UTERINE FIBROIDS

A large uterine fibroid

A growth in the uterus is a common problem among women, especially middle aged ones. With the introduction of the ultrasound, more and more women have been diagnosed with uterine growth. If adenomyomas are included, the figure would be even higher.

Uterine fibroids make up most of the uterine growths which usually occur in middle aged patient although we do see young women in the twenties with huge fibroids. It has been estimated some women aged 35 and above, one in five would developed uterine fibroids. Fortunately, many of these fibroids are benign and do not cause any symptoms.

Causes

1. Like most other tumours, the actual cause of uterine fibroids is not known although it appears to be related to the production of female hormones. Fibroids are very rare present in young girls before the start of menstruation. After the menopause, it is very likely that no new fibroids are formed. Even if found, they most probably existed before menopause. The peak incidence of uterine fibroids is in women in 30 to 40 year-old age group.
   
   The other evidence supporting the hormonal theory of fibroids is that during pregnancy, when female hormones (estrogen and progesterone) are markedly raised, the rate of growth of uterine fibroids is much faster than usual.
   
   
2. The genetic or hereditary factor also plays an important role in the developing of fibroids. Even though all women produce estrogens during the reproductive years, yet some have fibroids and others do not, and the estrogen level among those with uterine fibroids is not excessively high. Also it was found that the chances of other female of a family like mothers, daughters, sisters having this same disease is high.
   
   
3. Uterine fibroids may be related to infertility or a low number of children although this is controversial. What is true is that fibroids are seen in greater proportion among the infertile female. Women in Singapore tend to marry late and deliver late. Many of the patients with uterine fibroids are in the thirties. Although one might conclude that not having babies is the cause of uterine fibroids, a cause-effect relationship is difficult to establish. But it is known that many of the patients who are infertile and also with uterine fibroids, have increased their fertility once the fibroids have been removed.
   

Site of growth

The uterine fibroids may develop in the uterine body, the cervix of the uterus, or the broad ligament.

Pathology

It is quite common to see multiple uterine fibroids in the uterus. Each fibroid is a separate, round mass, with a capsule, separating from the muscle fibers of the uterus. The cut surface is pale yellow, smooth and firm to touch.

Types of uterine fibroids

The wall of the uterus comprises (1) the serosa, which is the outer layer. (2) the muscle layer. (3) the inner lining or the endometrium. The growth of uterine fibroid may be in any of the three layers.

1. Subserous fibroid - the fibroid grows from the serosa layer or from the muscle layer and protrudes through the surface. It may have a stalk-like attachment and is known as a pedunculated fibroid. The removal is easy.
   
   
2. Interstitial fibroid - this is the most common position for fibroids which grow from the uterine muscle fibers and have many different sizes, shapes, hardness and numbers.
   
3. Submucous fibroid - the growth is just below the endometrial lining and protrudes into the uterine cavity. It may have a stalk called pedicle and tends to fill up the uterine cavity or even pass out of the uterus into the cervix. Submucous fibroids often cause irregular and heavy bleeding per vagina.
   

Symptoms

1. Heavy menstruation & irregular bleeding - this is less common in the subserous fibroid, but is a frequent complaint in women with in interstitial fibroid and submucous fibroid.
   
   
2. Pain is an uncommon symptom except in situations like (a) cervical fibroid which is being passed out by the uterus - this results in severe pain (b) Torsion of the pedicle may also cause pain. (c) the fibroid may be affected by poor circulation resulting in degeneration and pain.
   
   
3. Pressure symptoms - uterine fibroids may cause pressure symptoms to the surrounding structures like bladder, ureter, blood vessels, nerve and gut.
   
   
4. Infertility - a submucous fibroid may hinder the passage of sperm resulting in infertility. The distortion of the uterine cavity from the fibroids may also affect implantation. On the other hand there are many women with uterine fibroids who do get pregnant and deliver just like normal women without fibroids.
   

Diagnosis

During the visit to the doctor, he will take a careful history, perform a pelvic examination, and carry out an ultrasound examination and blood tests.

Treatment

Not all fibroids need to be removed surgically especially if they are no symptoms. However regular follow ups are necessary.

When symptoms affects a woman adversely e.g. heavy bleeding resulting in anemia, pain and pressure symptoms, an operation may be considered. The doctor will discuss the various options and the method and type of surgery depends on the age, number of children, position of the fibroid, size and the seriousness of the symptoms.

Types of surgery

1. Myomectomy - this operation removes just the fibroids and the uterus is left behind. It is suitable for young patients who are still of the childbearing age and have not completed their families.
   
   
2. Total hysterectomy - a complete removal of the uterus. This is often done for patients nearing the menopause who suffer from severe bleeding not controllable by medication or other conservative methods. Total hysterectomy may be done by the open method (laparotomy) or by minimally invasive surgery known as laparoscopic hysterectomy or the more widely used term laparoscopic assisted vaginal hysterectomy (LAVH). For more information on hysterectomy, please refer to the topic in the section under "articles".