What are Fibroids?
- Fibroids or uterine fibroids are smooth muscle tissue growths of the uterus
- It can also be referred to as a myoma, which is a slow growing benign tumour
- There is a less than 1% chance of this tumour developing into a cancerous growth
- Fibroids can grow in various parts of the uterus, including the cervix and broad ligaments
- Fibroids can either occur singly or in multiples within the uterus
- Fibroids are a very common gynaecological condition
- About 20% to 40% of women will develop fibroids in their lifetime
What are the Different Types of Fibroids?
- Intramural fibroid: Found in the muscle of the uterus
- Submucosal fibroid: Found in the endometrium of the uterus
- Subserosal fibroid: Found on the surface of the uterus
What Causes Fibroids?
The exact cause of fibroids is unknown. However, certain risk factors have been observed to increase the occurrence of these growths.
- Genetics or family history
There is a higher chance of a woman developing fibroids if her mother or sister has fibroids.
There are certain ethnic groups that have an increased risk of developing fibroids, in particular, the Africans.
Fibroids usually grow during the reproductive age of a woman, when there are increased levels of estrogen and progesterone. When a woman reaches menopause and has low hormonal levels, the fibroids usually shrink. If fibroids are seen to increase in size after menopause, it should be investigated for any possibility of a malignant or cancerous fibroid, also known as a Leiomyosarcoma.
Could I have Fibroids?
Other fibroids like subserosal fibroids typically do not cause any symptoms unless they become very big, in which case you might experience bloatedness and observe an increase in the size of your abdomen. (That’s not a tummy!)
If these large fibroids press on the bladder, you might be urinating more frequently or have a constant urge to urinate.
Experiencing symptoms or suspect you may have fibroids?
Can Fibroids Affect My Chances of Pregnancy?
- Fibroids typically do not cause infertility unless they are found to be obstructing the fallopian tubes, in which case, the sperm is prevented from meeting the egg to facilitate fertilization.
- Fibroids found in the endometrium may affect the implantation of the embryo, reducing the chances of pregnancy. There could also be a higher chance of a miscarriage.
- Some intramural fibroids near the womb lining could also affect uterine contractility and embryo transport.
If you have been actively trying to conceive, with no success, it is highly advisable to get a fertility assessment with your gynaecologist early to resolve any underlying issues if any.
- Fibroids generally do not affect pregnancy or cause harm to the baby.
- Majority of the fibroids seen in pregnancy are small and usually do not cause problems.
- However, there may be some big fibroids that could continue to grow as the pregnancy advances.
- If they become too big, they can cause pain and uterine contractions, which are not good, especially if the baby is not due for delivery.
- Right after delivery of the baby, fibroids may inhibit the contraction of the uterus, which increases the risk of massive bleeding.
- In such cases, it is essential for the obstetrician to be fully aware of the condition in order to anticipate potential problems and take preventive measures.
How can Fibroids be Treated?
Most fibroids do not need to be treated because they are usually small and do not affect the woman. However, if the fibroids are causing symptoms, treatment should be initiated.
The type of treatment will take into consideration factors like:
- Your age
- Family planning
- Number of fibroids
- Your priorities
Symptoms like heavy menstruation can be treated with tranexemic acid (a medicine that helps to clot your blood) or hormonal pills. In some cases, if the patient is agreeable, a hormonal Intrauterine Device can be inserted into the uterus to reduce heavy bleeding. However, these methods only help to manage the symptoms and do not remove the fibroids.
GnRH (Gonadotropin-Releasing Hormone) Agonist injections are sometimes used to simulate a pseudo-menopausal state. This reduces the level of estrogen and causes the fibroids to shrink. However, this is only a temporary method as the patient cannot be receiving the injection permanently, especially if you are planning for a baby. This method is often used to shrink very large fibroids before surgery, hopefully by 50% so that they can be removed easily with a small incision to lessen the risk of bleeding.
New medications such as Selective Progestogen Receptor Modulators (SPRM) shows much promise in the treatment of fibroids. Initially used for pre-operative shrinkage of fibroids, studies have shown that they can be effectively used for long-term for up to 18 months and that the effect persisted for 3 months even after completion of the medication.
Ultrasound examinations can be done periodically by a gynaecologist to monitor the fibroids and their growth. If they increase in size significantly, surgery may be required.
- Hysteroscopy (Trans-Vaginal)
If the fibroids are present within the endometrial cavity, a minimally invasive procedure known as Hysteroscopy can be performed. A scope (hysteroscope) will be inserted into the vagina through the cervix into the endometrial cavity. The fibroids can then be cut out. Hysteroscopy is safe and can be done as a day surgery. As no incisions are made, there are no scars. Beside hysteroscopy, fibroids can also be removed by myomectomy, which is the surgical removal of uterine fibroids. Myomectomy can either be done through laparoscopy or open surgery.
- Laparoscopic Myomectomy (Minimally-Invasive)
Laparoscopic myomectomy is a minimally invasive surgery where a few small incisions are made in the abdomen. The surgeon first inserts a scope (laparoscope) to identify and examine the fibroids. Thereafter, thin surgical instruments are inserted through the few small incisions to remove the fibroids. The incisions are then stitched up. The recovery rate of this procedure is relatively high.
- Single Incision Laparoscopic Myomectomy
This is the least invasive form of laparoscopic surgery as there is only one incision in the belly button. The scar is hardly visible and therefore cosmesis and speed of recovery will be the main advantage of this form of surgery. Suitability for this procedure will depend on factors such as size, position and number of fibroids that are to be removed.
- Robotic Surgery
This utilises robotic instruments that follow the wrist and hand movements of the surgeon who operates at the console with 3D vision. As a result, the movements are intuitive and have the most maneuverability/ dexterity of any minimally invasive technology. Usually robotic surgery will provide an advantage in the deep pelvis where there is limited space and when a lot of suturing is required.
- Laparotomy (Open Surgery)
However, not all fibroids can be removed through laparoscopic surgery. There are occasions where there is a need to do a laparotomy also known as an open abdominal surgery. An incision is made on the lower part of the abdomen to remove the fibroids. The advantages of this method is the speed of removal of large fibroids and the surgeon can also feel for fibroids that are buried deep inside the muscle of the uterus. Also, almost all fibroids can be removed via this method. However, as this is an open surgery, it cannot be done as a day surgery and the patient usually has to stay in the hospital for 3 to 4 days depending on her recovery. Open surgery also tends to leave a larger scar upon recovery.
Once the fibroids are removed during surgery, they are sent for a tissue (histology) examination where the pathologist will examine the fibroid tissue under a microscope and provide a diagnosis.
Your gynaecologist will then provide a review after your surgery.
This is a procedure performed to block the blood supply to the uterus and the fibroids. As a result, the fibroids are starved of oxygen and undergoes degeneration. The degenerated cells are absorbed by the body and the fibroids shrink in size. This procedure may not be suitable for those who desire pregnancy since potentially the blood supply to the uterus may be affected.
What is HIFU?
HIFU is an advanced technology developed for the treatment of fibroids, adenomyoma, adenomyosis, and certain cancers. It is a non-invasive and non-surgical treatment that is done as a day procedure. With HIFU, there is no downtime for recovery and the patient is able to resume her daily activities after the session.
How does HIFU work?
HIFU uses real time ultrasound and high-intensity ultrasound waves to generate localised heat to specifically target individual fibroids and destroy the cells. The body then absorbs the broken-down cells to shrink the fibroids over time. It usually takes 3 months for the symptoms to improve significantly.
The selection criteria is important for the success of the procedure.
What are the benefits of HIFU?
- Non-invasive, non-surgical procedure
- No loss of blood
- Minimal disruption to surrounding healthy tissues
- Quick treatment procedure (How long?)
- No downtime
What to expect before and after each treatment session?
Before each session:
- No sex 3 days before treatment
- Remove IUD if any
- Shave entire pubic area
- Bowel preparation with enema
- Diet requirements:
- 3 days before: Light diet low in vegetables and beans
- 1 day before: Liquid diet
- 8 hours before: No eating
After each session:
- Lie prone for 45 minutes after treatment
- Liquid food is allowed 2 hours after treatment and normal diet can be resumed 24 hours after treatment
- Keep pubic area clean
- No sex after treatment till the next menstrual cycle
- Temporary contraception may be advised for a few months
- Inserting of IUD should only be done after 3 normal menstrual cycles
- Follow up with ultrasound or MRI scan is advised (3, 6 and 12 months)
Interested in HIFU?
HIFU is one of the latest advancements in the treatment of fibroids. As a highly experienced and skilled gynaecologist who believes in minimally invasive techniques for better outcomes, A/Prof Fong is one of the few specialists that has been trained in the HIFU procedure.