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Uterine Fibroids

Fibroids are benign tumours arising from smooth muscle tissues within the uterus typically in premenopausal women. Fibroids can be small or very large (as large as a water melon).

Terminology: according to the location of the fibroids, they can be described as intramural (within the myometrium), subserosal (fibroids deriving from just beneath the uterine serosa), or submucosal (fibroids deriving from just beneath the endometrium). Fibroids typically have more than one location.

Incidence: Fibroids are the most common pelvic tumours in women. While the true incidence of uterine fibroids is unknown, it widely accepted that fibroids affect as many as 25% of all women before the age of 50 years.  Most but not all women have shrinkage of fibroids after menopause.

Risk factors:

Early menarche, nulliparity, obesity (increased body size) as well as a familial predisposition increase the risk of fibroids. The risk factors point to the possibility that an oversupply of oestrogens possibly drive the growth of fibroids.

Oral contraceptive pill (OCP) does not cause fibroids to grow (except if the OCP is started at a very early age).

Symptoms:

  • Abnormal and painful uterine bleeding: can lead to iron deficiency anaemia and social embarrassment. Erratic vaginal bleeding (bleeding in between periods, postmenopausal bleeding) needs to be investigated before treatment commences.
  • Pelvic pressure and pain: When fibroids get very large, they can cause pressure symptoms on to the bladder (urinary frequency), rectum (constipation, back pain), or risk of deep vein thrombosis.
  • Reproductive dysfunction: Fibroids can cause difficulties in conceiving or miscarriages.

Fibroids can remain small and cause no symptoms. In that case, they do not require active treatment. However, fibroids may increase in size or number and cause symptoms that interfere with daily activities.

Investigations:

Pelvic exam: a bimanual pelvic/vaginal/rectal examination is helpful to determine size and mobility of the pelvic mass.

An ultrasound is the first step to determine pelvic symptoms. Ultrasound is inexpensive and allows small fibroids to be easily outlined. Very large fibroids should be investigated by MRI scan (preferred).

MRI scans: Women who wish to have a myomectomy (removal of fibroids, preservation of uterus) for fertility reasons should have an MRI prior to treatment. MRI scanning also is the imaging method of choice to diagnose adenomyosis, which is a common condition associated with fibroids.

Diagnosis:

A definitive diagnosis requires tissue which can be obtained through a myomectomy (if the uterus is preserved) or a hysterectomy. A hysterectomy is the most common surgical procedure to treat fibroids.

In premenopausal women in whom ultrasound has shown the typical features of fibroids, a tissue diagnosis does not need to be obtained.

Differential diagnosis:

Adenomyosis typically causes uterine enlargement and heavy uterine bleeding. Adenomyosis can usually be excluded on MRI scanning. The standard treatment of adenomyosis is hysterectomy.  

Sarcomas and Carcinosarcomas are uncommon but highly aggressive malignant tumours (cancer) arising in smooth muscle tissue of the uterus. We don’t believe that fibroids can turn into sarcomas.

Treatment options:

  1. “Wait and see” – Given that fibroids are benign tumours and may shrink substantially over time, expectant management is reasonable for women who have small fibroids that do not cause significant symptoms. Women who have erratic bleeding need to be investigated further (Pipelle) and an ultrasound follow-up should be organised on a yearly basis. Wait and see may not be the ideal option for women with very large fibroids or fibroids that cause concern. 
  2. Medical treatment – There is a general lack of good quality data on the medical treatment of fibroids. It is generally accepted that medical treatment provides initial symptom relief in a large number of women, but treatment failures after a year (recurrence of symptoms) are very common. A US study from 2006 suggested that 6 of 10 women who were randomly assigned to medical therapy required surgery by two years.
    • Oral contraceptives (OC): Experts are divided whether oestrogen-progesterone combination OCs are effective or not in the treatment of fibroids.
    • Levonorgestrel-releasing IUD (Mirena): Releases progestins at a very low rate into the uterus and is mainly used to treat women with heavy menstrual bleeding. There are no good quality studies available for the treatment of fibroids. However, some gynaecologists believe that it provides good symptomatic relief. Fibroids that grow into the uterine cavity should not be treated with Mirena.
    • Systemic Progestins are widely given to women with fibroids for symptom control to stop bleeding. Whether progestins are effective on the fibroids or have a beneficial effect on the endometrium is unknown. I recommend progestins in case of mild symptoms short-term. Long-term progestin use can lead to diabetes, weight gain and thromboembolic complications.
    • GnRH agonists, antagonists: not recommended to treat fibroids; require frequent injections and render patients menopausal, causing enormous risks and possible complications. Rapid regrowth of fibroids can occur once injections are stopped.
    • Antiprogestins: While progesterone can stimulate growth of fibroids, their antagonists may cause endometrial hyperplasia and even cancer as a complication.
    • Mifepristone (RU-486) has been shown to reduce uterine volume by 26% to 74%, provides symptomatic relief and improved quality of life. It is not approved in Australia for the treatment of uterine fibroids (due to political concerns).  
    • Tranexamic acid: Approved for symptomatic treatment of heavy menstrual bleeding. I recommend it to women in combination with Progestins to stop very heavy bleeding for a short time.

3.    Surgery

Hysterectomy is the definitive procedure with no chance of recurrence of bleeding or pain beyond the postoperative recovery. I recommend hysterectomy for the following women:

i.    Post- or perimenopausal women with significant and long-standing symptoms who desire definitive symptom control

ii.   Women who failed previous conservative treatments

iii.  Women with fibroids and additional conditions that would be eliminated by hysterectomy (e.g., adenomyosis, history of breast cancer, increased risk of uterine or ovarian cancer)

Hysterectomy should be done vaginally or laparoscopically (key hole or minimally invasive surgery); if the opening of the abdomen is recommended, I recommend that patients look for a second opinion. Information on hysterectomy can be found here.

Myomectomy is a surgical option for women who have subserosal and intramural fibroids and who desire fertility. Myomectomy is possible because there is often a distinct tissue plane between the fibroid and the surrounding uterus. At myomectomy the uterus is opened and the fibroid(s) are removed one by one. In premenopausal women the surgical approach (open vs. laparoscopic) needs to be discussed. There is a risk of uterine rupture during pregnancy following laparoscopic myomectomy. Because of the surgical risks plus the risk of an underlying cancer I do not recommend a myomectomy to postmenopausal women.

Endometrial ablation is a good option for treatment of bleeding irregularities but not a preferred choice for women with fibroids.

4.    Interventional radiology

  • Uterine artery embolization is an option for women who wish to preserve the uterus but are not interested in pursuing fertility. It is a minimally invasive procedure but associated with a much higher risk of treatment complications and readmissions to hospital than hysterectomy.
  • Magnetic resonance guided focused ultrasound is an emerging and novel procedure with very limited data to date. It was only introduced to Australia in 2009.

 What I recommend:

  • Women who have no or only mild symptoms: Wait and see, yearly scans or Mirena (if the periods are mildly stronger than usual)
  • Women who wish to fall pregnant: myomectomy
  • Women with significant symptoms or symptoms that recurred after conservative treatment and who do not wish to maintain fertility: hysterectomy