Uterine Fibroids 

When I was told to write an article about women’s health, my first thought was to write about the current trends so I set out to do just that. I found out that the new trend is the focus on technological advancements like different apps to monitor ovulation or calculate expected dates of delivery.

What I have found though, in my over two decades of practicing obstetrics and gynecology in four different countries is that women more often than not, want to be listened to and talked to rather than have machines answer their questions. They want their ob-gyn to explain things in detail which is what I will attempt to do with this article, talking about fibroids.

What are they?

They are benign tumours of the smooth muscles of the uterus that very rarely turn into cancer and are more common in African women than among Caucasians.

It is interesting how different connective tissue disorders occur between the two groups. Africans tend to have hypertrophied scars, keloids and large uterine fibroids.

I’m amazed at how different they feel of performing repeat Caesarean sections is between the two groups, much more difficult because of dense scar formation among the Africans.

Caucasian women commonly tend to have a higher incidence of prolapse from sagging of the pelvic muscles. 

Fibroids come in various sizes and can be found in different locations in the uterus. These factors determine what kind of problem a woman with fibroid could present with.

The most common presentation in my experience are heavy menstrual bleeding, a pelvic or abdominal mass which may be quite big or a combination of both. Sometimes a big fibroid will rest on the bladder and increase the frequency of passing urine and I have seen a case of total blockage of the urethra by a fibroid uterus. Until the time of surgery, the woman had to have a catheter to drain her urine. 

I remember another woman whom I had to deal with in my first year of residency. She had presented like she was nine months pregnant and bleeding heavily with clots.

It was difficult for me then to figure out what it could be because the abdomen was so big. When I presented her case to my senior registrar then and he had suggested it could be a fibroid, I couldn’t believe it until the time of surgery (those were days when ultrasound was not readily available and we relied heavily on clinical judgement). It was a huge fibroid uterus, the biggest I have ever seen till now.

The availability of ultrasound has afforded the opportunity to detect uterine fibroids even in women who have no symptoms and more often than not this has caused needless anxiety for a lot of them.

Fibroids are generally painless unless there is degeneration which most commonly occur during pregnancy. The pain can be really bad and may warrant hospitalization just for pain control and rehydration. 

Except at instances when the fibroid is located low in the uterus, blocking the possible passage of a baby, the presence of a fibroid is not an indication for caesarean section.

It could however make the baby lie in an abnormal way (for example transverse lie or breech) and require caesarean section for safe delivery. It could also be a cause of excessive blood loss immediately after delivery which can be managed medically but may be an indication for the removal of the uterus (hysterectomy) to save the life of the mother.

Removal of just the fibroids with the intention of preserving the uterus (myomectomy) is not done when a woman is pregnant, or has just delivered a baby because bleeding can be very bad and life threatening.

Can they cause infertility?

This is a million dollar question which I was asked when I was preparing for my part one exams. It could, but very rarely would fibroids be the only cause of infertility and that is when two fibroids are located at the beginning of both Fallopian tubes causing tubal blockages on both sides.

Fibroids are more often the cause of repeated miscarriages, again, that’s if it is located right inside the uterus. The interesting thing though, is that quite a substantial amount of women who undergo myomectomy get pregnant after the procedure. 

Treatment

There are medications that can shrink uterine fibroids but they tend to have rebound effects. Once they are stopped, fibroids tend to grow rapidly so they are often used just before surgery to decrease the size and achieve less bleeding during the procedure. 

Fibroids depend on estrogen for growth and multiplication therefore once a woman gets to menopause, they tend to stop growing, shrink, calcify or go through a combination of these.

Even if they were symptomatic before menopause, most of the symptoms would typically start to disappear when a woman is peri menopausal.

Myomectomy is typically a more bloody and technically difficult procedure than hysterectomy and is usually indicated for symptomatic fibroids that are present in a woman who still desires to have babies.

Hysterectomy may however be done in life threatening situations when the plan was to do just myomectomy.

Uterine artery embolization is a radiological procedure that is aimed at blocking the major arteries that feed the uterus. Once this is achieved, the fibroids tend to shrink and become less symptomatic. It is not a procedure for women who still want to have more babies.

Preventive measures 

There is a genetic disposition issue which makes uterine fibroids hardly preventable but the general advice is that women should have babies at younger ages because it is a known fact that fibroids tend to grow bigger and/or multiply in uteruses that are not pregnant soon enough or often enough particularly amongst Africans.