Understanding fibroids

Uterine myomas, commonly called fibroids, are very common in South Asian and African women. However, the risk of them turning malignant or cancerous is very rare. In an interview with the Sunday Island, Consultant Obstetrician and Gynaecologist and Senior Lecturer in Obstetrics and Gynaecology from the Kotelawala Defense University, Dr. Romanie Fernando throws light on the causes and treatment of fibroids which are found in 30% of Lankan women over 30 years.

by Randima Attygalle

Uterine fibroids are benign or non-cancerous muscular growths which could appear in the uterus (womb), uterine wall or on its surface. The uterine wall which is made of smooth muscle becomes harder as a result of fibroids. “There is a genetic pre-disposition involved in fibroids; South Asian and African women are at a higher risk of getting fibroids and why they are more pre-disposed is still unknown,” says Dr. Romanie Fernando.

Fibroids usually appear in women of reproductive age- generally between 30-40 years although in some, they could appear earlier than that. “They are very common, so much so, one in three Lankan women above 30 years will have fibroids. However, the risk of having a malignant change is very rare. Only less than 0.5% of uterine fibroids will have the risk of turning into cancer, hence women should not have unnecessary fears about them,” Dr. Fernando says.

Causes

Genetics and hormones largely influence fibroids and their growth. Estrogen and progesterone imbalance affect fibroid growth. When hormone production slows down during menopause, these fibroids usually shrink. “Family history, age and race are the other factors which could place a woman at a higher risk of developing them,” explains the obstetrician.

Symptoms

Symptoms depend on the size and site of the fibroid. Only about 30% of women with fibroids will have symptoms and the majority will be asymptomatic (not showing symptoms). “Some fibroids are so small and are of a size of a shirt button that they will go unnoticed and won’t cause any harm, while others grow in big masses and can affect the uterus and adjacent structures causing symptoms.”

If a fibroid is found inside the uterus or the uterine cavity, it could affect the menstrual cycle resulting in pain during menstruation, heavy periods and spotting (bleeding in between two cycles). “If a fibroid is found in a woman close to menopause and if it is not causing any menstrual or pressure symptoms, we usually wait until she reaches menopause without intervening because with low estrogen, the fibroids will naturally shrink.”

Diagnosis

Diagnosis is largely an incidental or accidental finding during a clinical examination. “During a routine pelvic exam a doctor may suspect fibroids if the shape of the uterus feels irregular or unusually large. Fibroids are also diagnosed during pregnancy when routine scans are done.”

Treatment

Treatment too depends on the age of the woman, size and site of the fibroid. The growth of most of the fibroids is very slow, usually about half a centimeter in two years, explains Dr. Fernando. “However, if the growth is very rapid within a short time, it could be worrying and we need to intervene to remove it.”

Although not a very common presentation, severe backache could also be a symptom of fibroids. “Some women with fibroids could also be anemic due to increased menstrual blood loss and in such instances, we address anemia as well.”

Fibroids are treated symptomatically. If a fibroid is found to be causing pain, heavy menstrual flow or pressure on other organs such as the bladder for example, (causing frequent urges to urinate or inability to control urine) investigations will be done to determine the best mode of treatment. “Treatment could be either with oral medication or surgery depending on the severity of each case.”

Fibroids and pregnancy

If fibroids larger than five centimeters are found in a woman before her pregnancy, they are usually surgically removed to avoid complications during pregnancy. During pregnancy, the blood supply to the womb is increased, hence removal of fibroids is very risky and is postponed until after the delivery. “After a pregnancy the hormone levels and the blood supply become less and the fibroids too tend to become smaller. There had been maternal deaths when trying to remove fibroids during cesarean operations because of the inability to control the heavy bleeding,” says the consultant.

Fibroids can cause foetal growth restrictions and premature labour in some women. The positioning of the baby could also be abnormal in some cases. “If the fibroid is found closer to the uterine cavity, there could be a higher risk of miscarrying and after normal delivery heavy bleeding (post-partum haemorrhage) is also common.

Types of surgery

There are many ways to treat fibroids. The treatment that works best for each woman will depend on symptoms, reproductive plans, age, and the site of fibroids in the womb. “In younger women with reproductive wishes (those who hope to get pregnant in future), we usually remove the fibroids with myomectomy. This type of surgery removes them while retaining the healthy tissue. Myomectomy could be performed in many ways from abdominal surgery to laparoscopy,” remarks Dr. Fernando.

Although several other non-surgical interventions including the latest high intensity focused ultrasound (HIFU) device which was developed for treating uterine fibroid and drugs to shrink fibroids are available in other parts of the world, locally we are still limited to treating fibroids surgically with myomectomy (removal of the fibroid) or hysterectomy (removal of the uterus), says the consultant.