According to medical history, during the lifetime of Greek physician Hippocrates in 460-375 BC, a fibroid was known as a “uterine stone”.
The first surgery for fibroid was done for the late American president Abraham Lincoln’s cousin in 1809. The term fibroid was introduced in 1860.
Many women are diagnosed with uterine fibroids. For some, the fibroid is not medically impactful, while for others, it can cause infertility.
What is a uterine fibroid?
A woman’s womb or uterus is made up of muscles known as myometrium. This myometrium is composed of many strands of muscle fibres.
Fibroids arise from genetic alterations in a single muscle fibre. This causes the fibres to overgrow and form a fibroid.
The circulating female hormone called oestrogen can cause growth of the fibroid.
However, fibroids can also grow in a low oestrogen environment, possibly due to conversion of the male hormone called androgen into oestrogen. Yes, women have male hormones too!
Many women may have fibroids without ever realising it. This is because not all fibroids cause symptoms. Whether the fibroid causes a problem or not depends on the size and location of the fibroid.
General problems with fibroids
These can include:
• Heavy period flow – Generally, a fibroid that is located close to the inner layer of the womb (endometrium), and which distorts or displaces the womb cavity, may cause heavy periods.
If untreated, this can lead to anaemia.
• Pelvic pain – Larger fibroids (more than 4-5cm) may also cause pain.
Sometimes, the core of the fibroid can become soft, leading to severe pain. This is called “red degeneration” of the fibroid.
A large fibroid can also lead to compression of the urinary bladder and bowel, which leads to difficulty in passing out urine or faeces.
How does a fibroid affect fertility?
A fibroid can adversely affect fertility through:
• Cervical displacement – After sexual intercourse, sperm is deposited in the vagina. It will find its way through the neck of the womb (cervix) into the womb. Large fibroids can displace the cervix and reduce womb exposure to sperm.
• Interfering with sperm migration – The sperm that enter the womb need to swim a long distance to meet the female egg. A fibroid that distorts the womb cavity can interfere with sperm migration.
• Obstruction of the Fallopian tube – Once the sperm swims through the entire length of the womb, it needs to enter the Fallopian tube. This is where the sperm will finally meet the egg.
A fibroid that is located close to the entrance of the tube can obstruct it.
• Interfering with egg uptake after ovulation – The egg, on the other hand, once released from the ovary, will be picked up by the Fallopian tube. A fibroid located close to the tube can actually change the anatomical relationship between the ovary and the Fallopian tube. This can interfere with the uptake of the egg into the tube.
• Affecting the implantation of the embryo – An embryo is formed after a sperm manages to fertilise an egg. The embryo will then have to “swim” back into the womb cavity.
A fibroid located close to the endometrial lining of the womb can distort the lining, so that when the embryo finally reaches its destination, it may be difficult to get implanted in the womb cavity.
So, even after the embryo is formed successfully, the woman is not pregnant until the embryo implants.
Generally, treatment will depend on the symptoms, size and location of the fibroid.
• Doing nothing – Even if you have been diagnosed to have a fibroid, it does not always mean that you need treatment.
So, do not be surprised if your doctor tells you to “just wait and see”. Fibroids that are small and do not cause any symptoms can be left alone.
• Non-surgical treatment – There are several options available.
Fibroid growth is dependent on the female hormones oestrogen and progesterone.
The production of these hormones from the ovary is controlled by Gonadotropin Releasing Hormone (GnRH). A synthetic form of GnRH can be used to stop the production of natural GnRH, which stops the production of oestrogen and fibroid growth.
This medication has been shown to reduce the size of a fibroid by up to 50%.
This is a temporary solution and it comes with side effects. GnRH makes a woman menopausal as long as she uses it. If used for more than six months, it can cause bone loss.
For this reason, the use of GnRH is limited to about six months, or as a preoperative measure to shrink the fibroid prior to surgery.
Ullipristal acetate is an oral tablet that has been used to control heavy menstrual bleeding due to a fibroid. It is as efficacious as GnRH and belongs to a group of medicines known as Selective Progesterone Receptor Modulator (SPRM). However, just like GnRH , it is not used as a long term solution.
Magnetic resonance imaging (MRI)-guided focused ultrasound is a treatment option where the fibroid is slowly “killed” by heating it using pulsed ultrasonic waves. This will cause cell death.
It is done with the help of an MRI to help the doctor see the fibroid in 3D.
Throughout the procedure, you are awake but painkillers will be given to keep you relaxed. The procedure generally takes about few hours.
• Surgical treatment – In the case of surgery, there are also several options available.
Sometimes, a fibroid can be removed vaginally via hysteroscopy (a telescope introduced vaginally into the uterus).
This method is best suited for fibroids that are located within the uterine lining (submucous fibroid).
A hysteroscope is used to see the fibroid under direct vision and the fibroid is cut using electricity. This method is also known as transcervical resection of fibroid.
Large fibroids generally need to be removed via a myomectomy.
The surgeon has two options on how to do the procedure.
The traditional way is called a laparotomy (open surgery), which involves a Caesarean-like abdominal cut.
The fibroid is removed abdominally and the uterine defect is sutured.
Generally, this method is associated with more pain after surgery and a longer recovery time.
Nowadays, more surgeons perform myomectomy laparoscopically.
In this technique, up to four small “holes” are made on the abdomen and laparoscopic instruments are introduced via the holes to perform the surgery.
Surgeons use a special instrument to cut the fibroids into small pieces before removing it.
For a woman who does not intend to become pregnant, a hysterectomy is sometimes needed, especially with multiple uterine fibroids.
This can be done by the traditional laparotomy or by laparoscopy (key hole) surgery.
However, hysterectomy is a big no-no if you are trying to conceive.
If you have a fibroid and have difficulty conceiving, visit your fertility specialist to determine if the fibroid needs to be removed.
Dr Agilan Arjunan is an obstetrician and gynaecologist, and fertility specialist. For more information, e-mail firstname.lastname@example.org. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.