Fibroids

Melbourne fertility specialist Dr Hugo has a wealth of experience treating fibroids and associated infertility. He’s uniquely able to offer both minimally invasive treatment and then tailor your fertility care with honest, effective treatment plans.

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What are Fibroids?

Fibroids are a very common and generally benign (non-cancerous) growth of the uterus (womb). They can range in size from that of a pea to much larger bulky masses that completely distort the uterus. Fibroids are also known as Uterine Leiomyomas or simply Myomas. They are typically round and are made up of cells from the uterine muscle that keep replicating (cloning) themselves. They are firm masses and look and feel like a ball of elastic bands when cut.

Whilst fibroids occur in 70-80% of women, less than half of these will actually be symptomatic. Symptoms are very dependent on the size, total number and location/type of fibroid.

Are there different types of Fibroids?

Fibroids are usually classified according to their origin and position within the uterus. This may be difficult to work-out, especially as they increase in size and distort the anatomy.

Submucosal fibroids:

These occur just beneath the inner lining (mucosa) of the uterus causing an indentation into the uterine cavity. As they enlarge, they can protrude even further into the cavity and become pedunculated (hang off a stalk – see below). Submucosal fibroids commonly cause abnormal or heavy periods even when only small in size. They are also associated with difficulty conceiving and pregnancy complications such as miscarriages.

Subserosal fibroids:

These occur at the outer most layer of the uterus (serosa) and tend to grow outwards into the abdomen. Whilst they don’t usually disturb the uterine lining, they can still be associated with heavy and irregular periods. They most commonly cause pressure symptom by putting increased weight on the bladder (urinary frequency) and bowel (constipation). Symptoms generally increase with size, so small subserosal fibroids may require no treatment at all.

Intramural fibroids:

The main bulk of these fibroids is located in the muscle that forms the walls of the uterus. As the uterine wall is only 0.5 – 2cm thick, larger intramural fibroids will outgrow this, pushing into and indenting the uterine cavity or outwards through the external uterine wall. These are often associated with heavy and extended periods, and pressure symptoms. They may cause infertility and miscarriage; and interfere with labour.

Pedunculated fibroids:

These are fibroids that have grown on a stalk (pedicle) from either the internal (submucosal) or external (subserosal) uterine wall. They can cause pain if they move and twist or tear the stalk and are associated with heavy bleeding and infertility if located within the uterine cavity. They can become a significant problem in pregnancy if they are ‘starved’ of blood supply (red degeneration).

What Causes Fibroids?

Fibroids occur when cells in the muscle of the uterine walls start replicating (cloning) without any control. We are not entirely sure why fibroids occur but there seems to be a genetic link as they are much more common in certain families and in patients that have African heritage.

There is a definite hormonal link (oestrogen and progesterone) as fibroids are rarely seen before puberty and will usually shrink after menopause when these hormones become low. Using hormones such as the oral contraceptive pill will not ‘cause’ fibroids, but may increase their size if they are already present.

Other risk factors for fibroids include early first period (menarche), never having given birth, obesity (BMI > 30) and Polycystic Ovarian Syndrome (PCOS).

Fibroid Symptoms

Most women with fibroids are not aware they have them. As the symptoms of fibroids can be vague or increase slowly over time, women often just ‘put up’ with them, not realising just how much these symptoms impact their day to day life. Fibroids are often diagnosed incidentally when women are being investigated for other issues or after being reviewed by a fibroid specialist.

The symptoms of fibroids are divided into 4 main groups.

Pressure Symptoms:

Need to void (urinate) often.

Feeling of smaller bladder capacity.
Not feeling ‘empty’ after opening bowel.
Feeling bloated or ‘fullness’ in pelvis.

Abnormal Bleeding Symptoms:

Heavier periods with clots and/or flooding.
Longer periods.
Anaemia & Iron deficinecy.
Spotting or irregular bleeding between periods.

Pain Symptoms:

Pelvic pain/discomfort.
Lower back pain/pulling.
Discomfort with intercourse.
Fibroid ‘degeneration/necrosis’ (breakdown).

Fertility Issues:

Difficulty conceiving.
Recurrent miscarriages.
Complicated pregnancies – bleeding, small babies, breech.
Abnormal or complicated labors.

Do Fibroids Affect Fertility & Pregnancy

Many women with fibroids will conceive naturally and have very normal and safe pregnancies. Some women with fibroids will either struggle to get pregnant or will experience complications such as bleeding, miscarriage, poor placentation, prematurity, and a higher risk of a caesarean. The negative effects on both fertility and pregnancy appear dependent on the number, size, location and type of fibroids. Fibroids distort the uterine walls and its though this leads to poor lining for implantation, abnormal contractions, blockage of the cervix and tubes, and changes to uterine blood supply. I have an extensive discussion on this topic at my Fibroids & Fertility page.

Concerned That Fibroids May be Affecting Your Health & Fertility? Contact Dr Hugo Today

If concerns about your fertility and issues conceiving are weighing on you, booking in for a review with a fertility specialist is always the best option. Whether it’s just straightforward advice, understanding your diagnosis, or a specific fibroid treatment you’re after, I’m always happy to sit down for a chat and to plan the best course forward for you.

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What are the Treatment Options for Fibroids?

Fibroids that are not causing symptoms do not require any treatment or removal. Most are slow growing and will generally shrink after the menopause. Depending on their location, size and how mild symptoms are, some women may benefit from ongoing follow-up (6-12m) with ultrasound to monitor any changes.

For women who are symptomatic, there are various medical and surgical treatments available. Treatment should always be individualised and based on:

The location and size of the fibroids,
The symptoms they are producing,

Whether your family is complete, or you want further children in the future,
How close to menopause you might be.

MEDICATIONS:

Most medical treatment is directed at managing the symptoms of fibroids (pain & bleeding) rather than treating the actual condition. Medications such as paracetamol and anti-inflammatories (Ibuprofen, Ponstan, Naproxyn) may help with milder pain and cramping, and some may also decrease blood loss. Antifibrinolytic medication (Tranexamic Acid) help blood to clot and are particularly useful when there is heavy bleeding. They are quick to work, only required at the time of the period and are not contraceptive. Patients who are iron deficient will also benefit from oral iron supplements, especially with added Vitamin C to help boost their reserves. These treatments are largely ‘Band-Aids’, and whilst effective for some symptoms, will not shrink or manage the actual fibroids.

Hormones:

Hormones in the form of oral contraceptives, implants, intra-uterine devices (IUD – Mirena) and injections may be more effective in managing bleeding. In high doses, some of these medications may help manage or decrease fibroid size, however this is usually only minimal and generally they do not assist with pressure symptoms. These are usually contraceptive and therefore unsuitable if the patient is trying to conceive.

Agonists (GnRHa):

This group of injections, implants (Zoladex) and nasal-sprays (Synarel) are best described as ‘anti-hormones’. Fibroids will typically shrink and their symptoms decrease in the menopause when hormones are reduced. These medications achieve a similar outcome by temporarily blocking hormone production/receptors, giving a ‘medical menopause’. Their main side effects are hot-flushes and headaches, and they can be expensive to purchase. Treatment is usually limited to 3-6m and whilst there can be significant decrease in fibroid size, these will grow again once the medication is stopped. This treatment is best for temporary relief of bad symptoms or to decrease fibroid size prior to surgery to make the operation easier, safer and more likely to be performed by key-hole techniques.

SURGERY:

Hysteroscopic Resection:

Fibroids growing into the uterine cavity (submucosal) may be accessed with a slender telescope that passes through the cervix into the uterus. An attachment can then be used to ‘shave away’ pieces of this fibroid until it is removed. This procedure is low risk, has no cutting or incisions of the abdomen, requires only a few hours in hospital and has a quick recovery time (1-2 days).

Myomectomy:

A myomectomy is a procedure where fibroids are removed surgically. A cut is made into the uterus, the fibroid is removed and then the muscular walls of the uterus are repaired. The procedure may be performed open through a caesarean type cut (laparotomy) or by a laparoscopic ‘key-hole’ technique. A Laparoscopic Myomectomy is less painful and allows quicker recovery, but requires an advanced surgeon who is specialised in this technique. The type of procedure is largely dependent on the size, type and location of fibroids. A myomectomy is best in women with pressure symptom, and those who want to maintain fertility or wish to have children after treatment. Recovery is generally 3-4 weeks and follows and 2-3 night hospital stay. As with any surgery, risks of this procedure should be discussed with your gynecologist.

Hysterectomy:

A hysterectomy is the surgical removal of the uterus. It is the only definitive and permanent solution for fibroids and may be required when they are particularly large, or when other treatments have failed. The procedure may be performed via an open incision (laparotomy) or by a laparoscopic ‘key-hole’ technique. Whilst the uterus, tubes and fibroids are removed as one, the ovaries usually remain, and the patients will therefore not experience menopause until the usual age (approx 50yo). Fertility is not preserved, and so this is best for patients who have completed their family and want definitive symptom management.

Endometrial Ablation:

In an ablation, the lining of the uterus (endometrium) is destroyed using heat. As a result, this layer becomes scarred and will generally stop or reduce bleeding with periods. There are various procedures/techniques for performing this, but none actually manage the fibroids and instead only treat the symptom (bleeding). This is best performed in women who have completed their family or who are close to menopause as it’s almost impossible and dangerous to become pregnant following the procedure.

OTHERS:

MRgFUS:

MRI guided Focus Ultrasound (MRgFUS) is a radiological technique where ultrasound waves are directed by an MRI scanner at the center of a fibroid. The sound waves heat up the fibroid core, injuring it so that it is slowly absorbed by the body over the next 4-12 months. Whilst there are no incisions, the procedure is expensive, not widely available and only certain types of fibroids are able to be treated this way. Patients report relief from some troublesome symptoms, but the fibroids are not completely removed and may regrow. Pregnancy is possible following treatment, but long-term effects on fertility and pregnancy are uncertain and not well published.

Uterine Artery Embolisation (UAE):

UAE is a radiological technique where x-rays are used to guide a wire through a blood vessel from your groin up to your uterus. Tiny plastic or gel particles are then injected into the vessel feeding the fibroid, blocking its blood supply and causing it to shrink over the next 4-12 months. This is only a day procedure, but there can be several weeks of pain/discomfort and bleeding following. It is quite effective at managing heavy bleeding and pressure symptoms but about a third of patients will have recurrence and require further surgical treatment within 2 years. Whilst there have been pregnancies following UAE, it is not recommended in those trying to conceive. There are concerns about possible compromised blood supply to the uterus and ovaries causing lower egg counts and the total radiation dose during the procedure is also quite high.

How do I decide on the best Treatment?

All options for managing fibroids have benefits and risk, so treatment needs to be individualised to your symptoms, and the number, size, type and location of fibroids.

The most important question you should consider is around fertility and whether you’ve completed your family. Many of the treatments are either contraceptive or not recommended if wanting future fertility.

The next decision is based on your symptoms and quality of life. As fibroids are slow growing, symptoms often ‘sneak up’ on patients and it can be difficult to remember what life was like before heavy periods and pressure just became your norm.

The aim of treatment should always be to give you the best outcome with the least risk or need for future intervention. This can only occur if you are well informed about your options and see a specialist who regularly manages fibroids and has the time and skill to offer you all treatments.

Why see Fibroid Specialist, Dr Hugo?

Gynecologists see patients for issues that are often very personal and private. Choosing one that you are comfortable with can be difficult enough, without then having to wonder about their qualifications and skill level. I can assure you that when you visit my experienced team, you will access excellent care tailored to your needs.

Whilst I am an Advanced Laparoscopic Surgeon, specialising in minimally invasive procedures such as laparoscopic myomectomy and hysterectomy, you can be assured that these are only offered when necessary. Your care is always personalised and you will have an important say in treatment and what you’re comfortable with every step of the way.

If fertility is a concern, I am uniquely placed as a surgeon and fertility specialist to actively treat both your fibroids and fertility at the same time. Care can be managed through my own state of the art unit, Newlife IVF, so that you don’t waste precious time or need to move between different specialists and offices.

Book an Appointment with Dr Hugo

The impact of fibroids on health and quality of life can be significant and occur so slowly that you can’t remember what it was like to be healthy and free of them. You deserve better. If fibroids are causing you concern, reach out to my team today, and we’ll find a time to start your journey to better health.

03 95162895

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