arteries that supply blood flow to the fibroids. This causes them to shrink and die. This is a good method for the older patient not suitable for surgery with 1-2 large fibroids and not keen for fertility. There is limited availability in Singapore.
- High Intensity Focused Ultrasound (HIFU) – Ultrasonic beams pass through the skin and soft tissue and target the focus area of the fibroid heating it for ablation while leaving the skin and other tissues unharmed. This less invasive method may aid in faster recovery but there is limited experience and not as much data on safety and efficacy as it is a newer method. Improvement in symptoms may also take several months for the full effect to be achieved.
MEDICATION THAT REDUCES SYMPTOMS OF BLEEDING AND PAIN
These options may help reduce symptoms but may not be very effective for larger fibroids.
- Anti-inflammatory painkillers eg NSAIDs – This is an effective treatment for the occasional pelvic pain or discomfort.
- Tranexamic acid – This is medication can help ease heavy menstrual periods, and it is only taken on days when you experience heavy bleeding.
- Combined contraceptive pill – This may help reduce menstrual volume for heavy menstrual bleeding but may increase the size of the fibroid. The pills prevent ovulation thereby preventing pregnancy.
- Progestogen (oral or 3 monthly injectible) – oral medication like Norethisterone, provera, duphaston etc that is taken in a cyclical manner may help reduce bleeding volume.
- Progestin–releasing intrauterine device (Mirena IUD) – This device can relieve heavy bleeding due to fibroids. However, it cannot shrink the fibroids or make them disappear and are not suitable for patients with a distorted uterine cavity due to protruding fibroids. It is also a contraceptive device and prevents you from getting pregnant.
MEDICATION THAT SHRINKS FIBROIDS
- Gonadotropin-releasing hormone agonists (GnRH agonists) – This lowers the levels of estrogen which then triggers a “medical menopause”. It can also make surgical treatment easier because it can shrink the fibroid over a few months and enable a key-hole approach. The long term risk is osteoporosis so it is not advisable for use beyond 6 months.
- Anti-hormonal agents Eg Esmya – These drugs counter the hormones that fuel the growth of fibroids. Esmya is under review and currently allowed for restricted use following reports of associated liver failure.
Seek prompt medical care if you experience severe vaginal bleeding or any sudden sharp pelvic pain. If you suspect you may be having symptomatic fibroids, book a consultation with Dr. Pamela Tan today for a comprehensive discussion.