Fibroids

This information package is not a substitute for a medical opinion. It is designed as an educational reference to allow you to make more informed decisions in consultation with your doctor. Much of what is conveyed during a consultation can be forgotten, this package is here to help remind you of various points that may have been discussed in your consultation and the suggestion of your tailor-made care plan.

What is a fibroid?
A fibroid is a benign (non-cancerous) growth of muscle that is found in or around the uterus. It is made up of irregular sheets of smooth muscle (like the type that forms bowel and bladder, not like the muscles in your arms and legs that are under voluntary control) and can be any size and shape. Approximately 35% of women over the age of 35 will have a fibroid of varying size, with approximately 50% of these being symptomatic. We do not know why women get fibroids, though it is likely that there is a combination of factors such as genetics, hormones such as oestrogen and progesterone, and the number of children that you have had. Some ethnic groups such as African women are more likely to get fibroids.

Symptoms of fibroids
Fibroids may be completely asymptomatic (cause no symptoms at all). If they do cause problems, then these can be one or more of the following: 1. Heavy menstrual bleeding (heavy periods) or irregular vaginal bleeding 2. Pelvic pain at the time of periods, or between periods 3. Problems with fertility (see sections on fertility and location) 4. Pressure effects (from pushing on the bladder, the bowel or other internal organs)

Location of fibroids
Fibroids are usually described in one of four locations: 1. Submucous fibroids (partly or wholly within the uterus) 2. Intramural fibroids (within the wall of the uterus) 3. Subserous fibroids (on the outside of the uterine wall) 4. Pedunculated fibroids (fibroids on a stalk) Large fibroids can occur in a number of these locations, that is start inside the uterine cavity and extend through the wall of the uterus and into the abdomen, therefore occupying a number of the above positions. The location of the fibroid may impact on the symptoms that you have. For example, a 1 cm fibroid that is inside the uterine cavity may present with heavy and sometimes painful periods. Removing it by hysteroscopic resection (see below) will likely improve this symptom. Compare this to a 1 cm fibroid within the wall of the uterus (intramural) which is unlikely to cause any symptoms. It is not recommended to remove such a fibroid as they can be difficult to find and remove.

Subserous fibroid

Pedunculated fibroid

Submucous fibroid

Intramural fibroid

Location of fibroids

The position of a fibroid can also lead to varying symptoms. A large fibroid (say 5 cm) that is present in the front of the uterus may press on the bladder and cause you to have the desire to go the toilet frequently and possibly have pain with intercourse when the uterus is moved, though the same size fibroid at the top of the uterus may not cause any symptoms at all, since there is more room for it to occupy and therefore not press on anything. If the fibroid is asymptomatic, then no treatment needs to be undertaken, though you and your doctor may decide to monitor the fibroid with clinical examination and/or ultrasound to look for changes in size. If you are having one or more of the symptoms above then you may decide to have treatment. Treatment for fibroids will depend on the number, size and location of the fibroids. Treatment is divided into three groups: 1. Medical (using medications) 2. Radiological (uterine artery embolisation) 3. Surgical (surgical removal of fibroids or the uterus)
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Medical treatments: Such treatments will usually be to treat the symptoms of fibroids such as heavy bleeding or pain. Treatments may include the oral contraceptive pill (the pill), other hormonal treatments, or a medication called Cyklokapron, which is designed to reduce the heaviness of your periods. Such treatments do not treat the fibroids themselves, only the symptoms. These treatments will usually not change the size of the fibroids. You should not use hormonal treatments if you are trying to become pregnant as these may prevent or interfere with pregnancy. There are other stronger medications that can be prescribed (a group of drugs called the GnRH agonists such as Zoladex). These medications may reduce the size of the fibroids whilst you are taking the medication, but the fibroid will usually return to the same size that it was before you started the medication. These medications are used to temporarily reduce the size of fibroids and may allow for a different approach to surgery for treatment (e.g. they may allow a vaginal or laparoscopic procedure when an abdominal procedure was previously planned). You cannot continue on these medications for a prolonged time, since they may have serious side effects. These drugs are not recommended, since they can only be used for short periods, have significant side effects, and do not get rid of the fibroids themselves. There are no known drugs that will cause fibroids to regress completely, and there are no drugs that will prevent new fibroids from developing even if some have been removed. Radiological treatments: Uterine Artery Embolisation (UAE) is a process whereby a thin tube is passed into the main artery in the leg at the groin and fed up to the large artery of the pelvis. It then is directed into the artery that supplies the uterus and also the fibroids. Small pieces of foam, or microcoils are then injected into the artery to block the blood supply to the fibroid. This will reduce the size of the fibroid by between 40% and 60%. The fibroid is not completely removed by this treatment, although the symptoms such as heavy bleeding or pressure effects may be improved. Not all fibroids are suitable to this type of treatment, and for women with submucous fibroids (within the cavity) this procedure should not be performed, since there is a significant risk of infection. This procedure is not recommended for women who are wanting to have further children. Surgery for fibroids: Surgery is the only way to completely remove fibroids, but this also involves an invasive procedure. It does not prevent recurrence of fibroids. There are three different modes of surgical treatment for fibroids: 1. Hysteroscopic removal (surgery performed through the cervix) 2. Laparoscopic removal (keyhole surgery through the abdomen) 3. Removal by laparotomy (large incision in the abdomen) The best surgery for your fibroids will depend on their size, number and location. Hysteroscopic surgery for fibroids: Generally, fibroids located inside the uterus (see location of fibroids above) are best treated by hysteroscopy. With this method and under a general anaesthetic, the cervix is gently and progressively opened to about 1 cm using dilators. A special telescope called an operating hysteroscope is then introduced into the cavity of the uterus. Fluid is used to open the cavity space so that all the walls and the uterine lining (the endometrium) can be seen. The operating hysteroscope has connections so that fluid can flow into and out of the uterus and maintain clear vision for the surgeon.

Type O fibroid

Type II fibroid

Type I fibroid

Submucous fibroids

At the end of the operating hysteroscope is a wire loop that can be connected to an electrical current used to cut through the fibroid. This loop is about 4 mm across and is used to cut strips from the fibroid until it has all been removed. Fibroids of up to 3 cm can usually be removed at one surgery. Large fibroids of 3-5 cm may require two or more procedures. Fibroids larger than this may require one of the other methods for removal. If you have a large fibroid, you should discuss treatment options with your doctor. Fibroids within the uterus (submucous fibroids) are further described by the amount of the fibroid that is within the wall of the uterus. A type 0 fibroid is wholly within the uterine cavity, a type 1 fibroid is mostly within the cavity, and a type 2 fibroid is mostly in the wall of the uterus, with a percentage (usually <40%) inside the uterine cavity. The type 2 fibroid is the most difficult to treat, since more is inside the wall of the uterus than in the cavity, and two procedures, or another surgical approach may be required. (see diagram above for location of submucous fibroids). Submucous fibroids are the ones most associated with heavy bleeding because: 1. They may prevent the uterus from contracting down during menstruation 2. They may increase the surface area of the lining of the uterus (the endometrium) 3. They may have an affect on blood vessels that cause them to be open for longer Fibroids themselves do not bleed, but their presence may contribute to heavy menstrual bleeding. Removing the fibroids may reduce the bleeding by alleviating one or more of the above causes. It is also possible to alleviate the problem of heavy bleeding from fibroids by performing an endometrial ablation (see information download on endometrial ablation)
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and leaving the fibroids in the uterus. This is safe, since fibroids are not pre-cancerous. This may be recommended by your doctor, particularly if bleeding is the main symptom and you do not wish to have a hysterectomy. Submucous fibroids are best treated by surgery, usually hysteroscopic. If you have fertility problems and a submucous fibroid (see fibroids and infertility), then hysteroscopic surgery is the best option to improve fertility. Laparoscopic surgery for fibroids: (Laparoscopic Myomectomy) If you are found to have subserosal, intramural or pedunculated fibroids, then your doctor may recommend that they are removed laparoscopically. You should refer to the information sheet entitled Laparoscopy located at this website for details about the basic operation and preparing for the procedure. There will be four incisions made in your abdomen, with a 1 cm incision in the umbilicus (belly button) and above the pubic bone. There will be two other incisions made above the hip bones, these are about 0.5 cm each. With a camera through the umbilicus, the fibroid is located on the uterus and a cut is made over the top of the fibroid and it is shelled out, a bit like peeling an orange. After the fibroid has been removed, it leaves a hole in the wall of the uterus and has to be stitched closed. This is done through the keyholes and usually requires a number of layers to close the hole left by the fibroid. You are likely to have discomfort following this type of surgery that requires on average 2 nights in hospital for pain relief. Following your surgery, you will wake up with a drip in your arm, a catheter (tube) in your bladder to keep it empty so you do not have to get up to the toilet, and likely a drain in your abdomen. The drain is to remove any blood or fluid from the surgery which will help to reduce the risk of infection, reduce pain and increase the speed of your recovery. All these are likely to be removed the morning following your surgery, although your doctor will discuss the removal of these with you when you are reviewed. Laparotomy and myomectomy: A laparotomy is a large cut that is made in the abdomen to perform surgery. This method for removing fibroids may be recommended if you have very large fibroids (more than 7 cm) or there are multiple fibroids. There are some exceptions to these size regulations, and your doctor will discuss the pros and cons of this type of surgery with you. Pedunculated fibroids (fibroids on a stalk) can usually be removed by keyhole surgery even when larger than 7 cm. Your doctor will discuss this with you if this is the case. A laparotomy incision means that there is good access to the uterus, though it causes more pain, a longer stay in hospital and is associated with a higher chance of adhesion formation (scar tissue forming). For very large fibroids however, this is often the safest and most efficient method for removing the fibroids. The incision is usually made over the bikini line in a horizontal manner, this will heal faster and be more cosmetically appealing, though for fibroids of 20 cm or greater this incision may not be adequate and a vertical incision from the umbilicus (belly button) to the pubic bone may be required. Whilst it is recognized that a large abdominal incision is not preferable, it is important to perform the appropriate incision for the size of the fibroid(s) as this will reduce the risk of complications and maximize your safety. Recovery following a laparotomy for fibroids will take longer. You will be in hospital on average 5 nights and will require 4-6 weeks off work. It will take a longer time to recuperate, though the features previously noted for recovery hold true for this method of myomectomy. Removing the entire uterus (hysterectomy) is the only way to guarantee that fibroids will not recur, though there are many other factors to consider. You should refer to the information sheet entitled Hysterectomy for further information on this subject.

Laparotomy scar Vertical -------- Possible line if required

Laparotomy scar Transverse

What are the risks of surgery to remove fibroids?

Complications may include wound infections, bladder infections, minor injuries to muscles or nerves from being positioned on the operating table, and a prolonged time for bladder function to return following removal of the catheter. These complications will usually be identified and treated and often will not require you to stay in hospital. The exception
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to this is if your bladder does not work as it should. The main reason for the bladder not working after a laparoscopic myomectomy is that the nerves to the bladder can be bruised or injured during the procedure. It may take a period of time for these nerves to recover their normal function. For this reason, a specific post-operative protocol is in place to scan the bladder by ultrasound to ensure that it has normal function. This will help to prevent short term problems such as urinary tract infections and may prevent long-term bladder problems. The main risks from removing fibroids by any route is bleeding, since the fibroid has a blood supply to it from the uterus and when it is removed, the hole that is left behind will bleed. Following repair of the defects in the uterus where the fibroids were, there may be bruising of the uterus. Whilst the blood remains in your body, it is not in the areas that it should be and with very large fibroids, you may require a blood transfusion. Generally, the larger the fibroids the more chance there is for bleeding, since a larger gap will be left that requires stitching closed and this will bruise to a greater extent. In the case of very heavy bleeding that could not be controlled, hysterectomy is a possible outcome though it is very rare indeed. This would only be performed in an emergency as a life saving procedure. Other serious but rare complications following surgery to remove fibroids include injuries to the bladder (the organ that holds urine), the ureter (the tube that leads from the kidney to the bladder), the bowel and the major blood vessels. In addition, medical complications such as clots that develop in the legs or lungs, or excessive stress that is placed on the heart and lungs from the surgery can occur resulting in heart attack or stroke. The likelihood of these complications occurring will depend on the size and location of your fibroids, your past surgical and medical history and your age. You will be given a tailor-made consent form that will outline the likely risks for you based on these factors. Specific problems can include bladder injuries, which are usually recognised at the time of surgery. If you are having a laparoscopic myomectomy, these can usually be dealt with by that route, without having to make a large incision in your abdomen. Occasionally a large incision in the abdomen would have to be made to repair the bladder. It is important factor to recognise that your long-term safety is the most important aspect of your treatment and the necessary steps to ensure your safety is the first priority. If you required a bladder repair following an injury, you would have a catheter in your bladder which may stay in for up to one week. You may be able to go home with the catheter in after instruction on caring for it at home if this is your preference. Injuries to the ureter (the tube that leads from your kidney to your bladder) may only require a stent a small hollow tube placed through the ureter from the kidney to the bladder for about 6 weeks. These can be inserted through the bladder without an incision in the abdomen and can be removed through the bladder in a simple procedure, again without an incision in the abdomen. Sometimes the ureter must be reimplanted in the bladder. This means that a large incision is made in the abdomen (vertical midline incision see picture), the ureter is cut and placed into the top of the bladder to drain normally. A stent would be placed as above and would need removing, usually at about 6 weeks. This procedure would normally be performed as an outpatient. The bladder and the ureter will usually function completely normally after this procedure. You will require a special X-ray test at between 6 weeks and 3 months to make sure that the bladder and the ureter are working normally. Injuries to the large blood vessels are the most urgent complication and require immediate attention. If you are having a laparoscopic myomectomy it is likely that a very large incision (midline vertical incision) would be made in the abdomen for immediate repair. Almost certainly there would be a blood transfusion. Your stay in hospital is likely to be longer than anticipated. Injury to a blood vessel is a very serious and life-threatening complication. Injuries to the bowel may occur during surgery for fibroids and can be very serious. The injury to the bowel may be very small and may not be detected at the time of the initial surgery. The injury may occur during any type of myomectomy. If they are detected, then they can often be repaired by the route that the procedure is being undertaken. If you are having a hysteroscopic or laparoscopic myomectomy, then you may require a laparotomy to repair the injury. You will be given antibiotics and you may require a colostomy. A colostomy is where a loop of bowel is brought to the skin and stitched in place with a bag is placed over this. The bowel contents will empty into the bag. This will usually be in place for three months after the surgery to allow the bowel time to heal. When the bowel is healed, the loop of bowel is closed and placed back in the abdomen. Very occasionally the colostomy may be permanent. If a bowel injury occurs during surgery and is missed, then there may be development of a serious infection in the abdomen. This will require surgery with a large incision in the abdomen and a colostomy (see above). You are likely to have a prolonged hospital stay whilst the infection is treated and may require admission to an intensive care ward. This is a very serious and life-threatening complication. The risk of bowel injury that is missed is rare with any type of myomectomy being less than 1/1000 cases. That is for every 1000 myomectomies performed, there will be approximately one missed bowel injury.

Other Post-operative Complications

Medical complications such as clots developing in the legs or lungs or ongoing bleeding from blood vessels cut during the surgery may also cause complications post-operatively. Whilst in hospital your observations will be taken and signs of temperature, increasing pain or problems with your urine will be monitored. You may require more tests and treatments if one of these complications occurs. After you have gone home, if you have an increasing amount of pain, increasing vaginal bleeding, high fevers or sweats or vaginal discharge that is offensive then you should contact your doctor and ask for further advice.
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Recovery following surgery for fibroids

Your recovery will depend on a number of factors: 1. The type of myomectomy that you have; 2. Your age; 3. Any associated medical problems that you have; 4. Individual response to surgery and post-operative pain; 5. The occurrence of any complications. Recovery rates will vary by each individual and are between a few days to 6 weeks. Generally, you should allow 3-5 days following a hysteroscopic myomectomy, 2-4 weeks recovery following a laparoscopic myomectomy and 6-8 weeks following an abdominal myomectomy. You should not do heavy lifting for 6 weeks and no heavy exercise for the first 2 weeks. You are encouraged to walk regularly each day and rest when you feel tired. You can drive a car when you are comfortable stopping in an emergency (usually about 10 days). You can resume intercourse after you have been seen by your doctor in follow-up or at 2-4 weeks. You should stop intercourse if there is pain or bleeding and contact your doctor. You should also note the following: 1. After any type of myomectomy, your period may occur earlier or later than expected and is likely to be heavy; 2. Following a laparoscopy or abdominal surgery for removing fibroids, you may have discomfort in your lower abdomen for about 2-3 weeks as the bruise is absorbed. You should have reducing pain each day, with the exception of a period; 3. Your first period may be painful even more than before the surgery. This is because there is a scar that is healing in the uterus. There should be improvement with subsequent periods; 4. If you are thinking about becoming pregnant, then you should wait for about 3 months to allow the scar to heal fully after a laparoscopic or abdominal myomectomy. If you have had a hysteroscopic myomectomy then you should wait for one menstrual cycle before attempting to become pregnant.

Fibroids and infertility

Fibroids may contribute to infertility in a number of different ways: 1. Acting like an intra-uterine device IUD 2. Changing the blood flow pattern in the uterine cavity 3. Taking space within the uterine cavity 4. Altering the endometrium (lining of the uterus), making it harder for an embryo to implant 5. Other as yet unrecognized factors Submucous fibroids are the most likely to be associated with fertility problems. It is recommend to remove them before trying to become pregnant. For intramural and subserous fibroids routine removal is not recommended. If there has been a difficulty with a pregnancy, such as premature labour or growth restriction of the baby, then your doctor may discuss with you removing the fibroid before trying for another pregnancy. If you have a peduncluated fibroid (one on a stalk), then removing it may prevent complications of pregnancy such as the fibroid twisting (called torsion) or outgrowing its blood supply and causing pain or possibly premature labour. If you have a pedunculated fibroid you should discuss with your doctor if you are planning a pregnancy. The role of intra-mural and subserous fibroids in infertility is less clear and you should discuss the pros and cons of taking a fibroid out with your doctor or an infertility specialist. We can remove fibroids from women who are having difficulty becoming pregnant after discussion with a fertility expert.

Alana Healthcare for Women Pty Ltd 2007 48-50 St Pauls Street Randwick NSW 2031 T: 02 9009 5255 F: 02 9009 5244 MAIL: PO Box 353, St Pauls NSW 2031 ABN 99 123 335 259

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