Fibroids can grow back. For some women, especially those who are ready to enter menopause, hysterectomy (surgically removing the uterus) is a reasonable alternative. Cleveland Clinic gynecologic surgeons are experts in minimally invasive forms of hysterectomy and are pioneers in robotic and single port
hysterectomy. With many modalities available to perform hysterectomy, our physicians will determine which route is best based on the size, number and location of your fibroids, and other clinical indicators.
“Open” abdominal hysterectomy is one of the most common surgeries performed in the United States. It involves removing the uterus through an incision at the bikini line. Cleveland Clinic specialists prefer to use less invasive alternatives whenever possible.
In this approach, the uterus is removed through an incision in the vagina, which avoids an abdominal incision and scar.
Some patients are eligible for removal of the uterus through slender instruments inserted into the abdomen using a laparoscope. In laparoscopic surgery, several tiny incisions are made in the abdomen so that a miniature camera and special instruments can be inserted. Benefits include a 23-hour hospital stay, less need
for postoperative pain medications and faster return to activity.
This advanced form of laparoscopy involves the use of robotic instruments guided by tiny 3-D cameras. The surgeon controls robotic arms that carefully remove the uterus and precisely suture tissue. Only small abdominal incisions are required. Similar outcomes to laparoscopic hysterectomy are also noted including
decreased postoperative pain, decreased need for pain medications and quicker return to normal activities.
Single port hysterectomy
This procedure utilizes one incision in the belly button. It has similar outcomes when compared to laparoscopic and robotic approaches. An additional benefit is that there is only one belly button incision.
WHAT IS FIBROID EMBOLIZATION?
Fibroid embolization is a new way of treating fibroids by blocking off the arteries that feed them, the uterine arteries, and making the fibroids shrink. It is performed by a radiologist, rather than a surgeon, and is an alternative to an operation. Fibroid embolization was first performed in 1995 and, since then, many thousands of women have undergone the procedure worldwide.
WHY WOULD I CHOOSE FIBROID EMBOLIZATION?
Other tests that you have had done show that you have fibroids and that these are likely the cause of your symptoms. Your gynaecologist and your family doctor will have told you all about the problems with fibroids and discussed with you ways of dealing with them. Hysterectomy, myomectomy, and embolization are possible treatments. Your doctor can address with you the risks and advantages of each so that you can make a decision regarding the most appropriate choice for your personal situation.
WHO WILL DO THE FIBROID EMBOLIZATION?
A specially trained doctor called an interventional radiologist will do the fibroid embolization. Radiologists have special expertise in using X-ray equipment and also in interpreting the images produced. They look at these images during the procedure. Interventional radiologists are trained to insert needles and fine catheters into blood vessels and through the skin in order to perform certain minimally invasive treatments.
WHERE WILL THE PROCEDURE TAKE PLACE?
Generally fibroid embolization takes place in the X-ray department, in a special “procedures room” adapted for such a procedure.
HOW DO I PREPARE FOR FIBROID EMBOLIZATION?
You will probably be asked not to eat for 4 hours beforehand, although you may be told that it is all right to drink some water.
You may receive a sedative to relieve anxiety. You will be asked to put on a hospital gown. As the procedure is generally carried out using the big artery in the groin, you may be asked to shave the skin around this area. If you have any allergies, you must let your doctor know. If you have previously reacted to intravenous contrast medium, the dye used for kidney X-rays and CT scanning, then you must also tell your doctor about this.
WHAT HAPPENS AFTERWARDS?
You will be taken back to a recovery room or to your ward on a stretcher. Nurses will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no untoward effects.
They will also look at the skin entrypoint to make sure there is no bleeding from it. You will generally stay in bed for 6 hours. Most patients experience pain such that they need narcotics either by pill or intravenous for several hours following the procedure. You may be kept in hospital over night.
The day after the procedure, you may resume normal activities as your symptoms allow, but most women require some time off work as they continue resting and taking pain medication for the first few days. Some patients may feel very tired for up to 2 weeks following the procedure, although some people feel fit enough to return to work 3 days later. However, patients are advised to take at least 2 weeks off work following
ARE THERE ANY RISKS OR COMPLICATIONS?
Fibroid embolization is normally a safe procedure but there are some risks and complications that can arise, as with any medical treatment. There may occasionally be a small bruise, called a hematoma, around the site where the needle has been inserted, and this is quite normal. If this becomes a large bruise, then
you should contact your radiologist to ensure that no treatment is needed. Most patients feel some pain afterwards. This ranges from very mild pain to severe cramping, period-like pain. It is generally worst in the first 12 hours but will probably still be present when you go home. While you are in hospital, this can
be controlled by powerful painkillers. If the pain is associated with nausea or vomiting, anti-nausea drugs will be prescribed. You will be prescribed further medications to take at home.
Most patients get a slight fever after the procedure, which may be due to degeneration of the fibroid. The painkillers you will be given will help control this fever. A few patients get a vaginal discharge afterwards, which may be bloody. This is usually due to the fibroid breaking down. Usually, the discharge persists for approximately 2 weeks from when it starts, although occasionally it can persist intermittently for several months. This is not in itself a medical problem. If necessary, wear sanitary pads rather than tampons.
If the discharge becomes purulent (has pus in it) and if you also have a high fever and feel unwell, infection may be present and you should ask to see your gynaecologist immediately.
Infection is the most serious complication of fibroid embolization.
This happens to perhaps 2 in every 100 women having the procedure. The signs that the uterus is infected after embolization include pain, pelvic tenderness, and a high temperature.
Lesser degrees of infection can be treated with antibiotics. Once severe infection has developed, it is generally necessary to have an operation to remove the uterus—a hysterectomy. One patient has died after fibroid embolization because of severe infection. If you would not want a hysterectomy under any circumstances, then it is probably best not to have fibroid embolization performed.
Up to 15% of women spontaneously expel a fibroid, or part of one, usually 6 weeks to 3 months afterwards. If this happens, you are likely to feel period-like pain and have some bleeding.
A few women have undergone an early menopause after this procedure. This has probably happened because the blood supply to the ovaries has been affected. Early menopause is more common in women who are over the age of 40 when they have UFE.
WHAT ARE THE RESULTS OF FIBROID EMBOLIZATION?
The results from most scientific series are very positive, with symptom relief in 50 to 90% of patients. Patients with fibroids and heavy bleeding as their reason for UFE typically have the
best results. On average, shrinkage of fibroids is about 50% of the volume of each fibroid. The majority of women are pleased with the results. If having a baby in the future is very important to you, you need to discuss this with your doctor, as there are reports that there may be more complications in pregnancy following UFE.
For women who are interested in future fertility, a myomectomy may be a better choice.
This leaflet should answer some of your questions about fibroid embolization. However, this is only a starting point for discussion about your treatment with your doctors.
Make sure you receive enough information about the procedure before you sign the consent form.
Fibroid embolization is considered a safe procedure, designedto improve your medical condition and save you having a major operation. There are some risks and complications involved and, because there is the possibility of a hysterectomy being necessary to deal with complications, make sure that you have discussed
all the options available with your doctors.
Fibroids treatment options include observation, drug therapy, myomectomy (surgical removal of the
fibroids, but not the uterus), embolization of the blood supply to the fibroids, uterine artery
ligation, and hysterectomy. There are no “alternative” therapies that have been objectively
demonstrated to shrink fibroids (fibroid cure).
* Fibroids Drug Treatment
GnRH analogues are the only currently available proven effective drug treatment. They create a pseudo-menopause (hypo-oestrogenic state). Their therapeutic use is largely confined to women who are peri-menopausal and wish to avoid surgery until menopause supervenes, and the fibroids shrink spontaneously.
They may also be used pre-operatively to shrink the fibroids to facilitate a laparoscopic, hysteroscopic or open myomectomy, as well as making it possible to perform a vaginal or laparoscopically assisted vaginal hysterectomy rather than an abdominal hysterectomy by shrinking the fibroids.
Embolic occlusion of the blood supply to the fibroid(s) can be performed as an outpatient procedure under local anaesthesia with non-steroidal anti-inflammatory drug premedication, e.g. Naprogesic. However, post-procedural pain necessitates overnight hospital admission for patient controlled analgesia in more than 50% of cases. It is very effective in treating menorrhagia, but its efficacy in shrinking fibroids is very variable,
especially if they are large.
The procedure is associated with a 3-4% risk of inducing premature menopause. Its effect on future pregnancy outcome is unknown, although case reports of successful pregnancies after embolization have been reported in the literature. It is currently not recommended for Fibroids treatment in women who are contemplating pregnancy in the future. The mortality rate for embolization is less than for hysterectomy, and the risk of complications necessitating hysterectomy is comparable to myomectomy.
* Uterine Artery Ligation
Laparoscopic uterine artery ligation with suture, clip or diathermy can result in resolution of heavy periods an fibroid shrinkage, and being a global therapy should have comparable results to embolization. There is only limited experience with this technique in Australia.
* Hysteroscopic resection
Submucosal fibroids, as long as they are not too large and ideally at least half within the uterine cavity, can be hysteroscopically resected. The procedure is not without risks, including fluid overload, bleeding and uterine perforation.
Whether this is performed laparoscopically, or as an open procedure, may depend not only on endosurgical expertise, but also on the number, size and location of the fibroids.
There are some concerns about scar integrity in pregnancy after laparoscopic myomectomy because the defect is often closed in a single or double layer, whilst a multilayered closure is usually performed with the open procedure. There are however reports of uncomplicated pregnancy after laporoscopic myomectomy.
Removal of a fibroid from the peritoneal cavity after its removal from the uterus, if it is large, can also be a problem unless an electric morcellator is available. If it isn’t, the specimen needs to be removed through a posterior colpotomy (vaginal removal through a cut at the top of the vagina behind the cervix) or a ‘bikini line’ mini-laparotomy.
Although a 30% recurrence rate after myomectomy is commonly quoted, one large series (3000 myomectomies) found only a 15% recurrence rate and a 10% re-operation rate, i.e. recurrence does not necessarily mean another operation.
If one subscribes to the philosophy that there are only two absolute indications for hysterectomy, i.e. cancer and life-threatening uterine haemorrhage, hysterectomy becomes just another treatment for fibroids, not the only one, but sometimes the most appropriate one.
It may be the treatment of choice in a 40 year old mother of 4 children who had previously been sterilized, and now day to day life is a struggle because of iron deficiency anaemia due to heavy periods associated with a uterus enlarged to the size of a 16 week pregnancy by a dozen fibroids.
Another genital tract problem such as prolapse associated with a fibromyomatous uterus may also make hysterectomy the treatment of choice.
Hysterectomy can be performed vaginally, abdominally, laparoscopically, or with laparoscopic assistance. The cervix and/or ovaries maybe removed or conserved. The pros and cons of the various techniques require discussion in each individual case.
P.S. Focussed Ultrasound under MRI control in appropriately selected cases is available through the Royal Women’s Hospital at no out-of-pocket cost. Otherwise the cost is going to be about $5,000. Pregnancy outcomes after this treatment are still under investigation.
• A uterine fibroid tumor is a benign growth that appears on the muscular wall of the uterus and is the most common in the female genital tract. They range in size from microscopic to masses that fill the entire abdominal cavity. In some cases, fibroids can be as large as a 5- month pregnancy. Uterine fibroids can affect women of all ages, but are most common in women ages 40 to 50. In most cases, there is more than one fibroid in the uterus. Fibroids consist of dense, fibrous tissue (hence the name ‘fibroid’) and are nourished and sustained by a series of blood vessels.
• Approximately 600,000 hysterectomies are performed annually in the United States, about 300,000 due to uterine fibroids.
• More than $5 billion dollars is spent on hysterectomies annually, and up to 144 million work hours are lost due to procedure recovery.
• Over 50 percent of women who get hysterectomies have their ovaries removed, rendering them infertile.
• Approximately 660 women die each year in the United States due to complications from a hysterectomy.
• As many as 80 percent of all women have uterine fibroids, and one in four have symptoms severe enough to require treatment.
• An estimated 13,000-14,000 uterine fibroid embolization (UFE) procedures are performed annually in the United States
• There are three different classifications of fibroids depending on where they are located in the uterus: intramural uterine fibroids, located in the wall of the uterus; submucosal uterine fibroids, located on the inside lining of the uterus; subserosal uterine fibroids, located outside the lining of the uterus.
• Embolization has emerged as the safest, simplest, cost effective way to treat fibroids. Embolization requires a very small incision, about the size of a freckle, which is made in the upper thigh. A tiny catheter is inserted through this incision and into the femoral artery. Using x-ray guidance, a trained physician locates the feeder vessels which supply blood to each fibroid. Microscopic inert particles are injected into the vessels, blocking blood supply that nourishes the fibroid. Without a steady blood supply, the fibroids begin to dwindle and
shrink. Embolization basically cures fibroids by starving them.
• Uterine Fibroid Embolization has an overall success rate of 94 percent. This means 94 percent of all patients who had the procedure experienced relief from their symptoms and significant fibroid shrinkage.
99 percent of patients had immediate relief from heavy bleeding
94 percent of patients experienced 50-60 percent shrinkage
33 percent of patients who attempted to conceive were successful
99 percent of patients returned to work in less than a week
• There are 10 primary advantages to embolization:
* It’s simple. Most procedures take about half an hour.
* It’s safe. More than 100,000 women have been successfully treated.
* No hospital stay. This is an out-patient treatment.
* It’s cost effective. No lengthy hospital stays or the fees that come with them.
* Symptom relief is immediate. Pain, heavy bleeding, anemia, fatigue will end with embolization.
* No recurrence. Fibroids don’t return, as they often do with surgeries like myomectomy.
* Less downtime. Most patients return to work in a matter of days.
* No cutting. With embolization there are no scalpels, sutures or scarring.
* No ‘going under’. You won’t be unconscious or exposed to the risks of general anesthetic.
* Keep your fertility. There’s no trauma to, or removal of, the uterus.
Generally, fibroids located inside the uterus (see location of fibroids above) are best treated by hysteroscopy. With this method and under a general anaesthetic, the cervix is gently and progressively opened to about 1 cm using dilators. A special telescope called an operating hysteroscope is then introduced into the cavity of the uterus.
Fluid is used to open the cavity space so that all the walls and the uterine lining (the endometrium) can be seen. The operating hysteroscope has connections so that fluid can flow into and out of the uterus and maintain clear vision for the surgeon.
At the end of the operating hysteroscope is a wire loop that can be connected to an electrical current used to cut through the fibroid. This loop is about 4 mm across and is used to cut strips from the fibroid until it has all been removed.
Fibroids of up to 3 cm can usually be removed at one surgery. Large fibroids of 3-5 cm may require two or more procedures. Fibroids larger than this may require one of the other methods for removal. If you have a large fibroid, you should discuss treatment options with your doctor.
Fibroids within the uterus (submucous fibroids) are further described by the amount of the fibroid that is within the wall of the uterus. A type 0 fibroid is wholly within the uterine cavity, a type 1 fibroid is mostly within the cavity, and a type 2 fibroid is mostly in the wall of the uterus, with a percentage (usually <40%) inside the uterine cavity. The type 2 fibroid is the most difficult to treat, since more is inside the wall of the uterus than in the cavity, and two procedures, or another surgical approach may be required. (see diagram above for location of submucous fibroids).
Submucous fibroids are the ones most associated with heavy bleeding because:
1. They may prevent the uterus from contracting down during menstruation
2. They may increase the surface area of the lining of the uterus (the endometrium)
3. They may have an affect on blood vessels that cause them to be open for longer
Fibroids themselves do not bleed, but their presence may contribute to heavy menstrual bleeding. Removing the fibroids may reduce the bleeding by alleviating one or more of the above causes. It is also possible to alleviate the problem of heavy bleeding from fibroids by performing an endometrial ablation (see information download on endometrial ablation)and leaving the fibroids in the uterus. This is safe, since fibroids are not pre-cancerous. This may be recommended by your doctor, particularly if bleeding is the main symptom and you do not wish to have a hysterectomy.
Submucous fibroids are best treated by surgery, usually hysteroscopic. If you have fertility problems and a submucous fibroid (see fibroids and infertility), then hysteroscopic surgery is the best option to improve fertility.
Laparoscopic surgery for fibroids: (Laparoscopic Myomectomy) If you are found to have subserosal, intramural or pedunculated fibroids, then your doctor may recommend that they are removed laparoscopically. You should refer to the information sheet entitled Laparoscopy located at this website for details about the basic operation and preparing for the procedure.
There will be four incisions made in your abdomen, with a 1 cm incision in the umbilicus (belly button) and above the pubic bone. There will be two other incisions made above the hip bones, these are about 0.5 cm each. With a camera through the umbilicus, the fibroid is located on the uterus and a cut is made over the top of the fibroid and it is shelled out, a bit like peeling an orange. After the fibroid has been removed, it leaves a hole in the wall of the uterus and has to be stitched closed. This is done through the keyholes and usually requires a number of layers to close the hole left by the fibroid.
You are likely to have discomfort following this type of surgery that requires on average 2 nights in hospital for pain relief. Following your surgery, you will wake up with a drip in your arm, a catheter (tube) in your bladder to keep it empty so you do not have to get up to the toilet, and likely a drain in your abdomen. The drain is to remove any blood or fluid from the surgery which will help to reduce the risk of infection, reduce pain and increase the speed of your recovery. All these are likely to be removed the morning following your surgery, although your doctor will discuss the removal of these with you when you are reviewed.
A laparotomy is a large cut that is made in the abdomen to perform surgery. This method for removing fibroids may be recommended if you have very large fibroids (more than 7 cm) or there are multiple fibroids. There are some exceptions to these size regulations, and your doctor will discuss the pros and cons of this type of surgery with you. Pedunculated fibroids (fibroids on a stalk) can usually be removed by keyhole surgery even when larger than 7 cm. Your doctor will discuss this with you if this is the case.
A laparotomy incision means that there is good access to the uterus, though it causes more pain, a longer stay in hospital and is associated with a higher chance of adhesion formation (scar tissue forming). For very large fibroids however, this is often the safest and most efficient method for removing the fibroids.
The incision is usually made over the bikini line in a horizontal manner, this will heal faster and be more cosmetically appealing, though for fibroids of 20 cm or greater this incision may not be adequate and a vertical incision from the umbilicus (belly button) to the pubic bone may be required. Whilst it is recognized that a large abdominal incision is not preferable, it is important to perform the appropriate incision for the size of the fibroid(s) as this will reduce the risk of complications and maximize your safety.
Recovery following a laparotomy for fibroids will take longer. You will be in hospital on average 5 nights and will require 4-6 weeks off work. It will take a longer time to recuperate, though the features previously noted for recovery hold true for this method of myomectomy.
Removing the entire uterus (hysterectomy) is the only way to guarantee that fibroids will not recur, though there are many other factors to consider. You should refer to the information sheet entitled Hysterectomy for further information on this subject.
Current medications typically treat only the symptoms of fibroids. For women who experience occasional pelvic pain or discomfort, a mild, over-the-counter anti-inflammatory or pain-killing drug such as Naproxen™ or ibuprofen often will be effective. More bothersome cases may require stronger drugs available by prescription. Additionally, these medications also may decrease the amount of menstrual bleeding, pelvic pain, clotting and gushing of blood that some women experience.
Some fibroids are treated with hormones that reduce the amounts of the hormone estrogen. Birth control pills (oral contraceptives) can be used to treat the bleeding symptoms and menstrual cramps caused by uterine fibroids because they decrease the production of female hormones and prevent ovulation. Birth control pills do not reduce the size of uterine fibroids, but often help to alleviate symptoms related to fibroids and regulate menses, and decrease the quantity of bleeding and cramps. Oral contraceptives rarely contribute to the growth of fibroids.
An emerging medical treatment for menstrual disorders is Mirena®. This progesterone intrauterine system can be placed into the uterus during an office visit.
Mirena is a method of contraception, but has the added benefit of dramatically decreasing the amount of bleeding, cramps and menstrual flow. In fact, up to 50 percent of patients experience temporary cessation of menstrual cycles. If desired, the Mirena system can safely remain in place for up to five years.
If periods are irregular due to obesity, a nutrition consultation is advised. After a thorough clinical evaluation, you may be referred to a bariatric specialist on our team who may advise bariatric surgery to help you manage your weight and improve your nutrition. Finally, we offer alternative treatments for problems such as severe cramping, to promote healing and relaxation, and to reduce stress. Alternative techniques include acupuncture, massage, Reiki, and yoga for stress reduction and healing.
How do you know if you have uterine fibroids? Probably you do not know.
Most fibroids do not cause any symptoms and do not require treatment other than regular observation by a physician. Fibroids may be discovered during routine gynecologic examination or during prenatal care. Some
women who have uterine fibroids may experience symptoms such as:
Menorrhagia(heavy periods): Heavy menstrual bleeding or irregular vaginal bleeding.
Heavy periods are the presenting symptom in 30% of women who have fibroids treated surgically. Submucosal and intramural, but not subserosal, fibroids are to blame (see below).
Pressure on the bladder, bowel and pelvic floor (most commonly from large and/or multiple subserosal and intramural fibroids) can cause urinary and bowel dysfunction, as well as dyspareunia (discomfort or pain with intercourse).
At the time of periods, or between periods.
Up to 30% of women with fibroids experience pain. It is usually acute and due to degeneration or torsion (twisting). Chronic pain is unusual, and other causes should be sought.
Fibroids may contribute to infertility by distorting the uterine cavity or interfering with the patency of the intramural (in the wall of the uterus) part of the Fallopian tube, and thus compromise sperm transport. Submucosal fibroids may adversely affect implantation. When all other causes of infertility are excluded, fibroids become responsible for only 2- 3% of infertility cases. Nevertheless, it is noteworthy that 27% of women with fibroids have fertility problems, and 40% become pregnant after myomectomy. Foetal loss decreases from 41% to 19% in women who have myomectomies performed because of recurrent foetal wastage.
Fibroids are usually described in one of four locations:
1. Submucous fibroids (partly or wholly within the uterus)
2. Intramural fibroids (within the wall of the uterus)
3. Subserous fibroids (on the outside of the uterine wall)
4. Pedunculated fibroids (fibroids on a stalk)
Large fibroids can occur in a number of these locations, that is start inside the uterine cavity and extend through the wall of the uterus and into the abdomen, therefore occupying a number of the above positions.
The location of the fibroid may impact on the symptoms that you have. For example, a 1 cm fibroid that is inside the uterine cavity may present with heavy and sometimes painful periods.
Removing it by hysteroscopic resection will likely improve this symptom. Compare this to a 1 cm fibroid within the wall of the uterus (intramural) which is unlikely to cause any symptoms. It is not recommended to remove such a fibroid as they can be difficult to find and remove.
The position of a fibroid can also lead to varying symptoms. A large fibroid (say 5 cm) that is present in the front of the uterus may press on the bladder and cause you to have the desire to go the toilet frequently and possibly have pain with intercourse when the uterus is moved, though the same size fibroid at the top of the uterus may not cause any symptoms at all, since there is more room for it to occupy and therefore not press on anything.
If the fibroid is asymptomatic, then no treatment needs to be undertaken, though you and your doctor may decide to monitor the fibroid with clinical examination and/or ultrasound to look for changes in size. If you are having one or more of the symptoms above then you may decide to have treatment. Treatment for fibroids will depend on the number, size and location of the fibroids. Treatment is divided into three groups:
1. Medical (using medications)
2. Radiological (uterine artery embolisation)
3. Surgical (surgical removal of fibroids or the uterus)
An extensive workup can pinpoint the cause, location and/or extent of fibroids or menstrual difficulties. We begin with a detailed menstrual and health history, and a gynecologic exam. Then we use one of the following imaging techniques to determine the health of your uterus before proceeding with treatment:
Use of a lighted tube, or endoscope, inserted through the vagina to examine the uterus. (Cleveland Clinic specialists have cumulatively performed more than 10,000 office hysteroscopies.)
Saline infusion sonography
A type of transvaginal ultrasound performed in the office that utilizes a small catheter placed through the cervix into the uterus. It is used to infuse a few tablespoons of salt water (saline) to provide excellent imaging of the uterine anatomy. This test can evaluate for ovarian masses, uterine polyps, uterine fibroids, pre-cancerous and cancerous conditions.
MRI (Magnetic Resonance Imaging)
Combining a powerful magnet, radio signals and a computer to obtain intricate pictures of the uterus and surrounding organs. This test is more commonly utilized when your physician is considering your candidacy for uterine fibroid embolization, extensive myomectomy, or to determine whether you are a
candidate for a laparoscopic procedure.
We also ask every woman we see whether or not she wants to preserve her fertility and/or her uterus. These considerations are very important in determining which treatments we will recommend. We aim for the best treatment outcome and the highest patient satisfaction.
Fibroid, which is called leiomyoma of the uterus in medical terms, is the commonest tumour of the uterus. It is estimated that fibroids are present in about 30% of all women. The cause is unknown. However, its growth is associated with the production of oestrogen (a female hormone), as it is noted that fibroids may become bigger during pregnancy and taking of contraceptive pills, and may become smaller after menopause. Pelvic examination revealing an irregularly enlarged uterus may suggest the presence of fibroid. Nowadays, ultrasound scan makes diagnosis simple. Occasionally, MRI scan can be used.
Problems Associated with Fibroids
Many fibroids are asymptomatic and are diagnosed at routine examination or by ultrasound scan. When symptoms are present, these are usually presented as one of the following:
(1) Abdominal swelling: The fibroid can be felt or the woman complains of abdominal distension or an increase in her waistline;
(2) Heavy periods: The periods usually remain regular, but the flow is heavier and often with clots;
(3) Anaemia: The woman looks pale, feels dizzy and gets tired easily;
(4) Frequency of urination;
(5) Back pain. Symptoms depend on the size, site and number of fibroids and therefore can be variable. Occasionally, it may be presented with acute retention of urine or abdominal pain.
Ways to Treat Fibroids
Asymptomatic fibroids can be left alone (treated conservatively). However, fibroids may continue to grow, cause symptoms later on and subsequently require treatment. Patients are advised to watch out for the symtpoms and montior the size of the fibroids by ultrasound scan at regular intervals. Current treatments of fibroid include:
1) Non–Surgical Procedures
(i) Uterine Fibroid Embolization (UFE)
It is a procedure that uses a technique similar to the one used in heart catheterization in which a catheter is placed in the uterine arteries under local anaesthesia. Small particles are injected to block off the blood supply to the fibroids. The fibroids die and shrink during the next few months, resulting in resolution of symptoms in most cases. The procedure usually takes 1-3 hours. The patient is required to stay for 1-2 nights, and may return to work within a week.
(ii) Non-Invasive MR Guided Focused Ultrasound Treatment
MR Guided Focused Ultrasound treatment uses high intensity focused ultrasound waves to destroy uterine fibroid, without affecting any of the other tissues around the fibroid. It is a non-invasive, outpatient procedure which does not require surgical incisions, anaesthesia and hospitalisation. The procedure is conducted using Magnetic Resonance Imaging (MRI) scanner to provide 3D imaging of the uterus without radiation. This allows the doctor to “see” inside the body to pinpoint, guide, and continuously monitor the treatment to make sure that the fibroid tissue has been destroyed resulting in a shrinkage of the fibroid without damaging nearby tissue and blood loss.
While our experienced gynaecologists will assess patient’s suitability for the therapy, the procedure is jointly performed by gynaecologists together with the interventional radiologists to ensure optimal treatment and maximum safety.
2) Surgical Procedures
(i) Myomectomy is performed when uterine function needs to be preserved as in young women who desire future pregnancy. This is an operation in which the fibroids are removed and the uterus is repaired. Patients should note that fibroids may recur.
(ii) Hysterectomy is a procedure in which the fibroids are removed together with the uterus. It is usually indicated when no further pregnancy is desired. There is no recurrence of fibroids after hysterectomy.
Conventionally, operations on fibroids are performed through an abdominal incision of 15 cm, the length depending on the size of the fibroids. This leads to significant post-operative pain, prolonged hospital stay and longer recovery period. Nowadays, these operations can be performed using minimally invasive technique as described below:
Minimally Invasive Surgery
(i) Laparoscopic myomectomy can be performed by utilizing 3-4 small incisions of 0.5 cm to 1.2 cm. The fibroids can be enucleated from the uterus and removed in small pieces using a morcellator. The uterus can be repaired with sutures laparoscopically.
(ii) Laparoscopic hysterectomy
can be similarly performed utilizing 3 to 4 small incisions of 0.5 cm to 1 cm either in the form of laparoscopic assisted vaginal hysterectomy or total laparoscopic hysterectomy. The uterus is removed either through the vagina or by morcellation through the abdomen. Sub-total hysterectomy can also be achieved laparoscopically by leaving the cervix behind and removing the body of the uterus together with the fibroids in small pieces using a morcellator.
(iii) Hysteroscopic myomectomy is performed using a hysteroscopic apparatus to remove the fibroid when the fibroid or part of it is situated in the uterine cavity. The operation is performed through the vagina and cervix, and there is no incision in the abdomen.
An operation performed laparoscopically effects the same magnitude of operations as in open conventional surgery, while the former has advantages including less blood loss, smaller surgical scars, less wound pain, less wound infection, quicker recovery and shorter hospital stay. When a hysteroscopic operation is performed, no incision is required and the patient can be discharged from hospital on the same day.