Fibroids, or leiomyomata, are benign tumours of the myometrium. Stimulated by oestrogen, they grow slowly over years and are of unknown pathology. The relationship between oestrogen, progesterone and fibroids is such that cyclical fibroid growth is induced, and fibroid growth is arrested at menopause. Moreover, fibroids often grow during HRT due to hormone stimulation.
Types of fibroids
Fibroids are classified according to their position in the uterine wall (see diagram)
- Intramural fibroids are the most common kind.
- Submusocal fibroids grow into the uterine cavity and are the most symptomatic kind of fibroids.
- Subserosal fibroids are located underneath the mucosal surface of the uterus.
- Polypoid fibroids can twist on their peduncle and cause torsion, leading to pain.
- Family history
- Use of oral contraceptive pill
Symptoms and Complications
Presenting complaints associated with fibroids can include:
- Menorrhagia (30%)
- Urinary frequency
- Reproductive dysfunction
- Constipation/cramping due to an enlarged uterus.
However, it is important to note that the majority of fibroids (50%) are asymptomatic until they reach a certain size. Severe fibroid cases can result in preterm labour, malpresentations, postpartum haemorrhage, sepsis or mass effect symptoms (growth pressing onto other organs, causing dysfunction).
Investigations and Management
Bimanual palpation can detect larger fibroids, however ultrasound scanning is a more reliable means of detection. At this point, bloods should be tested for signs of anaemia (due to menorrhagia), and a pregnancy test may prove useful. In order to identify the type, location, and size of a fibroid, an MRI scan or laparoscopy may be utilised.
Fibroids are generally treated only if symptoms are present and disruptive. First line treatment is appropriate analgesia, often involving tranexamic acid, NSAIDs or progesterones, as in menorrhagia. Alternative treatments may involve 6 months of GnRH analogues, in order to induce a menopause-like state and make surgery easier, however the resulting osteoporosis contraindicates GnRH-A treatment for longer than this. If the woman wishes to conceive in the near future, treatment must be appropriate to fulfil this wish.
Despite these pharmacological options, surgery is normally required as a final treatment for fibroids, including mymectomy or hysterectomy. Vaginal removal offers a quicker return to normal function than abdominal hysterectomy, and should be preferred wherever possible . Uterine artery embolisation is a newer surgical treatment which has an 80% success rate.
Fibroids may enlarge during pregnancy and become ischaemic, presenting with acute pain, tenderness and vomiting- this is called "red degeneration". If severe, this process may induce uterine contractions, leading to preterm labour or miscarriage. Surgical management is not an option as such, so simple analgesia, especially NSAIDS.
- Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD003677. DOI: 10.1002/14651858.CD003677