What are fibroids?
Fibroids are tumours found in the uterus. They are NOT cancerous by nature. Routine
ultrasonography done for various symptoms show that fibroids are
commonly seen in almost 40% of all women. These
tumours are made of fibrous and muscle tissue and are usually seen
in women who have excess of the hormone called “Estrogen” in
circulation. They are usually found in the reproductive age group
and may regress after the woman attains menopause. However, in the odd woman, symptomatic fibroids may be found
even after menopause. There is one variety called fibrosarcoma which
is cancerous by nature. But it is usually
symptomatic and grows very fast. It is very, very
rare and by nature cannot remain asymptomatic for long.
What are the symptoms caused by fibroids?
In many women, fibroids may
remain symptom free. However, in some women, it
may cause symptoms like excessive bleeding during periods, excessive
pain during periods, etc.
Some patients get symptoms
like increased urinary frequency, or excessive backache or pressure
sensation in the pelvis.
Which are the fibroids which need medical attention?
Today, ultrasonography is being done routinely for many
indications like indigestion, mild abdominal discomfort, etc. If fibroids are seen on ultrasonography incidentally at such times,
they could be ignored. On the other hand, a woman may go to a
doctor with specific gynaecological complaints like excessive
periods, excessive pain during periods,or severe pressure sensation
in the back or pelvis. If fibroids are found, either on
ultrasonography or even on clinical examination, in such a
situation, the symptoms are likely to have been caused by the
fibroids. They require treatment.
Is it possible to cure fibroids with medicines?
No, there are as of now, no medicines which could
permanently cure fibroids. There are certain
injections (GnRh analogues) which can reduce the size of the
fibroids,temporairily for a period of a few months. But these injections are costly . Each injection costs around
Rs.5000/- They are to be administered every 28
days for a minimum of 3 injections. The tumour
regresses temporarily and recurs after about 6 months. This sort of treatment is useful when one wants to postpone
surgery for some reason or other. It cannot be construed as a
the treatment for fibroids?
The 3 modalities of
treatment for fibroids are:
1.Surgery to remove the
2.Surgery to remove the
uterus along with the fibroids
therapy which will necrotize the fibroids.
What are the indications
for active intervention in a case of fibroids?
Active intervention in case of fibroids is necessary only
in severely symptomatic patients. In infertile
patients, surgery for fibroids need be done only if fibroids are
thought to be the cause of infertility.
the indications for hysterectomy (removal of uterus) in a case of
Hysterectomy as a treatment for fibroids is usually done
only in patients who have completed their family. However, hysterectomy being a major surgery, it should be
performed on a patient only if she is severely symptomatic. Certain
guidelines for the performance of hysterectomy are:
A.Documented growth is > 6
cm per year (any age patient)
with uterus > 12 week size or fibroid with documented growth rate > 2 cm/year
C.Patients age 30 years to
menopause who do not wish further children
1.Documented fibroid > 20 week size with or without symptoms
2.Documented fibroid 12-20 week size and one
of the following:
a.Documented submucous fibroid with
unresponsive to medical therapy, or
b.Urinary retention, frequency or
incontinence or difficulty evacuating stool
c.Uterine bleeding for more than 8-10
days in the last 2 cycles or last 40
days, and Hgb < 10 (or
transfusion within the
d.At least 6 months of moderate to
severe pelvic pain, interfering with daily
3.Fibroid < 12 week size and one of the following:
a.Documented submucous fibroid with
to medical therapy, or
b.Uterine bleeding for more than 8-10 days in the last 2
cycles or last 40
days, and Hgb < 10 (or transfusion within
the last 6 months).
patients in the reproductive age group, who have completed their
family, there may be a debate on the wisdom of removing the uterus.
It is generally felt that removal of the uterus may jeopardize the
blood supply to the ovaries and stop its function prematurely. This
may lead to the patient getting perimenopausal symptoms like hot
flashes, sweating, etc much before the actual time of biological
menopause. Hysterectomy is also known to
predispose to urinary symptoms later on. In view
of all these factors, some doctors prefer not to remove the uterus
even if the patient has completed child bearing.Instead of removing
the uterus, myomectomy, a surgery which removes only the fibroids is
done. Surgery for removing only the fibroids is
technically associated with more blood loss. Besides that, the
tendency for formation of fibroids being inherent, the patient is
also liable to have a recurrence of symptoms. Thus, weighing the pros and cons of hysterectomy vs
myomectomy, a mature decision has to be taken.
my practice, in the very young patient, I would prefer not to remove
only the fibroid, and uterus is not removed.. In
the older patient, above 35 years of age, I would prefer to do a
Are there different ways of doing a hysterectomy in a
patient with fibroids? What are they?
Hysterectomy can be
performed by various methods, viz,abdominal, vaginal,Laparoscopic,&Laparoscopically
Assisted vaginal hysterectomy.
Hysterectomy in the
traditional way was performed by making an incision in the abdomen.
This is called abdominal
hysterectomy. The patient is kept in the hospital
for 5-7 days depending on the time taken for removing the stitches
and wound healing. The patient has to convalesce at home for a month
and she has to avoid lifting heavy objects for 6 months, the time
taken for internal defects to heal. In the first
few days after surgery, generally there is some amount of pain and
assistance may be needed for getting up from bed, moving towards the
toilet, etc, as abdominal incisions tend to be painful. The degree of mobility achieved by a patient after surgery
varies from patient to patient depending on each patient’s pain
threshold ,length of incision, etc.
vaginal hysterectomy, the uterus and fibroids are removed by making
an incision in the vagina. The uterus being very
large in the presence of fibroids, it is usually removed after
morcellation and is taken out piecemeal. The patient is kept in the
hospital for 2-3 days. She can join her duties
after a week or so and it is not mandatory to avoid heavy labour for
a long period.
There being no wound on the
abdomen, the patient has very minimal pain post-operatively.
The patient does not need
assistance for doing routine chores like walking, going to the
toilet,etc from the very next day of the operation. This procedure is associated with fewer complications. Chances of injury to the ureter are less with this procedure. Moreover, there being no incision on the abdomen, there are
no chances of incisional hernia. Wound infections
vaginal hysterectomy is more difficult to perform for the average
gynaecologist and thus the facility is available only in selected
centers. The cost of therapy is the same for both
hysterectomy: The whole procedure is done laparoscopically. Laparoscope is an instrument through which the contents of
the abdomen are visualized through a telescope introduced through a
small 1cm incision below or in the umbilicus. The
intraabdominal organs are visualized n a TV screen via a CCD camera
fitted on to the telescope. The connections of
the uterus are severed through instruments inserted through small
5mm incisions on the abdomen and the final removal achieved through
the vagina. Sometimes, part of the connections is released
laparoscopically and the rest released vaginally. This is called laparoscopic assisted vaginal hysterectomy (LAVH).
The after effects of hysterectomy are the same as if the procedure
is done vaginally. There is minimal pain and hospital stay is
reduced. The choice of performing the surgery
either vaginally or with the use of the laparoscope depends on the
surgeon’s preference and the type of illness. In
cases where the pelvic organs are expected to be adherent to each
other, the help of a laparoscope may be absolutely essential. In
cases without adhesions, it is the surgeon’s preference. In our center, I do 90% of surgeries
with laparoscopic assistance. In patients
who have not completed childbearing, it is absolutely necessary that
the uterus be kept intact as it is necessary for childbearing. In
these patients fibroids are managed by myomectomy by all
gynecologists. In the patient who has completed
childbearing, the treating physician has to weigh the pros and cons
of removing the uterus against removing only the fibroids, keeping
back the uterus. Technically, the operation for
removing the fibroids is associated with more blood loss and in
multiple fibroids; it may be difficult to perform. There is, although very small, a chance for recurrence of
fibroids, as the exact cause which causes fibroids remains
untreated. However, hysterectomy has its own
complications like injury to bladder, bowel,etc and after effects
like bladder and bowel dysfunction in many patients. Even if the ovaries are preserved, it may lose its
bloodsupply and undergo atrophy long before natural.menopause. As a general consensus, Indian doctors by and large prefer
hysterectomy over myomectomy for patients with fibroids in the perimenopausal period. For others, (younger patients in the reproductive age group)
management varies from center to center.
If a patient who is infertile has fibroids, is it
necessary to do a myomectomy?
Superficial, small fibroids will not interfere with
conception and may be left alone. But some
fibroids are situated in particular areas which may be harmful to
conception. These may need removal. Again, if after prolonged treatment for infertility the
patient does not conceive and there is no abnormality seen except
for the fibroid, then, it may be worthwhile to remove the fibroid.
What are the ways in which myomectomy may be performed?
Myomectomy, or the surgery
for removing the fibroids may be performed by laparotomy,
laparoscopy or through the hysteroscope.
Laparotomy: This is the traditional route by which fibroids are removed. The abdomen is opened, usually through a low transverse incision to
remove the fibroids. It involves a longer hospital stay and
convalescence period, like any other laparotomy.
Laparoscopy: The procedure
is done through 3 or 4 tiny holes in the abdomen, with the help of
the laparoscope. This can be
done only in specialized
centers as it involves suturing the uterus using needle and thread
looking at a TV-monitor. Even in specialized
centers, if there are multiple fibroids, there are chances that deep
fibroids may be missed and left alone. There are many studies in medical literature which have shown
scientifically that even in multiple fibroids, laparoscopy is better
|Laparoscopic myomectomy. The white tumour in
the center is the fibroid. The edges of the wound have to
be sutured endoscopically.
However, in the author’s
opinion, Laparoscopic myomectomy is best reserved for single or at
the most 2 or three superficially located fibroids.
patients with fibroids that protrude into the lumen of the uterus,
it is best to remove them hysteroscopically. This is called hysteroscopic myomectomy. Hysteroscope is an instrument shaped like the laparoscope. It
is a tubular scope with a camera attached at one end. It is introduced into the uterus via the vagina. The fibroids protruding into the uterus like in the picture below are removed using
cautery. There are no incisions anywhere on the
body and the patient can start working almost immediately. This procedure is reserved for only small fibroids protruding into
the uterine cavity.
What is the
nonsurgical and permanent solution to fibroids?
late fibroids are being treated by “Embolization therapy.” Through a
small prick in the groin area, the main vessel supplying the lower
limb, viz, the femoral artery is cannulated. The
cannula is then guided into the uterine artery, the main blood
vessel supplying blood to the uterus. Some
particles are injected into this main vessel to block it and thus
the uterus is deprived of it’s main supply of blood. This causes the fibroids to
degenerate and undergo necrosis. The uterus does
not atrophy as alternate channels of blood supply take over and
supply enough blood to the uterus to keep it functioning, but not
enough to allow fibroids to grow. The procedure
can be done in any center with an angiography machine. It requires
specialized skills in radiology. The patient may get abdominal
cramps after the procedure and can be discharged from the hospital
in a day or two. At present, the procedure is not
recommended for women who have not completed childbearing.
What are the complications of a pregnant woman getting
Fibroids may grow in size along with the uterus. It may
cause abdominal pain in some patients. Rest and painkillers that are
safe in pregnancy may help tide over this period. Generally fibroids are not interfered with in the pregnant
state. Some fibroids may cause obstruction to
labour necessitating a caesarian section for delivery. In the past, it was thought it was best not to remove the
fibroids at the time of caesarian section. However, currently many surgeons, including the author have
successfully removed many fibroids at the time of caesarian section,
so that the patient does not need a second surgery to get rid of