Fibroids

Fibroids are non-cancerous tumours of the muscle of the uterus. They are one of the most common tumours found in women during their reproductive years, although their place in causing infertility has been somewhat controversial. There are several ways to treat and diagnose them, however at Nuada Gynaecology we have some of the leading specialists in the field of fibroid management and surgery so the decision on how to help you will be exceptionally well informed.

Fibroids are the single most common cause for hysterectomy. Fibroids will affect between 50% and 70% of all women. They are more common in women who have not had children, women who are overweight and black women. Only about a quarter of women with fibroids will experience any symptoms.

Symptoms include

  • heavy and painful periods
  • pain with sex
  • infertility
  • urinary or bowel symptoms caused by local pressure
  • pregnancy complications

In women who do conceive, the fibroids may cause complications in pregnancy, including miscarriage, premature labour and pain due to infarction or red degeneration caused by inadequate blood supply. Very rarely, a fibroid can undergo malignant change, particularly if the fibroid is very large or rapidly increases in size.

Diagnosis

Transvaginal ultrasound scan
This is a painless examination that uses high frequency sound waves to build up a picture of your anatomy on a video screen. In addition to the standard two-dimensional black and white images our ultrasound machine allows us to obtain three-dimensional images to more clearly define any abnormalities we come across and to perform doppler studies to assess blood flow to the pelvic organs.

For gynaecological conditions we prefer to use a transvaginal probe in which the scanner is mounted on the end of a probe, no larger than your index finger, which is introduced into the vagina. This enables us to use a higher frequency mode so that resolution is improved, as the scanner is much closer to the organs of interest than using an abdominal probe. It also means that your bladder does not need to be uncomfortably full.

Saline Sonography
This investigation is particularly useful for identifying the extent to which submucous fibroids extend into the cavity of the uterus. The cavity of the uterus is a potential space and although it grows to accommodate a 7lb baby during pregnancy, in the non-pregnant state the front wall lies in direct contact with the back wall. This can obscure the relationship of some fibroids to the cavity and clearer images are obtained when a small quantity of physiological saline is introduced into the womb to distend it. The fluid is introduced using a fine plastic tube through the cervix. It is no more uncomfortable than having a smear test and can be done in the office. Fluid conducts sound waves extremely well and enhances the image of the endometrium (lining of the womb) because it creates a clear black space caused by an absence of echoes into which the echo-dense fibroids can be seen to protrude.

Doppler Studies
Using the Doppler mode on the ultrasound scanner we can assess blood flow in and around the womb. Blood flow is increased in malignant cysts of the ovary and some cancers of the womb. Increased blood flow around benign fibroids can also make the surgery more complicated.

MRI Scan
When fibroids are very large or very numerous ultrasonography becomes more difficult to interpret as the sound waves only travel around 10cm through the body. In such cases much more informative results are obtained using Magnetic Resonance (MR) Imaging.

MR is a painless examination and will be performed in the same clinic as your consultant’s chambers. However it can sometimes cause feelings of claustrophobia and are also rather noisy.

Diagnostic Surgery
Where possible we try to avoid performing diagnostic surgery alone and will usually plan on a see and treat policy as we should have a fairly good idea of what we are likely to encounter following imaging. Occasionally this is not possible and we will recommend a diagnostic hysteroscopy and sometimes a diagnostic laparoscopy. In addition, we sometimes recommend a diagnostic hysteroscopy after a myomectomy, particularly if the cavity has been breached or appears very distorted on other imaging modalities.

Diagnostic Hysteroscopy
This is performed using a fine telescope, 2 millimetres in diameter, which is introduced through the cervix using physiological saline or carbon dioxide to distend the cavity. A clear view of the endometrial surface of the uterus is obtained and adhesions and submucous fibroids can be identified, allowing a careful assessment to be made of any anatomical disturbance. Even if a general anaesthetic is used you will only need to be in hospital for a few hours.

Diagnostic Laparoscopy
Diagnostic laparoscopy usually requires a general anaesthetic as it involves the distension of the abdominal cavity with carbon dioxide to create a space into which a small telescope can be introduced. Once the abdomen is distended with carbon dioxide, a 5-millimetre port is then introduced through the navel into the space this gas creates. A 5-millimetre telescope is passed through, from which video images of the abdominal cavity are obtained. Often a second port is introduced so that a probe can be used to move the organs around to improve the view.

Like diagnostic hysteroscopy, diagnostic laparoscopy is performed in an operating theatre and you will usually be allowed home a couple of hours after the procedure, once the effects of the anaesthetic have worn off, unless you have an adverse reaction to the anaesthetic. Modern anaesthetic techniques are very safe and usually very well tolerated and adverse reactions are extremely rare.

Treatment
Fibroids should be treated if they are causing symptoms, or in certain cases if a woman is trying to conceive. Sometimes the periods can be so heavy that women develop quite severe anaemia. Clearly this is an indication for urgent treatment. Most doctors would also agree that, in the absence of any symptoms, pedunculated fibroids are unlikely to cause major problems with conception, and only really need treatment if they are causing problems due to their size. Intramural and submucosal fibroids are rather more of a grey area. The decision about whether or not to treat them really depends on the woman’s age, how large the fibroids are, whether she has had miscarriages before and whether the uterus is distorted by their presence.

Age is an important factor. Since fibroids tend to continue to grow under the influence of oestrogen and it is true to say that in younger women it may be easier to remove them whilst they are small. lder women should beware of potential delays in waiting for surgery, particularly in the NHS. You should also be aware that you are likely to be advised not to conceive for up to three months after the operation. In these circumstances some doctors will recommend early fertility treatment rather than surgery so as to avoid any delay.

Medical Treatment

Progestogens
Treatment with progestogens (synthetic forms of the naturally occurring hormone progesterone) can reduce the blood loss in the short term, but does have side effects such as fluid retention and bloating. Progestogens can be administered as tablets, patches or as a Mirena intrauterine device.

Oral Contraceptive Pill
Treatment with an oral contraceptive can be useful in the short term to reduce the heaviness of the periods. It will not stop fibroids from growing and of course is not suitable for women who wish to conceive. Some women are sensitive to the hormones used in oral contraceptives and experience water retention and weight gain.

Anti-inflammatory Drugs
The most commonly prescribed anti-inflammatory drugs for heavy periods are Mefenamic acid (Ponstan) and ibuprofen. These work by reducing the body’s production of prostaglandins which are involved in menstruation. They are also effective pain-killers and so have the advantage of improving period pain or dysmenorrhoea.

Tranexamic acid
Tranexamic acid works by helping the blood in the womb to clot, thereby reducing the heaviness of the periods. It is taken in tablet form and treatment commences when the period begins and can continue for up to 4 days.

Gonadotrophin Releasing Hormone analogues (GnRH-a)
These are hormones that lower the oestrogen levels by blocking the production of the pituitary gland hormones which stimulate the ovary to produce oestrogen. They induce a temporary menopausal state with low blood levels of oestrogen. Fibroids are hormone sensitive and usually shrink after the menopause when oestrogen levels are low. Unfortunately the effect is only temporary and the fibroids will usually grow again quite quickly when treatment stops. GnRH-a cannot be taken for more than 6 months as the low oestrogen levels affect the bones leading to osteoporosis.

Surgical Treatment

Hysteroscopy
Hysteroscopy is the examination of the inside of the uterus using a small diameter telescope that is introduced through the cervix (neck of the womb) from the vagina. No incisions are required and diagnostic procedures can be done under local anaesthetic. Operative procedures are usually done under a general anaesthetic.

Hysteroscopic resection of fibroids
Using an operative hysteroscope with a wire resection loop we can remove sub-mucous fibroids in thin slivers up to 5mm in size. Fibroids of up to 4cm in diameter can be treated in this way.

Submucous fibroids can usually be treated by hysteroscopic resection provided they are less than 4 cm in diameter.

The fibroid is resected using a wire loop passed down an operating hysteroscope, an instrument of up to 8mm in diameter that is introduced into the uterus via the cervix after it has been gently dilated (stretched) to allow the hysteroscope to pass.

Laparoscopic myomectomy

  • Intramural and subserous fibroids up to 10 cm in diameter can be removed by laparoscopic myomectomy, through two small incisions 10 mm in length, one in the umbilicus (navel) and the other a little lower down in the midline of the abdomen.
  • Two smaller incisions only 5mm in length are made, one on either side of the abdomen about three inches from the midline.

Presently only a handful of surgeons in this country offer this procedure which takes much longer and is more challenging than conventional surgery.

Conventional Surgery

Open myomectomy
This is the conventional method used for treating fibroids where a woman wishes to retain her fertility. It should be possible for all consultant gynaecologists to offer this procedure, but some perform it more regularly than others, and as one might expect these surgeons tend to have better results than those who perform myomectomy infrequently. It is also true to say that some surgeons, especially those who are involved in fertility treatment recognise more particularly the importance of avoiding excessive tissue handling and employing microsurgical techniques to reduce adhesion formation after surgery.

A conventional myomectomy is performed through a low, horizontal or transverse skin incision along the bikini line (some fibroids are too large for this approach and may need a longitudinal or vertical incision). The muscle of the uterus is incised and the fibroid shelled out. The muscle must then be repaired with sutures taking care to handle the tissue as little as possible to avoid the risk of adhesion formation. Apart from adhesions there is a risk of haemorrhage and infection in the short term, and rupture of the uterus in the longer term during pregnancy and labour.

Many obstetricians will recommend a caesarean section after myomectomy because of the risk of uterine rupture. Some fibroids can be very vascular, and particularly in larger cases, and where the fibroid is close to the main artery supplying the uterus, women should be aware that there is a risk of such heavy bleeding that their surgeon may be required to perform a hysterectomy. This is only done as a last resort, as a life saving procedure in cases of catastrophic haemorrhage.

In such cases the fibroids are usually so large and the uterus so distorted that pregnancy would have been impossible anyway, however myomectomy is not a procedure to be undertaken lightly and should only be performed by experienced surgeons.

Hysterectomy
Some women, whose family is complete, or who are happy to remain childless, may elect to have a hysterectomy rather than try to save their uterus. A hysterectomy is often recommended for particularly large fibroids where the uterus is causing severe compression symptoms or causing notable distension of the lower abdomen. For some women, the time taken to recover from their surgery is much more important than whether or not they can conserve their uterus. Women with a very large fibroid mass will recover from a hysterectomy much more quickly than a myomectomy. Other women are so fed up with the problems they have had managing their periods, often for many years that the added guarantee of no periods following a hysterectomy is more than welcome. Hysterectomy also has an advantage over embolisation because tissue is sent to the laboratory for histological examination.

There are risks of complications with hysterectomy, notably from bleeding or infection and also of damage to the bowel, bladder or ureters and possibly prolapse at a later date. The risk of damage is greater with a larger uterus because the anatomy is often distorted by the sheer size of the fibroids, particularly cervical fibroids. The risks are also greater in women who have had previous surgery, Caesarean sections and pelvic infection in the past.

Some surgeons choose to reduce these risks by performing a subtotal hysterectomy so that the pelvic floor supports are left intact and the bowel or bladder are not disturbed. Recently a modest number of surgeons have been performing laparoscopic subtotal hysterectomy. Most women will be well enough to go home from hospital the day after a laparoscopic hysterectomy.

What about the ovaries?
A total abdominal hysterectomy means removal of the whole uterus, including the cervix and does not relate to the question of whether or not the ovaries are removed. he ovaries can almost always be conserved at hysterectomy, unless there is an unusually large fibroid close to the ovary, compromising its blood supply, or severe post-operative adhesions. In women of childbearing age who have elected for hysterectomy, or in the incredibly rare situation where we have been obliged to perform a hysterectomy due to bleeding in the course of a myomectomy, we will always try to conserve the ovaries.

Fibroid Embolisation – Uterine Artery Embolisation
Uterine artery embolisation is a non surgical procedure first performed in 1989. Since then tens of thousands of procedures have been carried out by interventional radiologists. At Nuada Gynaecology we work with some of the most experienced interventional radiologists in the country.

  • A tiny catheter (plastic tube) is inserted under local anaesthetic and intravenous sedation into an artery in the right groin. Under X-ray control this catheter is introduced selectively into each of the two arteries that supply the uterus.
  • The micro catheter is passed approximately half way down the artery and then fine particles like little grains of sand of a solid substance called PVA (Poly Vinyl Alcohol) are injected through the catheter into the uterine artery.
  • The particles are carried to the leash of vessels supplying the fibroids.
  • These vessels become silted up thereby depriving the fibroid of blood causing it to die and shrink.
  • PVA is an inert harmless material that has been used to occlude vessels in other parts of the body for decades.

More information & further reading

Endoscopic management of uterine fibroids
2006, Human Fertility Vol. 9, No. 4 , Pages 201-208.
Ertan Saridogan, and Alfred Cutner
http://informahealthcare.com/doi/abs/10.1080/14647270600560204

Uterine artery embolization for fibroids is associated with an increased risk of miscarriage
Fertility and Sterility, Volume 94, Issue 1, Pages 324-330. 2010
Hayden Homer, Ertan Saridogan
http://www.sciencedirect.com/science/article/pii/S0015028209004968

Laparoscopic Myomectomy.  Adrian Lower  In: Progress in Obstetrics & Gynaecology 15.  Ed Studd J.  2002