Fibroids are common in women and occur in 20 percent of females. They are fibrous growth occurring almost always in the uterus (womb) of females. There is no known cause for uterine fibroids. Many people pass through life without knowing they have fibroids and most without any complications from the fibroids.
The majority of the people having fibroids do not have symptoms. They are discovered on routine health checks and on ultrasound of the pelvis. The majority of them do not need surgery or treatment. The size of fibroids can remain the same, enlarge but rarely shrink unless in menopause.
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Signs and symptoms of fibroids include : (the 5 ‘P‘s )
Period problems: Heavy menses, sometimes with blood clots. The patient can feel giddy, tired and breathless due to anaemia (low blood count).
Palpable lump: On examination, the womb can be felt to be enlarged. Usually, the womb is small and behind the pelvic bone and cannot be felt from the abdomen. Once this can be felt, it is considered large, and large enough to consider even surgery.
Pressure symptoms: They can press on the bladder, causing one to want to pass urine frequently. If the compression is severe, the patient may have difficulty in passing urine and even have an inability to pass urine. They can compress on the rectum giving the sensation of wanting to pass motion often.
Pain: Fibroids can cause severe pain if they are twisted (those occurring on the surface of the womb) or if they enlarge too fast over a short period.
Pregnancy-related: If the fibroids blocks the fallopian tubes or occupy the area of implantation of the pregnancy, or if they occupy a large area of the womb, causing fertility problems, then surgery may have to be considered.
The fuel or cause of growth of the uterine fibroids is the hormone, oestrogen from the ovaries. This hormone will only disappear after the menopause. This goes to say that when a patient is still having monthly periods, there is a higher chance for the fibroids to grow, and when she goes into menopause, there is usually shrinkage of the fibroids by at least 50 percent.
If the patient does not have the above signs and symptoms, the uterine fibroids just need monitoring by regular ultrasound and examination. This is especially so if the patient is near the menopause age (average 51 – 53 years of age).
Fibroids being cancerous is in the region of 0.03 percent. These are usually more than 6cm in size.
Unfortunately, there is no medication to treat uterine fibroids. There is an injection that can shrink fibroids up to 50% in size over 3 – 6 months. This injection cannot be given for more than 6 months as it can cause side effects, especially brittle bones leading to fractures.
Once the injection is stopped, the fibroids will grow again. In recent years, an oral medication was developed to shrink the fibroid but has in year 2020 been banned from use in Singapore as there was an unacceptable risk of liver damage.
Surgery For Uterine Fibroids: Pros And Cons
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When surgery is considered, the question is whether to remove the fibroids (myomectomy) or to remove the whole womb (hysterectomy).
If fertility is desired or for whatever reason that the patient wishes to retain the womb, then myomectomy is done. The risk of fibroids occurring again is about 15%, and this can be from the same site or from new areas. Myomectomy can be done by the open abdomen method or by key-hole surgery.
Key-hole surgery cannot be done for very big fibroids and may not be able to remove small fibroids embedded deep into the womb. Key hole surgery is generally not advised for large fibroid because the fibroid needs to be cut into small pieces for removal and in the unfortunate event of it being cancer, the cancer will likely spread due to the cutting spillage.
It is also difficult to stitch deeply and strongly in very large fibroids with many questioning the strength of the laparoscopically stitched wound in the womb leading to the worry of increased risk of womb rupture in labour for normal vaginal delivery.
If the surgeon is skilled and in selected cases, myomectomy can be done through the vagina. Fibroids in the lining of the womb can be removed by hysteroscopic resection ( through a scope through the vagina and the cervix , opening of the womb).
Hysterectomy can be done by the open method, by keyhole surgery and through the vagina. The advantage of vaginal surgery, if it can be done, is that there are no abdominal scars, recovery is very fast, hospital stay is short (one day in some cases) and pain is very much less than the other methods.
Complications Of Fibroid Surgery
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Complications of surgery include anaesthetic risks, bleeding, infection and injury to surrounding structures such as bowel or the urinary system.
Newer methods include embolisation of the arteries ( blood vessel ) supplying the womb, and ultrasound waves / mri guided destruction of the fibroids. These newer methods may not be suitable for people desiring fertility as it may weaken the area in the womb, increasing the risk of womb rupture in the event of labour for vaginal delivery of the baby.
For large fibroids, the procedures can take many hours and the patient may complain of pain after the procedure. Also, for larger fibroids, as we do not have the histology (microscopic examination of the specimen), we may miss the unlikely case of cancer. For smaller fibroids, treatment may not be needed.
As of now, the newer methods are for selected cases, that is, not everyone is suitable and we await eagerly for more data and results on our patients.
My advice to my patients is always, “See a doctor when you are well, and not when you are unwell.” Do not wait for signs and symptoms from fibroids before seeking treatment. Best wishes for good health!
Dr Christopher Chong is a pioneer in Incontinence, Prolapse and Pelvic Reconstruction Surgery, being one of the first Urogynaecologist in Asia to perform such surgeries and has performed thousands of such surgeries to date.
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