Uterine fibroids are benign, non-cancerous growths of the muscle and connective tissue in the uterus. They develop from the smooth muscle tissue of the uterus, hence the name “fibroid.” The size, shape, and location of fibroids can vary greatly. Uterine fibroids are quite common and usually cause no symptoms, however, the prevalence and symptoms are such that they are assigned their own clinical category. Fibroids can cause a number of symptoms including abnormal uterine bleeding, heavy or painful periods, cramping, bloating, backache, and in some cases infertility. In extreme cases of fibroids, a female may require a hysterectomy. The many symptoms of fibroids suggest that the size and location of the fibroids is what determines whether or not they will cause symptoms. However, this is not entirely true. It is now thought that the symptoms result from the fibroids interfering with the normal function of the uterus as it prepares for menstruation. At this time, the uterus should decrease in size and so should the fibroids. However, they can grow in response to the hormones present during this time. This can lead to a temporary stop in the growth of the fibroids if a woman is at a time in which she has low hormone levels (postmenopausal) or hormonal therapy to decrease the hormone levels.
What are uterine fibroids?
In general, fibroids cause no problems. In fact, you can have fibroids and not realize it. They sometimes shrink on their own, often when a woman reaches menopause. On the other hand, some women with fibroids can experience: – Heavy bleeding (which can be heavy enough to cause anemia) or painful periods. – Feeling of fullness in the pelvic area (lower stomach). – Enlargement of the lower abdomen. – Frequent urination. – Pain during sex. – Lower back pain. – Complications during pregnancy and labor.
It’s unclear why fibroids develop, but several factors may influence their formation: – Hormones: Estrogen and progesterone are the hormones produced by the ovaries. They cause the uterine lining to regenerate during each menstrual cycle and may stimulate the growth of fibroids. – Family history: Fibroids may run in the family. If your mother, sister, or grandmother has a history of fibroids, you’re at increased risk of developing them. – Pregnancy: Pregnancy increases the production of estrogen and progesterone in your body. Fibroids may develop and grow rapidly while you’re pregnant.
Uterine fibroids are non-cancerous growths of the uterus that often appear during 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 never know it because fibroids don’t always cause symptoms. Your doctor may find fibroids incidentally during a pelvic exam or prenatal ultrasound.
Prevalence of uterine fibroids in Singapore
The study also found that women who have had at least one live birth are at a decreased chance of developing fibroid singapore and that physical activity and education level do not appear to have any impact on fibroid prevalence. Fibroids are more commonly found in women with higher BMI and in women who consume a greater amount of red meat. In contrast, women who consume a vegetarian diet, more dairy products, fruit and green leafy vegetables are less likely to develop fibroids. Other lifestyle factors associated with fibroid prevalence are alcohol consumption and coffee or tea intake. Women who consume alcohol have a 50% increased chance of developing fibroids and those who drink coffee are at a 10% decreased risk.
A study to determine the prevalence of fibroids in Singapore was carried out by the Singapore General Hospital involving 997 women between 2000 and 2004. It was found that the prevalence of fibroids increases as women become older and the overall prevalence in all ethnic groups was 19.7%. The highest prevalence was noted in Indian women at 25.4%, followed by the Chinese at 22.8% and Malays at 14.8%.
Uterine fibroids are the most common gynecological condition experienced by Singaporean women and present an important public healthcare issue. It is estimated that about 25% of women of reproductive age had uterine fibroids detected using ultrasound, increasing to around 30-40% on closer inspection of the uterus during their lifetime. The condition appears to be more prevalent in the Chinese and Indian ethnic groups compared to Malays.
Common symptoms of uterine fibroids
Uterine fibroids are benign growths of the uterus that often result in the formation of a tumor. Uterine fibroids are the most common type of tumor and occur in about 20% of women over the age of 35. It is also more common in African Americans than Caucasians. However, in general, it is rare in women under the age of 20 and most often occurs in women in their 30s and 40s. While some women do not show any symptoms of fibroids, other women experience more severe symptoms. In general, the severity of the symptoms often depends on the location of the fibroids. Some common symptoms include heavy or prolonged menstrual periods, abnormal bleeding between menstrual periods, anemia, heaviness or pressure in the pelvis, pain in the lower back or upper thighs, and reproductive problems like infertility or multiple miscarriages. Some women with uterine fibroids may also have problems during pregnancy. Fibroids are also known to cause complications during labor and may increase the risk of cesarean delivery. Having multiples or large fibroids can cause the uterus to become oversized and thus can actually block the birth of the baby. Fibroids located on the outer surface of the uterus or at the cervix can also cause the fetus to be in a breech position or cause pain while having vaginal labor.
Diagnosis and Treatment Options
A variety of methods are used to diagnose fibroids. Because all these methods have their limitations, usually more than one is used to confirm a diagnosis. The usual first step for diagnosing fibroids is an ultrasound. This is usually done abdominally, but for a more detailed look at the uterus, a transvaginal ultrasound should be done. This method uses soundwaves to get a picture of the uterus and is very effective. Another way to diagnose fibroids is an MRI scan. This is usually used when the doctor needs more information about the fibroids to decide on a treatment. MRI scans are very accurate in locating fibroids and the type of fibroid can be identified. Although fibroids can be detected using these methods, they are not always the best way to confirm diagnosis. Often, fibroids are confused with ovarian growths. Usually the only way to know for sure if a growth is a fibroid is to have it removed and looked at by a pathologist, but obviously this is not the best option. If the fibroids are causing severe symptoms, there are now a number of effective treatments available. Choice of treatment will depend on your age, the severity of the symptoms, whether you wish to have children in the future, and the type of fibroid or fibroids you have.
Diagnostic methods for uterine fibroids
The most common current methods of diagnosis are through pelvic examination or ultrasound. For the most part, ultrasound is the most effective means of diagnosing fibroids. It will show the uterus’s internal structure and any fibroids present, their size and location. If the ultrasound is inconclusive, the MRI (magnetic resonance imaging) is the best suited to give more detail. It’s important to see a doctor who specializes in gynecology to ensure an accurate diagnosis as fibroids can be mistaken for other conditions. For small or mildly symptomatic fibroids, sometimes it may be best to not treat the fibroids at all, occasionally they will regress and the patient can be treated symptomatically. If the fibroids are large and symptomatic there are a variety of methods to now remove them. The simplest is a myomectomy, which is the surgical removal of the fibroids only. The fibroids are removed leaving the healthy uterine tissue in place and is best suited to women who wish to retain fertility. It can be performed through a number of surgical methods such as open surgery of varying types, “key-hole” (laparoscopic) surgery or more recently robotic surgery. Hysterectomy is the surgical removal of the entire uterus and is the only certain cure for uterine fibroids. This will of course cease menstruation and as it is major surgery with major implications and should only be considered if there are no other options.
Medical management of uterine fibroids
Gonadotropin releasing hormone (GnRH) agonists include injections or nasal sprays. These medications cause temporary cessation of the menstrual cycle. Due to the low hormone state, fibroids often decrease in size, and once the medication is stopped, the menstrual cycle resumes and fibroids usually return to their original size. Side effects of GnRH agonists can be severe and are similar to what women experience when they are menopausal. They are useful to tide a woman over to menopause if she is near that time or for women with anemia due to fibroids. This is because the medications can improve iron levels. If these medications are to be used in the long term, low dose hormone add back therapy can decrease side effects and offset bone loss. This medication comes in the form of an injection and is given once a month. Fibroids grow in response to hormones, especially estrogen. Therefore, medications that decrease estrogen may decrease fibroid growth. These medications include a progestin-releasing IUD or tranexamic acid. A progestin-releasing IUD can decrease heavy menstrual flow and does not affect fertility. Tranexamic acid is non-hormonal and is a tablet taken only during the menstrual cycle to decrease heavy flow. It is useful for women who wish to maintain fertility.
Surgical options for uterine fibroids
The type of surgery that is best for you will depend on the size, number, and location of your fibroids. If the fibroids are large, a lot of fluid may be absorbed during the procedure, and this can leave you dehydrated. Let your doctor know if you have ever had a reaction to any contrast materials used for x-rays. You may need to be tested before the procedure. If you are taking any medications, the doctor will decide if you need to stop taking them before the procedure. This can depend on the medications and your general health. Do not start taking any new medications, herbal preparations, or vitamin supplements without asking your doctor.
Women who have no symptoms or whose fibroids are small and not causing any problems may not need any treatment at all. Uterine fibroids that are causing problems can be treated in a number of ways. Talk to your doctor about the best way to treat your fibroids. This will depend on the size and location of the fibroids, the symptoms they are causing, and your desire to have children in the future.
Uterine Fibroid Embolization (UFE) in Singapore
At the current time, it is difficult to provide data on the exact number of women in Singapore who have had this treatment. The Singapore public hospitals provided this service to about 100 women per year, and it is likely that the numbers of patients treated in private hospitals are higher. At present, this number is likely to be underrepresented given that UFE is not a registered procedure and up till recently, was not included in the Singapore Medical Procedures Fees Schedule.
At the moment, there are at least 6 hospitals or medical institutions offering UFE Singapore. This includes National University Hospital, Singapore General Hospital, KK Women’s and Children’s Hospital, Raffles Hospital, and Mount Elizabeth Orchard and Novena. It is likely that this procedure will be more widely available in the future, with more doctors being trained to perform the procedure and new private medical institutions opening in Singapore.
Uterine fibroid embolization (UFE) is a minimally invasive treatment for fibroid tumors of the uterus. The procedure is also sometimes referred to as Uterine Artery Embolization (UAE). UFE has been performed in Singapore since 2000. National University Hospital was the first center to offer this treatment, with Singapore General Hospital starting their service in 2003. Since then, the service has been offered in several other private hospitals. The doctors who perform this procedure come from various specialties including radiology, obstetrics and gynaecology, and even family medicine. The amount of experience in doing this procedure can vary greatly. Different centers may offer dissimilar advice on the suitability of this treatment for the patient, and specific details on the procedure itself can depend on the doctor who does it.
Uterine Fibroid Embolization (UFE)
Uterine fibroid embolization (UFE) is the newest minimally invasive treatment alternative for women with uterine fibroids. UFE is performed by an interventional radiologist, a physician who is trained to perform this and other types of embolization and minimally invasive procedures. Interventional radiologists use MRIs to determine if a fibroid can be embolized, and to determine which blood vessels to occlude. UFE is performed in a hospital or outpatient setting, and generally takes between 1-3 hours. Using real-time x-ray, the physician will make a tiny nick in the skin in the groin and insert a catheter into the femoral artery. She or he will then guide the catheter into the uterine arteries and release tiny particles, the size of grains of sand, into the blood vessels that supply the fibroid. This blocks the blood flow to the fibroid and causes it to shrink and die.
What is UFE?
Uterine fibroid embolization (UFE) is a way of treating fibroids without surgery. Interventional radiologists (doctors who specialize in image-guided treatments) carry out UFE, which is also known as uterine artery embolization (UAE). The procedure occludes the blood vessels that supply the fibroids, causing them to shrink over time. UFE is done in the X-ray department of a hospital. It is carried out under local anesthesia by numbing the skin and then putting a needle into the artery in your right groin and injecting some contrast medium. An X-ray is taken to show the blood vessels that supply the fibroids and a small catheter is then passed into these vessels. Tiny plastic particles are injected through the catheter into the blood vessels that supply the fibroids. The particles block the blood flow to the fibroids, which over time causes them to shrink. This process is then repeated through the left groin. The procedure takes about 35 to 40 minutes and usually involves an overnight stay in the hospital. Fibroids are very sensitive to hormones (e.g. estrogen) and usually grow when hormone levels are high, such as during pregnancy or when taking hormone replacement therapy (HRT). Because UFE does not destroy the uterus, it is possible for women to become pregnant after the procedure. However, it is not known what the effects of the procedure are on fertility and pregnancy. Due to the risk involved, women who may want to become pregnant in the future are advised to try other treatments.
How does UFE work?
The procedure is typically performed while the patient is conscious, but sedated, drowsy, and feeling minimal discomfort. This is because the patient needs to be able to follow the breathing instructions during the procedure. Firstly, a small catheter is inserted into the femoral artery at the crease of the groin. Using real-time x-ray, the interventional radiologist will guide the catheter to the uterine arteries. These are then blocked using tiny particles known as embolic agents. These particles block the blood vessels that feed the fibroids and cause them to starve and die. With the fibroids being cut off from their blood supply, they will begin to shrink and the symptoms that they cause will start to improve. The embolic agents continue to be effective in the blood vessels for 12-24 hours, so it is common to experience moderate to severe cramping during this time, and it is essential to be adequately medicated with painkillers. The groin puncture site is usually closed either by using a closure device or with manual compression. UFE is not an inpatient procedure, and usually an overnight stay at the hospital is not required, after which the recovery period usually lasts 7-10 days.
Benefits and risks of UFE
As UFE is a less invasive treatment than surgical alternatives, it is associated with fewer complications and shorter recovery times. The risk of major complications from UFE is less than 5 percent. Minor complications, such as post-embolization syndrome, occur less than 10 percent of the time and are managed easily with medication. The nature and rate of complications are comparable to those of myomectomy.
The potential for recurrent fibroids is not eliminated with UFE. Approximately 20 percent of women who have UFE will require a second procedure or a subsequent surgery for recurrent fibroids or persistent symptoms. For this reason, UFE is often discussed as an alternative to hysterectomy, rather than a procedure that eliminates the need for any future treatment of fibroids.
In addition to being substantially less invasive than surgical approaches to fibroid treatment, UFE allows for preservation of the uterus.
The benefits of UFE are numerous. For the majority of women with symptomatic uterine fibroids, UFE effectively improves or resolves related symptoms, including heavy menstrual bleeding, menorrhagia, and abdominal swelling and pressure. Clinical experience and studies have demonstrated that 85 to 90 percent of patients who undergo UFE experience significant reduction in symptoms within a few months.
UFE procedure in Singapore
Uterine fibroids are extremely common. They develop in about half of all women, most commonly between the ages of 35 and 45. Despite the availability of newer UFE procedure, many women in Singapore with symptomatic fibroids are still being advised to undergo hysterectomy. Some gynaecologists are unaware of UFE; others are familiar with UFE but have misconceptions about its safety and effectiveness, or the indications for its use. As a consequence, there are comparatively few UFE procedures being performed in Singapore. It is important for women to be aware of all treatment options for fibroids, including newer and less invasive treatments such as UFE. Given that UFE is safe, effective and has a quick recovery time compared to hysterectomy, it is not acceptable for the gynaecologist’s personal bias to unduly influence a patient’s decision about the choice of treatment for fibroids.
Choosing the Right Treatment Option
Information Background: Uterine fibroids affect 20-25% of women of reproductive age. There are many options available for the treatment of fibroids. Each treatment has its own risks and benefits. Some of the treatment options are aimed at providing symptomatic relief, others improve fertility, and some do both. Symptomatic relief is usually aimed at decreasing heavy menstrual periods and pelvic pain. There are surgical and medical options, some use a combination of both. Some are more effective than others. It is difficult to decide which treatment is right for you. You need to take into consideration your age, the severity of your symptoms, the size and location of your fibroids, future childbearing plans, and how the treatment may affect your life. This article is directed at the very common scenario of a woman in her thirties with a strong desire to maintain her uterus and a future fertility potential. This article mainly discusses the nonsurgical option of UAE and the surgical option of myomectomy.
Factors to consider when choosing a treatment
The age of the patient is an important consideration, particularly for women with infertility issues. If a woman is approaching menopause, it may be preferable to do nothing, particularly if the symptoms are mild or will resolve once the fibroids decrease in size. Women with severe symptoms close to menopause may opt for a hysterectomy. This can be performed in conjunction with an oophorectomy in postmenopausal women to prevent the need for a further procedure if adnexal masses are discovered to be the cause of persisting symptoms.
The management choices available to women largely depend upon the symptomatology rather than the fibroid itself. It is important, therefore, for a woman to consider how much the symptoms are affecting her quality of life. This will also determine how invasive a treatment she is willing to consider. Medical therapies are good for women with mild symptoms but, as discussed earlier, can only be used short-term. Some women may have particular fertility concerns.
Selection of a suitable treatment is of utmost importance for women contemplating the management of fibroids. There are a number of factors to be considered when choosing a treatment and it should be realized that in many cases the final decision will be made by the woman and her gynecologist after a comprehensive discussion of the options available.
Comparing UFE with other treatment options
Medical treatments to control symptoms. There are three types of medication that can be used to help relieve some fibroid symptoms. Gonadotropin releasing hormone (GnRH) agonists, such as leuprolide or nafarelin, cause a temporary menopause and may reduce the size and number of fibroids and thus be used preoperatively to make surgery easier. Unfortunately, fibroids usually regrow on cessation of these drugs. Hormonal treatments such as oral contraceptives or progestins can provide symptom relief. Non-hormonal options include tranexamic acid or nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce heavy menstrual bleeding. However, none of these treatments are a cure for fibroids, and usually the symptoms will return if the treatment is stopped.
Expectant management (watchful waiting) in which the woman makes no specific intervention, but has regular monitoring to assess for any symptoms or changes. This treatment is often recommended for women with few or no symptoms, or those nearing menopause. Asymptomatic fibroids will not require any specific treatment. However, if symptoms are due to the fibroids, and these are having a major impact on daily life, it is not correct to assume that symptom severity will not worsen. Data is lacking on how fibroids change in size and number over time, either independently or in response to hormonal treatments.
Before making a decision about treatment, a woman with fibroids should discuss thoroughly with her gynecologist the following treatment options, including the expected results, potential risks and benefits, and impact on fertility.
Consultation and decision-making process
Following the receipt of a diagnosis, patients face crucial decisions regarding the management of their symptoms. After a careful explanation of uterine fibroids and the treatment options, their values and preferences should influence the decision-making process. Because uterine fibroids are the number one cause of hysterectomy, a major surgical procedure, much of the research has focused on comparing the newer minimally invasive treatments to hysterectomy. This is a critical area for shared decision-making; while there are many factors which influence treatment decisions, the degree of invasiveness of the treatment and preservation of the uterus are often important considerations. Older women whose family is complete may be satisfied with hysterectomy while younger women often wish to avoid this procedure. The same is true for women with large fibroids. Although the more invasive surgical treatments may be evaluated for women with large fibroids, many will elect to undergo a series of GnRH agonist injections to shrink the fibroids, making them more amenable to a less invasive therapy. Stepwise iterative approaches involving patients in decision-making processes which carefully explain the clinical evidence and integrate the values of patients into the final decision have been shown to build greater consensus between physicians and patients.
