Treatment of Fibroids
OBGYN matters Fibroid Clinic aims to operate an outpatient clinic with a comprehensive patient centered approach to the care of women with fibroids. As in all areas of medicine the key to successful treatment of fibroids is in the careful selection of the right treatment for each individual patient. Patients have different needs and it is important that these are acknowledged and that treatment is centered round them.
For many conditions medical treatment is sufficient to either control symptoms or cure the disease. However, in the case of fibroids surgery is often required to achieve treatment aims.
Most gynaecologsits are not able to perform keyhole surgery for fibroids and even in those who do their expertise in this area varies widely. What Mr Barnick aims to do is to perform this type of surgery to the highest possible standard, thus maximizing the success of surgery and minimizing possible complications, even in fibroids up to 12cms in diameter.
WHAT WILL HAPPEN AT YOUR FIRST APPOINTMENT?
At the first appointment a detailed history will be taken and you will be carefully examined and an Ultrasound scan may be performed. You will be asked about your symptoms and the extent to which your lifestyle is being affected. The information gathered will form the basis upon which your treatment will be planned; a detailed treatment plan will be made at this visit. At OBYN matters we offer a comprehensive service for the treatment of fibroids. Fibroids or Leiomyomas are the commonest benign growth in women. They are not usually dangerous but can cause a number of symptoms which can have a negative impact on quality of life and may reduce fertility. As a result it is common for women with fibroids to seek medical assistance. Unfortunately this does not always lead to a satisfactory outcome as women are often advised to either do nothing or to have maximally invasive, open abdominal surgery.
At OBGYN matters we aim to offer individualised advice and treatment for women with fibroids, taking into account the individual patient needs and fertility requirements. This treatment may take the form of simple reassurance, embolisation therapy, minimal access surgical treatment or very rarely open surgery. Information will be given to you about fibroids and available treatment options. At this appointment you will have the opportunity to discuss issues concerning your treatment and any future fertility concerns. Any other necessary investigations will be arranged (blood tests, MRI).
What are fibroids?
Fibroids are benign, non – cancerous growths of the smooth muscle of the womb. They are not in fact fibrous, but are made up of smooth muscle cells compacted into a fibrous looking mass. As they are smooth muscle tumours the correct name for them is leiomyomas.
Uterine leiomyomas are extremely common and are found in up to 30% of women at the time of autopsy. They are oestrogen dependent growths and grow during adult life up to the menopause. They can also grow rapidly during pregnancy and are more common when oestrogen levels are high. As a result they are also more common in obese women. Normally the smooth muscle fibres of the womb do not multiply, as there is something within their genetic make-up, which prevents this. If for some reason this genetic system fails then a muscle cell may start to divide. If this continues then eventually a large ball of muscle cells grows forming a fibroid or leiomyoma. The genetic defect that allows this is more common in West African and West-Indian women who are much more likely to have larger and more numerous fibroids.
Some women will have only one fibroid but it is more usual for women to have multiple fibroids as there are many cells within the muscle of the womb which have started to divide in a similar fashion. These fibroids grow, developing their own blood supply form the surface of the fibroid. As the fibroid grows the blood supply is eventually out-stripped and the fibroid cannot grow any further. All fibroids are therefore supplied by small blood vessels and the extent of their growth is dependent on the success of this neo-vascularisation. As a result some fibroids will only grow to one or two centimetres but rarely can they grow beyond 12cms in size. Clearly, if there are several fibroids they will vary in size and the total fibroid mass may be very large.
Gynaecologists usually describe the size of the uterus enlarged by fibroids by the equivalent size of a pregnant womb. So we may talk of a womb being 12 weeks in size or at the other extreme 36 weeks! All leiomyomas are benign growths, and whilst they may sometimes be overactive and grow quickly, they very rarely if ever have any malignant potential.
Classification of fibroids
Fibroids are classified according to where in the womb they are found.
The leiomyoma is under the inside lining of the womb, projecting into the uterine cavity. These fibroids can grow as polyps, on a stalk, or can be more deeply embedded in the muscle of the womb.
These fibroids grow within the muscle of the womb itself. They enlarge the womb and increase the blood supply to the womb. They may also enlarge the cavity of the womb by stretching it.
Fibroids found on the the outside of the womb are classified as subserosal. Again they may grow on a stalk or be embedded in the womb but projecting into the abdominal cavity.
It is not uncommon to find fibroids in different locations within the same patient as seen in the MRI scan below.
Symptoms of fibroids
Many women do not have any symptoms and fibroids are picked up at routine examination or ultrasound scan.
Frequent symptoms are:
- Heavy, prolonged, painful regular periods
- Passing clots
- Irregular bleeding throughout the cycle
- Lower back pain
- Pain during intercourse
- Pressure symptoms
- Urinary frequency
- Abdominal swelling
- Problems during pregnancy
Heavy Menstrual bleeding
Symptoms of heavy painful bleeding can be very distressing and can lead to severe anaemia. Passing large clots is very unpleasant and painful. Some women need to use double protection in the form of Tampons and pads and may need to use pads or towels to protect their bedding at night.
Women who become anaemic are pale and get very tired and out of breath with the slightest exertion. They may occasionally faint if the anaemia is severe.
Pain and pressure
Pain is either caused because the fibroids themselves are tender or because they are pressing on adjacent structures such as nerves in the pelvis or on the sacrum (the lumbo-sacral nerve roots). Fibroids typically become painful when they out-grow their blood supply and degenerate (red degeneration). They may also cause pain if they twist on their own blood supply. This may happen with a pedunculated subserosal fibroid. Pain during sex occurs when the womb is stuck in position by fibroids or by pressure on the fibroids themselves.
Fibroid size and symptoms
Symptoms are not always related to size. For instance a small fibroid within the cavity of the womb may cause severe bleeding problems and problems with fertility, whereas a large subserosal fibroid may cause no problems. A 6 cms fibroid embedded in the pelvis may cause severe urinary and bowel pressure symptoms whilst a large intra-abdominal fibroid will not.
Infertility and pregnancy problems
Fertility can be effected at a number of different stages.
- If the womb is enlarged it may not be feasible for the egg and the sperm to get together.
- Fibroids around the opening of the fallopian tubes may block or distort the fallopian tubes.
- Intramural and subserosal fibroids may distort the pelvic anatomy making it more difficult for the egg to get to the fallopian tube.
- Small fibroids within the cavity of the womb can irritate the lining of the womb and cause difficulties with implantation of the fertilised egg.
Pregnancy problems can similarly occur at different stages.
- Ectopic pregnancy can occur if the fallopian tubes are distorted or partially blocked
- Early miscarriage may occur if the cavity is distorted or if the embryo tries to implant over the site of a fibroid.
- Late miscarriage (20-23 weeks) may occur if there are multiple fibroids and the womb is unable to expand properly to contain the growing baby. This may manifest itself as preterm premature rupture of the membranes with the leakage of amniotic fluid.
- Premature birth due to difficulty in the proper expansion of the uterus.
- Growth restriction of the fetus due to poor placental attachment over fibroids.
- Pain because of rapid fibroid growth during the first part of the pregnancy followed by red degeneration.
- Difficulty during childbirth due to obstruction of the birth canal by cervical fibroids in particular.
- Haemorrhage after the birth due to poor contraction of the womb following delivery of the placenta.
Treatment of fibroids
This needs to be carefully individualised for each patient. Decisions regarding treatment must be made in partnership, particularly taking into account the type of fibroids, the severity of symptoms and the desire for future fertility. At OBGYN Matters there are a number of treatments that may be considered.
- Medical treatment
- Uterine Artery Embolisation (UAE)
- MRI guided Focused Ultrasound (MRgFUS)
- Hysteroscopic resection (TCRF)
- Laparoscopic myomectomy
- Open Myomectomy
Watch and monitor size with ultrasound scans Drugs to make periods easier. The oral contraceptive pill Progesterone Ponstan and Cyclokapron GnRh analogues to stop periods and temporarily shrink fibroids (no medical treatment will have a sustained beneficial effect on fibroid growth).
Uterine Artery Embolisation (UAE)
As mentioned above, fibroids have a blood supply that is mainly made up of small blood vessels. As a result fibroids are relatively easy to embolise. During embolisation small particles are injected into the blood supply to the fibroid which block these small blood vessels and as a result the fibroid dies and shrinks in size. How much the fibroid shrinks depends on how solid it is but on average they shrink in volume by about 40%.
The procedure is ideal for women who have multiple intramural fibroids where surgery is contra-indicated.
How is it performed?
- It is performed as an outpatient procedure under local anaesthetic.
- A tube is passed into the main artery in the groin
- This catheter is manipulated into the uterine artery under X-ray guidance
- An arteriogram is performed to check the blood supply to the fibroids
- Small particles or foam are injected into this blood supply.
- A further arteriogram demonstrates that the correct blood vessels are blocked
- The catheter is removed
- Bleeding from the catheter entry point
- Damage to blood vessels (uncommon)
- Premature menopause
- Infection, rare but serious
- Persistent vaginal discharge due to breakdown of fibroid
Women are sent home on the day of the procedure and most make a quick recovery.
Hysteroscopic resection of fibroids
This treatment of fibroids is used to remove small sub-mucosal fibroids as these can be accessed through the cervix.
How is it performed?
- Under general anaesthetic
- The cervix is dilated
- A telescope is inserted into the womb
- The fibroid is visualised
- The fibroid is cut away in pieces and removed
- Most patients go home the same day
- Problems with anaesthesia
- Bleeding, usually not severe
- Perforation of the womb with the subsequent need for laparoscopic or open surgery to check for bowel damage
- Excessive absorption of the fluid used for visualisation of the fibroid
Problems rarely occur unless attempts are made to remove large fibroids this way.
The surgery normally takes up to 30minutes and women are discharged a few hours after surgery.
Women can return to normal activities within 3 – 5 days following surgery.
Key-hole surgical techniques are ideal for removing up to 3 fibroids of up to 7 centimetres each, in diameter. The major determining factors are the skill and experience of the surgeon, the amount of space within the abdomen and the position and number of the fibroids. If the womb is larger than 18 weeks in size it is difficult to insert the necessary instruments and get an adequate view of the womb and fibroids. If there are too many fibroids then multiple incisions need to be made into the womb and this may lead to excessive bleeding. If the fibroids are very low down behind the womb then they may be difficult to access Pedunculated fibroids are the easiest to remove using this technique.
The Major advantage of this technique is that patients make a much quicker recovery following the surgery. In addition to this the incisions are very small and cosmetic, The amount of blood loss and the risks of subsequent adhesions is also reduced. Despite these major advantages over open surgery it is often not performed because most gynaecologists do not have sufficient expertise in keyhole surgery to perform this procedure.
How is the operation performed?
- The surgery is performed under general anaesthesia.
- An instrument is placed within the womb from the vagina, to manipulate the womb during the surgery
- A needle is inserted through the navel and Carbon Dioxide is used to insufflate the abdominal cavity forming a space for the surgery.
- A 10mm instrument is then inserted through the umbilicus
- A telescope and light source are inserted through this trochar
- A good view of the internal organs is obtained
- The patient is tilted head down
- Two 5mm inscision are made below the bikini line on either side of the abdomen
- Two instruments are inserted to perform the surgery
- The womb and fibroid are visualised
- The fibroid is then removed using a special instrument , morcellator, which cuts the fibroid into thin strips which can be removed through a
- 12mm inscision
- The CO2 is released from the abdomen
- The small skin incisions are sutured and glued.
- The whole operation takes about 1-2hrs depending on the fibroids!
- After surgery patients are usually in hospital overnight
- They feel tired and bloated for two to three days following the surgery and then rapidly return to normal. Pain killers are used immediately postoperatively but are usually not needed after 2-3 days
- Most women are feeling well by two weeks and are completely back to normal within four to six weeks.
- All surgery carries risks associated with general anaesthesia
- In addition there are risks of bleeding, deep vein thrombosis and infection Special precautions are taken to minimise the risks of these complications which are all rare.
- More specifically to keyhole surgery there are risks of damage to internal organs: bowel, bladder or major vessel trauma (these are rare but may require open surgery to repair)
- Open surgery to complete the surgery if the fibroids cannot be removed or if there is excessive bleeding.
- Adhesion formation following surgery
- Weakening of the womb requiring caesarean section for safe delivery in subsequent pregnancy
Open surgery for fibroids
This should be reserved for those case where the fibroids are very large or numerous. Up to 20 fibroids may be removed at a single operation!
How is the surgery performed?
- The surgery is usually performed through a “bikini line “ incision but a large vertical incision may be required.
- The surgery takes 1-2hrs for the successful tratment of fibroids
- Patients are in hospital for 3 – 5 days
- After about a week they are able to walk around
- After six weeks things a re returning to normal
- It may be another 6 weeks before all normal activities can be resumed
These are similar for the surgery above but there is a greater risk of:
- Major bleeding
- Blood transfusion
- Return to theatre
- Emergency hysterectomy
- Wound breakdown
- Future caesarean delivery
It important to remember that fibroids are benign and usually not life threatening. The decision of whether or not to have the treatment of fibroids should therefore rest with the patient. If a decision for treatment is taken then the possible complications should be minimised and future fertility plans should be paramount.