Fibroids

What are fibroids?

A fibroid is a benign (non-cancerous) growth of the uterus (womb). They are also called uterine myomas, fibromyomas or leiomyomas. They can vary from pea-sized to the size of a melon. They can occur anywhere in the uterus and are named differently depending upon where they grow:

• Intramural fibroids grow within the muscle tissue of the uterus. These are the most common place for fibroids to form.
• Subserous fibroids grow from the outside wall of the uterus into the pelvis.
• Submucous fibroids grow from the inner wall into the middle of the uterus.
• Pedunculated fibroids grow from the outside wall of the uterus and are attached to the uterus by a narrow stalk.

How common are fibroids?

Fibroids are very common. At least 1 in 4 women develop one or more fibroids in their lifetime. They usually develop in women aged 30-50 years and can sometimes run in families. It is common to have several fibroids of various sizes, although some women just have one fibroid. Fibroids are more common in women from Afro-Caribbean origin. Fibroids are also more common in women who weigh over 70kg (11 stones). This is thought to be due to the higher levels of oestrogen that occur in heavier women. Fibroids can increase in size, decrease in size or even go away with time.

What causes fibroids?

A fibroid is like an 'overgrowth' of smooth muscle cells. (The uterus is mainly made of smooth muscle.) It is not clear why they develop. Like the uterus, fibroids are sensitive to oestrogen, the hormone that is made in the ovary. Fibroids tend to swell when levels of oestrogen are high, for example, during pregnancy. They also shrink when oestrogen levels are low, for example, after the menopause. Hormone replacement therapy (HRT) may encourage the growth of fibroids.

What symptoms and problems are caused by fibroids?

Symptoms only occur in about one in three women with fibroids. Many women who have fibroids are not aware that they have them. Sometimes one is found during a routine examination by a doctor or by chance during a scan which you may have for another reason.

Symptoms may include:

Heavy or more painful periods

Fibroids do not disturb the menstrual cycle but bleeding is often heavier than usual, sometimes with more pain. This can lead to low iron levels and anaemia which will be diagnosed by a blood test. This is easily treated with iron tablets.

Bloating or swelling

If a fibroid is large you may have discomfort or swelling in the lower abdomen. Some women experience lower back pain due to their fibroids.

Bladder or bowel symptoms

Occasionally, a fibroid may press on the bladder which lies in front of the uterus. You may then pass urine more often than usual. Rarely, pressure on the rectum (which lies behind the uterus) may cause constipation.

Pain during sexual intercourse

If the fibroids grow near to the vagina or cervix (neck of the womb) then this can cause pain or discomfort during sexual intercourse (dyspareunia).

Miscarriage or infertility

If the fibroids grow into the cavity of the uterus they can sometimes block the fallopian tubes leading to problems with infertility. This is not common though. Very rarely, fibroids can be a cause of repeated miscarriages.

Problems during pregnancy

Many pregnant women have one or more fibroids which do not interfere with their pregnancy in any way. However, fibroids can be associated with an increased risk of having a caesarean section, the baby lying breech (rather than head first) and early labour. Your doctor will advise you further if you are pregnant and have fibroids.

How are fibroids diagnosed?

Some fibroids can be felt during an internal (vaginal) examination by a doctor. Sometimes an ultrasound scan or other tests are done to confirm the diagnosis and to rule out other causes of any symptoms.

What is the treatment for fibroids?

Observation

If your fibroids are not causing any symptoms then treatment is not usually needed. Many women chose not to have treatment if they have symptoms that are not too bad. After the menopause, fibroids often shrink and symptoms tend to go or ease. You can change you mind and consider treatment if symptoms get worse. Your doctor may advise you to have a repeat scan to assess the growth and size of your fibroids.

Treatment with medication

There are currently no medicines available that will actually cure fibroids. Medication can be used to improve symptoms or to shrink the fibroids.

Medication to improve symptoms
The following medicines are used to treat heavy periods whatever the cause, including heavy periods caused by fibroids. They may not work so well if your fibroids are large. However, they may be worth a try if your periods are heavy and the fibroids are small.

• Tranexamic acid. This is taken 3-4 times a day, for the duration of each period. It works by reducing the breakdown of blood clots in the uterus.
• Anti-inflammatory medicines such as ibuprofen and mefenamic acid. These also help to ease period pain. They are taken for a few days at the time of your period. They work by reducing the high level of prostaglandin in the uterus lining. Prostaglandin is a chemical which seems to contribute to heavy periods.
• The contraceptive pill may help you to have lighter periods and can often help with period pain too.
• Levonorgestrel intrauterine system (LNG-IUS) is similar to an intrauterine device used for contraception. It is inserted into the uterus and slowly releases a regular small amount of progestogen hormone called levonorgestrel. It works by making the lining of the uterus very thin so bleeding is lighter. However, it can sometimes be difficult to insert into the womb in women with fibroids.

Surgery

There are now several different operations available to remove and treat fibroids.

Hysterectomy
This is the traditional and commonest treatment for fibroids which cause symptoms. Hysterectomy is the removal of the entire uterus (womb). This is either done by making a bikini scar in the lower abdomen or, if the fibroids are small enough, the uterus can be removed through the vagina so there are no scars. A hysterectomy may be a good option for women who have completed their family. See separate leaflet called 'Hysterectomy' for more detail.

Myomectomy
This is a possible alternative, especially in women who may wish to have children in the future. In this operation the fibroids are removed and the uterus is left. This procedure is not always possible. This operation can be done through an incision (cut) in the abdomen, via "keyhole" surgery (laparoscopically) or through the vagina (hysteroscopically). The type of operation depends on the size, number and position of the fibroids. Recurrence of the fibroid is fairly common after a myomectomy.

Uterine Artery Embolisation
This is a fairly new technique used to treat fibroids. This procedure is performed by a specially trained radiologist (X-ray doctor) rather than a surgeon. It involves putting a catheter (a thin flexible tube) into an artery (blood vessel) in the leg. It is guided using X-ray pictures to the arteries of the uterus. Once there, a solid substance called PVA (poly vinyl alcohol) is injected through the catheter into the uterine artery. The arteries supplying the fibroids become blocked which means the fibroid then loses its blood supply and so it shrinks. The complete process of fibroid shrinkage takes about 6-9 months. However most women notice a considerable improvement in their symptoms within three months. As this treatment is quite new, the long term safety and effectiveness are still uncertain. This treatment is not suitable if you are considering having children in the future.

Other techniques
MRI (magnetic resonance imaging) guided laser ablation and MRI guided focused ultrasound are newer techniques. In these procedures small needles are put through the skin into the centre of the fibroid. The correct position of the needles is shown by the MRI scan. The laser energy or ultrasound energy are then passed down the needles which destroys the fibroid. These techniques are not suitable for all types of fibroid. Also, there is still some uncertainty as to the benefits and risks of both these treatments.

Further information

Women's Health

52 Featherstone Street, London, EC1Y 8RT
Helpline: 0845 125 5254 Web: www.womenshealthlondon.org.uk
Operates a UK-wide enquiry service providing information on a wide range of gynaecological and sexual health issues including fibroids.

Fibroids Embolisation Website

Web: www.fibroids.co.uk
A website that seeks to provide all of the current information available on fibroids, together with a synopsis of the various forms of treatment, in particular uterine artery embolisation. Written by a UK doctor.