FIBROIDS Symptoms Abnormal uterine bleeding- heavy periods (menorrhagia) Painful periods (dysmenorrhoea)

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1 FACT SHEET FIBROIDS Uterine fibroids are the commonest benign (non-cancerous) tumour found in women. Fibroids afflict up to 60% of childbearing aged women and 80% of women during their lifetime. The fibroids themselves are composed of a certain type of muscle called smooth muscle which the womb is made up of. Fibroid start off as a single cell and then grow in a circular type of pattern, becoming bigger and bigger under the influence of one of the female hormones, oestrogen. Fibroids are not present before periods start (puberty) and shrink in size after the menopause (as long as hormone replacement therapy is not taken). Surveys have shown that fibroids do not affect the different races in the world equally. It disproportionally afflict women of African and Afro-Caribbean descent, where they tend to be not only more common, but more numerous and cause problems at a younger age. Fibroids can vary in size from only a few millimetres all the way up to 30cm or 40cm. Fortunately it is unusual for them to reach the larger size. The fibroids can also vary in the position they are found in the womb. They can be found hanging on a stalk, either inside the womb cavity itself, or hanging off the outside (pedunculated). They can be found distorting the womb cavity (submucous fibroid), be in the wall of the womb itself (intramural fibroid), or be bulging from the outside wall of the womb (subserous fibroid). The symptoms women will get from these fibroids will depend on the number, size and their location. The presenting symptoms also tend to be extremely variable from patient to patient and where some patients can experience absolutely no symptoms at all, even from very large fibroids, other patients can experience symptoms from relatively small ones. Directly trying to compare the size of fibroids with another person is therefore a pointless task. Symptoms As previously noted, women can present with an enormous variety of problems associated with these fibroids. Below is a list of various symptoms that may affect the person and some people may suffer from multiple symptoms. Abnormal uterine bleeding- heavy periods (menorrhagia) Although there are many causes of heavy periods (menorrhagia), fibroids is one of the commonest causes of heavy periods. They can cause heavy periods for two main reasons, firstly by increasing the size of the womb and hence increase the blood flow to the womb, as well as by increasing the surface area of the cavity of the womb, hence there is more area to bleed from. Submucous fibroids are particularly dominant in this second way. Even if the womb itself is not greatly enlarged, a relatively small submucous fibroid can distort the inside cavity of the womb and significantly influence its surface area, hence the amount of blood loss. Fibroids though do not generally cause irregular bleeding, bleeding after intercourse or bleeding in between periods. Painful periods (dysmenorrhoea) Although it is unusual for fibroids to directly cause painful periods (dysmenorrhoea), certain fibroids, particularly ones lower down in the womb, can cause pain during the period itself. More commonly though, a large mass of fibroids can contribute to a generalized pelvic pain which can occur at anytime throughout the menstrual cycle. Symptoms relating to the sheer size of the fibroid (pressure symptoms) Some fibroids can get so large that the patient starts to notice certain symptoms relating to the sheer mass of the fibroids, including abdominal distension. If the patient feels her own tummy, she can often feel a lumpy texture from the multiple fibroids. The pressure symptoms that can also be caused by these fibroids can cause the patient to feel as if she wants to pass urine more often or cause difficulty in passing urine as the fibroids press on the bladder. Apart from causing bladder problems, large fibroids can also cause bowel problems such as constipation by pressing on the bowel, preventing smooth passage of bowel contents.

2 Infertility Approximately a third of all patients with fibroids presents with infertility or sub fertility. A critical and still unresolved question in this field is the relationship between fibroids and infertility. This issue is assuming increasing relevance considering that there is now a general tendency to start a family at a later age when natural fertility in women is declining and the incidence of fibroids is increasing. There are several ideas suggested in attempting to answer the question of fibroid causing infertility. These ideas include mechanical blockage of the fallopian tubes impairing sperm or embryo passage through the fallopian tubes, altering the way the womb rhythmically contracts, altering the blood supply to the womb or abnormal development of the womb lining hence reducing the chance of implantation especially if they distort the womb cavity. In some people the fibroids can also cause an inflammatory reaction in the lining of the womb which may reduce the chance of implantation. However, the fact that a woman has fibroids does not mean that they will be infertile. Some fibroids are either too small or in the wrong place to contribute towards infertility. It is also of note that some patients can have multiple fibroids and still have absolutely no problem getting pregnant. The group of patients though who present to an infertility clinic tend to be a select group of patients where the fibroids are more likely to be contributing to the overall picture, depending on their size and location. Certainly if the fibroid is submucous and is distorting the uterine cavity, then this is more likely to be contributing, whereas other smaller subserous fibroids are less likely to be contributing to the overall picture. Fibroids that distort the uterine cavity as well as by increasing the sheer bulk of the womb, can also contribute to early pregnancy loss. During pregnancy, the fibroids can not only contribute to early pregnancy loss but can also outgrow their blood supply and cause pain during the pregnancy as well as making the baby lie in an unusual way (malpresentation) and make a caesarean section necessary. Diagnosis The diagnosis of fibroids is generally suspected on the basis of palpation of an enlarged irregular contour of the womb on pelvic examination. Investigation by ultrasound either through the abdomen or through the vagina is typically used to confirm the diagnosis. The transvaginal scan method gives far better and more accurate pictures in submucous or intramural fibroid as the vaginal probe is closer to the womb and fibroid itself. Normally the size and location of these fibroids can be clarified by the use of ultrasound, but sometimes various other tests are necessary. When the relationship between the fibroid and the womb cavity is unclear, a fluid-contrast ultrasound (sonohysterogram or Hy-Co-Sy ) can generally distinguish submucosal from intramural fibroid. This method involves fluid instillation into the womb cavity during the scan. Alternative to fluid-contrast ultrasound includes hysterosalpingogram which can also show if they distort the womb cavity. This involves an x-ray where a special contrast medium is instilled into the womb cavity and various x-ray images are taken. The dose of these x-rays is extremely low and generally equates to the radiation that a person gets from flying once across the Atlantic. Other diagnostic method includes high tech technique such as magnetic resonance imaging (MRI) which is unusual these days unless there is a particularly unusual presentation of the fibroid. Fibroids can also be diagnosed at an operation under anaesthetic either by laparoscopy (which involves a TV camera telescope passed through the belly button) or hysteroscopy (a smaller TV camera telescope passed through the neck of the womb/cervix to view the womb cavity). Quite often laparoscopy and hysteroscopy are performed after the fibroids have been diagnosed by ultrasound or x-ray. This will assess their significance and to assess whether the fibroids need to be removed or not. Laparoscopy and hysteroscopy will then inform the best way in which they are to be removed. Treatment options Treatment options for fibroids vary. It is important to realise that a lot of fibroids do not require any treatment at all. Treatment strategies are typically individualised based on the severity of the symptoms, the size and location of the fibroid, the patient s age and their proximity to menopause and their desire for future pregnancy. Although there is a small risk of these benign tumours changing by chance (approximately 1 in 1000 may have these changes) these tend to be related to

3 the fibroids that are rapidly growing and relatively large. If the fibroid is not causing any major symptoms or appears to be in a location that is insignificant, then follow up observation is often the best path as this does not require any further intervention of a surgical nature. As the fibroids are not being treated, they should be kept under surveillance to assess their rate of growth at a regular interval of between six months and yearly. Medical options If the only symptom due to fibroids is one of mild to moderate pain, then these can be treated by various forms of pain killing medications from the chemist or your GP. For patients having added symptoms of heavy periods and wishing to conceive, medications such as tranexamic acid or non steroidal anti inflammatory tablet such as mefenamic acid (Ponstan ) may help reduce the heavy period. Oestrogen hormone is regarded to be the most important hormone that stimulates fibroid growth. Due to this fact that the fibroids require oestrogen to continue growing, most other forms of medical treatment centres around antagonising oestrogen level in the body. These medications may also have contraceptive effects while in use. The more commonly tried medication to alleviate heavy periods includes the combined oral contraceptive pill, oral or injected progesterone and hormonal intrauterine coil. Stronger medications used to treat fibroids centres around the fact that the patient can be put into temporary menopause by the use of certain drugs called gonadotrophin releasing hormone analogues (GnRHa). This tends to be a long acting injection given every four weeks which put the patient into temporary menopause by starving the body of oestrogen. They are a successful form of treatment which may shrink the fibroid. However, they can only be used safely for a relatively short duration of time. One of the side effects of the menopausal effect is the thinning of the bones (osteoporosis) and this tends to be the time-limiting factor with treatment in this way. Normally people would only use these drugs for up to six months when one would expect the fibroids to shrink anywhere between a third and a half. This method tends to be a treatment that is used in the acute situation or just before further surgical treatment is undertaken. The length of time these drugs can be used (Zoladex, Prostap ) can be lengthened by the addition of add-back therapy. This is where extra oestrogen is given in the form of contraceptive pill or hormone replacement therapy (HRT) and can lengthen the GnRHa usage period by protecting against the osteoporotic changes. This though is not commonly used with fibroids, as again it is difficult to maintain this form of therapy for more than a year. Surgical options More commonly, fibroids are removed by some form of surgical method ranging from taking just the fibroids, to taking the whole womb away in the form of a hysterectomy. Although hysterectomy is a decisive and effective form of treatment for patients who for instance are getting very heavy period and pain, this is obviously not a suitable treatment for a patient desiring pregnancy. Myomectomy is the primary surgical treatment method for women with symptomatic fibroids who are of childbearing age and desire future pregnancy. It is a surgical treatment where the fibroids are carefully removed but the womb itself is left intact. The procedure can be done by open abdominal route (laparotomy) or by keyhole method (laparoscopy or hysteroscopy) depending on the size, site and type of fibroid. The crucial thing with fibroid surgery is that the surgeon is skilled in removing these fibroids and very carefully repairing the womb afterwards. This is of utmost importance in the infertile patient; otherwise you substitute one form of infertility for another, such as tubal disease due to the scarring left behind. Laparoscopic myomectomy has gained more recognition recently following advancement in instruments and expertise. However, the laparoscopic myomectomy require longer operative time compared to open procedure. It is also technically highly demanding and complex for the surgeon plus the requirement for specialised surgical instrument. Due to the complexity of the procedure, the laparoscopic method is only offered in limited centres around the country with special

4 expertise. The open micro surgical myomectomy is a safe and very effective method for removing fibroids. This method is more widely available as it is more widely practised. This is where the fibroids are carefully removed via an open abdominal route, and then the womb is repaired with a very fine suture material so as to prevent any post-operative scar occurring and to allow the patient to remain as fertile as possible. If the fibroids are predominantly growing inside the womb cavity itself then these can be removed by a different form of key hole surgery, namely that of hysteroscopic surgery. This is where a special telescopic instrument with a TV camera is inserted through the neck of the womb and the fibroids carved out from the inside. This is the optimal way to treat sub mucous fibroids. For patients desiring pregnancy, research has shown that submucous fibroid removal significantly improves pregnancy rate as well as decrease in miscarriage rate. Again it is important that the surgeon performing the operation is skilled with the hysteroscopic approach. Alternative/new treatment options and research techniques The traditional treatment of fibroids has been surgery. However, over the last several years, alternative techniques have begun to emerge. Furthermore, the biology of fibroid growth is continually re-examined and new medication has been developed based on new findings. Anti progesterone Traditionally, oestrogen hormone has been considered to be the most important stimulating hormone for fibroid growth. Surprisingly, recent research suggests that for the fibroids to maintain its growth, the fibroids are also very dependent on progesterone hormone. Due to this finding, development has been focussed on anti progesterone medication which could reverse fibroid growth. Currently, Ulipristal is available as pre-operative treatment of moderate to severe symptoms of fibroids. Ulipristal is classed as selective progesterone receptor modulator (SPRM). It has been associated with reduction in pain, bleeding and fibroid size by up to 30%. There are reports some patients even cancelled their planned myomectomy operation due to their effectiveness. However, it has been associated with an unwanted side effect of increased thickening of womb lining. As with a lot of new treatment, data on long term treatment is lacking. Uterine artery embolisation and uterine fibroid embolization This is a technique where the blood supply to the fibroid is blocked off, therefore starving it of nutrition and causing it to shrink and demise. Embolisation has been shown to be more successful with solitary fibroid. The main complications with this technique is because you are killing off the fibroid, the dead tissue can get infected and cause a severe problem inside the womb or abdomen. There have been cases reported of the infection spreading and affecting the bowel. This technique though has its place in the very ill patients or who are not well enough to undergo a major operation. The patient has to be observed extremely carefully after this treatment has been performed for signs of infection. The blocking of these blood vessels is performed by using either small coils or special glues. It can also cause problems with the blood supply to the ovary. It has been reported that up to 12% of patients can suffer premature ovarian failure. Certainly in well selected patients this should be significantly lower but obviously would be disastrous in the infertility sufferer. Furthermore, pregnant patients who had embolisation prior to pregnancy have been shown to have increased incidence of obstetric complications including miscarriage, preterm labour, placenta praevia and postpartum bleeding. It is for these reasons that embolisation technique should not be used in patients seeking pregnancy. It is likely to be more beneficial in patients with major problems particularly heavy periods from these fibroids and had completed childbearing, where loss of the function of the womb or the ovaries would not be so disastrous. Myolysis/radiofrequency ablation Myolysis or radiofrequency ablation (RFA) is a procedure using keyhole surgery, a laser fibre or an electric current is passed into the centre of the fibroid and then under a low heat the fibroid is cooked from the inside out. This destroys the blood supply to the fibroid and in theory should

5 prevent the fibroid from growing. This is only suitable for smaller fibroids and has not been found to be particularly good for any large fibroids. Magnetic Resonance Guided Focused Ultrasound Magnetic resonance-guided focused ultrasound technique is a more recently developed option for the treatment of fibroids in women who have completed childbearing. It is a non invasive technique that uses the ultrasound energy to destroy the fibroid by heat. However, this treatment is only available in selected centres and the long term research outcome is still lacking. Finally Fibroids are a very common factor in infertile women. The presenting problems from these can be very varied as can the treatment options available. The crucial point of note in the infertile patients is that the fibroid should be treated in a sensible fashion in a centre that has a lot of experience in dealing with these whilst maintaining fertility. There is no place for the patient being offered a hysterectomy if she still has not completed her family when there are other, more acceptable options open. Updated January 2014 By Mr Chun Ng Consultant in Reproductive Medicine and Surgery IVF Hammersmith Hammersmith Hospital Infertility Network UK Charter House 43 St Leonards Road Bexhill on Sea East Sussex TN40 1JA Telephone: / admin@infertilitynetworkuk.com Charity Registered in England No and in Scotland No SC039511