Fibroids:  causes, symptoms and treatment

Dr Kamlesh Tandon, MBBS,DGO
namita@womenfitness.net

Fibromyomas (Fibroids or myomas) are benign neoplasms commonly encountered in women in the reproductive age group. They are well circumscribed tumours of smooth cells and interlacing fibrous tissues connective cells.

Their growth is, in or on the uterus. There might be some women who have no symptoms with fibroids, other might experience pain or abnormal bleeding.

Fibroids may grow on stems or remain a part of the uterus wall. They grow from the muscle cell in the wall of the uterus as shown below.

CAUSES

The factors which induce the growth of fibroids remains unidentified, but it is suggested that contraction of the uterine muscles cause points of stress within the myometrium (lining of uterus), which in turn provides stimulus for the growth of immature cells inside and outside the uterus.

Fibroids range from the size of a pea to a size of a grapefruit. Oestrogen, growth hormone and human placental lactogen have been observed to promote the development and growth of fibroids. For the same reason fibroids have been observed to grow larger during pregnancy (when oestrogen productive increases) and shrink afterwards. Similarly as women near menopause, their growth is halted, thus they shrink and disappear.

SYMPTOMS

Large number of myomas (Fibroids) are encountered with no symptoms. The patient may have first one symptom or may present with multiple symptoms, depending on the size, number and location of tumours.

• (a) (i) Menstrual Disturbances:- Fibroids can cause an increase in the amount, frequency or duration of menstrual bleeding due to increased uterine surface, endometrial hyperplasia, and increased uterine vascularity.
  • (ii) Polymenorrhoea:- In some cases the menstrual bleeding might be reduced with increase in the duration of haemorrhage.
  • (iii) Metrorrhagie:- Intermenstrual bleeding occurs when the tumour is submucous and protecting into the uterine cavity.
• (b) Pain:- Patient with large myomas might complain feeling of weight in the pelvis or lower abdomen. Patient might complain of pain ranging from mild to severe in abdomen or lower back.
• (c) Pressure Symptoms:- Fibroids situated in the posterior uterine wall or situated in the pouch of Douglas may cause increase in the frequency of urination or even, retention of urine in acute stages.
• (d) Infertility:- Fibroids can cause infertility if they grow inside the uterus. A fertilized egg may not be able to implant itself in the wall of uterus. A fibroid that blocks the fallopian tube can cause infertility by obstructing the passage of sperm or fertilized egg. Large fibroids in the uterus can block the growth of a developing fetus and cause premature labor.

Very rarely do fibroids become cancerous. If they do occur, it is most often after menopause. If a patient observes abdominal swelling, painless in nature she must consult her doctor. A women suffering from fibroids might be anaemic on account of menorrhagia.

DIAGNOSIS

Once the fibroids have been identified, the doctor might intent to resort to some of these measurers to examine the tumors more closely, using any one these techniques:-

1. Ultrasound:- It is useful in establishing the diagnosis of fibroids by creating our image of the pelvic organ.
2. Laparoscopy:- Laparosope inserted through a small incision just below the can enable the doctor to view the interior of the pelvis. This might help the doctor to rule out endometriosis, ectopic pregnancy and inversion prior to laparotomy.
3. Hysteroscopy:- It enables the doctor to insert a viewing instrument through the vagina and cervix to examine the interior of the uterus.
4. A CAT scan helps to differentiate a myoma from an adnexal mass.
5. Hysterosalpingography:- It is a method of producing an X-ray image of the interior of the uterus and the fallopian tubes to determine if there are any changes in the size and shape of fibroids to check tubal blockage.

TREATMENT OF FIBROIDS

Treatment is not always necessary for fibroids unless they cause excessive bleeding or pain or if the doctor is not sure if the growth is a fibroid or a cancerous tumor.

In general, treatment may be conservative, radiotherapeutic or operative.

CONSERVATIVE TREATMENT

1. Correction of Anaemia:- It us a course of iron therapy is generally beneficial.
2. Danazol:- An androgenic and anti-oestrogenic, given orally (400-800 mg in divided daily doses) for 3-6 months, is seen to reduce the size of tumours.
3. Synthetic Gonadotropin:- Releasing hormone (GnRH) analogue, administered either subcutaneously (200 mg daily) or intranasally (300-400 mg three times daily) for six months is reported to reduce the size of fibroids by 50-80%. This treatment is useful in very young women and pre-menopausal women as shrinkage of the tumour eliminates the need of surgery.

RADIOTHERAPY

This therapy is resorted to in very occasional patients whose general condition is very poor and surgery needs to be avoided. A women younger than 45 is not a suitable candidate for radiotherapy. Besides patients on radiotherapy are liable to develop uterine sarcoma at a later date.

OPERATIVE TREATMENT

The methods available are myomectomy, in which the tumours are removed and the uterus is conserved and total hysterectomy, when the uterus containing fibroids is removed.

(1) Myomectomy:- This is ideal for young women who are anxious to have children or who are infertile and in whom the infertility is attributed to fibroids. A woman in early 30s is best suited for myomectomy.

In the operation, the myometrium over the tumour is incised and the tumour is completely shelled out from its capsule. It can be a bloody operation and thus an adequate amount of blood should be available during the operation.

(2) Hysterectomy:- Another treatment option is hysterectomy or the removal of the uterus (and the fibroids with it). This treatment is generally advised to women over 40 yrs of age. Occasionally, hysterectomy may be indicated in young women whose uterus is studded with fibroids, or if the tumours are associated with bilateral tubo-ovarian masses.

Hormone treatment is usually given to women with large fibroids to reduce the risk of bleeding during surgery, or to shrink the fibroids enough to be able to hysterectomy through the vagina instead through a incision in the abdomen.

References

1. Shawn's Book of Gynaecology, Hawkins & Bourne. Eleventh edition.
2. AMA, A Complete Guide to Women's Health.