Uterine Fibroid

Fibroid and Infertility
Fibroid may cause infertility in a number of different ways. A fibroid may cause compression on the fallopian tubes resulting in a blockage of the passage of sperm or eggs. A large fibroid may distort the pelvic anatomy sufficiently to make it difficult for the fallopian tube to capture an egg at the time of ovulation. if a fibroid protrudes into the uterine cavity or causes distortion of the uterine cavity, it may present a mechanical barrier to implantation.
FIBROID
Uterine fibroid is the most common benign (not cancerous) tumour of a woman’s uterus (womb). Fibroids are tumours of the smooth muscle that is normally found in the wall of the uterus.
They can develop within the uterine wall or attach to it. They may grow as single tumours or in clusters. Uterine fibroids can cause excessive menstrual bleeding, pelvic pain and frequent urination. Even though they are called benign (not cancerous) tumours, fibroids potentially can cause many health problems.
Fibroid growth occurs in up to 50% of all women and they are a leading cause of hysterectomy (removal of the uterus) in Europe and America.
Fibroids starts in muscle tissues of the uterus they can grow into uterine cavity (sub mucosal) into the thickness of the uterine wall (intramural) or on the surface of the uterus (subserosal) into abdominal cavity. Some may occur as pedunculated masses.
Uterine Fibroid Causes
The exact reasons why some women develop fibroids are unknown. Fibroids tend to run in families. Women of Africa descent (blacks) are 2 or 3 times more likely to develop fibroids than women of other races.
Fibroids grow in response to stimulation by the female hormone (oestrogen) produced naturally in the body. These growths can show up as early as 20 and shrink after menopause when the body stops producing large amount of oestrogen.
Fibroids can be small and cause no problems, but they can also grow to weigh several kilograms. Fibroids generally grow slowly.
The following factors have been associated with the presence of fibroids
–    Being overweight (obesity)
–    Never having given birth to a child
–    Onset of menstruation period before age 10
African and African heritage (3-9 times often than in Caucasian women)

Uterine Fibroid Symptoms
Most fibroids, even large ones, produce no symptoms. These masses are often found incidentally during a normal pelvic examination. When women do experience symptoms, the most common are the following:
–    Irregular vaginal bleeding or an increase in menstrual bleeding known as menorrhagia, sometimes without blood clots
–    Pressure on the bladder which may cause frequency in urination and a sense or urgency to urinate and very rarely inability to urinate
–    Pressure in the rectum, resulting in lower abdominal pain
–    Increase in size around the waist and abdominal swelling. Some women need to increase their cloth sixe but not because of significant weight gain.
–    Infertility
–    Pelvic mass during physical examination
When to Seek Medical Help
If a woman has any of the following, she should see her gynaecologist.
–    Irregular have menstrual bleeding. Menstrual bleeding soaking through more than 3 pads per hour requires your gynaecologist attention
–    Severe or prolonged pelvic or abdominal pain.
–    Dizziness, light headedness, shortness of breath or chest pain associated with excessive vaginal bleeding.
–    Vaginal bleeding associated with pregnancy
–    Infertility with long standing fibroid.
Uterine Fibroid Diagnosis
When uterine fibroid is suspected, your gynaecologist can arrive at a diagnosis by various methods:
A physical examination including a pelvic examination can reveal an irregularly shaped uterus when fibroids are present.
An abdominal or transvaginal ultrasound scan help identify the numbers, size and shape of most fibroid.
A hysteroscopic look at the uterus by passing a small fibreoptic camera through cervix can confirm a sub-mucous fibroid.
Hystero salpingogram (HSG) during infertility workup sometimes gives an indication about the presence of a fibroid. It helps in distinguishing those fibroids that cause tubal blockage from those that do not.
Laparoscopy is a minor surgical procedure to have a directive view of the pelvic. It is procedure done during routine infertility work up to confirm tubal patency. It can detect sub serous and intra mural fibroids, sometimes incidentally.
Uterine Fibroid Treatment
Uterine fibroid treatment depends on the symptoms, the size and the location of the fibroids, the age (how close to menopause) and the patient’s desire to have children and the patient’s general health.
Medical Treatment
In most cases of fibroid, treatment is not necessary particularly if the woman has symptoms, has small tumours or has gone through menopause.
Abnormal vaginal bleeding caused by fibroids may require surgical scrapping of the uterine cavity by D&C (dilatation and Curettage). If no malignancy found, the bleeding can be controlled by hormonal medications. Observe every 6 months to check for changes in size and symptoms is advisable.
Medication
Women with heavy bleeding, pains and fibroids may be given non-steroidal anti-inflammatory drugs (NSAIDS) oral contraceptive (birth control pills) gonadotrophin releasing hormone agonists and anti hormonal drug mifepristone.
Non-steroidal drugs such as ibuprofen have been shown to relieve pelvic pain associated with fibroids.
Oral contraceptive pills are also commonly used in women with fibroids. They often decrease the perceived menstrual blood flow and help with pelvic pain.
Gonadotrophin releasing hormone agonists are medications that act on the pituitary gland to decrease oestrogen produced by the body. A decrease in oestrogen causes fibroids to decrease in size.
These medications are usually used prior to surgery to shrink the fibroid, to decrease the amount of blood loss during surgery and to improve pre-operative blood count. The size of fibroid can be reduced up to 50% in 3 months, but fibroids can re-grow once treatment is stopped.
Long term treatment with drugs is limited by side effects of low oestrogen (much like menopause) which includes decreased bone density (osteoporosis) hot flushes and vaginal dryness.
Mifepristone has also been shown to reduce fibroid size by about half. It has also been shown to reduce pelvic pain, bladder pressure and lower back pain. Mifepristone can induce miscarriage s it should be used with caution if a woman is trying to conceive.
Danazol has been used to reduce bleeding in women with fibroids. It causes the menstruation to stop but does not shrink the size of the fibroid. Danazol is an androgenic (male hormone) drug that can cause side effects such as weight gain and muscular cramps decreased breast size, acne (oily skin) mood changes depression etc.

Surgery
Myomectomy is the surgical removal of the fibroid only. It can be accomplished by open surgery, hysteroscopic or laparoscopically depending on the size and location of the fibroid.
The uterus is left intact and the patient may be able to become pregnant. It is the most common surgical procedure in the treatment of fibroid in Nigeria.
Hysterectomy is the right surgical removal of the uterus (and fibroids). It is the most common performed surgical procedure in the treatment of fibroid in the UK and USA and it is considered a cure, but at the expense of fertility.  Depending on the size and location of the fibroid, it can be performed abdominally, vaginally or laparoscopically.
Uterine artery embolization or clotting of the arterial blood supply to the fibroid is an innovative approach that has shown promising results.
This procedure is done by inserting a catheter (small tube) into an artery of the leg (femoral artery) using special X-ray video to trace the plastic or gelatin spong particles the size of grains of sand.
This material blocks blood flow to the fibroid and shrinks it. Interventional radiologist performs these procedures.

Uterine Fibroid prevention
Women should avoid weight gain after age 18 and maintain a normal body weight compared to height. Body weight tends to increase oestrogen production thus aggravating fibroid growth.
Exercise can help women control weight gain and additionally decrease hormone production that stimulates fibroid growth.
Treatment success and future outcome in fibroid depends on the severity of fibroid prior to treatment and the chosen treatment. Fibroid may affect fertility, but it depends on the size and location f the fibroids.
Many women with fibroid are older than 35 years. This and other factors such as decreased egg quality and decreased ovulation contribute to their inability to become pregnant.
Fibroids rarely turn into cancer.