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Fibroids
Dr Asheesh Mehta Internal Medicine Specialist March 08, 2018
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Fibroids are benign tumours in the uterus, the womb. The name fibroid is a bit of a misnomer since they develop from smooth muscle in the wall of the uterus and not from fibrous tissue. The correct technical name for the tumour is leiomyoma. Other commonly used names are myoma and fibroma. They are a very common problem. It is estimated that by the age of 50 more than half of women have fibroids. Most women do not have symptoms and are unaware that they have fibroids. Fibroids range in size from microscopic ones to very large ones. The largest reported is a fibroid weighing 140 pounds which is roughly 64 Kg and that is indeed huge. To even think of a woman moving around with a mass of that size in her abdomen is mind boggling. The number of fibroids in an individual case too varies widely with some women having a solitary fibroid and others quite a few of them.

The uterus is a pear shaped hollow organ located in the pelvis which is the lower part of the abdomen. It is sandwiched between the urinary bladder in front and the rectum behind. The body of the uterus continues as the cervix below. It is made up of three layers called the endometrium, myometrium and the perimetrium. The endometrium is the inner layer, its superficial part being shed during menstruation. This is the layer in which the fertilized ovum embeds during pregnancy. The myometrium is the middle layer and is made up of muscular tissue. The perimetrium is the outer layer. Fibroids develop from muscle tissue in the myometrium. They may remain within the myometrium or may protrude into the endometrium and bulge into the cavity of the uterus or they may protrude into the perimetrium and bulge into the abdominal cavity. Small fibroids remain within the myometrium while larger ones tend to protrude into other layers of the uterus. In a few cases the fibroid protruding into the cavity of the uterus or into the abdomen develops a stalk and then is referred to as a pedunculated fibroid.

The exact cause as to why fibroids develop is not known. The hormone oestrogen is however believed to play a role
The exact cause as to why fibroids develop is not known. The hormone oestrogen is however believed to play a role. Fibroids generally develop only during the reproductive period of a woman’s life in tandem with higher oestrogen levels being present. Once the menstrual period ceases permanently at menopause oestrogen levels also reduce and existing fibroids tend to shrink in size and new ones stop developing. Fibroids are commonest in women approaching menopause. Obesity tends to increase risk for development of fibroids. Pregnancy reduces the risk for fibroids and women who have had more children have a lesser incidence while women who never become pregnant are at increased risk for them. Fibroids are also much commoner in women of African descent.

Symptoms due to fibroids are quite variable. Most of the time fibroids do not cause symptoms are are detected incidentally during clincial examination or ultrasound examination for unrelated symptoms. Among symptoms, excessive and prolonged bleeding during the menstrual period may occur. Sometimes there are also complaints of bleeding between periods. Pain during menstruation may also be attributed to fibroids. Pressure on the urinary bladder which is located in front of the uterus may cause increased frequency and urgency of urination while pressure on the rectum located behind the uterus can cause constipation. Pain in the lower abdomen or the back unrelated to menstruation is another symptom and is believed to be due to the weight of the fibroid pulling on tissues. Fibroids may also contribute to infertility which is defined as the inability to conceive after a year of attempting to do so.

Diagnosis of fibroids may be made on the basis of clinical examination. Ultrasound examination is the most convenient investigation to confirm the diagnosis. It may be possible to visualise the fibroids by transabdominal ultrasound in which the probe is placed on the abdominal wall. In some cases transvaginal ultrasound may provide more accurate visualisation. MRI is another imaging method to visualise the fibroids but its much greater strain on resources makes it a less preferred test except when there are complications or when doubts persist in spite of ultrasound examination. Hysteroscopy is visualisation of the interior of the uterus by means of an endoscope while hysterosalpingography is x-ray visualisation of the uterus and fallopian tubes after instillation of a radio-opaque dye and these investigations may also be useful when fibroids are present and are causing symptoms.

Most fibroids do not not warrant medical intervention. This is especially so with small ones detected incidentally and that are not causing any symptoms or medical problems like infertility. Further, fibroids tend to regress in size once menstruation ceases permanently at menopause. Hence, a wait and watch policy may be all that is required in women who are approaching menopause even when minor symptoms are present. There is some amount of debate whether fibroids always remain benign or whether they have the potential to become malignant; in other words whether they can become cancerous. Some people feel that fibroids do have the potential to transform into cancers occasionally while others believe that malignant tumours are a separate entity that were never true fibroids to start with. In any case, even if malignant transformation does occur it is a rare event and the fear of cancer occurring is generally not justifiable cause to opt for surgical intervention.

A number of medicines are helpful in reducing symptoms and some of them are also effective in reducing the size of fibroids. Oral contraceptive pill type of medicines are often helpful to reduce bleeding and pain during periods in women with fibroids. Another type of medicine used for fibroids is a gonadotrophin releasing hormone (GnRH) agonist. This acts on the pituitary to secrete hormones that in turn suppress secretion of oestrogen in the body. Reduced oestrogen levels result in regression of fibroids with improvement in related symptoms. The main utility of this medication is to reduce size of fibroids prior to surgery which makes surgery technically easier with much lower blood loss. Although fibroid size reduces quite a bit with this type of medication, suppression of oestrogen results in problems like osteoporosis and hot flashes and hence is largely unsuitable for long-term use. Another drug called RU-486 is an anti-hormonal drug that has actions somewhat similar to GnRH agonists. This too is used prior to surgery to reduce size of fibroids. However, lesser incidence of side effects may allow it to be used over the long-term for control of symptoms as an alternative to surgery in selected women. Danazol which is a synthetic steroid used mainly for endometriosis is another option but its substantial side effects including weight gain, hair growth at inappropriate sites such as the face and limbs, depression and acne make it less favoured for fibroids. Ulipristal acetate is a newer medicine which is effective in symptomatic fibroids. This medicine was originally promoted for emergency contraception but has been also found to reduce the size of fibroids. Recommended period of use varies from a month to as long as 6 months depending on symptoms and the response to treatment. It cannot be used in women who are already pregnant.

Surgery is the final option for fibroids. A number of different types of surgery can be done depending on the indication for surgery on fibroids, age of the woman, whether further pregnancies are desired, etc. Hysterectomy is the removal of the uterus and a large proportion of hysterectomies are done for the indication of fibroids. This is curative as once the uterus is removed, fibroids cannot occur. It can be done by the vaginal or the abdominal route, the latter by open incision or by laparoscopy, the latter being keyhole surgery involving insertion of the endoscope and operating instruments through small cuts in the abdominal wall. Presence of large fibroids usually necessitates the abdominal route. Pretreatment with GnRH agonists or other fibroid shrinking drugs facilitates the actual surgery and reduces bleeding. It is obvious that a hysterectomy is suitable only when the woman does not desire any further pregnancies. Another type of surgery which has become increasingly popular is myomectomy in which only the fibroid is removed leaving the uterus intact and allowing pregnancy at a later date, if so desired. The surgery can be carried out by laparoscopy or hysteroscopy. There is a chance that the fibroid may grow back or that other fibroids may develop and these recurrences may require further intervention later. A nonsurgical procedure is uterine artery embolisation in which the fibroid is destroyed by blocking blood supply to it in a procedure carried out under x-ray guidance. More recent nonsurgical procedures are MRI guided techniques which deliver either laser or ultrasound energy to the centre of a fibroid with the aim of destroying it. Experience in these techniques is still being gathered but they appear to offer promise in well selected cases.
 

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