Fibroids are benign growths of the smooth muscles of the uterus (womb). Two out of three women will have fibroids at some point in their lives.
What are the types of fibroids?
They are mainly found within the muscle wall of the uterus (intamural), on the outside of the uterus (subserosal) or on the inside of the womb (submucosal)
What are the symptoms of fibroids?
- Heavy, prolonged and/or irregular menstrual bleeding,
- Pressure on the bladder with frequent urination, or on the bowel with constipation
- Pain - this could be lower back pain, painful periods or discomfort during sex.
Sometimes women with fibroids will have no symptoms at all.
How are fibroids diagnosed?
Your GP will usually refer you for an ultrasound scan if you have the symptoms.
Can fibroids become cancer?
Fibroids are benign, and very rarely become cancer.
Your doctor will discuss the options with you and help you make a choice that is suitable for you. Sometimes a combination of treatments is needed and may be used together or one after the other.
- Do nothing - if fibroids are not causing symptoms
- Non-hormonal treatment
This will control bleeding but not reduce fibroid size. The drugs we use commonly in this category are tranexamic acid and mefenamic acid.
- Hormonal contraceptive treatments:
These are contraceptive treatments containing either oestrogen and progesterone or progesterone only. Oestrogen and progesterone are hormones that cause you to have menstrual periods. These treatments will reduce your bleeding symptoms but will not reduce the growth of your fibroids. These contraceptives come in the form of pills, implants which are placed under your skin and intrauterine systems (the commonest example is mirena coil). You may have already had one of these in the past, but your doctor can discuss them with you in more detail.
- Gonadotrophin releasing hormone (GnRH)agonists:
These synthetic hormones create a temporary menopause-like state (a natural state when menstrual periods stop). They may cause symptoms of menopause. They work by reducing the production of oestrogen and progesterone from your ovaries. Your periods will resume when you stop the medications. GnRH analogues will shrink the fibroids and reduce bleeding over several months. Your doctor can discuss the possible side effects of these medications with you and give you the specific leaflets.
When given, there is an initial increase in the production of oestrogen from the ovaries which may worsen your symptoms (a flare) that may last 2 to 3 weeks before settling.
They require add back treatment (HRT) if used for more than 6 months. Traditionally we have given the GnRH analogues as injections, and given HRT as add-back therapy separately. Examples of these drugs are goserelin (zoladex) and leuprorelin (prostap).
- Gonadotrophin releasing hormone antagonists: These drugs directly block the action of the hormones that stimulate production of oestrogen and progesterone from your ovaries. As a result, they do not cause any flare-up of your symptoms. There are 2 main types available:
Relugolix: this comes as 40 mg combined with HRT as progesterone 0.5 mg and oestrogen 1 mg in a tablet called ryeqo that is taken as one tablet daily.
Linzagolix: this comes without HRT and is in two tablet strengths, 200 mg and 100 mg. The higher dose will resolve symptoms faster but is likely to cause more side effects.
Your doctor will discuss these GnRH antagonists with you and can give you the specific information leaflets that outline the side effects. You would then be able to choose which is more suitable for you.
- Radiological treatment (Uterine fibroid embolization or Uterine Artery Embolization): Interventional Radiologists use MRI scan to first check whether your fibroids would be suitable for this procedure. If it is deemed that UAE is suitable and you have opted for this treatment, the Interventional Radiologists would make an appointment for you to have the procedure. It may be done as a day case procedure where you can go home the same day, however it is often necessary to be admitted overnight for pain relief. Under x-ray guidance, the Interventional Radiologist will inject a substance into the arteries supplying the fibroid, thus blocking the blood supply of the fibroid, and causing it to shrink. This takes months for the effect to be seen. Your doctor can provide you with the information leaflet for this procedure and discuss it with you.
- Ultrasound-guided radiofrequency ablation of fibroid: This is a brilliant new method of treating the fibroid which does not require an incision on your abdomen. The procedure is done through the vagina. There are 2 ways to do this: either the ultrasound probe remains in the vagina and the radiofrequency device is extended beside the cervix into the fibroid (transvaginal RFA) or the ultrasound probe together with the radiofrequency device are inserted into the cavity of your womb (transcervical RFA- also called Sonata). At present, only the Sonata RFA device is available at QAH, though this may change in future.
The prongs of the ablation device are then introduced into the fibroid itself to ablate it under direct ultrasound guidance. This can be done in the outpatient clinic using local anaesthesia or in theatre under general anaesthesia. Your doctor can discuss this with you, and you will choose which option you prefer. A patient information leaflet specifically for this device is also available.
- Hysteroscopic resection: This is for fibroids that are mostly or completely within the uterine cavity, The procedure is usually done in the outpatient clinic but could also be done under general anaesthesia in theatre.
- Surgery: This is either myomectomy (removing the fibroids and preserving the uterus) or hysterectomy (removing the uterus). With myomectomy, there is a chance that the fibroids can grow back. With the hysterectomy, there is no recurrence. Both are major surgeries, with significant risks, compared to the other less invasive options. Either of these surgeries can be done by laparoscopy or as open surgery. Very large or too many fibroids and previous history of abdominal surgeries may affect the decision as to whether a laparoscopic or open procedure is more suitable. Your doctor will discuss with you and help you choose the appropriate option.