UTERINE FIBROIDS

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UTERINE FIBROIDS

Dr. Theo Wangata, MBChB.

What Are Uterine Fibroids?

These benign (non-cancerous) tumors are found in most cases, in the uterus of women in their 30s and 40s. Fibroid tumors are solid tumors which are made of fibrous tissue, hence the name ‘fibroid’ tumor. Most often, fibroids occur as multiple tumor masses, which are slow-growing and often cause no symptoms.

What causes fibroids?

No one is sure why fibroid tumors develop, but some facts seem clear:

• Fibroids do not develop before the body begins producing estrogen during the onset of menstruation.

• Fibroids will continue to grow while estrogen is present.

• They will grow very quickly during pregnancy when the body is producing extra estrogen.

• They often shrink and disappear after menopause when the body stops producing estrogen.

• A woman will almost never develop fibroid tumors after menopause.

The estrogen connection appears to be quite clear, although there are still some schools of thought who doubt the role estrogen plays in the development of fibroid tumors because women with fibroids often have blood levels which reveal normal amounts of estrogen.

Factors that can increase a woman’s risk of developing fibroids

Age

Fibroids become more common as women age, especially during the 30s and 40s through menopause. After menopause, fibroids usually shrink.

Family history

Having a family member like a mother who had fibroids increases your risk.

Ethnic origin

African women are more likely to develop fibroids than white women.

Obesity

Women who are overweight are at higher risk of getting fibroids. For very heavy women, the risk is two to three times greater than average.

Eating habits

Eating a lot of red meat; for instance beef and ham is linked with a higher risk of fibroids. Eating plenty of green vegetables seems to protect women from developing fibroids.

Types of Fibroids:

They include the following:

Intramural

These are the most common types of fibroids and are located in the wall of the uterus.

Subserosal fibroids

These are located outside the wall of the uterus. They can develop into pedunculated fibroids (stalks). Subserosal fibroids can become quite large.

 Submucosal fibroids

These are located in the muscle beneath the lining of the uterus wall.

Cervical fibroids

These are located in the neck of the womb (the cervix).

What are the symptoms of uterine fibroids?

Most women have no symptoms. That is why most patients with fibroids do not know they have them.

When symptoms do develop, they may include:

• Heavy bleeding (which can be heavy enough to cause anemia), or painful periods

• Backache/Lower back pain

• Constipation

• Discomfort and swelling in the lower abdomen (especially if fibroids are large)

• Frequent urination

• Pain in the legs

• Pain during sex

• Feeling of fullness in the lower abdomen

• Complications during pregnancy and labour, including a greater risk of Caesarean Section

• Reproductive problems, such as infertility, repeated miscarriages

How are fibroids diagnosed?

In most cases, the symptoms of fibroids are rarely felt and the patient does not know she has them. They are often discovered during a routine pelvic examination.

Ultrasound

It uses sound waves to produce the picture. The ultrasound probe can be placed on the abdomen or it can be placed inside the vagina to make the picture, called a transvaginal ultrasound.

CT scan of the pelvis

Takes many X-ray pictures of the body from different angles for a more complete image.

Laparoscopy

A laparoscope is a small flexible tube that looks at the outside of the uterus where the doctor examines its size and shape. The scope has a bright light and a camera. This allows the doctor to view the uterus and other organs on a monitor during the procedure. Pictures also can be made.

Haemogram or total blood count

Is a blood test that checks blood level or signs of anaemia

How are fibroids treated?

Most women with fibroids do not have any symptoms.

If you have symptoms of fibroids, the method or type of treatment depends on:

• If you might want to become pregnant in future.

• The size and location of the fibroids.

• Your age and how close to menopause you might be.

 If you have no symptoms and the fibroids are not affecting your day-to-day life you may receive no treatment at all. Instead, your doctor will recommend watchful waiting. If you are nearing menopause, watchful waiting may also be an option for you, depending on how tolerable your symptoms are. After menopause, your estrogen and progesterone levels will drop, which causes most fibroids to shrink and symptoms to subside.

Treating fibroids with medication:

Medications for uterine fibroids target hormones that regulate your menstrual cycle. They also treat symptoms such as heavy menstrual bleeding, anaemia, and pelvic pressure. They don’t eliminate fibroids, but may shrink them. The medications are less effective with larger fibroids. These medications are described below.

Gonadotropin-releasing hormone (GnRH) agonists: These medications treat fibroids by causing your natural estrogen and progesterone levels to decrease, putting you into a temporary postmenopausal state. As a result, menstruation stops, fibroids shrink and anaemia often improves.

GNRHAs may have menopause-like symptoms as their main side effect, this might include hot flashes, increased sweating and vaginal dryness. They may be administered to the patient before surgery in order to shrink the fibroids. They are for short-term, not long-term use. GNRHAs combined with HRT (hormone replacement therapy) are sometimes prescribed to prevent menopause-like symptoms.

The contraceptive pill: As well as making bleeding lighter, some contraceptive pills can help to reduce period pain.

Tranexamic acid:  This is mainly used around the time of periods to reduce the amount of bleeding

Anti-inflammatory drugs: These medications are taken for a few days during the patient’s menstrual period. They may include such drugs as ibuprofen or diclofenac. They reduce the amount of prostaglandins the body produces, reducing the amount of bleeding and pain

Progestin-releasing intrauterine device (IUD) can relieve heavy bleeding and pain caused by fibroids. A progestin-releasing IUD provides symptom relief only and doesn’t shrink fibroids or make them disappear. It stops the lining of your womb from growing quickly, so that it is thinner and your bleeding becomes lighter. •

Iron tablets: For treatment of anaemia

Surgery options

 If you have fibroids with moderate or severe symptoms, surgery may be the best way to treat them. Here are the options:

Myomectomy– Surgery to remove fibroids without taking out the healthy tissue of the uterus. You can become pregnant after myomectomy. Myomectomy can be performed in many ways. It can be major abdominal surgery (involving cutting into the abdomen) or performed with laparoscopy/robotic or hysteroscopy. The type of surgery that can be done depends on the type, size, and location of the fibroids. After myomectomy new fibroids can grow and cause trouble later. All of the possible risks of surgery are true for myomectomy.

Hysterectomy – Surgery to remove the uterus. It is the surest way of curing fibroids. This surgery is used when a woman’s fibroids are large, if she has heavy bleeding, is either near or past menopause, or does not want children. It involves cutting into the abdomen to remove the uterus.

If the fibroids are smaller, the doctor may be able to reach the uterus through the vagina, instead of making a cut in the abdomen. In some cases hysterectomy can be performed through the laparoscope. Hysterectomy is a major surgery. It ends your ability to bear children. Most women with uterine fibroids can choose to keep their ovaries.

Other techniques

Endometrial Ablation:  This treatment is performed with a specialised instrument inserted into your uterus. The lining of the uterus is removed or destroyed to control very heavy bleeding. This procedure usually is considered minor surgery. Most people recover quickly, but, a woman cannot have children after this surgery. Endometrial ablation is effective in stopping abnormal bleeding, but doesn’t affect fibroids outside the interior lining of the uterus.

Uterine Fibroid Embolization (UFE), or Uterine Artery Embolization (UAE): This technique, performed by an interventional radiologist, is effective in shrinking fibroids and relieving the symptoms they can cause. Advantages over surgery include no incision and a shorter recovery time. A thin tube is thread into the blood vessels that supply blood to the fibroid. Then, tiny plastic or gel particles are injected into the blood vessels. This blocks the blood supply to the fibroid, causing it to shrink.

Not all fibroids can be treated with UFE. Complications including early menopause, are not common but may occur if the blood supply to your ovaries or other organs is compromised.

Some reasons for using this treatment method are in women who:

Have fibroids that are causing heavy bleeding

Have fibroids that are causing pain or pressing on the bladder or rectum

Don’t want to have a hysterectomy

Don’t want to have children in the future

New treatments

There are also two newer techniques for treating fibroids, which use magnetic resonance imaging (MRI).

They are:

Magnetic-resonance-guided percutaneous laser ablation – an MRI (magnetic resonance imaging) scan is used to locate the fibroids. Then very fine needles are inserted through the patient’s skin and pushed until they reach the targeted fibroids. A fiber-optic cable is inserted through the needles. A laser light goes through the fiber-optic cable, hits the fibroids and shrinks them.

Magnetic-resonance-guided focused ultrasound surgery – an MRI (magnetic resonance imaging) scan locates the fibroids, and then sound waves are aimed at them. This procedure also shrinks the fibroids.

Can fibroids turn into cancer?

Fibroids are almost always benign (not cancerous). Very rarely (less than one in 1,000) a cancerous fibroid may occur. This is called a uterine leiomyosarcoma. Doctors think that these cancers do not arise from an already-existing fibroid. Having fibroids does not increase the risk of developing a cancerous fibroid. Having fibroids also does not increase a woman’s chances of getting other forms of cancer in the uterus. What if I become pregnant and have fibroids? Women who have fibroids are more likely to have problems during pregnancy and delivery. This doesn’t mean there will be problems. Most women with fibroids have normal pregnancies. The most common problems seen in women with fibroids are:

• Caesarean section: The risk of needing a c-section is six times greater for women with fibroids.

• Baby is breech: The baby is not positioned well for vaginal delivery.

• Labour fails to progress.

• Placental abruption: The placenta breaks away from the wall of the uterus before delivery. When this happens, the fetus does not get enough oxygen.

• Preterm delivery.

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