Fibroids

FIBROIDS

TABLE OF CONTENTS

1 What Are Fibroids?

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Types of Fibroids

Risk Factors For The Development of Fibroids

3 Prevalence of Fibroids in Trinidad & Tobago

TABLE OF CONTENTS 7

5

Fibroids, Fertility and Pregnancy

What Are The Signs and Symptoms of Fibroids?

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6 Diagnosis

Common Treatment & Management Options

1 What Are Fibroids?

Fibroids are non-cancerous growths that develop in or around the womb (uterus).

The growths are made up of muscle and ďŹ brous tissue, and vary in size.

They're sometimes known as uterine myomas or leiomyomas.

ETIOLOGY OF FIBROIDS: The exact cause of ďŹ broids is unknown, but they have been linked to the hormone oestrogen.

Oestrogen is the female reproductive hormone produced by the ovaries (the female reproductive organs). Fibroids usually develop during a woman's reproductive years (from around the age of 16 to 50) when oestrogen levels are at their highest. They tend to shrink when oestrogen levels are low, such as after the menopause when a woman's monthly periods stop.

Reference: https://www.nhs.uk/conditions/ďŹ broids/#:~:text=Fibroids%20are%20non%2Dcancerous%20gro wths,as%20uterine%20myomas%20or%20leiomyomas

What causes fibroids?

The cause of uterine fibroids is not known, although studies demonstrate there may be a genetic component. There is no definite external exposure that a woman can have that causes her to develop fibroids.

Who is at risk for uterine fibroids?

Various factors can increase the risk of developing fibroids: ● Age: Fibroids become more common as women age, especially during their 30s and 40s and up to menopause. After menopause, fibroids are much less likely to form and usually shrink if they’re present. ● Family history: Having a family member with fibroids increases your risk.

If a woman's mother had fibroids, her risk of having them is about three times higher than average. ● Ethnic origin: African-American women are more likely to develop fibroids than other ethnicities. ● Obesity: Women who are overweight are at higher risk for fibroids. The risk may be two to three times greater than average.

2 Types of Fibroids

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Subserosal Fibroids: ❖ ❖ ❖ ❖ ❖

These form on the outer, smooth surface of the uterus known as the serosa. They grow outward from the uterus and project into the pelvic cavity.

They can grow large enough to make the womb appear bigger on one side.

These fibroids can sometimes grow on a stalk : pedunculated fibroids.

Due to being located outside the uterine wall, subserosal fibroids have less impact on the workings of the uterus and more affect the neighbouring organs.

Common symptoms include: ➢ Frequent need to urinate ➢ Constipation or bloating ➢ A feeling of heaviness or fullness ➢ Abdominal pain or cramping

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Intramural Fibroids: ❖ ❖ ❖

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These are the most common types of fibroids that grow from within the muscular uterine wall.

They can be very large if left untreated and it is very common to have multiple intramural fibroids located in the same area.

Depending on their location, Intramural Fibroids can be classified into three categories: ➢ Anterior Intramural Fibroid: forms in the front of the uterus ➢ Posterior Intramural Fibroid: forms in the back of the uterus ➢ Fundal Intramural Fibroid: forms in the upper part of the uterus Many people experience mild symptoms, some experience more severe symptoms including: ➢ Pelvic pain ➢ Lower back pain ➢ Heavy bleeding or extended menstrual periods ➢ Bleeding between menstrual periods

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Submucosal Fibroids/ Intracavitary Fibroids: ❖ These are the least common of the various types of fibroids. ❖ They are localized directly below the endometrial layer (uterine mucosa). ❖ Due to their location, submucosal fibroids often cause more bleeding problems than other types of fibroids. ❖ Large submucosal fibroids may increase the size of the uterus cavity and block the Fallopian tubes, which will then affect fertility. ❖ These types of fibroids are associated with very heavy, excessive menstrual bleeding and prolonged menstruation.

Image Source: https://www.msdmanuals. com/professional/gynecol ogy-and-obstetrics/uterine -fibroids/uterine-fibroids

3 Prevalence of Fibroids in Trinidad & Tobago

Fibroids are the most common tumors seen in women between 25 to 44 and 45 to 64 age groups in Trinidad and Tobago. Incidence rates are based on discharge data from the Ministry of Health Annual Statistical Report, 2005 (Tables 1 and 2).

The true incidence/prevalence is under-reported as the condition is probably not diagnosed in many women.

4 Risk Factors For The Development of Fibroids

● Race - Women of African descent are more likely to have fibroids than are women of other racial groups. Black women also tend to develop more or larger fibroids at younger ages with more-severe symptoms. ● Heredity- if your immediate family (mother, sister etc) developed fibroids, you are slos more likely to develop fibroids. ● Age- Fibroids occur more commonly between the ages of 30-50.

Pre-menopausal women are three to five times higher risk of developing fibroids than postmenopausal women. After menopause, fibroids are much less likely to form and usually regress overtime.

The early onset of menstruation can also increase one’s chances of developing fibroids.

● Weight- Being overweight increases your risk of uterine fibroids to two to three times greater than average. The lack of physical activity can also increase the risk of obesity and therefore fibroid development. ● Diet- Vitamin D deficiency, a diet higher in red meat and lower in green vegetables, fruit and dairy etc, tend to increase one's chances of developing fibroids. Regular alcohol consumption and food additives within the diet have also been linked to the development of fibroids. ● High blood pressure- Women with hypertension are more likely to be diagnosed with fibroids (fivefold increase).

Alternatively, factors that may lower the risk of fibroids ● Pregnancy (the risk decreases with an increasing number of pregnancies) ● Long-term use of oral or injectable contraceptives

5 What Are The Signs and Symptoms of Fibroids?

1. Abnormal Menstruation ● Hypermenorrhea (heavy periods), menorrhagia (high flow or prolonged bleeding), metrorrhagia (possibly associated anemia) ● Dysmenorrhea

2. Features of Mass Effect ● Enlarged, firm and irregular uterus during bimanual pelvic examination ● Back or pelvic pain/discomfort. Labor-like pain may occur if a leiomyoma is situated within the cervical os. ● Urinary tract or bowel symptoms (e.g., urinary frequency/retention, constipation, features of hydronephrosis)

3. Reproductive Abnormalities ● Infertility (difficulty conceiving and increased risk of miscarriage) ● Dyspareunia

6 Diagnosis

Uterine fibroids are frequently found incidentally during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus, suggesting the presence of fibroids.

Pelvic Ultrasound

This is the first-line study used to evaluate for uterine fibroids

Evaluate The Uterine Cavity For Suspected Submucous Fibroids or In Patients Desiring Fertility → Saline Infusion Sonography — Saline infusion sonography (sonohysterography) is an imaging study in which pelvic ultrasound is performed while saline is infused into the uterine cavity. This allows identification of submucosal lesions ( not seen on routine ultrasonography) and fibroids that protrude into the uterine cavity. → Hysteroscopy — Diagnostic hysteroscopy is useful for visualizing the endometrial cavity. Similar to saline infusion sonography, this allows evaluation for submucosal or protruding myometrial fibroids and can characterize the extent of protrusion. This can be performed in the office or operating room.

Additional Imaging (When Complex Intervention Is Planned or Malignant Disease Is Suspected)

Magnetic resonance imaging (MRI) — This imaging test can show in more detail the size and location of ďŹ broids, identify different types of tumors and help determine appropriate treatment options. An MRI is most often used in women with a larger uterus or in women approaching menopause (perimenopause).

7 Fibroids, Fertility and Pregnancy

Impact of fibroids on fertility — Fibroids themselves can contribute to a number of reproductive impairments, including infertility and recurrent pregnancy loss Generally, the literature has concluded that fibroids that distort the cavity have more of an impact on fertility, and surgical treatment can be effective in reversing that impairment. Likewise, the more the fibroids are located near the serosal surface, the less a role they appear to play.

Infertility and other reproductive dysfunction are often multifactorial, and, thus, a complete infertility evaluation of both partners is indicated before fertility treatment for fibroids.

● Elevated concentrations of hormones (estrogen and progesterone) promotes growth of leiomyomas ● Pain is caused by mass effects, necrosis (Rapid growth and insufficient blood supply lead to fibroid degeneration) and peritoneal irritation (Elevated hormone levels cause fluid retention within the uterus and fibroid) ● The expanding fibroid mass stretches the uterine wall causing premature contractions

● Depending on the location and size--------> fetal malpresentation, extrauterine pregnancy, placental abruption, prematurity, fetal deformities (congenital torticollis, limb reduction defects) and miscarriage. ● If there is an obstruction of the birth canal -------> C-section is indicated. ● PPH (atonic haemorrhages). Intramural fibroids usually impair uterine contractions, leading to atonic postpartum hemorrhage. ● Puerperium: fibroid regression accompanied by calcification.

Painful fibroids — Pregnant women with painful fibroids may require hospitalization for pain management. Supportive care and administration of acetaminophen as the initial intervention.

Short-term use of opioids in standard doses or a short course (ideally <48 hours) of nonsteroidal anti-inflammatory drugs (NSAIDs) can be given when pain is not controlled by supportive measures.

Pain may be managed with a short course of ibuprofen or indomethacin 25 mg orally every 6 hours for up to 48 hours. NSAID therapy should be limited to pregnancies less than 32 weeks of gestation because of the possibility of inducing premature closure of the ductus arteriosus, neonatal pulmonary hypertension, oligohydramnios, and fetal/neonatal platelet dysfunction. If the NSAID is continued for >48 hours, weekly sonographic assessment for oligohydramnios and narrowing of the fetal ductus arteriosus should be performed. If either of these ďŹ ndings is noted, the NSAID should either be discontinued or the dose reduced (eg, reduce indomethacin dose to 25 mg every 12 hours).

8 Common Treatment & Management Options

Conservative Treatment

Here the focus is on symptomatic relief and not definitive treatment ●

Analgesics e.g. NSAIDs like ibuprofen. In addition to pain relief, NSAIDs may also reduce menstrual flow.

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Iron replacement - a common presentation in patients with uterine fibroids is iron deficiency anemia. (it is important to confirm that anemia is due to iron deficiency before starting)

Conservative Treatment

Here the focus is on symptomatic relief and not definitive treatment ●

Oral Contraceptives- birth control pills may be used to control bleeding symptoms and menstrual cramps caused by uterine fibroids.

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Gonadotropin-releasing Hormone (GnRH) Agonists - These drugs can reduce the size of fibroids and may be prescribed several months before surgery. (they should not be taken long-term as they can cause osteoporosis)

Surgical Interventions Myomectomy - removal of the fibroids whilst leaving the uterus intact Hysterectomy - complete removal of the uterus, usually recommended for women who have completed their families. Nulliparous women undergoing a myomectomy should always be warned of the possibility of the switch to a hysterectomy as a common complication of myomectomies is life threatening bleeding.

Uterine Artery Embolization - This is a newer technique involving interventional radiology. During the procedure, the blood supply of the fibroids is cut off, causing the fibroids to shrink. The procedure takes about 60 to 90 minutes.

Example of a Uterine Fibroid

(A) Pre-treatment

(B) Post-treatment

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The patient firstly receives a sedative to relax them, then a local anesthetic is applied to the skin around the groin area.

The radiologist then makes a 1/4-inch-long incision through which a catheter is inserted into the femoral artery.Next the radiologist will thread the catheter into the uterine artery.

Small plastic or gelatin particles will be injected through the catheter into the blood vessels that supply blood to the fibroids. These particles block the blood supply to the tiny arteries that carry blood to the fibroids. Without this blood supply, the fibroids shrink and then die.

UAE is performed in both the left and right uterine arteries.

Women who may want to become pregnant in the future should NOT have this procedure.

FIBROIDS THANKS FOR READING!