When fibroids become difficult to live with

Q: I am 34-years-old and have been having heavy menses for the past 10 years. I am constantly taking iron supplements to deal with the anaemia caused by my heavy periods with little improvement. I recently went to visit my doctor who performed an ultrasound scan and found that I have uterine fibroids. He suggested that I have an operation to remove them but I feel that this approach is too drastic (especially since he informed me that I might lose my uterus in the process!) I want to have children in the future so I am not willing to take this chance. Is there medication that I can take to get rid of them? I read that they could lead to infertility, pregnancy problems and even cancer. Is this true? Please help.

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Fibroids are the most common tumours in the uterus. Most women with fibroids are not aware of their existence because they are often asymptomatic (or give minimal symptoms). A few women, however, develop problems like heavy (and sometimes painful) menses, big abdomen (you look like you are a few months pregnant), pressure on the bladder leading to frequent urination and rectal pressure causing changes in stool habits. As you have rightly read, they can cause problems during pregnancy. Infertility caused solely by the presence of fibroids is uncommon (there are often other factors involved).

Generally speaking, fibroids are more common in women above the age of 30 years. Overweight women and women with family members with fibroids have an increased risk of developing them.
No one quite knows why fibroids develop. They, however, respond to hormonal changes in a woman’s body (oestrogen and progesterone levels). They, therefore, increase in size during pregnancy and shrink after menopause.

What about links to uterine cancer?

Fibroids are generally not cancerous.
Rarely (less than 1 in 1,000) a cancerous fibroid will develop. Having fibroids also does not increase your chances of getting other forms of cancer in your uterus or ovaries.

What are the pregnancy complications?

Most women with fibroids have normal pregnancies.

Problems usually occur in women with either very large fibroids or those whose fibroids are located on the inner aspect of the womb or around the cervix. Complications include poor progress of labour, preterm labour and increased risk of requiring a caesarean section delivery. For this reason, all women with fibroids should deliver at a health facility.

What are your treatment options?

Most women with fibroids have normal pregnancies.

They are only treated if they are causing symptoms.

Medication

Majority of women with fibroids have normal pregnancies. Often, the pain or discomfort caused by fibroids can be managed with over- the- counter pain pills.

Anaemia treatment: Heavy menses can lead to anaemia which can be managed with iron supplements.

Hormonal contraceptives: Low dose oral or injectable contraceptives can help control heavy bleeding.

Fibroid “shrinking” medication: There are drugs medically referred to as “Gonadotropin” releasing hormone agonists’ which have been known to shrink fibroids. They also cause one’s menses to cease which can be useful for women who have severe anaemia due to heavy periods. These drugs are only effective when you are taking them. Once you stop, the fibroids become enlarged again. Common side effects of these drugs include bone thinning, hot flushes, sleep issues, mood changes and even low sex drive.

Surgery
Myomectomy:

This is surgery to remove fibroids without taking out the healthy tissue of the uterus. It is best suited for women who wish to have children after the surgery. The surgery is done either through accessing your uterus through a cut on your abdomen or through a special instrument inserted into your vagina. The route of surgery used depends on the location of your fibroids, the availability of specialised equipment and the expertise of your doctor. After myomectomy, you can successfully become pregnant but you are required to wait several months before conceiving. Delivery mode can be vaginal (normal) or via c-section.

Hysterectomy:

This is surgery to remove the uterus and is usually reserved for women who do not wish to have children or have achieved their desired family size. In rare instances, a myomectomy may be associated with excessive bleeding causing the doctor to perform a hysterectomy.

Myolysis:

During this procedure, a needle is inserted into the fibroids, and either electric current, heat, laser or freezing is used to destroy the fibroids. It is done through laparoscopic (keyhole) surgery.

Non-surgical options

Uterine Fibroid Embolization (UFE) or Uterine Artery Embolisation (UAE) This is a procedure through which the blood supply to the fibroids is blocked causing them to shrink. Usually, this procedure does not require surgery and is done with the help of special radiographic (x-ray) images and tubes. In some centres it is done as an outpatient procedure (or with an overnight admission).

MRI-guided focused ultrasound surgery: This is not surgery in the real sense. It is a procedure in which you are put into an MRI scan machine and after your fibroids are located, ultrasound waves and heat are used to destroy them.

Endometrial ablation: During this process, the lining of the uterus is removed or destroyed to control very heavy bleeding. Most women who have this procedure have no more menstrual bleeding or experience very light bleeding. After this procedure, a woman generally cannot get pregnant. This procedure does not remove fibroids, it only helps deal with severe bleeding in women who do not desire to have children.

Are these treatment options available in Kenya?

Yes, almost all these procedures are currently being done in Kenya and are covered by most health insurance plans (including NHIF).

Risk of developing new fibroids after surgery

A constant concern by women who have had treatment for their fibroids is whether or not they will recur. Unless you have had a hysterectomy (where the uterus is removed), you can develop new fibroids after treatment. This is often due to the presence of tiny seedlings left behind because your doctor was unable to see them during your initial surgery/procedure. New fibroids do not always require treatment.