Fibroids

Fibroids are benign (non-cancerous) muscular growths from the uterus (womb). Fibroids can be found anywhere in the uterus, and vary in size from a few millimetres to over 15cm.

Fibroids often cause no symptoms, or only minor ones. However, sometimes they can cause heavy and painful periods, and may cause anaemia, which is a low blood count as a result of heavy bleeding. Fibroids can also cause pain in the back or abdomen, pain during sex, difficulty passing urine or an urgent need to pass urine often. Most of the time, fibroids do not affect fertility, but when they are in certain locations, they can do.

If you have significant symptoms, you may wish to consider your treatment options. The position and size of the fibroids can affect what treatment options are best.

Fibroids are incredibly common – two to four out of every 10 women have fibroids at some point in their lives. The reason that fibroids develop is still not fully understood. They are more common as you get older, and if you have a family history of fibroids.

Black women are more likely to develop fibroids, though we are not sure why this is. Women who are overweight are also at higher risk of developing fibroids.

Fibroids can be suspected from your symptoms, such as heavy menstrual bleeding, and examination findings (a large uterus can often be felt by laying a hand on the lower abdomen). To help us confirm a diagnosis, an ultrasound scan is often recommended.

An ultrasound scan uses a probe placed on the abdomen or inside the vagina so that we can see the uterus and detect fibroids if they are present. A specially trained sonographer or doctor will perform this examination. Occasionally an MRI scan is recommended if you are considering uterine artery embolisation.
 

Your doctor will discuss your treatment options with you.

The treatment options available to you will depend on the size and location of your fibroids, and how they are affecting you. If you do not have any symptoms, or only mild ones, then there is no need to have any treatment.

A. Non-hormonal medications
Non-hormonal medications can treat heavy and painful periods, but they will not remove or shrink the fibroids. They do not have any effect on fertility so may be preferred to hormonal treatment in women who are trying to get pregnant. They include:

• Tranexamic acid

This medication is taken only on days that you experience vaginal bleeding. It helps the blood to clot, meaning you lose less blood during each period.

• Anti-inflammatory medications

Medications such as ibuprofen and mefenamic acid can help reduce pain and bleeding during periods.

B. Hormonal medications
Most hormonal treatments have a reversible effect on your fertility while you are using them, so are unlikely to be appropriate for women who are currently trying to get pregnant.

• Combined (oestrogen and progesterone) oral contraceptive pill (COCP):

The combined oral contraceptive pill can help to regulate your periods and reduce bleeding. Some women experience side effects such as changes to their mood, or acne. This medication can also increase the risk of clots in the legs, so it may not be recommended if you are at higher risk of this (for example if you are older, you smoke, or are overweight).

• Progesterone only pill, contraceptive implant (Nexplanon©) and contraceptive injection:

These contraceptive treatments all contain the hormone progesterone and can help to reduce symptoms of heavy and painful periods.

The progesterone only pill is a tablet that needs to be taken once a day. Nexplanon© is a small plastic device which is inserted under the skin of the upper arm.

It needs to be replaced every three years. A contraceptive injection is required every eight to twelve weeks and can be administered by a healthcare professional, or by yourself at home.

Women can have different reactions to these treatments: some have no periods whilst others may have frequent irregular bleeding. Other side effects include mood changes, headaches, and acne.

• Mirena© coil

This is a small, T-shaped, plastic device that sits inside the uterus and releases the progesterone hormone locally. It is the most effective hormonal treatment for reducing vaginal bleeding and pain.
Women often experience fewer side effects with the Mirena ® compared to the pill, implant, or injection, because the hormone is released locally. This means that the hormone does not enter the blood stream as much as the other hormonal treatments. The Mirena needs to be replaced after five to seven years.

• Gonadotrophin-releasing hormone analogue (GNRHa) injections

These are injections which can be used to temporarily reduce to the level of oestrogen in your body. They can be very effective at shrinking fibroids and stopping menstrual bleeding and pain.

However, they cause a temporary and reversible menopause. This results in side effects like hot flushes and changes to your mood, and can also lead to bone thinning if used in the long term. Depending on the situation, you may be able to use them with hormone replacement therapy (HRT) to treat these side effects.

GNRHa injections are sometimes recommended before having a surgical operation as it can help to reduce the fibroid size and blood loss during surgery.

• Other hormonal treatment options

Other hormonal medications are recently available. If they are appropriate for your care, your healthcare provide will discuss this further.

C. Surgical treatment options
There are several surgical options available for the treatment of fibroids. What is appropriate to offer you will depend on the size and location of fibroids.

• Transcervical resection of fibroid (TCRF)

This procedure can be used for fibroids that are located partially or fully inside the cavity of the womb (submucous fibroids). It is usually performed whilst you are asleep under a general anaesthetic.

A thin device called a resectoscope is inserted through the vagina and the cervix into the cavity of the uterus. This has a camera and a wire loop on the end of it. We pass an electrical current through this wire loop and use it to cut out the fibroid.

The procedure takes about an hour, and no cuts or stitches are usually needed. Usually you can go home on the same day as the procedure, but occasionally patients may need to stay overnight.

Symptoms improve for four out of five women who undergo this procedure. If the fibroids are large, the resection may need to be performed as two procedures with a few weeks or months in between.

Possible complications include excessive bleeding, making a small hole in the uterus (perforation) which can be repaired during the operation, injury to internal organs, infection, and anaesthetic complications.

• Myomectomy

This procedure involves removal of the fibroids through cuts to the outside of the uterus. It is performed while you are asleep under general anaesthetic. The surgery can be performed in two different ways, depending on the size and position of your fibroids:

- ‘Keyhole’ operation (laparoscopic) – this procedure may be appropriate for women with a small number of smaller fibroids. Between two and four cuts around 1cm in length are made in different places in the abdomen and the fibroids are removed through the holes. You may be able to go home on the same day, or the following day after your surgery.

For more information, please see Laparoscopic myomectomy.

- ‘Open’ operation – this surgery is performed by either making a cut horizontally (side-to-side) along the lower abdomen or vertically (up-and-down) from the pubic bone to the belly button. The type of incision used will depend on the size and location of the fibroids. After the operation, you will need to stay in hospital for one to three nights.

Four out five women who undergo a myomectomy have improvement in their symptoms. The recovery can vary between two to six weeks.

Possible complications include excessive bleeding, injury to internal organs, infection, anaesthetic complications, and in extreme cases, a risk of needing a hysterectomy (removal of the womb). Depending on where the fibroids are, you may be recommended to have a Caesarean section to deliver a baby in future pregnancies. There is also a risk that the fibroids can grow back over time.

• Hysterectomy

This procedure to remove your womb is carried out under general anaesthetic. It may be performed as keyhole surgery or open via lower abdominal incision or vertical incision, depending on the size of your uterus. You will usually need to stay in hospital after the procedure for one to three days. It usually takes six weeks to recover from a hysterectomy.

This surgery is the most effective treatment for fibroids as you will no longer have periods afterwards, and there is no chance that the fibroids could grow back.

Your ovaries should continue to function (unless you choose to have them removed), and so, although your periods will stop, you will not usually go through the other symptoms menopause.

Possible complications include excessive bleeding, infection, injury to internal organs, clots in the veins and lungs and anaesthetic complications.

D. Uterine artery embolisation (UAE)
Uterine artery embolisation is a procedure performed to shrink fibroids which is performed under sedation. It involves the injection of a fluid into the blood vessels that supply uterus. This fluid contains tiny particles that block the blood flowing to the fibroids causing them to shrink. It can be very effective at treating heavy and painful periods.

For more information, please see uterine artery embolisation.

For any procedure or treatment, it is important that you understand the risks, benefits, and alternatives, which will be explained to you in clinic. We will ask you to sign a consent form for any surgery as a record of our discussion with you. This confirms that you would like to have the procedure and understand what it involves.

If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak with a senior member of staff again. You are free to change your mind at any time before the procedure.
 

• NHS Choices fibroids – further information on fibroids: https://www.nhs.uk/conditions/fibroids/ 
• Royal College of Obstetrics and Gynaecology Fibroids – further information on fibroids and links to other websites: https://www.rcog.org.uk/

Gynaecology Outpatients direct telephone line: 020 3447 9411

Email: uclh.gynaeadmissions@nhs.net

PALS

The Patient Advice and Liaison Service (PALS) is a service that offers support, information and assistance to patients, relatives and visitors.

Telephone: 020 3447 9975 Email: PALS@uclh.nhs.uk

Address: PALS, Ground Floor Atrium, University College Hospital, 235 Euston Road, London NW1 2BU

Gynaecology Diagnostic and Treatment Unit Elizabeth Garrett Anderson Wing

Clinic 3, Lower Ground floor Grafton Way, WC1E 6DB