Fibroids are benign masses made up of uterine muscle tissue. They may be located inside the uterine cavity, within the uterin muscle or or grow from outer walls of the uterus. They may be in various sizes and shapes. There may be one or more fibroids in the uterus. They may grow slowly, fast or stay the same in size.
They are commonly found in females aged 30-40 years.
Submucous: Fibroids growing inside the uterine cavity
Intramural: Fibroids growing within the uterine walls
Subserous: Fibroids growing out from uterus,sometimes they be connected to the uterus with a stalk.
Most fibroids stay aymptomatic and they can be found incidentally on ultrasound. Others may cause:
Some complications may be expected in patients having fibroids such as:
When a subserous fibroid is connected to the outer uterine wall with a stalk, it may be twisted around the stalk, causing severe pain, nausea and fever, this is called fibroid torsion. Fast growing fibroids or fibroid degeneration may also cause pain. Sarcomatous changes may start within a fibroid very rarely. Some fibroids may cause infertility due to their location.
Genetic reasons: Fibroid cells may have different genetic composition than normal uterine muscle cells. Therefore it is hypothesized that there is a familial genetic tendency to have fibroids.
Hormones: Female hormones estrogten and progestin increase fibroid growth rate. Because fibroids have more receptors for these two hormones than normal uterine muscle cells. Therefore fibroids tend to grow fast during pregnancy due to increased hormones and they decrease in size during menopause.
Growth factors: Insulin like growth factor may cause fibroids to grow.
Extracellular matrix: It is increased in fibroids and is rich in growth factors which may play a role in fibroid growth.
Fibroids may be originating from a stem cell found in uterine muscle and may be growing due to uncontrolled cellular mitosis due to above factors.
Several risk factors have been defined in patients having fibroids.
Most fibroids are benign. Less than one per thousand fibroids may undergo sarcomatous degeneration and turn into leiomyosarcoma.
The differenciation of sarcoma from a benign fibroid can only be possible by pathological examination after fibroid removal.
Some fibroids may grow fast when left untreated and may cause pressure on surrounding organs such as colon and bladder. This may lead to symptoms such as constipation or frequent micturition.
They may also cause pain due to distention or may go under degeneration due to decreased blood supply.
Some asymptomatic fibroids do not need any treatment at all, they just need to be followed up. Other fibroids may be treated by alternative methods to surgery.
Some fibroids may decrease in size or disappear after menopause or child birth due to decreased hormone levels.
Most fibroids do not cause infertility. But some submucous fibroids may cause infertility or recurrent pregnancy loss.
Fibroids tend to grow during pregnancy due to increased hormones. They may also undergo some cellular changes during pregnancy called the red degeneration.
They may also cause:
Since most fibroids get smaller after birth and there is a high risk of bleeding during C-section, not all fibroids need to be removed during a C-section.
They can be diagnosed by various methods:
Most fibroids do not need treatment. But when the following findings are present,they may need to be treated:
Symptoms of fibroids may be treated by certain medications:
Oral contraceptives: may decrease heavy bleeding and menstrual pain
Gn RH agonists: They cause transient cessation of menses. They are indicated in some cases to decrease fibroids in size before surgery to decrease bleeding. They cause menopausal side effects and fibroids grow back once the medication is stopped.
Progestin Intrauterindevice: May decrease heavy bleeding and menstrual pain.
There are mainly two types of surgery for fibroids:
Type of surgery depends on patient’s age and willingness to become pregnant.
Hysteroscopic myomectomy: It is preferred for submucous fibroids. A camera and instruments can be inserted through the natural cervical opening and the fibroid can be removed in pieces through the cervix. Since no surgical incisions are necessary, most patients can be discharged on the same day after surgery.
Laparoscopic myomectomy: For intramural or subserous fibroids, a camera can be inserted through an umbilical incision, other 0.5-1 cm incisions on the abdominal wall can be made for instruments, and fibroid can be divided into small pieces by morcellation to be removed throught the small incisions.
Laparatomic myomectomy: Fibroids can be removed through an incision made in the lower abdomen similar to a C-section. It may be preferrred when there are adhesions in the abdomen, the fibroids are big and multiple in size.
Uterine Artery Embolisation:
It is an interventional radiology procedure. A special agent can be injected into the uterine artery by an angiography procedure to block the blood supply to the fibroid.
It is not recommended for patients who plan to get pregnant in the future. It is preferred for patients with heavy bleeding and pain and are not suitable for surgery.