Uterine leiomyomas are extremely common and are found in up to 30% of women at the time of autopsy. They are oestrogen dependent growths and grow during adult life up to the menopause. They can also grow rapidly during pregnancy and are more common when oestrogen levels are high. As a result they are also more common in obese women.
Normally the smooth muscle fibres of the womb do not multiply, as there is something within their genetic make-up, which prevents this. If for some reason this genetic system fails then a muscle cell may start to divide. If this continues then eventually a large ball of muscle cells grows forming a fibroid or leiomyoma. The genetic defect that allows this is more common in West African and West-Indian women who are much more likely to have larger and more numerous fibroids.
Some women will have only one fibroid but it is more usual for women to have multiple fibroids as there are many cells within the muscle of the womb which have started to divide in a similar fashion. These fibroids grow, developing their own blood supply form the surface of the fibroid. As the fibroid grows the blood supply is eventually out-stripped and the fibroid cannot grow any further. All fibroids are therefore supplied by small blood vessels and the extent of their growth is dependent on the success of this neo-vascularisation.
As a result some fibroids will only grow to one or two centimetres but rarely can they grow beyond 12cms in size. Clearly, if there are several fibroids they will vary in size and the total fibroid mass may be very large.
Gynaecologists usually describe the size of the uterus enlarged by fibroids by the equivalent size of a pregnant womb. So we may talk of a womb being 12 weeks in size or at the other extreme 36 weeks! All leiomyomas are benign growths, and whilst they may sometimes be overactive and grow quickly, they very rarely if ever have any malignant potential.
Heavy Menstrual bleeding
Symptoms of heavy painful bleeding can be very distressing and can lead to severe anaemia. Passing large clots is very unpleasant and painful. Some women need to use double protection in the form of Tampons and pads and may need to use pads or towels to protect their bedding at night.
Women who become anaemic are pale and get very tired and out of breath with the slightest exertion. They may occasionally faint if the anaemia is severe.
Pain and pressure
Pain is either caused because the fibroids themselves are tender or because they are pressing on adjacent structures such as nerves in the pelvis or on the sacrum (the lumbo-sacral nerve roots). Fibroids typically become painful when they out-grow their blood supply and degenerate (red degeneration). They may also cause pain if they twist on their own blood supply. This may happen with a pedunculated subserosal fibroid. Pain during sex occurs when the womb is stuck in position by fibroids or by pressure on the fibroids themselves.
Fibroid size and symptoms
Symptoms are not always related to size. For instance a small fibroid within the cavity of the womb may cause severe bleeding problems and problems with fertility, whereas a large subserosal fibroid may cause no problems. A 6 cms fibroid embedded in the pelvis may cause severe urinary and bowel pressure symptoms whilst a large intra-abdominal fibroid will not.
Treatment of fibroids
This needs to be carefully individualised for each patient. Decisions regarding treatment must be made in partnership, particularly taking into account the type of fibroids, the severity of symptoms and the desire for future fertility. At OBGYN Matters there are a number of treatments that may be considered.
Medical treatment:
Watch and monitor size with ultrasound scans Drugs to make periods easier. The oral contraceptive pill Progesterone Ponstan and Cyclokapron GnRh analogues to stop periods and temporarily shrink fibroids (no medical treatment will have a sustained beneficial effect on fibroid growth).
Laparoscopic Myomectomy
Key-hole surgical techniques are ideal for removing up to 3 fibroids of up to 7 centimetres each, in diameter. The major determining factors are the skill and experience of the surgeon, the amount of space within the abdomen and the position and number of the fibroids. If the womb is larger than 18 weeks in size it is difficult to insert the necessary instruments and get an adequate view of the womb and fibroids.
If there are too many fibroids then multiple incisions need to be made into the womb and this may lead to excessive bleeding. If the fibroids are very low down behind the womb then they may be difficult to access Pedunculated fibroids are the easiest to remove using this technique.
The Major advantage of this technique is that patients make a much quicker recovery following the surgery. In addition to this the incisions are very small and cosmetic, The amount of blood loss and the risks of subsequent adhesions is also reduced. Despite these major advantages over open surgery it is often not performed because most gynaecologists do not have sufficient expertise in keyhole surgery to perform this procedure.
Chris Barnick is regarded as one of the best in London Gynaecology. He has delivered babies and performed gynaecological operations for more than 25 years.
A specialist Private Obstetrician at OBGYN Matters in central London he qualified at Guys Hospital in 1984. He has trained and worked ever since in top London teaching hospitals
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