As many as one in five women suffer with heavy and painful periods. Every month, this can have a huge impact on our day-to-day activities, and cause social, emotional and physical distress. Heavy and painful bleeding can be a sign of a range of conditions, and it is best to seek help early. One of the causes of heavy and painful bleeding is fibroids.
Uterine fibroids are also known as fibromas, myomas or leiomyomas, and are benign ( non-cancerous) tumours that grow in the wall of the uterus. They are also known as myomas or fibromyomas. They are growths of smooth muscle and fibrous tissue. The size of fibroids can vary from as small as a pea to that of a melon. At least one in five women develop a fibroid at some stage of their life, usually between the ages of 30-50 years old. It is estimated that between two and four in every ten women have, or will develop fibroids at some point in their lives. Fibroids are more common in women who are overweight and women of Afro-Caribbean origin.
Benign tumours will eventually stop growing and will not spread to other parts of the body, unlike cancers or malignant tumours. Fibroids are benign tumours and are limited to the uterus. They mostly appear as round, white or pale pink nodules that can vary in size from a few millimetres to large masses.
The exact cause of fibroids is still unknown. However, they have been linked to the female reproductive hormone oestrogen, which is produced by the ovaries. They have oestrogen receptors and grow in response to stimulation from oestrogen. They are quite rare after menopause and before puberty. They tend to shrink when oestrogen levels are low, such as after menopause
How common are fibroids?
Fibroids are fairly common, being present in about 30-50 per cent of women who are of reproductive age and are symptomatic in roughly half of those women.
What are the symptoms of fibroids?
Fibroids do not tend to cause any initial symptoms and roughly half will have no symptoms at all. Depending on the position and size of the fibroids within the uterus, they can cause pain, pressure, or heavy bleeding.
The most common form of heavy or abnormal bleeding is periods becoming very heavy and lasting longer than usual. Any form of increased or irregular bleeding in women aged in their 30’s and 40’s can be caused by fibroids.
Fibroids do not usually cause severe pain and are not associated with infertility, but can be the cause of miscarriages.
Fibroids are classified depending on where they are found in the uterus. They are classified as:
- Subserosal – near the serosa or outer layer of the uterus
- Submucous – near the mucosa or internal layer of the uterus and can protrude into the uterine cavity
- Intramural – within the width of the myometrium or uterine muscle
- Pedunculated – grown on a stalk either to the outside of the uterus or inside the uterine cavity
This classification system is not perfect and is limited, as most fibroids are big enough to fall into more than one category, but this can help clinicians make a diagnosis and plan treatment.
What are the long term implications if frenotomy is not done?
May cause speech articulation problem. May cause increased interdental space . May cause difficulty in oral hygiene.
How are fibroids diagnosed?
A diagnosis is made based on clinical symptoms. A physical internal examination is done by a gynaecologist to reveal an enlarged or irregular uterus. An ultrasound is the most common diagnostic test and is able to accurately show the presence of fibroids. Ultrasounds can measure the size of a fibroid and indicate their position.
In cases where an ultrasound is not conclusive or a more precise diagnosis is necessary, your doctor may order a hysteroscopy, a laparoscopy, or an MRI.
What are the treatment options?
The treatment will vary according to what symptoms are being displayed, the size and type of fibroid, the rate of growth, the desire for future fertility, and personal preference. The possible treatment options are:
- Conservative treatment
- Medical treatment
- Endometrial ablation
- Arterial embolisation
Asymptomatic fibroids do not usually require any treatment and their growth can be periodically monitored by a doctor or gynaecologist. If there are no significant changes between check-ups and the woman remains asymptomatic, there will be no need for any other treatment.
Medication can be used to treat the symptoms of fibroids. The most common symptoms can generally be treated with hormone-based medication and regular pain killers. Anti-inflammatory medicines such as non-steroidal antiinflammatory drugs (NSAIDs). Tranexamic acid which helps to decrease the amount of bleeding. Both tranexamic acid and NSAIDs are not contraceptives, meaning they can be used while you are trying to get pregnant. Hormonal treatments to help regulate periods such as the contraceptive pill, the intrauterine system (also known as the hormonal coil) and progesterone tablets or injections. These are normally contraceptives meaning they you will not be able to get pregnant whilst taking these.
Uterine artery embolisation – this technique blocks the blood vessels supplying blood to the fibroids. A specially trained doctor, called an interventional radiologist, will insert a catheter (thin flexible tube) into your groin. Then using an X-ray camera they will guide the catheter to the blood vessels of your womb. Once the fibroid blood supply has been identified, a fluid containing tiny grain-like particles is injected into the catheter and delivered to the blood vessels blocking the blood supply. Fibroids deprived of blood will shrink, and may even be expelled from the body through the vagina
There are many factors both you and your gynaecologist will need to consider when thinking about surgical options for fibroids, to determine the best treatment option for you. Sometimes, some factors such as the size and number of your fibroids, or history of myomectomy (see definition below) will rule out certain procedures. Once you have been referred to see a gynaecologist, you may have an imaging test to help get a more accurate idea of the location, size and number of your fibroids. Often, an ultrasound scan is enough. Sometimes you may have a hysteroscopy (where a small camera is used to look inside the womb) to look at submucosal fibroids or to rule out any other causes of bleeding. If your fibroids are large and are causing severe symptoms, your gynaecologist may recommend surgical options to remove the fibroids.
Transcervical resection of fibroids
This procedure is only suitable for submucosal fibroids that are under the lining of the womb and pushing into the womb, or hanging into the womb on a stalk. A resectoscope (an instrument used for internal examinations of the womb) is passed into your womb, through your vagina and cervix (neck of the womb). An electric current is passed through a fine wire loop at the end of the resectoscope. This is then used to cut your fibroids away from your womb.
A myomectomy is an operation where incisions are made on the uterus to completely remove the fibroids. This treatment is recommended for women who wish to have children in the future. A myomectomy can be done through an open incision or through laparoscopy.
Can I become pregnant after a myomectomy?
It is not possible to guarantee until you have the procedure done, but the point of a myomectomy is to remove fibroids while preserving fertility. You should be able to have a normal pregnancy in the absence of other complications.
Is it possible to have a normal delivery after a myomectomy?
This will depend on the size of the incision made on the uterus and on the position of the fibroids. Large fibroids that are imbedded in the uterine wall will require surgery, which means that most women who have a myomectomy will end up with a uterine incision and scar. If this is the case, then a caesarean section will be recommended over natural birth. In some cases where the fibroids are subserosal or submucosal, a large incision is not necessary, and a vaginal delivery is possible. The best way to know what delivery method is best for your health and the health of your baby is to ask for advice.
A hysterectomy is the process of removing the whole uterus, but only a small number of women with fibroids will require this treatment. A hysterectomy may be suggested if other medical treatments fail to control symptoms, fibroids are large, and in women who do not desire further fertility.
Can I become pregnant if I have fibroids?
You will most likely be able to become pregnant even if you have fibroids. They do not, in most cases, cause infertility and most pregnancies tend to develop well. There is the possibility for problems and complications to form, and close antenatal care is recommended. Some miscarriages can be caused by fibroids, so if you are having trouble becoming pregnant, or had a miscarriage and fibroids may be the cause, a myomectomy may be suggested.