Fibroids are innocent (benign) round balls of fibrous tissue found in the womb (uterus). The medical name is uterine leiomyoma or uterine myoma. They are very common and are often without symptoms. If they are small and not causing a problem, they do not always need treatment.
Fibroids can grow
- in the lining of the womb (submucosal fibroid),
- inside the womb muscle (intramural fibroid),
- from the outside of the womb (subserous or pedunculated fibroid) and the cervix (cervical)
They can be as small as a pip or as large as a water-melon. Whether they cause any symptoms depends on their size and where they are growing. They can cause abnormal bleeding, pressure on the bladder or bowel, and difficulty getting pregnant.
Treatment options for fibroids
There are now several options for treatment of fibroids. There are drug treatments, radiological and surgical options. Fibroids without symptoms don't always require treatment.
Drug treatment for fibroids
Hormone contraceptive pills or the Mirena can help the symptoms of heavy periods. Esmya (ulipristal acetate) can reduce the size of fibroids and stop periods. Treatment is for 12 weeks and the course of treatment can be repeated.
Treatment with Gonadotrophin releasing hormone agonist given as an injection or nasal sniff reduces the size of the fibroids, but the fibroids re-grow to their original size, within a few months of stopping treatment. Side effects are related to the low oestrogen hormone levels, typically hot flushes and night sweats. These medicines are mainly used to reduce the size of fibroids prior to surgery and to reduce the amount of blood lost at operation.
This is a major operation with 2-3 days in hospital and 4-6 weeks recovery. Intramural fibroids are shelled out from the womb - rather like peeling an orange from inside its peel.
If the fibroid is growing into the lining of the womb, the fibroids can be cut away using a special telescope inserted through the entrance of the womb (cervix). This type of operation is called a Transcervical resection of fibroid and involves a day in hospital. It is still considered a major operation, but the recovery is shorter (usually about 2 weeks).
About 1 in 4 women need further surgery after myomectomy, either because more fibroids grow, or because their symptoms still need some treatment. If there is major bleeding at the time of the operation, it is possible to place extra stitches to control it, but an emergency hysterectomy may be required for life-theatening bleeding. The literature reports that this happens in 1 in 200 operations.
Myomectomy will leave a scar on the womb. This will be very strong, but can weaken during labour. You may be advised that Caesarean section is needed. The operation can result in adhesions that reduce your chance of getting pregnant naturally.
If you have completed your family, then hysterectomy may be the right choice for you. Fibroids are the commonest reason for a woman choosing a hysterectomy.
Hysterectomy has less blood loss at operation, is a shorter operation, is less painful afterwards, fewer complications and a shorter hospital stay (2-3 days) than myomectomy.
Uterine artery embolisation
Uterine artery embolization was introduced about ten years ago and there is no longer-term data available. This treatment is only recommended if you need an operation because of symptoms from your fibroids and if the fibroids aren't too large.
A needle is inserted into the groin (femoral) artery, through an area of skin that has been locally anaesthetised. A plastic tube (cannula) is inserted down the centre of the needle and threaded through to reach the uterine artery. Tiny particles of plastic are injected which block the uterine artery and deprive the fibroid(s) of their blood supply, so that they shrink.
Treatment takes one to two hours and involves a hospital stay of one to two days (because of pain as the fibroid shrinks). Recovery time is about two weeks. The majority of women will have complete or significant resolution of their symptoms for up to five years.
Pregnancy has been reported following Uterine artery embolization, but there is little data regarding pregnancy outcomes. Careful discussion regarding fertility before the procedure should include the risk of premature menopause (1 in 100 women) and hysterectomy (3 in 200 women) in the event of serious complications such as infection. Fertility may be better following surgical myomectomy compared with Uterine artery embolization, but there has not been enough research involving a direct comparison of the procedures to determine any significant difference.
There is no clear evidence of a difference between Uterine artery embolization and surgery in the risk of major complications, but Uterine artery embolization was associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure.
Around 7% of women will need further surgery within two years of hysterectomy or myomectomy, however, between 15% and 32% will need further surgery within two years of Uterine artery embolization. Thus although Uterine artery embolization is a safe alternative to surgery, patient selection and counselling are important.
High frequency focussed ultrasound
Using MRI to locate and target fibroid(s) ultrasound energy is used to heat the fibroid to a temperature above 55°C for a few seconds which results in local coagulation and necrosis.
Fibroids need to be accessible to the ultrasound beam without bowel loops between the beam and the fibroid. An abdominal incision in the way of the beam is a contraindication because skin burns have been reported.
Treatment takes 1 - 3 hours with a day's stay in hospital. Patients recover within one to three days. Minor complications have been reported to occur in up to 10.4% of cases and include first- and second- degree skin burns, abdominal, temporary lower back and leg pain, fever, mild subcutaneous or abdominal muscle oedema and vaginal spotting of blood or discharge. The incidence of major complications is 0.4%, including bowel perforation and damage to sciatic nerves,