What are Fibroids?

What are Fibroids?

FIBROIDS AND TREATMENT OPTIONS

What are Fibroids?

Fibroids are benign (non-cancerous) tumours. They grow on or in the muscle layer of the uterus (womb). The medical name for fibroids is uterine leiomyoma. Doctors usually describe the size of a uterus enlarged by fibroids in the same way they talk about the size of a pregnant uterus.

Types of Fibroids

Submucosal fibroids

Under the lining of the womb, can cause heavy periods and anaemia.

Intramural Fibroids

Within the wall of the womb, most common type.

Subserosal

On the outer wall of the uterus and usually this causes no symptoms until it grows large enough to cause interference to adjacent organs. Sometimes, they grow on a stalk or pedicle and may be called pedunculated fibroids.

Symptoms of fibroids

Many patients don’t have any symptoms and therefore you probably don’t even know you have fibroids. However, some patients who have uterine fibroids may experience the following symptoms:

• Prolonged and heavy bleeding or painful periods
• Bleeding between periods.
• Anaemia
• Feeling “full” in the lower part of your belly.
• Frequent passing of urine.
• Lower back pain.
• Constipation.
• Haemorrhoids.
• Painful sex.
• Infertility.
• Miscarriages.
• Premature labour during pregnancy.

Heavy menstrual bleeding

This is the most common symptom. You may experience any of the following:

• Flooding: a sudden gush of blood.
• Prolonged periods: much longer duration than you had in the past, e.g. 10 days compared to 4/5 days previously.
• Large blood clots, probably size of 50p coin or more.

These symptoms can be distressing, make you feel very tired and restrict your daily activities. You could be changing you tampons/pads very frequently and find it difficult to go to work.

Anaemia

Heavy monthly bleeding can lead to iron deficiency which may make you feel very weak, tired and dizzy. It may be so severe to warrant at least iron level correction while waiting for a decision on the treatment of the fibroids.

Pain

Large blood clots or multiple fibroids cause severe pain & cramps. Large fibroids can press on the nerve trunks to cause chronic pelvic pain.

Pressure-related on adjacent organs

Large fibroids exert pressure on the nerve and blood vessels which can result in a dull ache in the thighs and varicose veins.

Pressure from large subserous fibroid can cause the following:

• Increase in frequency to pass urine.
• Leaking and dribbling of urine
• Urgent need to pass urine but only small amount comes
• In severe cases, difficulty or inability to pass urine which requires a catheter.
• Occasionally, cystitis: caused by trapped urine which later becomes infected.
• Constipation & haemorrhoids: caused by pressure on the rectum.

Pain during sex

This happens when the fibroids press on the cervix or they hang through the cervix into the vagina. Bleeding may also occur.

Complications of Fibroids

Fertility: Large fibroids can affect fertility

Pregnancy and labour: Fibroids if present in the lower part of the uterus can obstruct labour and increase the need for Caesarean section. Large fibroids may also be associated with pain in pregnancy as premature labour.

Pressure symptoms: Fibroids can cause pressure on the bladder and bowel and can cause urinary and bowel symptoms.

Cancer: Fibroids are benign tumours and malignant change is very rare. About 0.2% fibroids can become malignant.

Treatment options

Medical Management

NSAID (Ibuprofen or Mefenamic acid) in combination with birth control pills or intrauterine system (LNG-IUS) has been effective in reducing menstrual blood loss. The combined oral contraceptive pill containing oestrogen may be better avoided in fibroids.

Intrauterine device with Levonorgestrel (Progesterone hormone)

Can be used in uterine size less than 12 weeks and is not effective if the size of the womb is large or there is a fibroid in the lining of the womb. The coil will reduce the amount of blood loss. The IUS will not reduce the size of the fibroid. The device can reduce the need for surgery. Your doctor can provide you further information and check your suitability.

Tranexamic acid

Tranexamic Acid encourages clotting in the lining of the womb been shown effective in reducing blood loss during periods. In patients with fibroids who have mild bleeding, 3 or 4 days per month treatment has been very useful.

GnRH analogues

This medication stops the ovarian activity temporarily and reduces the level of oestrogen and progesterone in the blood. Due to the reduction in the hormone level this can cause menopausal symptoms. The medication can help in reducing the risk of open surgery, midline incision, blood transfusion and anaemia.

You may be offered this treatment a few months before surgery to reduce the size of the fibroid and reduce risks associated with surgery. The doctor prescribing this medication will also discuss add back treatment in form of hormone replacement therapy called as “add back therapy” to reduce menopausal side-effects. This is recommended prior to fibroid surgery and the doctor in charge of your care will discuss this with you.

Ullipristal Acetate (Esmya)

Oral medicine to control the symptoms of fibroid where surgery is not possible. This is initiated in the first 7 days of your cycle. Most patients will notice a significant reduction in their blood loss. The doctor will go through your details and your clinical history to see if this is a suitable option. You will need monitoring of your liver while you are on this treatment. This is offered as an option for patients who are not able to have surgery for medical reasons.

Ryeqo

This a most recently approved treatment for moderate to severe symptoms of uterine fibroids in adult patients of reproductive age above the age of 18 years. This can be discussed as an option if suitable for you. This medicine can help in reducing symptoms and in some cases surgery can be avoided. After taking the tablets for 2 months 50% patients will stop having periods and 70% will stop periods after takin this tablet for 12 months. Your doctor will take medical details and examine to see if you are suitable for this treatment. hot flushes, indigestion symptoms, hair loss, night sweats, development of clots in veins and irregular bleeding are known side effects. Further patient information will be provided if you are initiated on this treatment.

Surgical and non-surgical options

Uterine artery embolization

This involves injecting small particles into the blood vessels that bring blood to the womb particularly those vessels feeding the fibroids causing blockage. Without further blood supply, the fibroids could no longer grow and they eventually shrink. This technique is not suitable for every type of fibroids.

The procedure is carried out by an interventional radiologist. An interventional radiologist is a doctor who is specially trained to diagnose and treat many conditions using tiny, miniaturised tools, while monitoring their progress on X-ray or other imagining equipment. Typically, the interventional radiologist performs procedures through a very small nick (incision) in the skin. Because this treatment does not use a surgical incision the patient benefits from a much shorter stay in hospital and recovery time is reduced to 1-2 weeks. The interventional radiologist will work closely with the primary care doctor and gynaecologist to ensure the highest standards of care.

This minimally invasive procedure, previously known as uterine artery embolization (UAE), is carried out while the patient is conscious but sedated, drowsy and feeling no pain.

The catheter is guided through the arterial tree to the uterus while the radiologist watches the progress of the procedure using a moving X-ray (fluoroscope). Tiny microspheres, the size of grains of sand, are injected into the artery that is supplying blood to the fibroids, cutting off the

flow. Both left and right sided arteries are treated, usually requiring a single micro-incision.

What are the disadvantages of uterine fibroid embolisation?

• Possible persistence of symptoms, requiring alternative treatment. This depends upon the type and size of fibroids
• Possible emergency hysterectomy due to infection of the womb 1:100
• Pain
• Vaginal discharge or rarely vaginal passage of fibroid

Myomectomy

This involves surgical removal of the fibroids; can be done via keyhole in some cases. It enables you to retain your womb and most suited when you still want to have children. This technique is not always possible because it depends on the size, number and location of the fibroids. Depending on the type of fibroid the surgery can be performed the abdominal route (keyhole or open procedure) or through the neck of the womb (hysteroscopic) route.

Below are the type of incisions (cuts) which could be made for your surgery.

Removal of submucosal fibroid from the lining of the womb using a special telescope called resectoscope.

Hysterectomy

The womb is surgically removed; in most cases the ovaries are left behind to avoid pre-mature menopause. You should have completed your family or have no desire for pregnancy to have this procedure. It is a permanent solution to all symptoms caused by fibroids. The doctor will discuss details of hysterectomy, types of hysterectomy depending on the individual symptoms, size and the number of fibroids.

Patient resources

www.britishfibroidtrust.org.uk

https://patient.info/womens-health/periods-and-period-problems/fibroids

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

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If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

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How to contact PALS:

Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

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The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day. If you are unable to understand this leaflet, please communicate with a member of staff.

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