What is Uterine Fibroids? - Types, Clinical Features, Symptoms, Diagnosis and Treatment

Uterine Fibroids

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Definition of Fibroid: 

Fibroid tumors are benign tumors arising in the myometrium which can protrude into the uterine cavity, bulge through the outer layer or grow within the myometrium.

Growth of Fibroids

1. Fibroids develop due to proliferation of smooth muscle cells. The tumors usually grow very slowly, about 1 to 2 cm per year.

2. Fibroids are estrogen dependent and thus grow rapidly during pregnancy. They do not occur before menarche and growth cessation occurs after menopause.

Types of Fibroids:

Alternatively named myomata or leiomyomata, uterine fibroids are the commonest of all pelvic tumors. They are benign fibromuscular swellings, arising in the muscle wall of the uterus. Fibroids are oestrogen sensitive.

➦ Submucous: It lies immediately below the endometrium and enlarges the surface of the uterine cavity often leading to menorrhagia. Fibroids may become pedunculated forming polypi which can extrude through the cervix.

➦ Intramural: The commonest site for fibroids, surrounded by smooth muscle, enlarging the uterine wall and distorting venous drainage.

➦ Subserous: Fibroids just beneath the peritoneum on the outer uterine surface. May be on an elongated stalk (pedunculated) with a risk of torsion; may grow into the broad ligament.

Clinical Features of Fibroid:

1. Majority of fibroids (75%) remains asymptomatic and are detected during routine examination or at laparotomy or laparoscopy.

2. The uterus reaches a 4 to 5 months gestation size without symptoms in most cases.

3. In symptomatic type, menorrhagia is the classic symptom.

4. Metrorrhagia or irregular bleeding is seen in some women.

5. Dysmenorrhea is a symptom when it is associated with pelvic congestion or endometriosis.

6. Infertility is seen in about 30 percent of women.

7. Recurrent pregnancy loss (Miscarriage or preterm labor).

8. Lower abdominal or pelvic pain.

Symptoms of Fibroid:

• None: a pelvic swelling is found incidentally on examination.
• Occasional tightness of waistband of clothes.
• Pressure: bladder compression causing daytime frequency and occasionally impaired urinary stream. In the supporting ligaments it causes backache and overall sensation of pelvic heaviness.
• Pain: associated with red degeneration or torsion of subserous pedicles. Dysmenorrhoea may indicate the presence of a submucous fibroid.
• Menstrual disturbances:
a. Menorrhagia: heavy bleeding;
b. Metrorrhagia: prolonged menses;
c. Irregular, intermittent bleeding: often associated with polyps and other surface lesions.

Diagnosis of Fibroid:

1. Majority of uterine fibroids can be diagnosed from S history and pelvic examination

2. Ultrasound and color Doppler are used to locate the fibroids accurately.

3. Laparoscopy is useful if the uterine size is less than 12 weeks and associated with pelvic pain and infertility

4. Uterine curettage is done in the presence of irregular bleeding to detect any coexisting pathology and to study the endometrial pattern.

Differential diagnosis

• Pregnancy: particularly if fibroids have been softened by cystic degeneration.
• Ovarian tumor: often cystic, unilateral and does not move with cervical displacement.
• Adenomyosis: more commonly causes uniform diffuse and tender uterine enlargement.

Management of Fibroid:

Therapeutic intervention depends on the woman's desire for future pregnancy and the tumor size.

Medical management:

Hormone therapy may be used as a short-term intervention to decrease the size of fibroid and to minimize blood loss. Drugs used are antifibrinolytics, antiprogesterones, Danazol, GnRH analogous and prostaglandin synthetic inhibitors. Use of hormones for more than 6 months can increase the risk of osteoporosis.

●    If small and asymptomatic, conservative management with annual examination and ultrasound monitoring of size is sufficient. This is especially used in women over 40 because fibroids do not grow after menopause and may shrink.

●    Menstrual or pressure symptoms may dictate surgery.

●    Pain-requires analgesia.

●    Heavier and longer periods with anemia are the commonest indication for proceeding to surgery.

●    Embolization under radiological control: A cannula is passed into the uterine arteries via the femoral artery. The uterine arteries are embolized by injecting tiny silicon particles causing the fibroids to degenerate. Pain relief is essential for 48 hours. In women with large/multiple fibroids there is an increased risk of hysterectomy compared to surgical treatment. Pyrexia and abscess forination can occur. It is not recommended for women who wish to preserve their fertility, although live births have been reported following the procedure.

Surgical management :

1. Abdominal hysterectomy:
Suitable when family is complete with women over the age of 40 or when the uterus is grossly enlarged and distorted by multiple fibroids.
2. Vaginal hysterectomy:
When fibroids are small and few in number and there is an associated prolapse of the uterus.
3. Myomectomy:
In young women whose families are incomplete or when there is a personal desire to retain the uterus. The procedure is often vascular and may cause scarring, with adhesion formation impairing fertility. If the fibroids are numerous it may be impossible to remove them all, and growth of the remainder may cause problems in the future. Women undergoing this procedure should be warned that the surgeon may have to proceed to a hysterectomy and consent to the possibility of this (1% risk).

Submucous fibroids may be resected with laser or diathermy through a hysteroscope.