Fibroid In the Uterus: The Definitive Guide (In Nigeria)
Fibroid Uterus Meaning
What does Fibroid Uterus mean?
Uterine fibroids (Fibroid uterine or fibroid uterus) are benign or non-cancerous tumors of the uterine smooth muscle layer. Fibroid uterine is also known as leiomyoma or simply myoma. The uterus consists of three layers:
Endometrium, which is the inner epithelial layer consisting of uterine glands,
Myometrium, which is the middle layer, consisting of smooth, muscle cells,
Perimetrium, which is the outermost layer.
Fibroid in the Uterus
Fibroid in the uterus develop in the myometrium layer of the uterus.
Fibroid in women
Fibroid uterine or fibroids are highly prevalent, found in approximately 40% of women overall. Fibroid in the uterus affect women of reproductive age and they are extremely uncommon before puberty. Fibroid uterine usually multiple and can substantially increase the size of the uterus.
Fibroid Uterus Location
Fibroid uterus are classified according to their location in relation to the myometrium:
Intramural fibroids, as the name suggests, are located within the myometrium.
Submucosal fibroids protrude into the endometrium and the uterine cavity.
Subserosal Uterine Fibroid: Subserosal uterine fibroid protrudes outwards into the perimetrium.
The fibroid in the uterus could be either pedunculated or non pedunculated. Pedunculated fibroids are connected to the uterus by a stalk. Non pedunculated fibroids do not have a stalk.
What is the Cause of Fibroid?
What is the cause of fibroid? This is a puzzling question for a lot of people. The exact etiology, that is, causes or pathophysiology behind uterine fibroids is not known. However, their growth is primarily dependent on circulating estrogen levels and more precisely endogenous estrogen. Therefore, they can enlarge during pregnancy in response to high estrogen levels and shrink after menopause due to the lack of estrogen.
Why do Fibroids happen? It does seem like there's some family component, but there's also environmental links that we found.
One of the most interesting causes is being looked at right now- And that is Vitamin D deficiency predisposing people to fibroids. We believe this one is interesting because if it turns out that there is a link here, this would be something that we could study as a preventative measure- Making sure you don't get vitamin D deficient, if you are at an increased risk or predisposed to fibroids in general and seeing if that lowers your risk in the long term.
It's
also being studied right now in animal models as a treatment for fibroids.
Another really interesting link that we
found is with exercise. Some studies actually say that regular exercise can
help prevent fibroids this is not completely understood but there is some
interesting research on it. And that is just one more reason to make sure you
are being physically fit and exercising.
Research on what is the cause of fibroid, also indicates that these fibroids start from a single smooth muscle cell, which is then followed by deviation from normal signalling pathways and ultimately develop into a fibroid.
Moreover leiomyomas and fibroid in the uterus over- express certain estrogen and progesterone receptors compared to the normal surrounding myometrium.
Fibroid and Pregnancy pain (Is Fibroid Painful?)
Fibroids are not usually very painful unless they are degenerating. Degenerating means losing their blood supply and that is extremely painful. So a dying fibroid can be really painful.
Another way fibroids can be painful is that the submucosal ones that are on the inside of the uterus, can very rarely start to basically deliver through the cervix and that is extremely painful. Usually associated with lots of bleeding, lots of pain people typically end up in the emergency room with this type of painful fibroids.
Pregnancy and Fibroid
There are several conversations around pregnancy and fibroid, and they should be well understood if you have fibroid when pregnant. Our fibroid doctors at Christian Miracle Hospital make sure to do a few extra ultrasounds throughout the pregnancy to ensure that it's not getting larger or causing growth restriction in the baby.
Another pertinent issue is: Degenerating fibroid during pregnancy.
Degenerating Fibroid during Pregnancy
Fibroids can undergo degenerative change due to the increased demand of the proliferating smooth muscle cells.
Three forms of degeneration are recognized:
Fibroid Red degeneration where necrosis and Hemorrhage occur within the fibroid. Patients experiencing fibroid red degeneration typically present in the mid second trimester pregnancy with acute pain.
Hyaline degeneration, another form of degenerative fibroid during pregnancy characterized by asymptomatic softening and liquefaction of the fibroid
Sarcomatous or Cystic degeneration, which is characterized by asymptomatic central necrosis of the fibroid leaving cystic spaces in the center. With time, they can become calcified, and rarely, cystic degeneration can lead to malignant fibroid tumor in certain individuals. These malignant fibroid tumor increases rapidly in size after menopause.
Although etiology or fibroid causes is medically acknowledged to be uncertain, certain risk factors are found to be associated with uterine fibroids, including the following:
Early menarche
Nulliparity
Obesity
Late entry to menopause
A positive family history of uterine fibroids.
African descent is the most significant non-modifiable risk factor for the development of fibroids. These patients usually present with more severe symptoms.
It's more common in African women than
non-Africans for a variety of reasons that we don't fully understand from a
medical standpoint. Most likely, this is a Genetic and environmental overlap,
which is what we call multifactorial- meaning that some people probably are
genetically more inclined to get fibroids, coupled with the fact that they are
in an environment that allows those fibroids to develop.
Conversely, increased parity, late menarche, quitting smoking and use of oral contraceptives, which reduce the action of endogenous estrogen are associated with prevention of fibroids, or at the least, a reduced risk of fibroids.
Fibroid Symptoms and Signs
Now, let's discuss the clinical features of fibroids. They are fibroid symptoms and signs; and can cause several gynecological complaints, and are one of the commonest indications for hysterectomy. However, the vast majority of them are asymptomatic.
Common Fibroid Symptoms and Signs
Fibroid bleeding
Can fibroid cause bleeding? If present, the most common symptom is abnormal uterine bleeding. This could either be heavy menstrual bleeding or intra-menstrual bleeding, which refers to vaginal bleeding at any time during the menstrual cycle other than during normal menstruation.
Sometimes there could be a combination of these two types. Other less common fibroid symptoms and signs include:
Dyspareunia or pain during sexual intercourse,
Pelvic pain,
Urinary frequency as a cause of the fibroid
Bladder and bowel dysfunction
Subfertility
Recurrent pregnancy loss.
Pain is unusual except in the special circumstances of acute fibroid red degeneration or torsion of the pedunculated fibroid.
Can Fibroid cause Infertility?
To understand if fibroid can cause infertility, we need to talk about subfertility in fibroid cases.
Subfertility, with regards to fibroid causing infertility, occurs due to mechanical distortion or occlusion of the Fallopian tubes and submucosal fibroids that distort the endometrial cavity preventing implantation of a fertilized ovum. In this instance, surgical removal of the submucosal fibroids may enhance the fertility of the woman.
Apart from these fibroid symptoms, other common fibroid symptoms in females that present in medical examination include:
Signs of anemia on general examination,
Visible or palpable mass on abdominal examination,
On bimanual examination, an enlarged, firm asymmetric uterus may indicate the presence of fibroids.
Now, let's discuss the diagnosis of fibroids. Often the clinical features obtained from history and examination alone will be sufficient to establish the diagnosis. However, an imaging test is usually performed to confirm the diagnosis. Useful tests when uterine fibroids are suspected include the following:
Fibroid Ultrasound
Transvaginal fibroid ultrasound scan is good for detecting and locating submucosal and small intramural fibroids.
Trans-abdominal fibroid ultrasound scan and pelvic examinations is good for detecting larger intramural and subserosal fibroids
Saline infusion sonohysterography is good for detecting and locating submucosal fibroids
Hysteroscopy is good for detecting submucosal fibroids and planning subsequent hysteroscopic surgical treatment
MRI scanning is good for describing the morphology and location of fibroids.
Uterus Fibroid Treatment
Finally let's discuss how to treat a fibroid: There are different options on how to treat a fibroid, and these would depend on the following factors:
How the fibroids present (Symptomatic or asymptomatic),
Fertility desire of the woman,
Age,
Pregnancy with fibroid or otherwise,
Location of the fibroid,
Cost of fibroid treatment option (In Nigeria), and
The expert opinion of the team of gynaecologists and obstetricians managing the fibroid
Asymptomatic fibroids usually do not require any treatment or they are managed with conservative therapy.
Symptomatic fibroids can be treated with
medical treatment,
surgical treatment, or
radiological treatment depending on the type and severity of fibroids, fertility desire of the patient and many other factors.
Commonly used medical treatment for uterine fibroids is injectable GnRH agonists, which inhibit and vary an estrodial production and induce a menopausal state. However, GnRH treatment is not tolerated by all women because of the severe menopausal symptoms. Ulipristal acetate is a newer drug that is given orally and has the same action as GnRH agonists. Most importantly, it does not induce a menopausal state and associated symptoms. However, it is not widely used in clinical practice.
It is important to note that medical treatment is not a viable, long-term treatment option for uterine fibroids. And once the treatment is stopped, they may regrow to their previous dimensions.
If you would like to know more about fibroid treatment in Nigeria, including cost of fibroid surgery in Nigeria, visit Christian Miracle hospital, No. 3 Akutu Crescent Independence Layout Enugu or speak with Prof. Obioma Okezie, Consultant Gynaecologist and Obstetrician on 08037007773.
Surgery of Fibroid
Common surgery to remove fibroids include the following:
Hysterescopic myomectomy: Hysterescopic myomectomy is a minimally invasive procedure to remove submucosal fibroids using a hysteroscope inserted through the vagina. It avoids surgical incisions and useful for relieving symptoms of heavy menstrual bleeding. However, other types of fibroids cannot be removed by this hysteroscopic myomectomy, which is why we do not use this method in our hospital, as it is not a definitive surgery option to remove fibroid for most patients.
Another surgical option is myomectomy, which is an invasive, but fertility-sparing surgery to remove fibroid. This can be done either with laparotomy or laparoscopic technique. However, laparoscopic technique is effective only for smaller and fewer number of fibroids, which is prime reason for the use of minimal incision open surgery in our hospital.
Fibroid Hysterectomy: The other type of surgical treatment option for fibroid is hysterectomy or removal of the uterus. This is indicated for women with no future fertility desires. It may be achieved vaginally, laparoscopically or via open surgery depending on the size of the uterus.
Both myomectomy and hysterectomy may be facilitated by treatment with GnRH agonists over three months prior to the surgery. This reduces the bulk and vascularity of the fibroids resulting in rapid recovery and fewer post-operative complications.
Radiological therapy for uterine fibroids include uterine artery embolization. Also called Uterine fibroid embolization- Uterine fibroid embolization (ufe) is a technique which is performed by a trained radiologist. In this procedure, a small incision is made in the groin under local anesthesia and a cannula is placed into the femoral artery and guided into the uterine arteries. Embolization particles are then injected reducing the blood supply to the uterus, which induces infarction and degeneration of the fibroids. Note that Uterine Fibroid Embolization (UFE) is for patients who do not wish to get pregnant in the future; and you should know that if you choose to go the route of uterine fibroid embolization.
For more information and consultation, visit Christian Miracle hospital, No. 3 Akutu Crescent Independence Layout Enugu or call our Consultant Gynaecologist and Obstetrician on 08037007773
