JOIN USBe aware of myomas
Uterine fibroids, otherwise called myomas, are the most common benign (non-cancerous) tumours arising from the uterus in women of reproductive age. They are known to occur in 50-60% of all women. About 5-10% of women with fertility-related issues have uterine fibroids. Fibroids can be single or multiple and their presence changes the size and shape of the uterus.
Fibroids are hormone-responsive tumours and the female hormone or estrogen is known to promote their growth. They are rarely seen before periods commence and stop growing after menopause. The cause of fibroids is still unclear but it is likely to be a combination of genetic, hormonal, and environmental factors.
What are the symptoms?
The most common symptoms of fibroids include increased bleeding during periods and pelvic pressure. They may also cause infertility, complications during pregnancy, and pain. Not all fibroids are problematic, in fact, most tend to be asymptomatic. Whether fibroids result in symptoms and require treatment depends on their location, size, and number.
What are the types of fibroids?
The uterus has three layers — an inner lining called the endometrium, a middle layer of muscle, and an outer thin covering. The inner cavity of the uterus is lined by the endometrium. Fibroids are growths that arise from the middle muscular layer. Fibroids are classified based on their location in relation to the uterine cavity. Fibroids that project into the uterine cavity are called submucous fibroids. Those that are present within the muscular wall are called intramural. Those that project towards the outer wall away from the cavity are called subserous. Of these, the submucous fibroids which project into the uterine cavity and distort it, cause most symptoms.
Do fibroids decrease fertility?
Uterine fibroids are seen in just 5-10% of women suffering from infertility. Symptoms are largely based on their location and size. Cavity distorting or submucous fibroids are most symptomatic and have a detrimental effect on fertility. Fibroids well away from the uterus or subserous fibroids do not affect fertility. The impact of fibroids in the wall of the uterus is controversial with a probable mild impact on the ability to conceive.
How do fibroids affect fertility?
Fibroids affect fertility by interfering with sperm transport, implantation of the embryo, blood supply, hormonal changes, and endometrial receptivity. In any woman with fertility-related issues, a diligent attempt should be made to evaluate the presence, size, location, and a number of fibroids. Fibroids can be diagnosed by a combination of modalities such as physical examination, ultrasound, hysteroscopy, and MRI. Ultrasound is an easy, non-invasive, and excellent modality in experienced hands.
How are fibroids treated?
Treatment of fibroids is mainly surgical. All submucous fibroids irrespective of size increased bleeding during periods, large intramural fibroids and large fibroids causing pressure symptoms are indications for removal.
Removal of fibroids or myomectomy may also be considered to improve the access of ovaries during Invitro Fertilisation (IVF). Fibroids on the outside or subserous fibroids need not be removed. Intramural fibroids may have a mild impact on fertility and their removal is individualised based on many patient factors. A surgical approach to fibroid removal can be either through the vagina or abdomen. The route of surgery depends on the location, size, and number of fibroids.
The vaginal approach is preferred for submucous fibroids that project into the cavity. There is sufficient evidence that the removal of submucous fibroids improves pregnancy rates. This is done by hysteroscopic removal where a camera is inserted into the uterus and the fibroid is resected out using energy sources under vision. This is the least invasive approach as the hysteroscope is introduced through the natural openings and this does not require incisions or cuts in the body.
Hence, postoperative pain is much lesser and recovery is faster. If the fibroids are large in size or are in multiples, it may require more than one sitting. Conception following surgery should be delayed for 6 to 8 weeks to allow for adequate healing.
The abdominal approach is better suited for intramural and subserous fibroids. It can be done through open surgery or laparoscopy/minimally invasive surgery. Open surgery involves a large incision and is associated with greater postoperative pain, longer recovery time, and greater intraoperative blood loss and adhesion formation. The formation of postoperative adhesions can be an added hindrance to conception postoperatively. Laparoscopy is a minimally invasive surgery using
keyhole incisions. Consequently, the postoperative pain is lesser, recovery is faster and adhesion formation is much lower. In patients with infertility, this is the route of choice. Conception should be delayed for three months post-surgery to allow adequate healing. Hysteroscopic and laparoscopic removal of fibroids require tremendous technical expertise and are best performed by specialist gynaecologists trained in minimally invasive surgery.
Non-surgical options
There have been some recent advances in the non-surgical management options for fibroids. These techniques include uterine artery embolisation (UAE), MRI-guided focused ultrasound surgery (MRgFUS), oral drugs like ulipristal, mifepristone, etc. Uterine artery embolisation (UAE) is a technique where the artery supplying blood to the uterus and in turn, the fibroid is blocked and the fibroid undergoes irreversible necrosis. This method is not preferred in women with infertility in view of its detrimental effects.
Lower pregnancy rates, lower egg reserve and adverse pregnancy outcomes have been observed following UAE. MRgFUS involves the destruction of the fibroid tissue by heat using high-frequency ultrasound beams. Its safety in women with infertility is still uncertain.
Oral drugs like ulipristal had been used in the past but have currently been withdrawn in view of adverse events. In short, fibroids are very common benign growths arising from the uterus. Most fibroids do not cause symptoms and do not need removal.
Fibroids that distort the uterine cavity (submucous) definitely warrant removal. Subserous fibroids can be left alone. The decision to remove some intramural fibroids can be taken in individual situations. Hysteroscopic and laparoscopic removal are the preferred routes of choice.
(The author is a consultant in infertility & reproductive medicine.)