Everything you need to know about fibroids and fertility

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As many as three in four women will have fibroids at some point in their lives.

Medically reviewed by Dr Roger Henderson and words by Annie Hayes

Fibroids are non-cancerous tumours that grow inside or outside of the womb. They’re incredibly common – in fact, as many as three in four women will have fibroids at some point in their lives, though only half will know they have them, because they are often symptomless.

Dr Deborah Lee of Dr Fox Online Pharmacy and Pandelis Athanasias, consultant obstetrician and gynaecologist at The Medical Chambers Kensington, share their expert insight about the signs, potential symptoms and treatment of fibroids:

What are fibroids?

Fibroids are abnormal growths in or on a woman’s uterus made from lumps of enlarged tissue. They vary greatly in size, from just a few millimetres in diameter to 20cm or even larger, says Dr Lee, and are generally pale, pink or red, and rubbery.

Although fibroids can be solitary, they are often found in multiple numbers. They may be located at different positions within the uterus, described as:

  • Intramural: the most common type of fibroids, they appear within the wall of the uterus. They may grow larger and stretch the womb.
  • Subserosal:these fibroids are located on the outer surface of the uterus, called the serosa. They can grow large enough to make your womb appear bigger on one side.
  • Submucosal:these types of fibroids develop in the middle muscle layer, or myometrium, of your uterus.
  • Pedunculated: these fibroids occur when subserosal fibroids develop a stem.

In most cases, fibroids cause no signs or symptoms at all. However, sometimes they become large and cause severe abdominal pain and heavy periods. Generally, they are benign or non-cancerous.

What causes fibroids?

The uterus is made up of smooth muscle cells, collectively known as the myometrium, Dr Lee explains. ‘Like all the other cells in your body, myometrial cells are constantly undergoing cellular repair,’ she says. ‘Fibroids are thought to occur when something goes wrong with this process.’

While we can’t say for sure what causes fibroids, they seem to be dependent on oestrogen and progesterone; hormones produced by the ovaries. ‘Levels of oestrogen are low until the onset of periods, and there are no reports of fibroids occurring before puberty,’ says Dr Lee. ‘Fibroids are more common in women who have had higher exposure to oestrogen.’

Fibroids are abnormal growths in or on a woman’s uterus made from lumps of enlarged tissue.

This includes women who started their periods early, then had a late menopause; women who are nulliparous – which means they have not had any pregnancies – and women who are obese, since oestrogen is produced in adipose tissue.

Lifestyle factors also influence the development of fibroids, including a lack of exercise, stress, drinking alcohol, high blood pressure and diabetes. Diet plays a part, specifically:

  • Citrus fruit:studies link a lower incidence of fibroids to a higher intake of citrus fruits.
  • Red meat:studies link an increased risk of fibroids to a diet high in red meat.
  • Vitamins:low levels of vitamins A and D are known to increase the risk of fibroids.
  • Dairy:a diet rich in calcium and phosphorus reduces the risk of fibroids.
  • Soy:fibroids are less common in women who eat a diet rich in soy protein, which contain large quantities of isoflavones.

Additionally, there appears to be a genetic link, as fibroids tend to run in the family. Black women suffer disproportionately from fibroids and are three to five times more likely to develop them than white women. Pregnancy also increases the production of oestrogen and progesterone in your body, so fibroids may be more likely to develop while you’re pregnant.

Fibroids symptoms

Most of the time fibroids cause no symptoms at all. If you do experience symptoms, they will vary depending on the number of fibroids you have, their location and also their size. Common symptoms include:

  • Heavy periods
  • Heavy bleeding between periods
  • Abdominal, pelvic and lower back pain
  • Increased urination
  • Increased menstrual cramps
  • Pain during sex
  • Abdominal swelling
  • Anaemia

It can be difficult for the doctor to ascertain whether they’re due to the fibroids or something else entirely, says Dr Lee. ‘In fact, only 20 to 50 per cent of fibroids are thought to result in symptoms.’

Fibroids diagnosis

How are fibroids diagnosed? There are three main ways to diagnose fibroids: a transvaginal ultrasound scan (TVU), a hysteroscopy, and Magnetic Resonance Imaging (MRI).

Transvaginal ultrasound scan (TVU)

This is the easiest way to look for fibroids, says Dr Lee. ‘The ultrasound probe is inserted gently into the vagina and angled appropriately to get good views of the uterus, ovaries, and fallopian tubes,’ she explains. ‘TVU is uncomfortable, but not usually painful, and is done as an outpatient. The fibroids can be identified and measured.’

Hysteroscopy

A hysteroscope is a long, thin, flexible telescope containing a camera. It’s passed through the cervix, the lower portion of the uterus, and up inside the uterine cavity, Dr Lee explains. ‘A hysteroscopy can be done under a local anaesthetic as an outpatient procedure,’ she says. ‘The lining of the uterine cavity, the endometrium, can be directly visualised, and biopsies can be taken. Fibroids can also be treated using a hysteroscope, by passing instruments through the scope itself, and into the uterine cavity.’

Magnetic Resonance Imaging (MRI)

This is a specialised scan using radio and magnetic waves, which can be used to get detailed images of the pelvic organs, says Dr Lee. ‘It can be especially useful to localise fibroids before treatment and to rule out the rare finding of a leiomyosarcoma – a cancer of smooth muscle,’ she says. ‘It is painless and done as an outpatient.’

If you have other symptoms, such as heavy menstrual bleeding, your doctor will organise a range of tests for you. ‘These will include blood tests, such as a full blood count to exclude anaemia, as well as a scan,’ says Dr Lee. ‘You should also have a pregnancy test.’

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Do fibroids affect fertility?

Fibroids can affect fertility and can also cause miscarriages, says Athanasias. ‘If you are dealing with submucosal fibroids, which distort the lining of the womb, then this can affect fertility. If you have previously had miscarriages, your consultant will advise surgical removal. If your fibroid is inside the intermuria muscle, then it depends on the size.’

Small fibroids here may not be an issue, but larger ones can make it hard to conceive, he says. In this instance, your doctor would seriously consider removal. However, ‘every patient is different, and therefore your consultant should work closely with your fertility specialist to decide upon the best approach for you,’ Athanasias adds.

Fibroids treatment

How are fibroids treated? Fibroids treatment depends on factors such as your age, the severity of symptoms, and the need to preserve fertility, says Dr Lee. ‘It also depends on the size and number of fibroids, and where they are sited,’ she says.

Fibroids may not need treatment at all if they’re small, don’t produce symptoms, or if you’re going through menopause. This is because fibroids naturally shrink during this time due to a drop in oestrogen and progesterone levels.

Lifestyle changes to treat fibroids

Since lifestyle factors also influence the development of fibroids, they can also help relieve them. Exercising more, reducing stress levels and managing your diet can all go a long way towards relieving symptoms. Following a Mediterranean diet with plenty of fruits, green vegetables, and fatty fish such as salmon, tuna, and mackerel may help. Avoiding red meat and alcohol, and losing weight if you are overweight, is also advised.

Medications to treat fibroids

Your doctor may prescribe medication to regulate your hormone levels and therefore shrink the fibroids. There are several varieties that do this via different mechanisms:

  • Gonadotropin-releasing hormone (GnRH) agonists, which causes your oestrogen and progesterone levels to drop.
  • GnRH antagonists,which halt production of the reproductive hormones follicle-stimulating hormone (FSH) and luteinising hormone (LH).
  • Selective progesterone receptor modulators (SPRMs),which block progesterone receptors.

Other medications can help to alleviate the symptoms of fibroids, including bleeding and pain – though it’s important to note that they don’t shrink the growths. These include:

  • Hormonal contraception:‘This can be highly effective at treating heavy menstrual bleeding,’ says Dr Lee. ‘The combined pill is well known to reduce the frequency and severity of menstrual bleeding. Nowadays, women may also be offered the contraceptive patch or the vaginal ring. The pill, the patch and ring are combined hormonal contraceptive (CHC) methods with a very similar mode of action.’
  • Intrauterine device (IUD): ‘This is an intrauterine device – a coil – which does not contain copper, but the core of the device contains progesterone,’ says Dr Lee. ‘Once inserted into the uterine cavity, the device releases progesterone slowly and steadily every day. This has the effect of shrinking the lining of the uterus, such that there is very little to be shed every month.’
  • Non-steroidal anti-inflammatories (NSAIDs):‘Women with heavy menstrual bleeding have higher levels of prostaglandins,’ Dr Lee explains. ‘NSAIDs block the enzyme cyclo-oxygenase, which is needed to produce prostaglandins.’
  • Antifibrinolytics:‘Fibrin is a major constituent of blood clots, hence agents which increase fibrin levels can reduce bleeding,’ says Dr Lee. ‘Tranexamic acid is effective in treating heavy menstrual bleeding because it prevents the breakdown of fibrin and so it encourages blood to clot.’

Medical procedures and surgery to treat fibroids

Recovery time varies from woman to woman, and is dependent on both the size and type of fibroids you have, as well as the surgical procedure used to remove them, says Athanasias. Here are the options:

  • MRI focused-ultrasound therapy (FUS): ‘This is a radiological procedure which uses MRI scanning to locate and monitor the fibroids during treatment,’ Dr Lee explains. ‘Ultrasound waves heat the fibroids to a sufficient temperature to destroy them. This is a new treatment and not available at all centres in the UK.’
  • Endometrial ablation: This procedure destroys the lining of the womb. ‘Although the fibroids remain, because the bleeding surface of the uterus has been removed, it often results in a reduced menstrual loss,’ says Dr Lee. There are different ways to do this, including cryoablation (freezing), electrocautery, and high energy radio-waves.
  • Uterine fibroid embolisation (UFE): ‘A small thin tube, called a catheter, is inserted into an artery in your groin,’ says Dr Lee. ‘Under X-ray, this is fed through your arterial system until it reaches the main artery supplying your fibroid. This is injected with a special fluid, containing numerous tiny particles, which block the vessel and block the arterial blood supply. The fibroid is then unable to survive and is destroyed.’
  • Myomectomy:This is the surgical removal of a fibroid. Myomectomy can be performed laparoscopically, which means a small telescope is inserted through the abdominal wall and into the pelvic cavity, says Dr Lee, though it depends on the site and size of the fibroid.
  • Hysterectomy:A hysterectomy is an ultimate solution for fibroids. ‘This is an operation to remove the uterus, with or without the fallopian tubes and ovaries,’ says Dr Lee. ‘The operation is not without risks and means the permanent loss of fertility.’ There are different types: abdominal hysterectomy, vaginal hysterectomy, laparoscopic hysterectomy, and subtotal hysterectomy.

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