Fibroids are common tumours of the uterus (womb) found in over 20 % of young women. There are firm, ball like and may vary in size from pin point to very large. Fibroids are diagnosed by the history, gynaecological examination and sonography. The management of fibroids depends upon their size and location, age of the patient, symptoms and the patient's desire for children in the future.
There are many types of fibroids:
Subserosal fibroids
These grow on the outer side of the uterus. They usually cause no problems unless they grow very big, causing pressure on the urinary bladder or intestines and patient begins to experience difficulty in passing urine or stools. These fibroids may start showing as a bulge in the lower part of the stomach if they are large and may sometimes grow as big as a 3-5 month size pregnancy.
Large serosal fibroids causing symptoms have to be removed. The surgery can be done by an age old method of making a cut on the stomach (abdomen) which is usually a bikini scar, opening the abdomen and removing the tumor. The gap in the womb is stitched and the abdomen is closed. This method requires longer hospitalization and rest and recovery period is also longer. There is also a higher tendency to develop adhesions (intestines getting stuck to each other and the womb) by this method and this can cause long term stomach pain and sometimes infertility.
Nowadays, most of the fibroids can be removed by the new method of keyhole or endoscopic (laparoscopic) surgery. This method calls for a telescope to be put into the stomach through a very small cut on the stomach wall. The telescope has a camera attached to it and the entire operation is done watching it on a TV screen. . The tumor is removed and the gap on the womb is stitched using special equipment which can enter through a one cm cut on the stomach. Nowadays, even large fibroids are being removed by the laparoscopic route. This has been made possible due to the availability of a new machine called Morcellator, which reduces the tumor to small pieces. For added safety the fibroid is made into small pieces inside a bag put within the abdomen so that there is no spread, in the rare event of the tumour being cancerous. The surgery is cosmetic as there is no large scar. Furthermore the patient has to stay in hospital only for 2-3 days, has less pain and adhesions and can get back to an active life very soon.
Intramural fibroids
These fibroids lie in the middle of the womb and may cause pain during periods and sometimes problems during pregnancy, specially if they are large. These fibroids may sometimes prevent a normal delivery or cause heavy bleeding or infection after delivery. They can be removed in the same way as Serosal fibroids.
Submucous fibroids
The submucous fibroids cause maximum problems. They grow on the inner side of the womb - where the baby grows or the part which sheds during menses. Even small submucous fibroids can cause pain, heavy and irregular menses, infertility, recurrent abortions and difficulty in normal delivery. Submucous fibroids need to be removed and this is achieved by hysteroscopic surgery. A thin telescope with a camera attached to it (hysteroscope) is introduced into the womb through the vagina and the fibroid is shaved off. This is done using a machine called a Resectoscope or the new technique using the versapoint. The versapoint is a laser like device with which the fibroid can be vaporized. This is a safe and efficient system.
Hysteroscopic surgery gives rapid recovery and relief to the patient.
The fibroids usually are non cancerous tumors but they can recur. Hence even if all fibroids are removed - new ones may regrow in a couple of years. Young women who want to have children should plan to become pregnant within a few months after the fibroid surgery so that there is no risk of recurrence.
Till now there was no efficient and permanent non surgical treatment available for recurrence of Fibroids. Expensive, once a month hormone injections can only temporarily shrink the fibroids but the fibroids tend to increase in size once treatment is stopped. Recently a new drug called Ullipristal has been launched –this is the first tablet available for treatment of fibroids. Within 3 months there is a reduction in size of the fibroid with minimal side effects.
Until recently, fibroids could only be treated by operation but now with the introduction of the MRI guided focused ultrasound (MRgFUS) , for the first time- there is an alternative. Treatment of fibroids can now be done without surgery, hospitalization and anesthesia.. As the MRI is a very accurate technique, the fibroid is properly localized and a fine beam of ultrasound waves is focused on the fibroid raising temperature within it so as to cause necrosis and reduction in size.
The patient has no pain during or after the procedure. She is able to go home the same day and can resume work the next day.
Patients who are high risk for surgery or those who are scared to undergo an operation can now walk in, treat their fibroids and walk out without an operation. The womb (uterus) is preserved and so is fertility, that is, the patient can safely have children in the future if they want. The procedure has a very low risk of complications and hence is a simple, safe and effective treatment for fibroids.
If the woman is older, has multiple fibroids and has completed her family, the entire uterus along with fibroids can be removed (Hystrectomy) This can be done by opening the abdomen (laparotomy) or by laparoscopy.
Since fibroids may be found in women of all ages from those in 20's to those in their 50's, it is good for all women to have regular gynaecological check ups even if they have no symptoms.
(Dr Rishma Dhillon Pai, Consultant Gynaecologist & Infertility specialist attached to Lilavati Hospital, Jaslok Hospital and Hinduja Healthcare Surgicals Hospital)
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