UTERINE FIBROID14 February 2022
Before I begin, I will like to correct a misinformation about fibroid treatment; that it can be pass in stool. This is not true whatever be the treatment modality. It is very important to know that no medication or intervention can make one pass fibroid in stool. There is no anatomic connection between the reproductive and digestive system. Uterine fibroid also known as leiomyoma or myoma is a benign smooth muscle neoplasm arising from the myometrium. The myometrium is the second layer of the womb made up of smooth muscle. The true incidence is unknown as many women do not have symptoms.
CAUSES OF UTERINE FIBROID
How uterine fibroids come to be is poorly understood however, it is common in female of reproductive age (15 to 49years) with the following risk factors;
- High estrogen state: age at first menses <10years, polycystic ovarian syndrome, obesity.
- Nulliparity (no child birth)
- Black women
- High fat diet
- Family history in first degree relative
- Late menopause
The following are protective factors for myoma formation:
- Increased number of children
- Late menarche (late onset of first menses)
- Early menopause
- Use of oral contraceptive
SIGNS AND SYMPTOMS OF UTERINE FIBROID
The clinically presentation of this condition varies from asymptomatic to symptomatic. These symptoms include;
- Menstrual abnormalities: heavy menstrual bleeding, intermenstrual bleeding
- Painful menses
- Pain during sexual intercourse
- Pelvic pain
- Abdominal swelling
- Pressure symptoms: frequent urination, urinary retention, constipation
COMPLICATION OF UTERINE FIBROID
Some may present with complications such as;
- Obstructive uropathy; injury to the kidney from the blockage of urine flow
- Venous thrombo-embolism; formation of blood clot in the vein
CHANGES IN UTERINE FIBROID
The size or composition of a fibroid changes with time due to hormonal influence. These changes are called secondary changes and they include; some degenerative changes such as hyaline degeneration which is the most common, cystic, fatty and calcific degeneration that occurs at menopause, red degeneration occurs in pregnancy. Other changes are atrophy, necrosis, infection, vascular changes and it may become a cancer in <0.1% of the cases.
LOCATION OF FIBROID
Leiomyoma based on their location in relation to the uterus can be classified into;
- Sub-mucous Leiomyoma; arise from the smooth muscle close to the endometrium which is the inner layer of the womb.
- Intramural leiomyoma; arise within the myometrium which is the muscle layer of the womb
- Sub-serous leiomyoma; arise from the smooth muscle adjacent to the serosa of the uterus. The serosa is the outer covering of the womb
- Other variants are the pedunculated leiomyoma; which is attached by a stalk to the womb. The parasitic leiomyoma is a pedunculated fibroid that attaches itself to nearby pelvic structures where it gets it blood supply.
DIAGNOSING UTERINE FIBROID
Uterine fibroid can be diagnosed from the clinical presentation and findings on pelvic examination; firm mobile or slightly mobile, uniform or nodular pelvic mass. Hysteroscopy and hysterosalpingography will confirmed the presence of a sub-mucous fibroid and also define tubal patency. Ultrasonography will confirm the fibroid in any location with associated secondary changes and complication. If still in doubt, magnetic resonance imaging can distinguish fibroid from adenomyosis; when the endometrial or inner lining of the womb is implanted in the muscle layer.
TREATMENT OF UTERINE FIBROID
The management of uterine myoma depends on the size, number, location of the fibroid, age of the woman and the desire for fertility. This could be expectant (indicated when patient is asymptomatic with fibroid size <12weeks), surgical (myomectomy, endometrial ablation, myolysis and hysterectomy) or non-surgical (medical or interventional radiology). Medical treatment is indicated for symptomatic patient, alternative to surgery in perimenopausal women, pre-operative adjunct and patient not suitable for surgery. This could be by the use of non-hormonal agents (Aromatase inhibitor, antifibrinolytic and non-steroidal anti-inflammatory drugs), or hormonal agents (gonadotrophin releasing hormone antagonist, progesterone antagonist, progesterone therapy, selective progesterone reception modulator and androgen therapy). Interventional radiology involves the use of uterine artery embolization and magnetic resonance-guided focused ultrasound scan.
For women with persistent symptoms despite conservative efforts, surgical management is an option. Myomectomy which could be laparoscopic, hysteroscopic or open is the most common fertility preserving surgery for women who desire fertility and hysterectomy a non-fertility conserving surgery is the definitive treatment.
No intervention or medication is given here but periodic examination at interval of 6 months is carried out. If the symptoms of fibroid appear and or it grows and increases in size, expectant management will be abandoned. Before contemplating expectant management, a certain diagnosis of fibroid should be a must. Other indications for expectant management includes;
- Size of the womb <12 weeks (of pregnancy size)
- Follow up is possible