Fibroids

Women who do have symptoms (around 1 in 3) may experience:

• heavy periods or painful periods (sometimes leading to anaemia)
• tummy (abdominal) pain, bloating or swelling
• lower back pain
• a frequent need to urinate
• constipation
• pain or discomfort during sex

Pregnancy

Having fibroids does not cause any problems in the vast majority of women when they are pregnant. However, in a small number of cases fibroids can be associated with a higher risk of miscarriage, premature labour, caesarean section and breech delivery.

The likelihood of complications occurring during pregnancy will depend upon factors such as the position of the fibroids and their size.

The womb (uterus) is made mainly of smooth muscle and fibroids. Fibroids result from an overgrowth of the smooth muscle cells as well as other cells from the lining of the womb.

The exact cause of fibroids is unknown, but they have been linked to the hormone oestrogen. Oestrogen is the female reproductive hormone produced by the ovaries.

Fibroids usually develop during a woman’s reproductive years (from around the age of 16 to 50) when oestrogen levels are at their highest. They tend to shrink when oestrogen levels are low, such as after the menopause when a woman’s monthly periods stop. However, this shrinkage may be delayed if you take hormone replacement therapy (HRT).

Fibroids are thought to develop more frequently in women of African-Caribbean origin.

It’s also thought they occur more often in overweight or obese women because being overweight increases the level of oestrogen in the body.

Women who have had children have a lower risk of developing fibroids, and the risk decreases further the more children you have.

Fibroids can grow anywhere in the womb:

• Intramural fibroids are the most common type of fibroid which develop in the muscle wall of the womb.
• Submucosal fibroids develop in the muscle layer beneath the womb’s inner lining and grow into the cavity of the womb.
• Subserosal fibroids develop outside the wall of the womb into the pelvis and can become very large.

In some cases, subserosal or submucosal fibroids are attached to the womb with a narrow stalk of tissue. These are known as pedunculated fibroids.

To see an image depicting the different types of fibroids (produced by the Oxford University Nuffield dept. of Women’s & Reproductive Health) click here.

You should consult your GP if you have persistent or troublesome symptoms suggestive of fibroids (see above), or if you have known fibroids and are considering becoming pregnant.

If a GP suspects fibroids, they’ll usually carry out a pelvic examination to look for any obvious signs. They will then refer you for a pelvic ultrasound scan which should be able to confirm the diagnosis.

Once the diagnosis is confirmed, your GP will discuss any symptoms that you may be having and the potential role of medication. They may also refer you to a specialist if the fibroids are causing significant issues or if further investigation such as hysteroscopy or laparoscopy may be required.

Ultrasound scan

One of the main tests carried out to diagnose fibroids is an ultrasound scan. This is a painless scan that uses a probe to produce high frequency sound waves to create an image of the inside of your body.

Two types of ultrasound scan can be used to help diagnose fibroids:

• an abdominal ultrasound scan – where the ultrasound probe is moved over the outside of your tummy (abdomen)
• a transvaginal ultrasound scan – where a small ultrasound probe is inserted into your vagina

Images produced by these scans are transmitted to a monitor so the doctor can see if there are any signs of fibroids.

Hysteroscopy

A hysteroscopy is where a small telescope (hysteroscope) is inserted into your womb through the vagina and cervix so a doctor can examine the inside of your womb. This is usually performed in the outpatient clinic or as a day-case procedure. A biopsy (small piece of tissue from the lining of the womb) may be taken to confirm the diagnosis and it may be possible to treat small fibroids during the hysteroscopy.

Anaesthetic is not usually necessary, but a local anaesthetic may be used to numb the cervix (neck of the womb). General anaesthetic may be required for longer more complex procedures.

It is a good idea to take a painkiller such as ibuprofen an hour before the procedure as it can cause some cramping similar to period pain.

A hysteroscopy is most often used to look for fibroids within your womb (submucosal fibroids).

Laparoscopy

A laparoscope is a small telescope with a light source and camera at one end. The camera relays images of the inside of the abdomen or pelvis to a television monitor.

During a laparoscopy a surgeon will make a small cut (incision) in your abdomen.

The laparoscope will be passed into your abdomen to allow the organs and tissues inside your abdomen or pelvis to be examined.

General anaesthetic is used, so you’ll be asleep during the procedure.

A laparoscopy can be used to look for fibroids outside your womb (subserosal fibroids) or fibroids in the layer of muscle surrounding the womb (intramural fibroids) that have affected its size and shape.

Biopsy

In some cases, a small tissue sample (a biopsy) may be removed during a hysteroscopy or laparoscopy for closer examination under a microscope.

In most cases, fibroids do not cause any symptoms and do not interfere with pregnancy and therefore no treatment is required.

Fibroids often shrink after the menopause, and any symptoms will usually either ease or disappear completely.

Treatment is only warranted when the fibroids are causing intrusive symptoms or are large (>3cm diameter) and could interfere with pregnancy or fertility.

The principle aims of any treatment for fibroids are:

1. The management of symptoms such as abnormal uterine bleeding (AUB) or menorrhagia (heavy periods), anaemia, pelvic pressure effects (e.g., bladder and bowel symptoms) and pelvic pain.

2. An attempt to improve fertility (reducing the risk of miscarriage).

The initial treatment for symptomatic fibroids is medical. This includes both hormonal and non-hormonal medication aimed at either reducing heavy periods and/or pelvic pain or shrinking the fibroids.

Your GP may recommend that you see a gynaecologist (a specialist in the female reproductive system) for further medication or surgery if these are ineffective.

Please note: Under local clinical commissioning guidelines in all but exceptional circumstances, surgical treatment for fibroids will only be funded where “conservative management” (medical treatment) has proven ineffective.

Medical treatment

The levonorgestrel intrauterine system (LNG-IUS) is the first-line treatment for heavy menstrual bleeding and can also be helpful for period pain; it is also a highly effective method of contraception. It is a plastic device that sits inside the womb and slowly releases a regular small amount of progestogen hormone called levonorgestrel. It works by making the lining of the womb very thin, so bleeding is lighter and may stop altogether over time. However, it can sometimes be difficult to insert in women with fibroids protruding into the womb cavity.

The combined oral contraceptive (COC) pill may help you to have lighter periods and can often help with period pain too.

If you are unable to take this, the progestogen-only contraceptive pill (POP) may help.

Progestogen tablets at certain times in your cycle or the progestogen-only injection may also be effective in reducing heavy menstrual bleeding.

Tranexamic acid is taken 3-4 times a day, for the duration of each period. It works by reducing the breakdown of blood clots in the womb (uterus).

Anti-inflammatory medicines such as ibuprofen and mefenamic acid are helpful for managing period pain and may also help to reduce bleeding. They are taken for a few days at the time of your period. They work by reducing the high level of a chemical (prostaglandin) in the lining of the womb. Prostaglandin seems to contribute to heavy and painful periods.

Medicine to shrink fibroids

Gonadotrophin-releasing hormone (GnRH) analogues are hormones that cause you to have a very low level of oestrogen in your body. Fibroids shrink if the level of oestrogen falls. This can ease heavy periods and pressure symptoms due to fibroids. However, a low oestrogen level can cause symptoms similar to going through the menopause (hot flushes, etc). It may also increase the risk of ‘thinning’ of the bones (osteoporosis). Therefore, this treatment is given for a maximum of six months.

GnRH analogues, such as triptorelin, are often prescribed for three to four months before having an operation. This will make it easier to remove fibroids.

Sometimes a low dose of HRT is also given to reduce menopausal side-effects.

Ulipristal acetate (UPA) works by blocking the effects of the hormone progesterone. Progesterone is thought to play a role in fibroid development, so (by blocking progesterone) this medicine shrinks fibroids and is sometimes used when surgery is not possible or has failed.

Surgical treatments

Under local clinical commissioning guidelines in all but exceptional circumstances, surgical treatment for fibroids will only be funded where “conservative management” (medical treatment, as above) has proven ineffective.

Hysteroscopic resection of fibroids

A hysteroscopic resection of fibroids is a procedure where a thin telescope (hysteroscope) and small surgical instruments are used to remove fibroids.

The procedure can be used to remove fibroids from inside the womb (submucosal fibroids) and is suitable for women who want to have children in the future.

No incisions are needed because the hysteroscope is inserted through the vagina and into the womb through the entrance to the womb (cervix).

The procedure is often carried out under general anaesthetic, although local anaesthetic may be used instead. You can usually go home on the same day as the procedure.

After the procedure you may experience stomach cramps, but they should only last a few hours. There may also be a small amount of vaginal bleeding, which should stop within a few weeks.

Endometrial ablation

Endometrial ablation reduces menstrual bleeding by removing the lining of the womb using heat or laser.

It is mainly used to reduce heavy bleeding in women without fibroids, but it can also be used to treat small fibroids in the womb lining.

The procedure can be carried out either under local anaesthetic or general anaesthetic. It is quick to perform, taking around 20 minutes, and you can usually go home the same day.

You may experience some vaginal bleeding and pelvic pain for a few days afterwards, although some women have bloody discharge for 3 or 4 weeks.

It may still be possible to get pregnant after having endometrial ablation, but the procedure is not recommended for women who want to have more children because the risk of serious problems, such as miscarriage, is high.

The Royal College of Obstetricians and Gynaecologists (RCOG) have more information about endometrial ablation.

Read Information for you after an endometrial ablation to find out more.

Uterine artery embolisation (UAE)

Uterine artery embolisation (UAE) is an alternative procedure to a hysterectomy or myomectomy for treating fibroids. It may be recommended for women with large fibroids.

UAE is carried out by a radiologist, a specialist doctor who interprets X-rays and scans. It involves blocking the blood vessels that supply the fibroids, causing them to shrink.

During the procedure, a special solution is injected through a small tube (catheter), which is guided by X-ray through a blood vessel in your leg.

It’s carried out under local anaesthetic, so you’ll be awake but the area being treated will be numbed.

You’ll usually need to stay in hospital a day or two after having UAE. When you leave hospital, you’ll be advised to rest for 1 to 2 weeks.

Although it’s possible to have a successful pregnancy after having UAE, the overall effects of the procedure on fertility and pregnancy are uncertain.

It should therefore only be carried out after you have discussed the potential risks, benefits, and uncertainties with your doctor.

Myomectomy

A myomectomy is surgery to remove the fibroids from the wall of your womb. It may be considered as an alternative to a hysterectomy if you’d still like to have children.

Myomectomy is not suitable for all types of fibroids. Your gynaecologist can tell you whether the procedure is suitable for you based on factors such as the size, number, and position of your fibroids.

Depending on the size and position of your fibroids, a myomectomy may involve making either several small incisions in your tummy (keyhole surgery) or a single larger incision (open surgery).

Myomectomies are carried out under general anaesthetic, and you’ll usually need to stay in hospital for a few days afterwards. You’ll be advised to rest for several weeks while you recover.

Myomectomies are usually an effective treatment for fibroids, although there’s a chance the fibroids will grow back, and further surgery will be needed.

Hysterectomy

A hysterectomy is a surgical procedure to remove the womb. It is the most effective way of preventing fibroids coming back but it is a major procedure so will only be considered if other treatments have failed.

A hysterectomy may be recommended if you have large fibroids or severe bleeding and do not wish to have any more children.

A vaginal approach is usually the preferred option as recovery time is longer with abdominal surgery.

Depending on the technique used, a hysterectomy can be carried out using a spinal or epidural anaesthetic, where the lower parts of the body are numbed.

Sometimes a general anaesthetic may be used, where you’ll be asleep during the procedure.

You’ll usually need to stay in hospital for a few days after having a hysterectomy. It takes about 6 to 8 weeks to fully recover, during which time you should rest as much as possible.

Side effects of a hysterectomy can include early menopause and a loss of libido (sex drive).

Non-surgical procedures

As well as traditional surgical techniques to treat fibroids, non-surgical treatments are also available.

MRI-guided procedures

• MRI-guided percutaneous laser ablation
• MRI-guided transcutaneous focused ultrasound

These techniques use MRI to guide small needles into the centre of the fibroid being targeted. Laser energy or ultrasound energy is passed through the needles to destroy the fibroid.

These treatment methods cannot be used to treat all types of fibroids, and the long-term benefits and risks are unknown.

As these procedures are relatively new, they’re not yet widely available in the UK.

Research is still being carried out, but there’s some evidence to suggest that these non-invasive procedures have short- to medium-term benefits when performed by an experienced clinician.

But the effects on pregnancy and women who want to have a baby in the future are not fully known, so this should be taken into consideration.

For further information, read the NICE guidance about:

• MRI-guided percutaneous laser ablation for uterine fibroids
• MRI-guided transcutaneous focused ultrasound for uterine fibroids

If you have been referred for a specialist opinion your details will be reviewed and it may be recommended that you are seen by a hospital clinician. Information to support you in choosing your preferred hospital, including waiting times can be found using the links below.

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