Fibroids

Uterine fibroids (also known as leiomyomas) are benign tumours of the muscular layer of the uterus (the myometrium). They be a nuisance for many women, causing issues such as heavy periods, pelvic pain and complicating pregnancies. There are a range of treatments available, but uterine artery embolisation offers a fast, safe option that preserves fertility.

Fibroids lie within the muscle layer of the uterus.

Prevalence
Fibroids are one of the most common tumours in women. 70-80% of women will have had one by the age of 50. Most commonly, they tend to affect middle-aged women, although most are too small to cause symptoms.

History, Symptoms, Signs
Although most fibroids do not cause symptoms, it can be quite debilitating when they do. The symptoms of fibroids include:

• Bleeding
  • Heavy periods that may be irregular or last longer than usual
• Pelvic pain or pressure
  • This may occur as the fibroids get larger or degenerate or bleed.
• Pregnancy issues
  • Large fibroids may prevent pregnancy or cause recurrent miscarriage.
• Urinary or bowel issues
  • Fibroids may put pressure on other organs in the pelvis such as the bladder and rectum, causing urinary symptoms (eg. frequency or urgency) and intestinal symptoms (eg. constipation) respectively.

Occasionally, fibroids may be felt on examination of the pelvis, but usually requires imaging to confirm the diagnosis.

Diagnosis, Assessment
The diagnosis is made by a combination of history, examination, and imaging. Ultrasound is a cheap and effective method of looking at the layers of the uterus. The For best results, women are asked to have a full bladder before the ultrasound. MRI is the next most accurate imaging test, but it is more expensive than ultrasound.

Treatment
There are many treatments for fibroids, including a wide range of medications and surgeries. Fibroids that do not cause symptoms do not require any treatment.

Medical
The range of medications to treat fibroids include:

• Analgesics (pain relief)
  • NSAIDs (Non-steroidal anti-inflammatory drugs) - These reduce the pain associated with fibroids, but have no action against the fibroids.
• Hormones or hormone analogues
  • Progestins are drugs similar to the naturally occuring hormone progesterone. They can suppress fibroid growth and fibroid symptoms. They need to be taken daily and have a contraceptive effect.
  • GnRH agonists mimic a naturally-occuring hormone called GnRH (Gonadotropin releasing hormone). They can reduce the size of fibroids as well as improving symptoms. They are generally only used for less than 6 months, because of regrowth of the fibroid and loss of bone mass. They are usually given for 3-4 months prior to surgery in order to reduce the size of the fibroids and make surgical removal easier.

Surgical
There are a number of different techniques for treating fibroids surgically. Either the fibroids may be removed alone (myomectomy) or the entire uterus removed (hysterectomy). Both of these may be done either as an open procedure (laparotomy) or using keyhole surgery (laparoscopy). A newer technique called hysteroscopic fibroid removal involves removing fibroids through the cervix using a special telescopic device (a hysteroscope).

Interventional
One minimally invasive method of fibroid removal is uterine artery embolisation. This method treats the fibroids by blocking off the arteries that supply them. A catheter (link to catheterisation) is introduced into the groin and is directed (using x-ray imaging) to the arteries supplying the uterus. Once in the right place, an embolic agent is injected. The agent is made of small synthetic particles that cause the blood vessel to close up permanently. This causes the fibroids (and the uterus) to shrink in size, and relieves the symptoms for most women. It has a much quicker recovery rate compared to surgery, both in terms of length of hospital stay and return to normal activities. Pregnancy is possible after this procedure. There is currently limited evidence about the long term outcomes of this procedure.

The left pictures shows an angiogram of a uterine fibroid. The diagram on the right highlights the process of uterine artery embolisation. A special embolic agent causes the artery that supplies the fibroids to block off, causing the fibroids to shrink.

Links
Wikipedia article on Fibroids
Medline article on Fibroids