Non cancerous (or benign) tumours of the muscle wall of the uterus are called Fibroids. These are common in women who are in the latter half of their reproductive life.

Dr K Satyavathi, MBBS, DGO, speaks on the types of fibroids, the problems they cause and treatment options available.

What causes fibroids? Who is at risk?

The occurrence of fibroids is believed to be due to the unopposed action of oestrogen on the uterus. Women in the following groups show a greater tendency to develop fibroids:

• Those who have had early marriages and early pregnancies and deliveries followed by a long period of infertility. Early child bearing is one of most common causes for fibroids in such patients.
• Nulliparous group or women who have not conceived at all. This includes both married and unmarried women. Hormonal activity is uninterrupted in their cases and can result in the growth of fibroids.

Do Birth Control Pills Cause Fibroids?

Birth control pills are not known to directly cause fibroids. However, persons diagnosed as having fibroids SHOULD NOT be given birth control pills. These pills can cause aggravation of the fibroids and are to be avoided in women with this problem.

Where are fibroids likely to occur? And what are the symptoms associated with them?

Two types of fibroids grow inside the uterus: intramural and sub mucosal. Subserous fibroids are those which grow outside the uterus. The site of the fibroids will determine the nature of risk and associated problems.

Intramural fibroids are those that are located close to the fallopian tubes and cause infertility. These are more difficult to treat due to their location and surgery is risky as it may further affect the tubes, which are very small and delicate.

Submucus fibroids are located in the muscle wall of the uterus. Such fibroids cause severe pain during menstruation, during contraction of the uterus. If located nearer the cavity, these fibroids may cause excessive bleeding.

Subserous fibroids can grow to a large size without detection due to lack of symptoms like pain or bleeding, as is the case with other types of fibroids. Their detection is related to problems/complaints of dysfunction of other organs like the bladder. The size of the fibroid and its location impacts other organs near uterus. Being asymptomatic they are not easily detected.

What are the problems that fibroids can cause?

Fibroids may result in:

• Sterility in the reproductive age.
• Dysfunctional uterine bleeding
• Pain during menstruation.
• Urinary problems.
• Problems during pregnancy

Sterility:

When fibroids are located near fallopian tubes they tend to cause infertility. Cornual fibroids block the opening of tubes causing sterility and are also difficult to rectify. Multiple fibroids also can cause infertility.

Bleeding Problems

Submucus fibroids located closer to the cavity cause severe bleeding and/or dysfunctional uterine bleeding.

Pain

Pain or pressure is closely associated with submucus and subserous fibroids. The site of the tumour is an important element in the nature of the complaint. Pain is caused by fibroids located in the muscle wall of the uterus while fibroids outside the uterus can cause pressure on other organs.

Urinary Problems

Subserous fibroids can result in urinary problems. The symptoms could be either frequent need for urination or otherwise in retention of urine. This is due to the pressure on the bladder from outside by the enlarged tumour. The fibroid usually grows undetected and can impact organs like the bladder.

Problems during pregnancy

There is a high possibility of miscarriage in the presence of fibroids in uterus.

Fibroids tend to either hinder the growth of the foetus in the uterus or can cause obstruction during delivery. It may also result in birth defects. Apart from this, the actual site of fibroids is also critical. Fibroids can also cause pain during contractions at the time of delivery.

Sometimes during pregnancy presence of fibroids can produce sudden pain. In very rare cases, subserous fibroids cause pain due to twist of the pedicle (portion of fibroid that is attached to the uterus).

Can fibroids turn cancerous?

It is extremely rare for fibroids to turn malignant.

If a woman with fibroids is pregnant, will it result in a Caesarean section?

No, not necessarily. It totally depends on the location of the fibroid. If situated near the birth canal of the uterus, then it may necessitate a Caesarean section as it will obstruct delivery. Usually, fibroids are not removed during a caesarian section as removal of the fibroids may cause a lot of bleeding.

What are the treatment options for a person with fibroids?

Treatment may not be always necessary. If the fibroid is asymptomatic and less than 5 cm it can be just followed up. Asymptomatic fibroids are usually detected only during routine examination. The seedling fibroids (around peanut size) are often left untouched and patients are advised to watch for symptoms.

The options are:

• Observation - for asymptomatic fibroids
• Medication _ as temporary relief
• Surgery – in cases of bleeding and other complications.

Observation:

It is necessary to monitor fibroids once detected to avoid complications. Growth, size and location apart from age, site of tumour and condition of the patient are other parameters, which will determine how often monitoring is necessary. Normally a review is recommended every six months to one year.

Medication:

In cases where the patient is anxious to conceive, medication is prescribed to provide temporary relief under strict medical supervision. This is taken up only for childbearing purpose as this medication only provides temporary regression of size and growth of fibroids. Fibroids have been found to recur or grow when the medication is discontinued.

Surgery:

Surgery is advised only to avoid future complications in case of rapid growth in size of tumour, or to facilitate conception, etc. Only in the case of profuse bleeding, severe pain or other complications is surgery recommended as an immediate intervention.

General condition of the patient like any for other surgery is one of the considerations.

What are the types of surgical interventions possible in the case of fibroids?

• Myomectomy: Myomectomy means removal of the fibroid alone while preserving the uterus. This is carried out for the reproductive age group of women who are anxious to conceive. It is done to avoid removal of the uterus.
• Hysterectomy: This involves the removal of the uterus. In case of very large fibroids, multiple fibroids and irregular ones hysterectomy may be needed.

Types of Myomectomy:

• Laparoscopic Myomectomy

  This surgery is possible when the fibroids are uniform in size. The fibroids are encapsulated and sucked out.

• Myomectomy using laser

  Laser coagulation is being used to puncture the fibroids.

Other procedures:

Myoma Coagulation (Myolysis)

This procedure is useful for certain types like central and fundal myoma. The fibroids are punctured and then left to be absorbed naturally.

What are the risks in undergoing Myomectomy?

Myomectomy may result in infertility due to infection. A scar is formed at the site of the surgery and scar related complications might occur. (Only a minimal scar is formed in case of laser surgery) A patient with scar has to be carefully observed during pregnancy. There is risk of scar rupture during pregnancy and delivery. Decision for surgery has to be taken weighing these risks.

What after care is advised after surgery?

Post operative care as in any abdominal gynaecological surgery is advised. Six to Eight weeks of rest may be required for full recovery from surgery especially if hysterectomy is done.

DR K SATYAVATHI completed her medical education at Andhra University, Visakhapatnam. Currently she is the Consultant Obstetrician at Sugam Hospitals and ESSEVEE Hospitals, Chennai. She has over 20 years of experience, much of it as the Head of the Obstetrics & Gynaecology department at the Sir Ivan Stedford Hospital , Ambattur, Chennai, in treating patients from semi-urban and rural areas.