Uterine Fibroids: Types, Symptoms, Causes, Diagnosis and Treatment Options

In short: Uterine fibroids are benign tumours that arise from the muscle of the uterus and are more common with excess weight. Symptoms are heavy periods lasting more than a week, pelvic pain and frequent urination. Medication controls the bleeding only; treatment is surgical, by laparoscopy or open operation, or by cutting off the blood supply to the fibroid. See the doctor if symptoms appear or when planning a pregnancy.

Uterine fibroids, medically known as leiomyomas, are common non-cancerous (benign) growths that develop in the muscle of the uterus. If you’ve been told you have a fibroid, please know this is a very common finding and there are many ways to manage it comfortably.

Fibroids are the most common tumor of the uterus; by the age of 50 up to 70% of women have at least one fibroid, although many never cause symptoms.

Classification of Uterine Fibroids

Fibroids are classified depending on their location within the uterus:

1-Submucous fibroid: The tumor protrudes into the uterine cavity.

2-Intramural fibroid: The tumor is located within the muscular wall of the uterus (myometrium).

3-Subserosal fibroid: The tumor is located at the outer border of the myometrium.

4-Pedunculated fibroid: The tumor is attached to the outer border of the uterus by a narrow stalk (pedicle) containing blood vessels.

5-Fibroids can also arise as a separate growth away from the uterus, in the broad ligament, mainly from embryonic remnant tissue.

Pathology of Uterine Fibroids

Macroscopic appearance

Fibroids present as single or multiple circular or irregular masses. They have a false capsule consisting of compressed uterine muscle tissue surrounding the tumor.

On cross section, the tumor has a characteristic whorled arrangement of tissue bundles, and its centre may show different types of degeneration.

Microscopic appearance

Fibroids consist of smooth muscle fibers and fibrous connective tissue.

Types of fibroid degeneration

Fibroid Uterus

1-Red degeneration

This follows a sudden loss of blood supply to the fibroid during a period of active growth, most often seen during pregnancy.

Patients may notice the sudden onset of abdominal pain and tenderness localized to the uterus, sometimes with a mild fever and raised white blood cell count.

The symptoms and signs usually resolve over a few days, and surgical intervention is rarely required.

2-Hyaline degeneration

This type of degeneration is caused by a gradual decrease in the blood supply to the fibroid.

It is usually symptom-free and can cause central tissue breakdown, leaving cystic spaces at the center known as cystic degeneration.

Calcification of a fibroid

This change happens when calcium deposits build up within the fibroid and can sometimes be detected on an abdominal x-ray in postmenopausal women.

Malignant changes

Submucous Fibroid

Cancer of the uterine muscle (leiomyosarcoma) is rare; it is usually a separate tumour rather than a fibroid turning malignant, and is found in fewer than 1 in 500 women operated on for fibroids. A fibroid that grows after menopause, or grows very fast, should be assessed promptly, usually with MRI.

Clinical features of Uterine Fibroids

The location and size of the fibroid affect the type of symptoms a woman may experience.

1- Menstrual disturbance

Fibroids are an important cause of abnormal uterine bleeding, mainly heavy periods (menorrhagia) or bleeding between periods, especially with submucous fibroids, and this can lead to symptoms of anemia such as fatigue.

2-Pressure symptoms, especially needing to urinate frequently or constipation, caused by the growing fibroid pressing on nearby structures like the bladder and rectum.

3-Pain is unusual, except in cases of red degeneration of a fibroid.

4-Sub-fertility

This can occur due to mechanical distortion or blockage of the fallopian tubes, and distortion of the uterine lining by a submucous fibroid, which can interfere with implantation of a fertilized egg.

Cervical Fibroid

5-Pregnancy-related complications

In late pregnancy, if the fibroid is located in the cervix or the lower part of the uterus, it can cause an abnormal position of the baby or obstructed labor.

After delivery, there is a higher risk of postpartum hemorrhage due to the uterus not contracting efficiently.

Signs of fibroids

An abdominal examination may reveal a firm mass arising from the pelvis.

On a bimanual pelvic examination, the mass is felt to be part of the uterus, with some limited mobility.

Predisposing factors for Uterine Fibroids

1-Never having given birth (nulliparity)

2-Obesity

3-Family history

4-African racial origin

Differential diagnosis of Uterine Fibroids

1- Ovarian tumor, whether benign or malignant.

2- Adenomyosis.

3- Leiomyosarcoma; the patient presents with a history of a rapidly enlarging abdominal-pelvic mass and decreased mobility of the uterus, along with general signs of wasting (cachexia).

Diagnosis of Uterine Fibroids

1-Ultrasound, mainly transvaginal ultrasound, gives accurate information to distinguish a uterine fibroid from an ovarian mass.

Fibroids appear as circular, well-demarcated lesions.

2-Hysteroscopy is used for diagnosing and treating submucous fibroids.

Treatment of Uterine Fibroids

The choice of treatment depends on many factors, such as general health, age, whether you have had children before, whether you wish to have more children in the future, and the size and location of the fibroid.

Medical treatment of Uterine Fibroids

Small fibroids that cause no symptoms usually need no treatment and no routine scans; see your doctor if new symptoms appear. When symptoms appear and treatment is needed, options include tranexamic acid or anti-inflammatory tablets during periods, the hormonal IUD (Mirena) when the fibroid does not distort the cavity, and hormonal pills. Newer daily tablets (relugolix combination therapy) can shrink fibroids and control bleeding for long periods, while GnRH agonist injections are mainly used for a few months before surgery.

GnRH agonists and relugolix combination therapy shrink fibroids while they are taken; when they are stopped, ovarian function returns and the fibroids tend to grow back. Tranexamic acid, anti-inflammatory tablets and the hormonal IUD reduce bleeding but do not shrink fibroids.

Surgical treatment of Uterine Fibroids

Submucous and intrauterine fibroids can often be removed by hysteroscopy.

Other types of fibroids may be removed by abdominal myomectomy or hysterectomy.

1-Myomectomy

This is usually done for younger women who wish to preserve their fertility. It can be performed by laparoscopy or open surgery (laparotomy), especially for larger fibroids.

When fibroids are removed laparoscopically, they are cut into small pieces inside a special protective bag, to avoid spreading tissue inside the abdomen in the rare case that a hidden cancer is present.

2-Hysterectomy; generally reserved for patients above 40 years who have completed their families, performed as either a total or subtotal abdominal or vaginal hysterectomy.

GnRH agonist pretreatment over a two-month period can sometimes help make hysterectomy or myomectomy easier by reducing the size and blood supply of a fibroid prior to surgery.

Indications for surgery for Uterine Fibroids

1-Heavy or prolonged menstrual blood loss.

2-Large-size fibroid.

3-Pressure symptoms such as urine retention.

4-Possible malignant changes.

Fibroid destruction

1-Myolysis (fibroid ablation); older laparoscopic laser techniques have largely been replaced by radiofrequency ablation (through laparoscopy or through the cervix) or focused ultrasound guided by MRI, which destroy the fibroid tissue with heat and are offered to selected women.

A disadvantage of this method is that it may be associated with internal adhesions, especially between the uterus and the intestines.

2-Embolization of the uterine artery

This method involves selectively blocking the uterine artery.

This is a more modern type of treatment, performed by percutaneous selective catheterization. It is associated with a substantial reduction in fibroid size and improvement of menstrual symptoms over the following 6 months.

Embolization is usually offered to women who do not plan a future pregnancy; for women who wish to conceive, myomectomy is generally preferred, because information about pregnancy after embolization is limited.

Fibroids in pregnancy

What is the effect of fibroids on fertility and pregnancy?

The presence of fibroids in the female reproductive system can affect fertilization and pregnancy in a few ways:

• They can cause a distortion in the shape of the uterus, which affects the ability of sperm to enter the uterus or fallopian tubes, which

reduces the chance of fertilization.

• They can change the lining of the uterus in terms of size and the amount of blood reaching the endometrium, which may cause difficulty with

the implantation of the fertilized egg or the development of the pregnancy.

-They may also reduce the efficacy of infertility and fertility treatments.

Some possible complications in pregnancy include:

a. Repeated miscarriages and preterm birth

b. Bleeding in pregnancy

c. Dystocia or obstructed labour

d. Effects on the fetus

For these reasons, women who are trying to conceive are encouraged to see their doctor to check whether fibroids are present, in order to help avoid

complications before or during pregnancy. If you have questions about fibroids and how they may affect your fertility, the team at Dr. Najeeb Layyous’s clinic is available to guide you through diagnosis and the treatment options best suited to your situation.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist