Uterine fibroids (also known as leiomyomas or myomas) are benign tumours of the smooth muscle of the uterus (myometrium). Fibroids can either be singular or multiple, varying in size from microscopic to large masses that can cause enlargement or distortion of the uterus. Fibroids are common in women of reproductive age, being found in 70-80% of all women (the risk of fibroids increases with age, up to the menopause). Fibroids are very rarely found in premenarcheal girls and, although the exact aetiology of fibroids remains uncertain, it is thought that the growth and maintenance of fibroids is influenced by the sex steroids.
Patients with fibroids may be asymptomatic and the pathology only discovered upon investigation for other complaints such as difficulty conceiving. The most common symptom in premenopausal women with fibroids is heavy and prolonged menstrual bleeding (menorrhagia), menstrual blood loss becoming more unpredictable during the perimenopause with bouts of intermenstrual bleeding. (1) In addition to menstrual symptoms there are other associated symptoms that may present depending on the size/location of the fibroid. These include:
– A feeling of ‘fullness’ in the pelvic area.
– Chronic pelvic pain or lower abdominal pressure.
– Pain during urination (if a fibroid is pressing against the bladder).
– Rectal pressure (if a fibroid is pressing against the bowel).
– Pain during intercourse (dyspareunia).
It is important to consider that the symptomology of fibroids overlaps with several other conditions, like endometriosis, adenomyosis, ovarian cysts and several gynaecological malignancies. Given the high prevalence of fibroids, it is therefore important to establish which pathology is causing the patient’s symptoms so optimal treatment can be given. It is also worth noting that several studies indicate that uterine fibroids are more common in women with endometriosis, (2) where tissue resembling normal endometrium grows outside the uterus, which is typically associated with pelvic pain and dysmenorrhoea.
There are several methods for identifying fibroids, ranging from physical examination to imaging techniques. Upon physical examination a fibroid would feel firm or have a hard consistency, with the uterus having a knobbly or irregular shape, additionally any movement of an abdominal mass that moves the cervix would be an indication for fibroids. Physical examination alone though is not enough to confirm a diagnosis of fibroids as highlighted by the finding that only 12.5% of fibroids measuring 3-5cm and 42% of fibroids measuring >5cm were diagnosed by physical examination alone. (3)
The simplest and most common technique used for imaging fibroids is transvaginal sonography (TVS), although this does have the drawback of being the least sensitive methods for fibroid identification. Sonohysterography (SHG) and hysteroscopy offer superior sensitivity and specificity over TVS. However, SHG is considered less invasive, more cost effective and less painful (which may be an important consideration for women with dyspareunia) than hysteroscopy. (4) Magnetic resonance imaging (MRI) offers accurate mapping of fibroids prior to surgery, however multiple small diffuse fibroids may be difficult to distinguish from adenomyosis.
Accurate diagnosis of fibroids is essential to rule out other causes of pelvic mass, including:
– Ovarian cancer.
– Endometrial cancer.
– Haemorrhagic ovarian cyst.
– Dermoid cyst.
To exclude the more serious pathologies the National Institute for Health and Care Excellence (NICE) guidelines (5) recommend the following:
– For women displaying the typical features of fibroids but no features of cancer – arrange a routine ultrasound scan.
– For women that have a mass not obviously caused by fibroids but no other features of cancer – arrange an urgent ultrasound.
– For women with a mass not obviously caused by fibroids but with other features of cancer, such as abnormal bleeding or weight loss – make an urgent referral to a gynaecologist.
fertility and obstetric outcomes
One of the most pressing concerns for women with fibroids who desire to conceive is the effect they may have on fertility and any adverse effects during pregnancy. Starting from the point of conception and implantation, submucosal fibroids are considered to have the greatest impact on implantation and placentation, while the effect of intramural and subserosal fibroids remains unclear, large fibroids that distort the uterus may impact on implantation and removal of the fibroids may be a desirable option to improve chances of conception. (6)
Several studies have shown that women with fibroids are more likely to require a caesarean section, mostly due to malpresentation. A review of current evidence on reproductive outcomes found that while pre-term delivery was more common in women with fibroids, they are not at an increased risk of pre-term premature rupture of the membranes and that birthweights are similar between women with and without fibroids when correcting for gestational age. (6)
Presently there is no consensus as to the effect of fibroids on the outcome of assisted reproductive therapy (ART).
Complications during pregnancy
Depending on their size and location, fibroids may increase the risk of miscarriage, placenta praevia, pre-term labour and post-partum complications such as post-partum haemorrhage and infection. (1,6)
Fibroids grow in response to both oestrogen and progesterone, during pregnancy this means fibroids may increase or decrease in size. If a fibroid regresses during pregnancy, this can lead to abdominal pain that may be distressing to the expectant mother. Although surgical removal of fibroids during pregnancy is possible, care must be taken when deciding on optimum treatment for fibroid associated pain in pregnancy. Taking into account the level of pain and the gestational age of the foetus.
Although benign, fibroids may present with complications, sometimes serious. The heavy menstrual bleeding associated with fibroids can, in some cases, result in anaemia leading to headaches, dizziness and fatigue. Rarely a pedunculated submucosal fibroid may prolapse through the cervix, into the vagina; if left untreated this can lead to ulceration or infection. Transcervically prolapsed fibroids can be removed through the vagina without the need for abdominal surgery.
A common treatment for fibroids is the placement of a levenorgestrel-releasing intrauterine system (LNG-IUS, such as Mirena). The presence of fibroids, particularly submucosal fibroids, may distort the uterine cavity or the cervix affecting the efficacy of the IUS, resulting in its expulsion or increased risk of uterine perforation. (1) Fibroids are not thought to increase overall cancer risk or the risk of any specific cancer.
Risk factors and fibroids
As with many other conditions there are factors that can influence a person’s risk of developing fibroids, summarised in Table 2. (1,7)
Once a definitive diagnosis of fibroids has been made, appropriate treatment needs to be planned based on the size, location and number of fibroids.
According to NICE guidelines, (5) women who are asymptomatic should be managed expectantly. Although fibroids generally grow slowly, they can occasionally undergo spontaneous growth spurts, particularly after cessation of gonadotrophin releasing hormone agonist (GnRH) therapy. (9) Therefore, it is important that asymptomatic women with fibroids seek medical advice if they notice any changes in menstrual characteristics or appearance of fibroid related symptoms. In asymptomatic cases, referral to secondary care is not indicated unless:
– Fibroids are palpable during an abdominal exam.
– Intracavitary fibroids are present.
– Uterine length at ultrasound or hysteroscopy is greater than 12cm.
Several pharmacological treatment options are available for symptomatic women with fibroids, however the patient’s desire to conceive needs to be taken into consideration when choosing appropriate therapy. For the management of menorrhagia:
– A levenorgestrel-releasing intrauterine system (LNG-IUS) is generally considered the first choice treatment and may be used provided the fibroids are less than 3cm and causing no distortion of the uterus and that at least 12 months contraception is acceptable.
– If contraception is not desired or the LNG-IUS is unsuitable, then tranexamic acid can be prescribed while further investigation or different treatment options are explored.
– Non-steroidal anti-inflammatory drugs (NSAIDs), such as mefenamic acid (this particular agent may also reduce blood loss too), may be considered to reduce menstrual pain if dysmenorrhoea is also present.
– Similarly, the combined oral contraceptive pill (COC) offers relief from dysmenorrhoea and menorrhagia with a more readily reversible contraceptive effect than the LNG-IUS.
– Progestogen only injectable contraceptives (oral progestogens are relatively ineffective in reducing blood loss), such as Depo Provera, can reduce excessive bleeding and it may induce amenorrhoea.
– While not recommended for use in primary care, gonadorelin analogues (such as leuprorelin or buserelin) have been shown to reduce the size of fibroids. However, significant side effects such as hot flushes, menstrual disturbances, mood changes and osteoporosis limit the use of these agents and they are not suitable for long-term usage.
– It is also worth noting that hormone replacement therapy (HRT) can moderately increase fibroid size, however fibroids usually regress after HRT cessation. (5)
Women should be referred if, despite treatment, symptoms are causing distress, or compressive symptoms (such as dyspareunia, constipation or urinary symptoms) are present as a result of large fibroids, or obstetric/fertility issues associated with fibroids.
If pharmacological management is inappropriate or fails to provide symptomatic relief, there are several surgical options available for the treatment or removal of fibroids.
– Myomectomy, or surgical removal of fibroids, can be performed during laparoscopic, laparotomic or hysterocopic surgery and would be recommended for women desiring to conceive or retain the uterus for other reasons. Patients should be made aware that fibroids can recur after surgical removal. Myomectomy of intramural fibroids during pregnancy can result in haemorrhage, therefore women undergoing surgery for fibroids during pregnancy need to be made fully aware of the risks.
– Hysterectomy provides greater long-term symptomatic relief from fibroids compared to myomectomy or uterine artery embolization (UAE) and prevents recurrence. However, some women may be reluctant to opt for hysterectomy due to irreversible infertility and potential complications of surgery. Depending on the requirements of surgery, hysterectomy can be performed via laparotomy, laparoscopy or vaginally, with the option of retaining the cervix. Although vaginal and laparoscopic hysterectomy offer significantly reduced recovery times.
– Uterine artery embolisation is a procedure whereby the blood supply to the fibroid is disrupted resulting in atrophy. In brief, the femoral artery is cannulated and, using radiological techniques for guidance, the uterine arteries are located and an embolic agent is injected to induce local infarction. While there have been few large and long-term studies investigating the efficacy of UAE for fibroid management, it is known that compared to hysterectomy, UAE offers quicker recovery time, reduced hospital stay and fewer complications during surgery, but lower rates of symptomatic relief (however there is still a high degree of long-term symptomatic improvement with UAE). (10)
1. McCool WF, Durain D, Davis M. Overview of latest evidence on uterine fibroids. Nursing for Womens Health 2014;18(4):314-31.
2. Uimari O, Jarvela I, Ryynanen M. Do symptomatic endometriosis and uterine fibroids appear together? Journal of Human Reproductive Sciences 2011;4(1):34-8.
3. Muram D, Gillieson M, Walters JH. Myomas of the uterus in pregnancy: ultrasonic follow-up. American Journal of Obstetrics Gynecology 1980;138(1):16-9.
4. Griffin KW, Ellis MR, Wilder L, DeArmond L. Clinical enquires. What is the appropriate diagnostic evaluation of fibroids? Journal Family Practice 2005;54(5):458-462.
5. National Institute for Health and Care Excellent. Fibroids – Revised 2013. http://cks.nice.org.uk/fibroids#!topicsummary (accessed 29th March 2015).
6. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. American Journal of Obstetrics Gynecology 2008;198(4):357-66.
7. Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertility Sterility 2007;87(4):725-36.
8. Catherino WH, Eltoukhi HM, Al-Hendy A. Racial and ethnic differences in the pathogenesis and clinical manifestations of uterine leiomyoma. Seminars in Reproductive Medicine 2013;31(5):370-9.
9. Baird DD, Garrett TA, Laughlin SK, Davis B, Semelka RC, Peddada SD. Short term change in growth of uterine leiomyoma: tumour growth spurts. Fertility and Sterility 2011;9(1):242-6.
10. Mara M, Kubinova K. Embolization of uterine fibroids from the point of view of the gynaecologist: pros and cons. International Journal of Women's Health 2014;6:623-9.
Article Source: Click Here (Read More)
The Mission of The Fibroids Project is to Make Life Better for Women with Fibroids. Twitter: @FibroidsProject
Facebook: The Fibroids Project on FB