Other names for uterine fibroid: fibromyoma, leiomyoma, myoma or simply fibroids.
Nigeria is the headquarter of fibroids in the world. The incidence of fibroids is quite high in Nigerian women over the age of 25 years. In fact, it is the commonest tumour in our female population. It is reckoned that over 80 percent of the women over age 25 years have fibroids if only of the size of a seedling. Invariably, no operation list of a gynaecologist in this country is complete without a myomectomy or hysterectomy for removal of fibroids.
The cause of fibroids is unknown although there have been some postulations. There may be racial and genetic factors which make fibroids more common in black than white women. The role of ovarian steriod hormones as causative factors are also now recognised.
In Nigeria, an association between fibroid and pelvic inflammatory disease has been observed and may be the basis for the assumption that fibroids cause infertility and vice versa. It is a fact that pelvic inflammatory disease invariably results in infertility.
Another explanation for the association of fibroid and infertility is also derived from the assumption that fibroid can change the normal appearance of the uterine cavity and adversely affect the endometrium. Successful implantation depends on a normal receptive endometrium.
sites of fibroids
The common sites of fibroids in the womb are:
- Subserous, when it is beneath the serous(outer)covering of the uterus. Sometimes. Sometimes this may possess a stalk and may be referred to as pedunculated fibroid
- Interstitial, when it is with the muscle of the womb.
- Submucous, when it is beneath the endometrial lining of the womb. It may sometimes develop into a fibroid polyp.
- Cervix, when it is situated in the cervix.
- Broad ligament, when a subserous fibroid narrows into the broad ligament.
symptoms of uterine fibroids
Fibroids may be symptomless especially if they are small. Symptoms associated with fibroids include:
- Menorrhagia (Heavy menstrual bleeding): This is more common with the submucous type, which increases the endometrial surface from where bleeding occurs. Other explanations for menorrhagia are increased vasscularity associated with the tumour and also more degree of endometrial hyperplasia.
- Abdominal swelling: The woman may complain of a swelling in the abdomen or increased abdominal girth if the fibroid is a big one.
- Irregular bleeding: The menstrual pattern may become irregular and the bleeding heavy in the presence of fibroid polyp or when a submucous fibroids become ulcerated.
- Pressure symptoms: A large fibroid may compress the surrounding organs and present corresponding symptoms below. Examples of pressure symptoms are leg swelling, constipation, urinary frequency or retention, varicose veins, and pain due to pressure on the sacral plexus (nerves)
- Infertilty: It is allerged that fibroids may cause infertility. It is supposed this may probably be possible only if the fibroid is situated at the ends of the Fallopian tube thus obstructing the flow of spermatozoa to the released ovum. It is not quite certain to what extent implantation of fertilized ovum is prevented by the presence of submucous fibroid. Some Nigerian women with pre-existing fibroids are however known to have become pregnant.
The following tests may be carried out to confirm diagnosis of myoma;
- Plain abdominal X-ray: A soft tissue mass may indicate a fibroid tumour. This may be more diagnostic if areas of calcification are shown within the tissue.
- Intravenous urogram: An intravenous urogram should be mandatory in a case of large uterine fibroids. Apart from some degree of hydroureter and hydronephrosis which may be noted, this will also show the course of the ureters which is a great advantage to the surgeon especially in this country where frequently myoma coexists with pelvic inflammatory disease with resulting adhesions and distortion of ureteric outline.
- Ultrasound: This will show echoes typical of a solid mass. It may also show the kidneys and ureteric course.
- Diagnostic curettage:This is done mainly to exclude the presence of a other diseases like endometrial cancer especially if the surgeon is thinking of treating the woman by myomectomy (removing only the fibroid masses) as opposed to hysterectomy( total womb removal).
Treatment of uterine fibroids
No treatment is required if a fibroid is symptomless. However fibroids that enlarge the womb to about 12 weeks pregnancy size, whether symptomless or not should be removed. Most gynaecologists in Nigeria will remove fibroids in the uterus of any woman who complains of infertility if no other cause is found. Some of these women have indeed been known to become pregnant after such operation.
Treatment of fibroid could medical (non-surgical) and surgical. Surgical treatment may be minimally invasive or the traditional.
Medical(non-surgical) treatment of fibroids
This involves the use of medications. Medications for uterine fibroids target the hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids, but may shrink them.
The use of gonadotropin- releasing hormone (Gn-RH) agonists such as Lupron and Synarel treat fibroids by blocking the production of estrogen and progesterone, putting you in a temporary postmenopausal state. As a result, your period stops, fibroids shrink and anemia improves. These drugs may be taken to shrink the size of your fibroids before your planned surgery.
Many women have significant hot flashes while using Gn-RH agonists. Gn-RH agonists are typically are used for no more than three to six months because symptoms return when the medication is stopped and long-term use can cause loss of bone mass and make you prone to osteoporotic fractures.
Progestin-releasing intrauterine device (IUD) can relieve heavy bleeding caused. A progestin-releasing IUD provides symptom relief only and doesnt shrink fibroids or make them disappear. It also prevents pregnancy.
A non- hormonal medication called tranexemic acid (Lysteda) is taken to ease heavy menstrual periods. It is only taken on heavy bleeding days.
Other medications like combined oral contraceptives or progestins can help control menstrual bleeding, but do not reduce fibroid size. Non steriodal anti-inflammatory drugs may be effective in relieving pain related to fibroids, but they doon’t reduce bleeding caused by fibroids.
Minimally invasive surgical treatment of uterine fibroids
- uterine artery embolization: Normally fibroids masses have a rich blood supply and cutting-off or blocking the blood supply to shrink the fibroid mass. Following a good embolization, there is a marked reduction in the size of myoma after 6 months. Hemorrhage disappeasrs immediately in most cases, and there is no recurrence usually. Pelvic symptoms also disappear in most women.
- Laparoscopic myomectomy: Myomectomy is the removal of fibroids leaving the uterus in place. Laparoscopic myomectomy is minimally invasive. It has replaced abdominal myomectomy in many advanced countries. Good success rates have been reported and the danger of subsequent rupture of the uterus in labour in subsequent pregnancy has not been recorded. It involves minimal bleeding and reduces length of hospital stay.
- Hysteroscopic myomectomy: This is a minimally invasive surgery of removing myomas if the are contained in the uterus (submucosal). This technique is a safe and effective treatment of choice in the treatment of submucous fibroids in patients with abnormal uterine bleeding.
- Laparoscopic assisted transvaginal hysterectomy: Hysterectomy is the total removal of a womans uterus. Women who have had hysterectomy can no longer carry pregnancy but can still have babies through egg donation, surrogacy or adoption. Laparoscopic assisted transvaginal hysterectomy is a modern method of dealing with fibroids which are about 12 weeks pregnancy size or less without resorting to laparotomy (opening up the abdomen). The procedure lessens possibility of injuries and shortens hospitalization.
Traditional surgeries for fibroids
This method is still very much popular in developing countries. It involves opening opening up the abdomen so as to gain direct contact to the uterus for the fibroids removal. The fibroids mass may be enucleated from the uterus leaving the uterus intact (myomectomy) or the whole uterus may be removed (hysterectomy).
This is the operation of choice for fibroids in our environment. Hardly is any gynaecological operation list complete without a myomectomy. Child bearing is an essential part of our culture and tradition any woman of child bearing age will prefer to preserve her uterus. The operation invariably demands preoperative blood transfusion as most women are already anemic from long standing menorrhagia. At least, two or three pint of blood are made available before the surgery. After making an incision in the abdomen, the fibroid uterus exposed. An incision is then made over the fibroids and they are then shelled out through a line of cleavage. As many fibroids as can be visualised or felt may need to be enucleated to prevent to prevent subsequent re-growth, no matter how tiny. Abdominal myomectomy is the best treatment for large fibroids.
Abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of the ovaries) is offered to women with fibroids if they are over 40 years or they have completed child bearing or are perimenopausal. In Nigeria (developing countries), this procedure is not readily acceptable to women of child bearing age.
The recurrence rate of uterine fibroid is extremely low indeed especially with newer operative techniques and preliminary ultrasound to determine the number of fibroids to be removed.
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