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MANAGEMENT OF FIBROIDS

Majority of African women do not want their uterus removed under any circumstance. The culture and custom enshrine certain beliefs in them that perpetuates “I rather die than have my womb removed”. They present late with advanced large symptomatic uterine fibroids as last resort to physicians who may recommend hysterectomy after evaluation.

Among African women, many die with fibroids essentially due to lack of access to care, affordability and poor cultural beliefs and practices.

Very often after a physician has evaluated a woman with symptomatic fibroids and counseled the woman on her various options for management, the patient does not return to the physician again. Rather, she will seek local consultations with her mother, mother in law, friends and relatives and follow their advice and not her doctors advice. She will try local herbs and concortions which many a time are destructive to the uterus and cause mutilations to her pelvic organs and vagina.

Treatment

Most fibroids do not require treatment unless they are causing symptoms. After menopause most fibroids generally shrink and it is unusual for fibroids to cause problems.

Management of fibroids depends on the expertise of the consultant, physician or caregiver, the severity of the patient's presenting complaints, her ultimate desire and the patient’s age. Small fibroids found without symptoms should be left alone.

Many pregnancies have occurred in women with fibroids. The pregnancies will co-exist with the pathology. Even large fibroids can co-exist with viable and successful pregnancies if they are located on the surface of the uterus, but not within the muscle or the endometrium.

Fibroid treatment can be harmful or helpful depending where you go for consultation and evaluation. Many women have sought help and treatments from places like massage clinics, prayer houses, herbalists, with hopes that their fibroids will dissolve or simply go away. Such women soon discover that their fibroids have even grown larger because of unnecessary delays. Young and unmarried females with symptomatic fibroids often delay evaluation and treatment of their condition for fear that men will not marry them if they know that the woman has undergone such an operation.

A good specialist or caregiver will consider a lot of issues before recommending any form of treatment for fibroid to the afflicted woman. He/She will consider

  • the woman’s age
  • fertility desires
  • how serious are her fibroid symptoms
  • how big and the locations of her fibroids.


If a woman shows no symptoms of her fibroid and the fibroid is not inside her endometrium and she is desiring pregnancy, the couple will be counseled on conservative management of her fibroid condition. She may not need any treatments.

When a woman has problems with her fibroids, she may be offered medical or surgical therapy after thorough investigations.

Symptomatic uterine fibroids can be treated by:

  • medication to control symptoms
  • medication aimed at shrinking tumours
  • ultrasound fibroid destruction
  • various surgically aided methods to reduce blood supply of fibroids
  • myomectomy or radio frequency ablation
  • hysterectomy
  • treatment for infection and anemia
  • embolization

    In order to select the proper treatment, it is essential to ascertain the location and number of myomas, which can be accomplished by a combination of pelvic ultrasound and saline infusion sonography, or MRI. Submucous myomas can cause heavy bleeding in 30% of cases. Most can be removed by hysteroscopic resection on an outpatient basis. Endometrial biopsy is required to rule out endometrial carcer or hyperplasia. Hypothyroidism can be associated with menorrhagia, and TSH measurement is the most cost-effective assessment. Serum estradiol levels are not helpful in the evaluation of menorrhagia.

    If a woman has significant symptomatic fibroids including abdominal distension, pain, pressure, heavy bleeding resulting in anemia, tubal obstruction or causing intra-cavitary distortion, surgery may be the best form of treatment.

    Any fibroids found to be a real cause of infertility should be removed by experienced gynecologic surgeon. Delaying the surgery complicates the situation because with time, the fibroids can undergo degeneration, calcification and sometimes, may even progress to cancer. Sometimes the fibroid can form bulky irregular uterine masses pressing on the urinary bladder and causing urinary frequency and urinary retention. So it is dangerous to delay removal of bad fibroids. Fibroids found within the endometrium (submucus fibroids) can interfere with implantation of embryos or may cause cornual occlusion, and as such should be removed preferably by hysteroscopy or laparotomy.

    Medications

    If you have fibroids and have mild symptoms, your doctor may suggest taking medications. Drugs such as ibuprofen or acetaminophen can be used for mild pain. If you have heavy bleeding during your period, taking an iron supplement can keep you from getting anemia or correct it if you already are anemic.

    Several drugs commonly used for birth control can be prescribed to help control symptoms of fibroids. Low-dose birth control pills do not make fibroids grow and can help control heavy bleeding. The same is true of progesterone-like injections (e.g., Depo-Provera®). An IUD (intrauterine device) called Mirena® contains a small amount of progesterone-like medication, which can be used to control heavy bleeding as well as for birth control.

    Other drugs used to treat fibroids are "gonadotropin releasing hormone agonists" (GnRHa). The one most commonly used is Lupron®. These drugs, given by injection, nasal spray, or implanted, can shrink your fibroids. Sometimes they are used before surgery to make fibroids easier to remove. Side effects of GnRHas can include hot flashes, depression, not being able to sleep, decreased sex drive, and joint pain. Most women tolerate GnRHas quite well. Most women do not get a period when taking GnRHas. This can be a big relief to women who have heavy bleeding. It also allows women with anemia to recover to a normal blood count. GnRHas can cause bone thinning, so their use is generally limited to six months or less. These drugs also can be very expensive, and some patients cannot afford it. GnRHas offer temporary relief from the symptoms of fibroids; once you stop taking the drugs, the fibroids often grow back quickly.

    Surgery

    If you have fibroids with moderate or severe symptoms, surgery may be the best way to treat them. Here are the options:

    • Myomectomy) – Surgery to remove fibroids without taking out the healthy tissue of the uterus. It is best for women who wish to have children after treatment for their fibroids or who wish to keep their uterus for other reasons. You can become pregnant after myomectomy. But if your fibroids were imbedded deeply in the uterus, you might need a cesarean section to deliver. Myomectomy can be performed in many ways. It can be major surgery (involving cutting into the abdomen) or performed with laparoscopy or hysteroscopy. The type of surgery that can be done depends on the type, size, and location of the fibroids. After myomectomy new fibroids can grow and cause trouble later. All of the possible risks of surgery are true for myomectomy. The risks depend on how extensive the surgery is.
    • Hysterectomy) – Surgery to remove the uterus. This surgery is the only sure way to cure uterine fibroids. Fibroids are the most common reason that hysterectomy is performed. This surgery is used when a woman's fibroids are large, if she has heavy bleeding, is either near or past menopause, or does not want children. If the fibroids are large, a woman may need a hysterectomy that involves cutting into the abdomen to remove the uterus. If the fibroids are smaller, the doctor may be able to reach the uterus through the vagina, instead of making a cut in the abdomen. In some cases hysterectomy can be performed through the laparoscope. Removal of the ovaries and the cervix at the time of hysterectomy is usually optional. Women whose ovaries are not removed do not go into menopause at the time of hysterectomy. Hysterectomy is a major surgery. Although hysterectomy is usually quite safe, it does carry a significant risk of complications. Recovery from hysterectomy usually takes several weeks.
    • Endometrial Ablation – The lining of the uterus is removed or destroyed to control very heavy bleeding. This can be done with laser, wire loops, boiling water, electric current, microwaves, freezing, and other methods. This procedure usually is considered minor surgery. It can be done on an outpatient basis or even in a doctor's office. Complications can occur, but are uncommon with most of the methods. Most people recover quickly. About half of women who have this procedure have no more menstrual bleeding. About three in 10 women have much lighter bleeding. But, a woman cannot have children after this surgery.
    • Myolysis – A needle is inserted into the fibroids, usually guided by laparoscopy, and electric current or freezing is used to destroy the fibroids.
    • Uterine Fibroid Embolization (UFE), or Uterine Artery Embolization (UAE) – A thin tube is thread into the blood vessels that supply blood to the fibroid. Then, tiny plastic or gel particles are injected into the blood vessels. This blocks the blood supply to the fibroid, causing it to shrink. UFE can be an outpatient or inpatient procedure. Complications, including early menopause, are uncommon but can occur. The best candidates for UFE are women who:

      Have fibroids that are causing heavy bleeding

      Have fibroids that are causing pain or

      pressing on the bladder or rectum

      Don't want to have a hysterectomy

      Don't want to have children in the future



      Other ways to treat uterine fibroids are available , though not widely used.
    • MRI-guided ultrasound surgery shrinks fibroids using a high-intensity ultrasound beam. The MRI scanner helps the doctor locate the fibroid, and the ultrasound sends out very hot sound waves to destroy the fibroid.
    • Some health care providers use lasers to remove a fibroid or to cut off the blood supply to the fibroid, making it shrink.
    • Mifepristone®, and other anti-hormonal drugs being developed, could provide symptom relief without bone-thinning side effects.
    • Other medications are being studied for treatment of fibroids.


Myomectomy is a surgery to remove one or more fibroids. It is usually recommended when more conservative treatment options fail for women who want fertility preserving surgery or who express desire to retain the uterus. This surgery is fertility preserving although in some circumstances subsequent pregnancies can be difficult or impossible.

There are three techniques types of myomectomy:

  • In a hysteroscopic myomectomy, the fibroid is removed by the use of a resectoscope, an endoscopic instrument inserted through the vagina and cervix that can use high-frequency electrical energy to cut tissue. Hysteroscopic myomectomies can be done as an outpatient procedure, with either local or general anesthesia used. Hysteroscopic myomectomy is most often recommended for submucosal fibroids.
  • A laparoscopic myomectomy requires a small incision near the navel. The physician then inserts a laparoscope into the uterus and uses surgical instruments to remove the fibroids.
  • As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids.
  • A laparotomic myomectomy (also known as an open or abdominal myomectomy) is the most invasive surgical procedure to remove fibroids. The physician makes an incision in the abdominal wall and removes the fibroid from the uterus. A particularly extensive laparotomic procedure may necessitate that any future births be conducted by Caesarean section. Recovery time from a laparatomic procedure is generally longer than for hysteroscopic or laparoscopic myomectomies.


FIBROID AND CANCER

About 1 out of 1000 lesions are or become malignant, typically as a leiomyosarcoma on histology. A sign that a lesion may be malignant is rapid growth of the fibroids after menopause. There is no consensus among pathologists regarding the transformation of leiomyoma into a sarcoma. Most pathologists believe that a Leiomyosarcoma is a de novo disease.

Metastasis

There are a number of rare conditions in which fibroids metastasize. They still grow in a benign fashion, but can be dangerous depending on their location.

  • In leiomyoma with vascular invasion, an ordinary-appearing fibroid invades into a vessel but there is no risk of recurrence.
  • In Intravenous leiomyomatosis, leiomyomata grow in veins with uterine fibroids as their source. Cardiac involvement can be fatal.
  • In benign metastasizing leiomyoma, leiomyomata grow in more distant sites such as the lungs and lymph nodes. The source is not entirely clear. Pulmonary involvement can be fatal.
  • In disseminated intraperitoneal leiomyomatosis, leiomyomata grow diffusely on the peritoneal and omental surfaces, with uterine fibroids as their source. This can simulate a malignant tumor but behaves benignly.

Society and culture



The Center for Uterine Fibroids which is associated with Brigham and Women’s Hospital in Boston MA has carried out investigation of all aspects of the aetiology, pathology of fibroids and development of treatment options. This institution also has a lot of clinical trials focused on African American women. The focus of one study is the search for a specific gene associated with the development of fibroids. Since one risk factor for uterine fibroids is having a family history of fibroids, the results of this study may provide some answers on the heredity of the fibroid condition. Some women may benefit by getting an ultrasound to diagnose symptoms if they’ve had a mother, sister or grandmother who has previously suffered with fibroids.