Uterine Fibroids (Myomas)

What is a fibroid?

A fibroid (medical name leiomyoma or myoma) is a benign (non-cancerous) lump that grows from the muscle layer of the womb. It arises from the multiplication of a single muscle cell and is surrounded by a thin covering (capsule).

• Very common: it is the most common type of tumour in the pelvis (the lower part of the abdomen) in women. Fibroids are found in about 70–80% of women of childbearing age and women approaching the menopause.
• They are more common in Black women and can be more severe.
• The growth of fibroids depends on the female hormones (oestrogen and progesterone). This is why they usually shrink after the menopause.

Can a fibroid turn into cancer?

According to the sources, fibroids are almost always non-cancerous, and an existing fibroid is not expected to turn into cancer. The very rare muscle cancer of the womb (leiomyosarcoma) usually develops not from a change in a fibroid but as a separate, independent tumour.

Even so, the possibility is not zero: in the tissue examination of women operated on for presumed fibroids, this cancer has been found unexpectedly in about 1 in 400 to 1 in 1000 operations, according to studies. A fibroid that grows after the menopause in particular needs a detailed assessment (see the "Fibroids after the menopause" section below).

Types of fibroid: why does the position matter?

The International Federation of Gynecology and Obstetrics (FIGO) numbers fibroids from 0 to 8 according to where they sit in the wall of the womb. In plain language there are three main groups:

• Those growing into the cavity of the womb (submucosal, FIGO 0–2): they lie under the lining of the womb and bulge into the cavity. Type 0 is entirely inside the cavity; in types 1 and 2 part of the fibroid is inside the muscle wall. Even when small, they can cause heavy periods and pregnancy problems.
• Those inside the muscle wall (intramural, FIGO 3–4): the most common type. Type 3 touches the lining of the womb, type 4 is entirely in the middle of the muscle wall.
• Those growing towards the outer surface of the womb (subserosal, FIGO 5–7): they project outside the womb; type 7 is attached to the womb by a stalk. They usually cause pressure and a feeling of fullness rather than bleeding.
• Others (FIGO 8) and mixed types: fibroids in the neck of the womb or in places with no direct connection to the womb are type 8. Those reaching both the lining and the outer surface are called mixed (for example "2-5").

What are the symptoms?

The great majority of women with fibroids (about 70–75%) have no symptoms at all; the fibroid is found by chance during an examination done for another reason. When there are symptoms, the most common are:

• Heavy, long or clotty periods: the most common symptom. Over time it can lead to anaemia (low blood count) due to iron deficiency, and tiredness. For details see Irregular and Abnormal Bleeding.
• Pressure and a feeling of fullness: large fibroids can cause a lump, heaviness and bloating in the abdomen.
• Pressure on neighbouring organs: pressure on the bladder can cause frequent urination, urine leakage or difficulty passing urine; pressure on the bowel can cause constipation. Rarely, squeezing of the tube carrying urine from the kidney can cause swelling of the kidney (hydronephrosis).
• Pregnancy problems: fibroids that distort the cavity of the womb and large fibroids in the muscle wall can make it harder to become pregnant; they have been linked with repeated miscarriage, premature birth and problems with the position of the afterbirth (placenta).

How are fibroids diagnosed?

• Gynaecological examination: enlargement and irregularity of the womb can be felt during a hand examination.
• Ultrasound: the first step and the standard method for diagnosis. The number, size and position of the fibroids are assessed with an ultrasound done through the vagina or over the abdomen.
• Saline ultrasound (saline infusion sonography): an ultrasound done after a small amount of sterile fluid is placed inside the womb; it shows the relationship of the fibroid to the lining of the womb more clearly.
• MRI (magnetic resonance imaging): used when there are many fibroids, to map them, to tell them apart from adenomyosis (lining-type tissue growing into the muscle wall of the womb) and to plan surgery.
• Hysteroscopy (looking inside the womb with a camera): a thin camera is passed through the neck of the womb to look directly into the cavity. It is the method used for the definitive assessment of fibroids growing into the cavity of the womb.

Diagnosis and follow-up of fibroids are carried out at the practice in Muratpaşa, Antalya.

What is done for a fibroid that causes no symptoms?

For fibroids that cause no complaint (bleeding, pain, pressure, difficulty becoming pregnant) and raise no suspicion of cancer, no surgery or medicine is needed. This approach is called "monitoring" or "watchful waiting":

• keeping track of symptoms,
• gynaecological examinations at intervals,
• usually a yearly ultrasound check is enough.

If something changes between check-ups, such as heavier bleeding, a new pressure symptom or a plan to become pregnant, the approach is reassessed.

Medicines

Medicines do not remove fibroids. The aim is to reduce bleeding, correct anaemia or, when needed, shrink the fibroid temporarily. The groups of medicines used are:

• Hormonal intrauterine device (hormonal coil): thins the lining of the womb, clearly reduces menstrual bleeding and corrects anaemia. It is not recommended for fibroids that clearly distort the cavity of the womb.
• Medicines that stop clots from breaking down too early (antifibrinolytics): a hormone-free option taken only on the days of the period that reduces the amount of bleeding.
• Contraceptive pills and pills containing the hormone progesterone: often used as first options to ease bleeding and period pain; however, they do not shrink fibroids.
• Anti-inflammatory painkillers (NSAIDs): reduce period pain; their effect on heavy bleeding caused by fibroids is limited.
• GnRH agonists (medicines that suppress the hormone centre in the brain): by creating a temporary menopause-like state they clearly reduce the fibroid and the bleeding. When the medicine is stopped, the fibroid returns to its former size. Because of bone density loss and side effects they are usually used for a short time (3–6 months) before surgery, to stop bleeding, raise blood levels and shrink the fibroid.
• GnRH antagonists: suppress the same hormone centre more quickly; they reduce bleeding and fibroid volume. In current practice they are used together with a small amount of added hormone (add-back therapy) to reduce side effects.
• Medicines that modulate the effect of progesterone (SPRMs): can stop bleeding and shrink the fibroid; however, because of regulatory decisions about liver safety, they are considered only after careful assessment by the doctor.

Which medicine is suitable is decided according to age, the complaint, the position of the fibroid and the wish for pregnancy.

Surgical options: which one for whom?

The decision on surgery and the method are individual: age, the severity of the complaints, the position and size of the fibroid and the wish to have children are assessed together. An operation in which only the fibroid is removed and the womb is kept is called a myomectomy.

Hysteroscopic myomectomy (removing a fibroid from inside the womb)

It is done without any cut in the abdomen, with thin camera instruments passed into the womb through the vagina. It is the method of first choice for fibroids growing into the cavity of the womb (FIGO types 0 and 1); the patient can usually go home the same day. For details see Hysteroscopy.

Laparoscopic (keyhole) and open myomectomy

Used for fibroids that do not reach the cavity of the womb (those in the muscle wall and on the outer surface), in women who wish to have children in the future or to keep their womb: the fibroid is removed and the muscle of the womb is repaired with stitches.

• Laparoscopic myomectomy: done through small openings in the abdomen with a camera (laparoscopy). Compared with open surgery there is less pain and blood loss, and recovery is faster. It can also be done with robotic assistance. For details see Laparoscopic (Keyhole) Surgery.
• Open myomectomy: done through a cut in the abdomen if the fibroids are very many or very large, or if removing them by the keyhole method would be technically risky.

Hysterectomy (removal of the womb)

Used in women who do not wish to have children, who want a permanent solution, and whose heavy bleeding or pain has not settled with other treatments. It is the only definitive method that completely removes the risk of fibroids coming back and of fibroid-related bleeding; however, pregnancy is not possible afterwards. It can be done through the vagina, laparoscopically or as open surgery.

Other non-surgical options

Uterine artery embolisation

A procedure carried out by interventional radiologists: a thin tube is passed into the artery in the groin, and very small blocking particles are released into the blood vessels that feed the womb. The fibroids, with their blood supply reduced, shrink.

• Who it suits: women who do not want surgery or whose surgical risk is high, who have bleeding and pressure complaints, and who are not planning a future pregnancy.
• Studies have reported that bleeding and pressure complaints improve in most women (about 80–90%).
• Warning: because it may affect the ovarian reserve (the stock of eggs) and may increase the risk of miscarriage and afterbirth (placenta) problems in later pregnancies, it is not recommended for women who wish to have children.

Focused ultrasound and heat-based shrinking

The fibroid tissue is destroyed and shrunk using high-intensity sound waves under MRI guidance (focused ultrasound) or with heat energy (radiofrequency) delivered by laparoscopy. These are counted among the womb-sparing, non-surgical or minimally invasive options; who they suit is assessed individually.

Fibroids when you want to become pregnant

• In women who want children and who cannot become pregnant or have repeated miscarriages because of fibroids, if surgery is needed the first choice is a myomectomy (the womb is kept).
• Removing fibroids that distort the cavity of the womb by hysteroscopy has been reported to increase pregnancy and live birth rates.
• After a myomectomy, it is usually recommended to postpone pregnancy for 3 to 6 months so that the wall of the womb can heal.
• If the muscle of the womb was cut deeply during the operation or the cavity of the womb was entered, birth by caesarean section is recommended because of the risk of the womb tearing during labour.

If you are planning a pregnancy, the effect of the fibroid on pregnancy can be discussed beforehand — see Preconception Counselling.

Fibroids after the menopause

At the menopause the ovaries stop working and the oestrogen level falls. For this reason fibroids usually shrink, and fibroid-related complaints ease on their own.

For general information about the menopause see What the Menopause Is.