What are Fibroids?
Uterine fibroids are benign (not cancer) growths in the womb (uterus). They are made of muscle and other tissue. Fibroids almost never develop into cancer. They are also called leiomyomas or myomas.
Uterine fibroids are very common in women of childbearing age (20-45 years).
The size, shape, and location of fibroids can vary greatly. They may appear inside the uterus (submucous fibroids), on its outer surface (subserosal), within its wall (intramural), or attached to it by a stem like structure (pedunculated).
Fibroids can range in size from small, pea-sized growths to large, round ones that may be more than 5–6 inches wide. As they grow, they can change the normal structure of the uterus and disturb the lining (endometrium).
A woman may have only one fibroid or many of varying sizes and location. They may remain very small for a long time, suddenly grow rapidly, or grow slowly over a number of years
What are the types of Fibroids?
Fibroids are categorised by where they grow in the uterus
These grow in the wall of the womb and are the most common type of fibroid.
These fibroids grow from the outer layer of the womb wall and sometimes grow on stalks (called pedunculated fibroids). Subserous fibroids can grow to be very large.
Submucous fibroids develop in the muscle underneath the inner lining of the womb. They grow into the womb and can also grow on stalks which, if long enough, can hang through the cervix (Mouth of uterus).
Cervical fibroids grow in the wall of the cervix (neck of the womb) and are difficult to remove without damaging the surrounding area.
What is the incidence of Fibroids?
Fibroids affect more than 1 in every 5 women under age 50. Many women who have fibroids are not aware of them because the growths can remain small and not cause symptoms or problems. However, in some women, fibroids can cause problems because of their size, number, and location.
What is the cause of uterine fibroids?
Although fibroids are quite common, little is known about what causes them. There are various theories as to the cause of fibroid.
Fibroids tend to run in family. If a woman has fibroids chances are that her mother, sister, aunt and her daughters may also have them at some time of their lives.
Some studies prove that fibroids are hormone dependent. Estrogen, which is a hormone present in women of childbearing age, tends to increase the size of fibroids. This is proven by the fact that the size of fibroids decreases during menopause, when this hormone secretion reduces. However there is no definite relation.
What are the symptoms?
Many women don’t feel any symptoms. Without symptoms, you probably won’t even know that you have fibroids. Fibroids can cause some of these symptoms
- Changes in menstruation – More bleeding, longer or more frequent menstrual periods, menstrual pain (cramps), vaginal bleeding at times other than menstruation i.e bleeding between periods.
- Anemia (from blood loss)
- Feeling “full” in the lower part of your stomach (pelvic pressure)
- Continuous lower back pain or lower abdomen pain.
- Increased frequency of urination or sensation of incomplete urination.
- Constipation or straining at stools
- Infertility, miscarriages/abortion or premature labour and delivery (before 8 months)
How do fibroids cause infertility?
Fibroids may cause infertility in a number of different ways:
- A fibroid may cause compression on the uterine tubes resulting in a blockage of the passage of sperm or eggs.
- A large fibroid may disturb the relation between the uterine tube and ovary making it difficult for the uterine tube to capture an egg at the time of its release.
- If a fibroid pushes the lining of the uterus, there may not be enough space in the womb for the embryo to attach itself to the lining (Implantation).
- Some studies have suggested that fibroids in the muscle portion of the uterus may cause an alteration or reduction of blood flow to the uterine lining making it more difficult for an implanted (attached) embryo to grow and develop causing miscarriage or abortion.
How do fibroids cause abortion?
Fibroids that bulge into the uterine cavity (submucous) or are within the cavity (intracavitary) may sometimes cause miscarriages. The fertilized egg comes down the fallopian tube and takes hold in the lining of the uterus. If a submucosal fibroid happens to be nearby, it can thin out the lining and decreases the blood supply to the developing embryo. The fetus cannot develop properly, and miscarriage may result.
However, with the next pregnancy, it is possible that the egg will settle in another location, and pregnancy may proceed without problems. However, if you do have a miscarriage and a fibroid is found bulging into the uterine cavity, it is advisable to have it removed
How are fibroids diagnosed?
The first signs of fibroids may be detected during a routine pelvic exam. There are a number of tests that may show more information about fibroids:
Ultrasonography (USG) or pelvic scan is the commonest way of detecting fibroids. It helps in detecting the exact location and size too. Transvaginal scan done with a probe introduced through the vagina is more informative than transabdominal. This is a non-invasive and easily acceptable investigation for detecting fibroids.
USG picture of fibroid uterus
Hysterosalpingography (HSG) is a special X-ray test done by pushing dye into uterus through vagina. It may detect abnormal changes in the size and shape of the uterus and fallopian tubes. It is not very confirmative and may require a USG to definitely diagnose fibroid.
Sometimes small or asymptomatic fibroids are diagnosed on routine diagnostic laparoscopy.
Hysteroscopy uses a slender device (the hysteroscope) to help the doctor see the inside of the uterus. It is inserted through the vagina and cervix (opening of the uterus). This permits the doctor to see some fibroids inside the uterine cavity.
Detailed discussion is done in the section of hysteroscopy
Cervical fibroids grow in the wall of the cervix (neck of the womb) and are difficult to remove without damaging the surrounding area.
Is it necessary to treat fibroids?
Fibroids that do not cause symptoms, are small, or occur in a woman nearing menopause often do not require treatment. Certain signs and symptoms, though, may signal the need for treatment:
- Recurrent abortions
- Heavy or painful menstrual periods
- Bleeding between periods
- Uncertainty whether the growth is a fibroid or another type of tumor, such as an ovarian tumor
- Rapid increase in growth of the fibroid
- Pelvic pain
In which cases of infertility do fibroids need to be operated?
Fibroids that change the shape of the uterine cavity (submucous) or are within the cavity (intracavitary) decrease fertility by about 70% and removal of these fibroids increases fertility. Other types of fibroids, those that are within the wall (intramural) but do not change the shape of the cavity, or those that bulge outside the wall (subserosal) do not decrease fertility, and removal of these types of fibroids does not necessarily increase fertility.
It’s easy to understand how a submucous fibroid which protrudes into the uterine cavity or causes distortion of the uterine cavity may act as a foreign body, and present a mechanical barrier to implantation. However, most other fibroids do not affect fertility. This is still controversial, because some doctors believe that intramural fibroids may cause an alteration or reduction of blood flow to the uterine lining, making it more difficult for an implanted embryo to grow and develop. Subserosal fibroid near cervix or tubes or more than 5 cm in size need to be removed.
Most fibroids in infertile women do not need any treatment at all, because they do not affect fertility or pregnancy. They are best left alone! In fact, unnecessary surgery can actually reduce your fertility, because it causes adhesions and scarring which can damage the tubes.
However, submucous and few intramural fibroids in infertile women (those within the uterine cavity or causing significant distortion of the cavity) do need to be removed; and these are best removed by doing an operative hysteroscopy and laparoscopy.
In general irrespective of its position, a fibroid which is more than 4cm is removed as it may cause problems in conception as well as delivery of the baby. If there are multiple (7-8 or more) small fibroids (2-3 cm each), then it is better that these are also removed as it has been seen that removal of these increases chances of pregnancy.
What are the treatment options for management of fibroids in an infertile woman?
Treatment options would include medical and surgical management. The medical management includes use of oral contraceptive pills or injections called as GnRh agonist. These drugs may help in shrinkage of fibroids and will also provide relief from symptoms. Medical management is not of much use in women having difficulty conceiving as the treatment itself is a contraceptive treatment. Also as soon as the medicines are stopped fibroids tend to grow again.
The ideal and quickest method of dealing with fibroids in an infertile woman would be surgical removal. Removal of fibroids surgically is termed as myomectomy. With the advance in surgical techniques and under the hands of experienced surgeon this can easily be done by laparoscopy or hysteroscopy. Medical treatment prior to surgery is beneficial in cases where the fibroid is to be removed hysteroscopically, as it reduces the size of fibroid. However it also makes the fibroid soft and hence not advised before laparoscopic surgery as it makes the removal of fibroid difficult. Other radical options may include uterine artery embolization and hysterectomy. Both of these are to be avoided.
VIDEO of Myomectomy
Myomectomy is the surgical removal of fibroids while leaving the uterus in place. Because a woman keeps her uterus, she may still be able to have children in future. Myomectomy may be done in a number of ways:
The method used depends on the location and size of the fibroids. For a laparotomy, an incision (cut) is made in the abdomen. The fibroids then are removed through the incision.
Fibroids also can be removed through the laparoscope that is used to view the inside of the abdomen.
Hysteroscopy can be used to remove fibroids that protrude into the cavity of the uterus. It is done in cases where around 1/4th or more of the fibroid bulges within the uterine cavity. The fibroids may be removed with a resectoscope, a tiny wire loop that uses electric power, or with a laser. Either of these instruments can be inserted through the hysteroscope.
- Uterine Artery Embolization
Another way to treat fibroids is called uterine artery embolization (UAE). With this procedure, the blood vessels supplying blood to the fibroid are blocked.
This cuts off the blood flow to the fibroid and causes it to shrink. The procedure works even if you have more than one fibroid. However this is not the treatment of choice in women with fertility related problems as this procedure may also reduce the blood flow to ovaries and uterus thus further compromising fertility.
Hysterectomy is the removal of the uterus. The ovaries may or may not be removed. It depends on other factors. This is not an option for infertile women. However in women with multiple symptomatic fibroids with severely distorted cavity the uterus may have to be removed to cure symptoms.
In such a case surrogacy with IVF may be the only option.
The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Two or three small, half-inch incisions are made below the pubic hairline and instruments are passed through these small incisions to perform the surgery.
Video of lap myomectomy
(Steps of surgery : Injection of vasopressin, Incision over the fibroid, Enucleation / morcellation of fibroid, Achieving hemostasis at the bed of fibroid, Closure of the incision)
(Picture showing injection of vasopressin in the fibroid to reduce bleeding during dissection)
For laparoscopic myomectomy, a small scissors is used to open the thin covering of the uterus. The fibroid found underneath this covering is grasped, and freed from its attachments to the normal uterine muscle. After the fibroid is removed from the uterus, it must be brought out of abdominal cavity. The fibroid is cut into small pieces with a special instrument called a morcellator, and the pieces are removed through one of the small incisions. The openings in the uterus are then sutured closed. The entire procedure can take one to three hours, depending on the number, size, and position of the fibroids.
How Can We Remove a Big Fibroid Through a Small Laparoscopic Incision?
Less than a decade ago, removing fibroids after laparoscopic myomectomy was a difficult and time-consuming task. However, a few years ago an electrically powered device, called a morcellator, was invented and now allows us to quickly cut up the fibroid and easily remove it from the abdomen. The device is a hollow tube with a sharp circular blade at the end that rotates quickly and takes small slices off the fibroid in a few seconds. A large fibroid can now be removed by cutting it into small sausage shaped pieces and also removed by a small abdominal incision. All this takes a few minutes only. Therefore, we are now able to perform laparoscopic myomectomy on women with even large fibroids. This device has allowed a major advance in our laparoscopic technique.
Will I definitely become pregnant after Myomectomy?
Surgical removal of submucous or intramural fibroids has shown to improve implantation rates (attachment of embryo to uterine lining) and also reduce abortion rates. However one has to remember that there are several factors which can contribute to infertility which includes proper and timely release of egg, patency of uterine tubes, good quality motile sperms, timely fertilization and implantation. Age of the female partner also has a contributing factor in conceiving.
The chances of pregnancy will definitely improve after surgery if fibroid is the only contributing factor. Therefore it is advisable to get yourself completely investigated for other factors causing infertility before making a decision for surgery. Complete discussion and clarification of doubts from your doctor will help you in making a decision.
What are the complications of surgery?
Complications incidence is same as in any laparoscopic surgery. Commonest includes intraoperative bleeding and wound infection. But with modern advances in surgery, skilled surgeon and potent antibiotics the incidence of complications are almost negligible. One of the important long term complications is rupture of scar of myomectomy. Such cases are fortunately very few. In these cases there may be rupture of the scar tissue from where the fibroid was removed either during pregnancy or delivery. This occurs mostly in cases of neglected labour and delivery.
How many days after surgery should I wait to get pregnant?
It varies depending upon the extent of surgery but is ideal to give 6 weeks or 2-3 months for the sutures to heal completely before trying to get pregnant. Your fertility specialist will be able to guide you depending on your condition.
What if I have fibroids and become pregnant? Will they affect my pregnancy?
If you are pregnant and have fibroids, they mostly won’t cause problems for you or your baby.
During pregnancy, fibroids may increase in size. Most of this growth occurs from blood flowing to the uterus. Coupled with the extra demands placed on the body by pregnancy, growth of fibroids may cause discomfort, feelings of pressure, or pain. Sometimes the fibroid also becomes very soft and large due to increased vascularity (red degeneration). However, fibroids decrease in size after pregnancy in most cases.
However, fibroids may increase the risk of:
- Miscarriage (in which the pregnancy ends before 20 weeks)
- Preterm birth (early labour and delivery)
- Breech and transverse position (in which the baby is in a position other than head down)
- More blood loss after delivery
Rarely, a large fibroid can block the opening of the uterus or keep the baby from passing into the birth canal. In this case, a cesarean delivery is done. In most cases, even a large fibroid will move out of the fetus’s way as the uterus expands during pregnancy. Women with large fibroids may have more blood loss after delivery. Often, fibroids do not need to be treated during pregnancy. If you are having symptoms such as pain or discomfort, your doctor may advice rest. Sometimes a pregnant woman with fibroids will need to stay in the hospital for a while because of pain, bleeding, or threatened preterm labor.
Can Fibroids Hurt the Developing Baby?
Fibroids almost never cause injury to a baby. Review of the entire world’s medical literature for the past 25 years discovered only four babies affected by a fibroid.
Do Fibroids Mean You Need a Caesarean Section?
Rarely, a fibroid may grow near the cervix (mouth of the uterus) during pregnancy. If it is large enough, it may prevent the baby from coming through the birth canal. This is not dangerous and can often be diagnosed by a sonogram before labor begins.
Sometimes this problem is discovered during labor because the baby does not come down the birth canal. A caesarean section is then performed. However, most women with fibroids deliver their babies normally without any problems.
Sometimes during a cesarean section if fibroids are encountered , especially serosal fibroids , then these can be removed in the same sitting . This is known as cesarean myomectomy.