Most women with uterine fibroids have no symptoms. However, some of the common symptoms of fibroids include: heavy or prolonged periods, pelvic pressure or pain, frequent urination, difficulty emptying the bladder, constipation, backache or leg pains and pain during sexual intercourse and activity. Fibroids can cause the above symptoms depending on their size, number and location within the uterus.
The prevalence of uterine fibroids among Asian women is as high as 40%. However, there is currently no local data on the prevalence of uterine fibroids in Singapore and the actual figure may be even higher. Studies have been performed to gather data on the prevalence of fibroids in Western populations but prevalence of the same in Asian countries are difficult to obtain due to cultural and socioeconomic differences. As such, a prevalence study needs to be done in Singapore to better understand this condition in the local context. This is important as the prevalence of fibroids in the community will have a great impact on healthcare resources.
Uterine fibroids are benign growths that appear in the uterus during a woman’s childbearing years. Also called leiomyomas or myomas, uterine fibroids aren’t associated with an increased risk of uterine cancer and almost never develop into cancer. Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. You can have a single fibroid or multiple ones. Many women have uterine fibroids sometime during their lives. But most women don’t know they have uterine fibroids because they often cause no symptoms. Your doctor may discover them incidentally during a pelvic exam or prenatal ultrasound.
What are uterine fibroids?
The size and location of the fibroids may also determine what symptoms occur. If the fibroids are located near the uterine lining or interfere with the blood flow to the lining, it can cause heavy periods, painful periods, prolonged periods, or spotting between menses. It can also cause pain during intercourse. Endometrium and submucosal fibroids are also a cause for miscarriages or infertility. If the fibroids push and distort the shape of the uterus, this can cause prolonged, frequent urination, as well as constipation and painful defecation if the fibroids are pressing on the back of the bladder or the rectum. Other symptoms of fibroids include abdominal fullness, anemia from heavy periods, and lower abdominal pain. Women who are obese or of African-American heritage also have a higher rate of fibroids.
Uterine fibroids are non-cancerous growths in the uterus that often appear during childbearing age. Also known as leiomyomas, these growths range in size from the size of a seed to a size of a small grape that can appear as singular growths or in clusters. The cause of fibroids has yet to be known, but studies have shown that hormones estrogen and progesterone play a role in their growth. When fibroids form, it is usually in the muscular wall of the uterus. This growth is not a rapid process and takes several years to develop. When fibroids start small and begin to grow, the symptoms may become evident. But some women have fibroids and never notice any symptoms at all during their entire lifetime.
Prevalence of uterine fibroids in Singapore
The prevalence of fibroids in Asian women living in Western countries is lower compared to those in their home countries and those who live in Asian countries. For example, studies have shown that the prevalence of fibroids in Japanese women living in Japan ranges from 30% to 70%, and from 3% to 10% in those undergoing surgery or imaging procedures, respectively. However, the prevalence of these women having fibroids drops to 20% and 7%, compared to 70% and 30%, for those living in the United States. This suggests that dietary and environmental factors may also influence the development and growth of fibroids. There are no specific studies on changes in prevalence rates for Singapore women who migrate to Western countries.
It is difficult to obtain accurate figures on the prevalence of uterine fibroids in Singapore because not all women with fibroids have symptoms or seek help, so they may remain undiagnosed. Also, there are no available figures on the incidence of fibroids in Singapore due to the absence of a reporting system for fibroid treatment or diagnosis. Consequently, no statistics are available on the number of women with fibroids. However, based on hospital admission rates for hysterectomy, it is estimated that 25% of women in Singapore have or have had fibroids.
Symptoms of uterine fibroids
Uterine fibroids are a common cause of heavy, painful periods in women. Uterine fibroids may cause any of the following symptoms: heavy or painful periods. The heavy periods may lead to anemia, a low red blood cell count, that sometimes requires treatment. Pain or feeling of pressure in the low back or legs. Occasionally, severe pain if the fibroids go through a degenerative process. This happens when the blood supply to the fibroids is decreased, causing pain and fever. This can be treated with medication and rest or, in rare cases, by embolisation or surgical intervention. Pressure on the bladder and bowel. Frequent urination, incontinence or difficulty emptying the bladder. Fibroids pressing on the rectum can cause constipation. Infertility. Inability to conceive or maintain a full-term pregnancy. If the fibroid obstructs the fallopian tubes or prevents the embryo from implanting, then it might cause infertility. Fibroids can be a cause of recurrent miscarriages. This can often be overcome with treatment. Fibroids should not be removed if they are not causing symptoms. If there is a small fibroid or a few fibroids on one side of the uterus, and it is the only cause of infertility, myomectomy is the treatment of choice. In vitro fertilisation is an alternative if the fallopian tubes are involved and is also an option for the infertile couple who do not want to pursue myomectomy.
Diagnosis and Evaluation
Medical history taking and a physical examination are the first steps to diagnosing uterine fibroids. During the medical history, the doctor may ask a woman to describe her symptoms in detail. It is important for the doctor to know the duration and severity of the symptoms, if the woman is pregnant or wants to become pregnant, what her menstrual periods are like, if she has used hormone medications, and if she has any other medical conditions. The doctor can diagnose fibroids during a pelvic examination. During a pelvic examination, the doctor will feel the size and shape of the uterus. If fibroids are suspected, an ultrasound is the most useful test to determine the number, location, and size of the fibroids. Ultrasound uses sound waves to create a picture of the uterus and is done on the outside of the abdomen or inside the vagina. If a woman has severe pain or abnormal bleeding and she is not planning to have more children, other tests may be done. Hysterosalpingography is a type of x-ray used to examine the inside of the uterus and fallopian tubes. It also can show if the fallopian tubes are blocked and is helpful in diagnosing the problem. Hysteroscopy and laparoscopy are minimally invasive surgical procedures that are used to diagnose and sometimes treat fibroids. Hysteroscopy uses a hysteroscope, a thin tube with a light, to look inside the uterus. Laparoscopy uses a laparoscope, a thin tube with a light, to look outside the uterus to the other pelvic organs. Both procedures are performed under general anesthesia and allow a direct look at the pelvic organs. They may be used if a woman is having infertility problems or recurrent miscarriages.
Medical history and physical examination
According to Dr. Kevin Elias, M.D., of the Fibroid Treatment Collective, patient history and physical examination are crucial in the diagnosis of fibroids and evaluation of female patients presenting with symptoms suggestive of fibroids. He reports that the key elements of the patient history involve obtaining a detailed account of symptoms and obtaining past medical and surgical history. Symptoms such as heavy or prolonged menstrual bleeding, pelvic pain or pressure, urinary or bowel symptoms, pain during intercourse, low back pain, and abdominal bloating are common in women with fibroids. It is also important to find out if there is a family history of fibroids. Detailed questions are asked to determine if symptoms are related to the zygosity of fibroids and to exclude other gynecological conditions and bleeding disorders. Dr. Elias goes on to say that the aim of the physical examination in the scenario of a patient with suspected fibroids is to detect evidence of an enlarged pelvic size or an irregularly shaped or enlarged non-pregnant uterus. A bimanual exam is performed to assess the size and shape of the uterus. This involves palpating the uterus between the two hands placed on the abdomen and in the vagina. Usually, this can give a fairly accurate indication of uterine size and if fibroids are present. A bimanual exam is a simple and non-invasive procedure, thus it is an important and useful step in the evaluation of the patient with suspected fibroids.
Imaging tests for diagnosing uterine fibroids
Transvaginal ultrasound provides a more clear picture of the reproductive organs including the uterus. Saline infusion sonography or hysterosonography involve the ultrasound being performed after the uterus is expanded with saline. This provides a clearer picture of the inside of the uterus. Sonohysterography uses a small device attached to the tip of a catheter, inserted into the vagina. The device then emits sound waves to generate images of the inside of the uterus. A CT scan is an x-ray commonly used to detect and monitor internal conditions. High resolution 3D images are produced of internal organs to display their shapes, sizes, and relative positions. MRI is often used to provide additional information about tumors located in body organs. An MRI ordered to evaluate fibroids would provide a precise locational map of the size and site of fibroids within the myometrium.
Imaging tests are regularly used to assist in diagnosing fibroids. Types of imaging tests include ultrasound, MRI, and a CT scan.
Blood tests to evaluate fibroid-related symptoms
A hormone test called 17-hydroxyprogesterone can help find the cause of high blood pressure and symptoms of androgen excess. A clinically useful blood test has not been developed for androstenedione, a weak hormone that can be overproduced in certain conditions. Another hormone called inhibin is overproduced by certain fibroids and may be the cause of other hormone-related symptoms and perhaps the growth of some fibroids. Inhibin can be measured by a relatively new blood test, but this test has not yet become widely available.
Analysis of a blood sample obtained in a doctor’s office is used to measure the amount of certain hormones that are made by the ovary and the adrenal gland. The changes in the amount of these hormones can change the menstrual cycle and can cause numerous symptoms such as bloating and pelvic pressure, pain with menstruation, and breast swelling and discomfort. In rare cases, these changes in hormone levels and anatomy can cause a type of kidney damage that results in high blood pressure.
Other diagnostic procedures
Magnetic resonance imaging (MRI). MRI is a noninvasive (no incision) medical test that helps physicians diagnose and treat medical conditions. MRI uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. MRI does not use ionizing radiation (x-rays).
Ultrasound. Ultrasonography, a simple, painless test that uses sound waves to create a picture of the internal organs, is often the first test used to view the uterus because it is widely available and involves no exposure to radiation. Transvaginal ultrasound, in which the ultrasound transducer is inserted into the vagina, is a type of ultrasound that may be helpful in diagnosing fibroids.
If the patient’s symptoms are typical of fibroids and a pelvic examination confirms the diagnosis, further imaging tests may not be necessary. Occasionally, however, fibroids are hidden within the uterine wall or beneath its outer surface, and these may be more difficult to detect. Therefore, various types of imaging studies may be recommended.
Treatment Options
The following medications are used in fibroids treatment Singapore: – Oral contraceptives: reduce the heavy menstrual bleeding and painful periods associated with fibroids. – Progestins: can also be effective in reducing heavy menstrual bleeding. – GnRH agonists: can shrink fibroids, however they have several side effects and are usually used short-term to shrink fibroids before surgery. – Tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs): can be used alone or in conjunction with hormonal medication to help reduce heavy menstrual bleeding.
Medications for managing uterine fibroids Medication can be effective in controlling the symptoms of fibroids; however, it is important to remember that medication alone cannot cure fibroids. Furthermore, the reduction in the size of the fibroids brought about by medication is generally temporary, meaning that continuation of medication is usually not a long-term option.
Medications for managing uterine fibroids
Tranexamic acid is the cheapest medication of the above, and simple reductions in menstrual bleeding and pain can occur with improvement in hemoglobin levels in the blood. However, the reduction in fibroid size is not sustained once the drug is stopped. The contraceptive pill is generally well tolerated and is the choice for women who prefer not to take iron supplementation; however, the fibroids often start to grow again once the pill is stopped. Mini-coil is often used in women who have a small fibroid distorting the uterine cavity and wish to avoid surgery. Gonadotrophin releasing hormone analogue (GnRHa) is a type of injection that induces a state of temporary menopause. This stops menstrual periods and causes the fibroids to shrink. It is used in cases of severe symptoms such as anemia due to heavy periods. Common side effects are due to the low hormone levels and can cause symptoms that are similar to menopause. This can result in bone thinning (osteoporosis) if used long term; hence, it is often used as a temporizing measure before surgery. The fibroids usually grow back to their original size once the injections are stopped.
In general, medications for managing fibroids can be divided into two broad categories – hormonal and non-hormonal. Hormonal medications work by changing hormone levels, which in turn reduces the size of the fibroids and the associated heavy menstrual bleeding and/or menstrual pain. These medications can be in the form of a contraceptive pill, a gonadotrophin releasing hormone analogue (GnRHa), or a progesterone-releasing intrauterine device (IUD). Non-hormonal medication is usually in the form of tranexamic acid, which is a medication that reduces heavy menstrual bleeding and pain. It can be used alone or in combination with hormonal medication. The type of medication prescribed will depend on the symptoms experienced by each individual patient, taking into consideration factors such as desire for fertility and potential side effects of the medication.
Minimally invasive procedures
Uterine Artery Embolization (UAE) This is a technique used to block the blood supply to the fibroid, causing it to shrink and die. The procedure is carried out by an interventional radiologist, rather than a surgeon. A thin, flexible tube is threaded through an artery in the groin into the blood vessels that supply the fibroid. The procedure is guided by the use of a moving X-ray image. When the tube is in place, small plastic particles are injected into the blood vessel. These particles block the blood supply to the fibroid, starving it of nutrients.
Minimally invasive procedures can be carried out to destroy the fibroids without actually removing them. The great advantage of these procedures is that they are minimal surgical procedures. They are generally performed as outpatient procedures and involve a much quicker recovery than the surgical approaches. The techniques can effectively decrease fibroid-related symptoms in 80% to 90% of women but may not improve fertility. It is very important to discuss the treatment and your expectations with your gynecologist.
Surgical interventions for fibroid removal
Comparing to hysterectomy, myomectomy is a less invasive conservative surgical method to remove fibroids and preserve the uterus. Changes in the woman’s menstrual bleeding are the best indicator of treatment failure for heavy menstrual bleeding. Women with very heavy menstrual bleeding may experience slower resolution of this symptom. Anemia status should also be assessed during the follow-up period. Any recurrence of severe or sudden onset of symptoms warrants prompt additional assessment. This sort of treatment helps to reserve the opportunity of future conception for a woman. So myomectomy is best practiced using a minimally invasive surgical approach. This method can help to diminish problems associated with fibroids like abnormal uterine bleeding and pelvic pain.
Surgical approaches used to treat uterine fibroids include hysterectomy, myomectomy, hysteroscopic resection, and MRI-guided percutaneous laser ablation and MRI-guided focused ultrasound. Hysterectomy (surgical removal of the uterus) remains the only proven permanent solution for uterine fibroids. It is also the most radical. Potential side effects from future pregnancy also are a consideration. Women must take mifepristone once a day for three months, starting menstruation during the third month, and having a bone density test within two weeks after the last dose. Women should also use effective contraception during treatment. After having surgery, women should have a follow-up visit. The decision about a second course of mifepristone therapy should depend on the extent of symptom relief, the woman’s desire to have additional therapy, and her satisfaction with not having found a reversible medical alternative to surgery. This study helps to avoid and streamline development of treatment procedures for women with symptomatic fibroids.
It is important to be fully informed and educated about several possible treatment options for this condition, and how each may impact other gynecological conditions or childbearing potential, before making a decision to use one therapy over another.
Alternative and complementary therapies
In approaching the management of fibroids, whether with conventional or alternative methods, it is useful to use a systematic approach and the Four Step Plan is a sensible one to follow. This plan was developed by a doctor and fibroid patient who was frustrated with the lack of clear guidance about managing fibroids. This method is aimed at stopping the growth of fibroids, shrinking them and relieving symptoms, as well as preventing re-growth and it can be applied when using alternative methods. The first step is to reduce the amount of estrogen in the body, as this hormone stimulates fibroid growth. This can be achieved by eating organic foods wherever possible, as well as avoiding exposure to environmental estrogens such as hormone-meat and plastics. Weight loss can be effective in reducing estrogen levels, and it is known that fat cells store estrogen, so the more overweight a person is, the higher their estrogen levels are likely to be. The second step is to make changes to your diet and this is a very important part of the Plan. Eating the right kinds of foods can affect the production of estrogen and the way it is metabolized in the body. The third step is to try and relieve the symptoms of fibroids and there are many ways that this can be achieved. The final step is to visit a medical practitioner who is experienced in treating women with fibroids and who can outline the different conventional and alternative treatment options, considering the specifics of each case. He or she can monitor the progression of the fibroids and symptoms and any changes to diet and lifestyle, helping to determine the effectiveness of alternative treatment methods.
The use of alternative and complementary therapies in treating fibroids has been steadily gaining in popularity over the past decade, as patients look for effective and safe methods of managing their fibroids and avoiding surgery. These treatments are often used in combination with more traditional therapies, and their effects are difficult to measure, as many patients report feeling better overall, rather than specifically feeling an improvement in their fibroid symptoms. The overall aim with the use of holistic methods is to boost the overall health and resistance of the patient, both physically and emotionally.
Post-Treatment Care and Support
Following treatment for fibroids, you may be asked to refrain from heavy lifting or intense exercise for a period of time. This will allow your body to recover from the effects of the procedure. If you have had a UAE or myomectomy, your doctor may recommend an ultrasound scan (MRI) 6-12 months after your treatment to ascertain how successful it has been. If you have had a myomectomy or hysterectomy, we recommend you try our scar minimization therapy program to reduce visibility of scarring in the safest possible way. If you have had a myomectomy or hysterectomy, we do not recommend that you undertake physiotherapy until after your post-operative consultation. Due to the wide variety of reconstruction in myomectomy and hysterectomy patients, undergoing physiotherapy at an early stage may impair your long-term recovery. Following a myomectomy or hysterectomy, it is common to experience swelling in the abdominal region due to the nature of the surgery. Our chartered physiotherapists can ensure that you are receiving the best form of treatment in the case of swelling, where the session will include a full assessment, followed by appropriate treatment in whichever form the physiotherapist feels is necessary.
Recovery after fibroid treatment
Another factor that may influence a woman’s recovery after fibroid treatment is her fertility desires. Women who wish to become pregnant following their fibroid treatment need to be aware of how long they should wait before attempting to conceive and what possible effects their treatment may have on their ability to have children. This topic will be discussed under fertility and pregnancy implications of fibroid treatments in a later section.
It is normal to experience menopausal symptoms such as hot flashes, decreased libido, and vaginal dryness for several weeks after UFE. Additionally, patients may experience pain and swelling in the incision areas for several days after a laparoscopic treatment and may have a small amount of bloody discharge for up to 2 weeks. Women who have had myomectomy are especially at risk of uterine infection in the weeks following the surgery, so patients should receive instructions regarding what symptoms may indicate a problem with the recovery. On average, patients will have a significant reduction in symptoms and increased quality of life within the first three months after UFE.
After treatment, recovery time may range from a few days to a few weeks depending on the type of treatment received. For example, myomectomy patients may require 4-6 weeks of recovery, whereas UFE patients may require 1-2 weeks. Patients are generally prescribed pain medication and told to rest for several days.
Lifestyle modifications for managing fibroids
The same impact could also be put into design form of a chart. Dietician and Bikram yoga teacher Robin Downes from Santa Monica, California expressed that there were certain yoga poses which could be beneficial towards fibroid symptoms. This information could also be incorporated into a lifestyle education program.
Healthy diet Dr. Lauren A. Wise, ScD, a Boston University associate professor of epidemiology, advised that there needed to be more research specifically geared towards finding ways in lowering hormone levels in order to have an impact on fibroid prevention. She led a follow-up study to her research in July 2011 focusing on dietary patterns and the risk of developing uterine fibroids. During the 14-year period of studying, 22,583 African American women who lived in 11 US states, aged from 23-42 years, were registered into the US Black Women’s Health Study. Dr. Wise and her team were able to conclude from the results that higher consumption of fruit and cruciferous vegetables was associated with a lower risk of developing fibroids: “Our study suggests that uterine fibroids can now be added to the list of conditions for which diet might be an important modifiable risk factor.”
A study at Boston University School of Public Health in May 2010 suggested that there were certain risk factors that contributed to an African-American woman’s increased likelihood in developing fibroids due to stress. Genial Scientist discovered in July 2010 that genetics did play a part in an African-American woman’s likelihood in developing fibroids. A team, led by Dr. Ayman Al-Hendy, M.D., Ph.D., analyzed the genes of uterine fibroids in 23 African-American women and compared them to the genes of fibroids in 32 Caucasian women. He stated that “In this study, the first of its kind, we found these growths to be more genetically diverse in black women, a possible explanation for their higher risk of developing fibroids.”
Support groups and resources for fibroid patients
Another excellent resource for fibroid patients in search of a solace is the Internet. There are several websites with information about fibroids and treatments. Some internet sites even have chat rooms or message boards for women to post questions and offer support to one another. An example of one such site can be found at obgyn.net/fibroids. This site offers information about fibroids and treatment options and has a chat room for women to discuss their concerns. At a similar website, ivillage.com, women can find information about fibroids and can join a discussion group about fibroids. The option to converse with others and share personal stories can be very helpful to women who feel isolated in their experience.
Women undergoing treatment for fibroids may find consolation in speaking to other women who have undergone similar treatments. Some hospitals provide support groups for women undergoing treatment. A social worker or therapist may also help women cope with emotional stress that fibroids and treatment may bring.
