FIBROIDS: WHAT YOU NEED TO KNOW

Published by Dr Gigi on February 1, 2019

What Are They?

The wall of the uterus has 3 layers, from inside to outside are endometrium (inner layer), myometrium (middle or muscle layer, ) and the serosa (outer layer). Uterine Fibroids are the most common benign tumors of the female reproductive tract. They develop from the muscle layer of the uterus. They are not cancerous and will not spread to involve other parts of the body as is the custom of malignant tumors. Fibroids are not known to cause death, atleast not directly, however, their symptoms may result in significant morbidity and poor quality of life. They vary in numbers and sizes, an individual may have multiple or single, large or small sized fibroids.

Fibroids are fairly common, as about 70% of all women would have developed fibroids by age 50. It is estimated that only about 30-50% of women with fibroids will experience  symptoms.15 Some ethnicity have higher prevalence of fibroids compared to others. Women of African descent are two to three times more likely to experience symptoms associated with fibroids, and the prevalence is estimated to be about 40%.18  

Causes

There is no clear understanding on the cause of fibroids. Similar to all abnormal growths in the body; a particular cell transforms into a tumor cell and then grow and multiply. Fibroids respond highly to sex steroid hormones; estrogen and progeterone.17   

Types

The different types of fibroids are classified based on their location in the uterus 

Intramural: These are fibroids that grow in the wall of the uterus. They are likely to distort the shape of the uterus when they grow very large.

Submucosal: this refers to fibroid growing directly under the lining off the uterus. They grow into the uterine cavity, are more likely to cause heavy menstruation and interfere with fertility.

Subserosal: This refers to fibroids growing outside the wall of the uterus. Large sized subserosal fibroids may put pressure on surrounding organs. 

Pedunculated: They are fibroids that are attached to the uterus via a stalk. They may be found inside or outside the uterus

Symptoms

If you have a number of the following symptoms, it is advised that you see a doctor for further investigations of fibroid. 

Anemia: Iron is needed for the production of blood in the body. Excessive blood loss will reduces iron stores in the body causing anemia (low blood level). The individual becomes pale, headaches, fast heart beat, dizziness. For some individuals, anemia is the only indication of the presence of fibroids. 

Menstrual cramps/pain

Pelvic pain/pressure: Fibroids may cause pelvic pain and if it grows too large may put some  pressure . 

Menorrhagia: One of the symptoms of fibroid some women often report is excessive menstrual bleeding, which in some cases may be associated with blood clots. Note that, not all women with fibroid will experience excessive menstrual flow and not everyone with high flow has fibroid. An ultrasound study reported a higher incidence of increased menstrual flow Intramural and submucosal fibroids often. 15,16  

Metrorrhagia: Fibroids may cause an individual to bleed or spot in between menstrual cycles. 

Bloating

Abdominal Enlargement: Very large fibroids may distend the abdomen causing the individual to appear pregnant.

Frequent urination/retention: The enlarged uterus may put pressure on the bladder causing increased urinary frequency or urine retention

Constipation: Uterus may put pressure on the large intestine/rectum impeding the passage of stool  

Dypareunia: Fibroids may cause pain during sex.

Infertility/Sub-fertility: Many women may have fibroid without experiencing the usual symptoms, with the only indication being recurrent miscarriage or infertility. Submucosal and intramural fibroids are usually the common types to cause infertility; they distort the uterus and may prevent implantation of the baby.   

What Are the Associated Risk Factors

• Age: Fibroids occur mostly in women between the ages of 30-40 years of age but may occur at any age. 
• Race: Women of African ancestry are more likely to develop uterine fibroid (three times higher) than women of other ancestry. They tend to develop fibroids earlier, have more symptoms (heavy menstrual flow, pelvic pain) and show unpredictable response to medications. 1,2,3 The reason for the ethnic disparities in the development of fibroid is still unclear. 
• Steroid Hormones: Fibroids are very sensitive to sex steroid hormones like estrogen and progesterone, and would increase in size under its influence. 
• Exposure to environmental hormones: Exposure to environmental estrogen before puberty will reprogram the uterus, make it hypersensitive to estrogen and increase the risk of developing fibroids. Types of environmental estrogen include bisphenol-A (BPA, found in plastics), diethylstilbestrol (DES), genistein (an Isoflovane), dioxin, and polychlorinated biphenyls (PCBs, found capacitors and transformers.) 22
• Obesity: High BMI will increase an individual’s risk of developing fibroids. 23 A study by Ross et al reported a 20% risk increase for every 10 kg increase in body weight. 24
• Heredity: Female relatives of women with fibroids are at high risk of fibroids. 
• Nulliparity: pregnancy has been shown to have protective effects on the uterus against fibroids. Having children early reduces the risk of developing fibroids. 
• Poly cystic ovarian syndrome
• Lifestyle factors: Unhealthy diet; especially those high in fat, lack of exercise, use of tobacco all increase one’s risk of developing fibroids.
• Menarche (onset of menstruation): Early onset of menstruation is related to higher risk of developing fibroids. 21, 22
• Oral Contraceptives:  Early use of oral contraceptives especially between the ages of 13-16 years is associated with higher risk of developing fibroids. Taking oral contraceptives after the age of 16 does not present any risk of fibroids. 21, 22. Contraceptives such as long acting progestin (e.g medroxyprogesterone), protects against fibroids.  
• Vitamin D deficiency. Vitamin D deficiency is a a known risk factor for fibroids.  Women of African ancestry are prone to vitamin D deficiency and as a result, are more likely to have fibroids.

Can It Be Prevented

There is no known preventive measure against developing fibroids. However, parity (carrying multiple pregnancies to term and vitamin D supplementation have been reported to have protective effect against fibroids  

• Parity: Having children; being pregnant and carrying it to term, multiple times may reduce your chances to develop fibroid. 
• Vitamin D supplementation: Several studies report the direct influence of vitamin D deficiency in the development of fibroids. Taking vitamin D supplements may reduce the risk of fibroids. 25-27

Fibroids and Fertility

Not all uterine fibroid cause infertility. The location of the fibroid is more likely to cause infertility than the size. Submucosal and intramural fibroids (greater than 5cm) have been reported to cause infertility.

Fibroids and  Menopause

The risk of developing fibroids in women who did not previously have it decreases after the onset of menopause. In women who already have fibroids at the time of menopause, they may still persist, however, the fibroids tend to shrink, become less symptomatic and eventually disappear. .

Fibroids and Pregnancy Outcomes

Multiple pregnancies or having many children have been reported to have protective effect against fibroids. 19-21. Some individuals may experience regression of fibroids during or after pregnancy, especially if there are just a few. A possible mechanism by which this happens has been explained by some experts to include; the remodeling of the uterus associated with pregnancy and the shortage of blood supply to the fibroids occurring at the time of delivery both of which essentially lead to shrinkage of the fibroids.

In some women with severe symptoms of fibroids, the rate of 1st semester pregnancy loss is twice as common. It is common in women with multiple fibroids as opposed to a single fibroid. 13 Several studies have reported the improvement in the outcome of pregnancy following the removal of fibroids. 3-8.

Large uterine fibroids are likely to cause pregnancy related complications such as abnormal positioning of the baby, abnormal implantation of the placenta (placenta previa), premature delivery, low birth weight, stillbirth, postpartum bleeding. These complications account for the high incidence of cesarean section in these women. 9-12.

A rare complication of fibroids in pregnancy is spontaneous rupture of the fibroid, which is likely during pregnancy, delivery or even after delivery. Rupture will result in blood loss, and if excessive may lead to shock. If you This is a medical emergency and would require surgery. 14

Fibroids and In Vitro Fertilization (IVF)

Fibroids, especially, submucosal, intramural or large fibroids may distort the uterus and have been reported to reduce the chances of successful pregnancy. 

Some studies recommend treating the fibroids before the IVF process to increase the chances of a successful pregnancy. 28-31.

Most importantly, note that each individual case is different and your doctor will be in the best position to determine what treatment option is appropriate for you. If in doubt, always sseek a second opinion.

Diagnosis

Fibroids are often incidentally discovered during office visit to the doctor. Some individuals may present with heavy or prolonged menstrual bleeding, pelvic pain and fullness or other symptoms of fibroids. The doctor will perform a pelvic examination and if during the exam some irregularities in the shape of the uterus are felt, further tests may be required to either confirm or rule out fibroids:  

• Complete blood count CBC: This checks to see if the individual has anemia. Anemia is a common finding in people with heavy or prolonged menstrual bleeding as they lose a lot o blood. This test does not diagnose the presence of fibroid, it only detects anemia. 
• Ultrasound: It is a test that involves the use of sound waves to obtain images of the uterus.
• Hysterosalpingograpy: This is an X-Ray test where a dye is injected into the uterus to outline the uterus and fallopian tubes. It is particularly useful if infertility and fibroids co-exist, as it shows if the fallopian tubes are open.
• Hysteroscopy: This is a test where an instrument; a hysteroscope (a small lighted instrument) is used to inject saline into the uterus to expand the cavity and aid visualization of the walls of the uterus.
• Laparoscopy: This is minimally invasive procedure where the doctor inserts an instrument with a camera through the abdominal wall to view the uterus, confirm the presence of fibroids and possibly remove them.
• Sonohysteroscopy: is a procedure where saline solution is injected into uterus, this solution expands the cavity of the uterus and makes it easier to obtain images of the uterus.

Treatment

Not all fibroids will require treatment. Small sized fibroids with no symptoms or those found in women nearing menopause may not require any treatment. The usual indications for treatment include excessive menstrual bleeding and pain, infertility, rapidly growing fibroid e.t.c. Your doctor will recommend an appropriate treatment suitable for you.   

Medications: Your doctor may prescribe certain medications to relieve some of your symptoms. It is regarded as the initial line of therapy to be explored. Medications help relieve the symptoms, do not make the fibroids go away completely. They are only taken short term because of the possible adverse effect when taken over a long period.  Vitamin D supplementation recently came to light as a possible medication for fibroids.

Surgery:

• Myomectomy: Myomectomy is a type of surgery to remove the fibroid tissue from the uterus. It is particularly indicated in cases where fibroid are few and /or the woman still desires children. The uterus is left in place and may still be able to carry pregnancy to term. Women who have  Fibroids may choose myomectomy if they intend to have children in the future. Fibroids however may return even after surgery. 

• Hysterectomy: It is a surgery to remove the uterus, sometimes together with the ovaries. Until recently, doctors routinely performed hysterectomy (surgery to remove the uterus) as the treatment for fibroid. Hysterectomy may be done in women with large fibroids, or when other treatments have not worked. It is a definitive and irreversible procedure of consequence, especially in younger women who would like to have children. Not all fibroids require hysterectomy, due to its invasive nature and associated risk of adverse outcomes; prolapse of the vagina, urinary incontinence, death from surgical complications, excessive bleeding, longer recovery period. Several studies suggest that about 90% of hysterectomies performed yearly are unnecessary so It is important to seek out second opinion to be certain you will need hysterectomy. It should be considered as a last resort after all other options have been explored and found ineffective.  

Other treatment options include:

• Hysteroscopic myomectomy: This procedure is for fibroids located inside the cavity of the uterus. The doctor inserts a hysteroscopy that aids the visualization of the uterus and removal o the fibroids..
• Magnetic Resonance Imaging- guide ultrasound surgery
• Uterine Artery Embolization: In this procedure the blood vessels feeding the fibroid is blocked off by injecting small particles to clog the vessels. The fibroid becomes starved of nutrients and eventually shrink away.

References

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