Types, Pathophysiology & Management of Fibroids

Fibroids are benign growths formed on muscle and tissue from the uterine wall. They can be as small as a pea to as large as a watermelon. They rarely are cancerous.
Other names include Leiomyoma, Myomata and fibromyomata.

Incidence

Most fibroids occur in women of reproductive age, and according to some estimates, they are diagnosed in black women two-to-three times more frequently than in whites. They seldom are seen in young women who have not began to menstruate, and the symptoms of uterine fibroids usually stabilise or go away in women after menopause.
About 20-80% of women develop fibroids by the time they reach age 50. Its most common in women in their 30s and 40s but can occur at any age.

Globally, approximately 235million people are affected with uterine fibroids as at 2010(6.6% of females). About 20-40% of women will be diagnosed with leiomyoma at some point in life but only a fraction of those will cause problems or require treatment. Of the 600,000 hysterectomies performed annually in United States, one-third are due to fibroids.

types of fibroids

Aetiology

The exact cause is unknown but are thought to be caused by
-Hormones in the body(Estrogen and progesterone levels)
-Genes (Runs in families)

Risk Factors
-Obesity
-Nulliparity
-Late age menopause
-Early menarche
-Ethnic origin(African-American)
-Family history
-Ages between 30s and 40s through menopause
-Eating habits. Eating a lot of red meat(eg beef) and ham is linked with higher risk of fibroids. Eating plenty of green vegetables seems to protect women from developing fibroids.

Types of fibroids

myomas

1. Intramural: This type appears within the lining of the uterus(endometrium). Intramural fibroids may grow larger and actually stretch the womb.

2. Subserosal: It forms on the outside of the uterus, which is called the serosa. They may grow large enough to make the womb appear bigger on one side.

3. Submucosal: This type develops in the innner lining(myometrium) of the uterus. It causes heavy menstrual bleeding and trouble conceiving.

4. Pedunculated: It is when subserosal fibroid develop a stem(a slender base that supports th fibroid).

5. Intraligamentary: Here the fibroids are implanted in the cervix and the broad ligaments.

6. Cervical fibroids: It is when the fibroids grow on the cervix that obstructs the cervical canal.

uterine fibroids

Pathophysiology

Uterine fibroids arise from the myometrial layer of the uterine corpus or, less commonly, the uterine cervix, and may occur singly or multiply. Fibroids may remain within the muscular layer (intramural) or protrude outwardly to become subserosal in location or inwardly towards the endometrial cavity, where they become known as submucous fibroids. Subserosal and submucosal fibroids may become pedunculated.

Abnormal vaginal bleeding that often accompanies the presence of fibroids is felt to occur as a result of distortion of the endometrial lining and therefore is seen much more commonly with submucous fibroids. For the same reason, cavity distortion can cause recurrent second trimester loss.

Uterine fibroids that obstruct menstrual flow can cause dysmenorrhoea. Large uterine fibroids, regardless of location, can cause mass effects on contiguous organs such as the bowel and bladder and cause symptoms of urinary frequency, urgency, and incontinence as well as constipation. They can outstrip their blood supply and cause acute or chronic pain as they degenerate. Pedunculated submucous uterine fibroids can dilate the uterine cervix and prolapse into the vagina where they can become infected.

Clinical manifestations

In most cases, fibroids do not cause any symptoms. But some women may experience the following

-Excessive bleeding during menstruation.
-Bleeding between periods
-Feeling of fullness in the lower abdomen
-Frequent urination resulting from a fibroid that compresses the bladder
-Pain during sexual intercourse
-Low back pain
-Chronic vaginal bleeding
-Inability to urinate
-Urinary urgency
-Severe menstrual cramps
-Constipation
-Infertility

IMG-20151106-WA0101

Diagnostic Investigations

An extensive work up can pinpoint the cause, location and/or extent of fibroids or menstrual difficulties. These include

  • A detailed menstrual and health history
  • Gynaecological examination
  • Hysteroscopy:Use of a lighted tube, or endoscope, inserted through the vagina to examine the uterus.
  • Saline infusion sonography: A type of trans vaginal ultrasound performed that utilises 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.
  • Magnetic Ressonance Imaging(MRI): Combining a powerful magnet, radio signals and a computer to obtain intricate pictures of the uterus and surrounding organs. This test is more commonly utilised when your physician is considering your candidacy for uterine fibroid embolization, extensive myomectomy,nor ti determine whether you are a candidate for a laparoscopic procedure.
  • Ultrasound: Uses sound waves to produce the picture. The ultrasound probe can be placed on the abdomen or it can be placed inside the vagina to make the picture.
  • X-rays: Uses a form of radiation to see into the body and produce the picture.
  • Computerized Tomography(CT scan): Takes many X-ray pictures of the uterus from different angles for a more complete image.
  • Hysterosalpingogram(HSG):Involves injecting x-ray dye into the uterus and taking x-ray pictures.
  • Laparoscopy: The Doctor inserts a long, thin scope into a tiny incision made in or near the navel. The scope has a bright light and a camera. This allows the doctor to view the uterus and other organs on a monitor during the procedure.

Possible Complications

  1. Infertility
  2. During pregnancy, fibroids may lead to breech presentation, preterm birth, placenta previa, post partum haemorrhage and caesarean section delivery.
  3. Anaemia. This is due to heavy bleeding.
  4. Urinary tract infections.
  5. Uterine cancer(in rare cases).

Medical Management

  • Women with fibroids who experience mild symptoms the Doctor may prescribe ibuprofen or acetaminophen for mild pain. For heavy bleeding during menses, taking iron supplement can keep the woman from getting anaemia or correct it if she is already anaemic.
  • Birth control drugs can also be prescribed to help control symptoms of fibroids. Low dose birth control pills do not make fibroids grow and can help control heavy bleeding. The same is true of progesterone-like injections (eg Depo-provera). An Intrauterine device (IUD) called Mirena contains a small amount of progesterone-like medication, which can be used to control heavy bleeding as well as for birth control.
  • Other drugs used to treat fibroids are Gonadotropin releasing hormones agonists(GnRHa). The one most commonly used is Luspron. These drugs, given by injection, nasal spray, or implanted, can shrink the fibroids.
  • Sometimes they are used before surgery to make fibroids easier to remove. Side effects of GnRHas include depression, hot flashes, insomnia, decreased sex drive, and joint pain.
  • Androgens(eg Danazol) may effectively stop menstruation, correct anaemai and even shrink fibroids and reduce uterine size. Side effects include weight gain, acne, headache, dysphoria(feeling depressed, anxious or uneasy), unwanted hair growth and a deeper voice.

Surgical Treatment

For women who want to preserve fertility.

Here, the surgeon removes only the fibroid leaving the uterus intact. The procedure is called myomectomy.
There are a number of techniques that can be used to perform myomectomy. The appropriate procedure is determined by the size, number and location of the fibroids and the physician’s surgical expertise. They include
1. Laparoscopic and single port myomectomy or robotic myomectomy: this involves the use of thin, telescope-like instrument attached to a small video camera called a laparoscope inserted through a tiny incision at the bottom of the abdomen. The surgeon uses a specialised surgical instruments inserted through this incision with one or ,ore thumbnail-sized additional small incisions in the abdomen to remove the fibroids. Patients are often able to be discharged home within a few hours or onl require a 23-hours stay in the hospital.
2. Hysteroscopic Myomectomy. This is a procedure in which some fibroids are removed through the vagina using a surgical instrument called a hysteroscope. This does not require any abdominal incisions. Hysteroscopic myomectomy most often is a same day surgery, which permits patients to return to work within two days. This technique can be employed when fibroids are within the uterine cavity.
3. Laparostomy: This involves an abdominal incision to remove all fibroids and it is most often employed when excessive size and number of fibroids are present.

For women not interested in having children
1. Endometrial Ablation. Some women, despite having very small uterine fibroids or a normal uterus, experience excessively heavy menstrual cycles. For women who fail medical therapy and do not desire children, endometrial ablation can be performed generally taking less than 10minutes. A thin layer of the uterine lining is destroyed, leading to marked decline in the amount of menstrual bleeding.
2. Uterine fibroid Embolization (UFE): This procedure generally takes less than 60-90minutes to perform with minimal sedation. A slender catheter is placed under X-ray guidance into the uterine artery, and tiny particles are then injected to block the flow of blood to the fibroid. Robbed of oxygen and nutrients, the fibroid shrinks over a period of months
3. Fibroids can reccur. For some women, especially those who are ready to enter menopause, hysterectomy (surgically removing the uterus) is a reasonable alternative. There are many modalities available to perform hysterectomy.
The physician will determine which route is best based on the size, number and location of the fibroid and other clinical indicators.
a. Abdominal hysterectomy: 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.
b. Vaginal hysterectomy: In this approach, the uterus is removed through an incision in the vagina, which avoids an abdominal incision and scar.
c. Laparoscopic hysterectomy: Some patients are eligible for removal of the uterus through slender instruments inserted into the abdomen using the 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 post operative pain medications and faster return to activity.
d. Robotic hysterectomy: This advanced form of laparoscopy involves the use of robotic instruments guided by tiny 3-D cameras. The surgeon controls the robotic arms that carefully remove the uterus and precisely suture tissue. Only small abdominal incisions are required.
e. Single port hysterectomy: This procedure utilises one incison in the lower abdomen. It has similar outcomes when compared to laparoscopic and robotic approaches. An additional benefit is that there is only one belly buttom incision.

Possible complications after surgery

  • Haemorrhage
  • Anaemia due to excessive blood loss
  • Adverse reaction due to anaesthetics
  • Puncture of bowel/bladder during surgery.
  • Deep vein thrombosis (DVT) leading to pulmonary embolism.
  • Wound infection
  • Pelvic adhesion that can cause pain or bowel blockage.
  • Death

Donkor Abdul-Ghaffar

Donkor Abdul-Ghaffar holds Bachelor of Science degree in Paediatrics from University of Ghana, Legon.

2 thoughts on “Types, Pathophysiology & Management of Fibroids

  • November 12, 2015 at 3:08 am
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    I am in fact thankful to the owner of this website who has shared
    this wonderful piece of writing at here.

    Reply
  • December 23, 2015 at 2:36 am
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    “black women fibroids”

    just wanted to thank you for these visuals. i have to learn more about this growth. from my preliminary research on the internet, it seems like the conception is the same, and copied over and over.

    i am writing from Ontario Canada, where the province medical system is terrible because the focus is not getting to the root of problems. the approach is to mask problems and use pharmecy-narcotics to make problems or do unethical testing.

    i like the visuals in this article, and will also ask for a copy of the image where these fibroid things were spotted in my body. will do that tommorrow, and just saying thank you for the visuals so that i can see what this fibroids thing is and study why black women get this.

    my hormone unbalance is from work-place stress, racism, sexism, dirty air and noise, smoke and light pollution.

    thank you again for posting this. will also see how the U of Ghana, conceptualizes what medicine should be.

    best,
    🙂

    Reply

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