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Uterine Leiomyomata

 

Incidence

Uterine fibroids or leiomyomata are the commonest benign tumours in women of reproductive age having an incidence of up to 80% at post-mortem. [40],[41] The peak incidence occurs between 35 and 40 years old. [42]

There is a higher incidence in nulliparous women, Afro-Caribbean women and the obese. There is a lower incidence in those on the contraceptive pill and those who smoke. [42],[43]

The aetiology is not known, but thought to be associated with oestrogen and progesterone since fibroids appear in women of reproductive age and can reduce after menopause. [42],[43]

 

Pathology

Embolisation procedureFibroids can be classified according to their position:

  • Subserosal. Symptoms include compression on the surrounding tissues, such as the bladder and bowel pain
  • Intramural. Symptoms include pressure on the bladder and / or uterus and infertility or miscarriage and menorrhagia
  • Submucosal. Symptoms include menorrhagia, pain and infertility. [42],[43]

Click on the diagram for a larger view of types and locations of fibroids.

They can also be pedunculated, or non-pedunculated. Women can have a mixture of types of fibroid.

 

Symptoms

Approximately 25% of women with fibroids have symptoms. These vary with the position, type of fibroid and size. Common symptoms are: -

  • Menorrhagia
  • Iron deficiency anaemia
  • Dysmenorrhea
  • Bladder incontinence/urgency
  • Infertility or miscarriage
  • Pressure symptoms on the bowel leading to constipation
  • Pressure symptoms on the ureters, bladder and/or kidneys
  • Back pain and sciatica
  • Abdominal swelling, as in pregnancy
  • Indigestion, discomfort sitting, etc., as in pregnancy
  • Dyspareunia
  • Dyspnoea
  • Varicose veins and haemorrhoids [42],[43]

 

Diagnosis

Ultrasound scans have been the traditional method of differential diagnosis between cysts and solid tumours. However, the size, location and number of fibroids cannot be accurately determined by this method.

MRI (magnetic resonance imaging) has the advantage that myomata can be mapped exactly, especially multiple fibroids, and adenomyosis and endometriosis can be more accurately diagnosed than with ultrasound. Diagnosis of the latter has traditionally been by laparoscopy or hysteroscopy. [45],[46],[47],[48],[49],[50]

 

Treatment Options

Until recently only surgical intervention was available for fibroid treatment. Unless the women was particularly young and wanted a family only hysterectomy was offered. Now a number of procedures are available: -

  • Embolisation
  • Hysterectomy
  • Myomectomy
  • Drugs
  • MR-Guided Focused Ultrasound and Myolysis

Uterine artery/fibroid embolisation (UAE/UFE) is an interventional radiology technique. Recovery is much quicker than hysterectomy (return to work 1-5 weeks compared with 2-3 months), much less invasive with fewer long term side effects and lower morbidity and mortality. It requires an overnight hospital stay and no general anaesthetic. [1]-[31],[60],[65],[68] - see comparison chart.

 

Hysterectomy is probably one of the most dreaded and feared surgical operations for women. As well as being a very invasive procedure with a long recovery, many feel that it also robs women of their femininity. Many women suffer terribly from the symptoms of fibroids rather than 'have it all whipped out'. Some feel that a hysterectomy is only appropriate for cancer treatment and is too invasive to treat a disease that is not life threatening. Women also resent the fact that many surgeons do not give them the option of keeping their ovaries. NICE Clinical Guidelines on Heavy Menstrual Bleeding state that healthy ovaries should not be removed.

There is also long term morbidity - urinary incontinence, clinical depression and sexual dysfunction, which can make this a very costly procedure for the women and the NHS. After hysterectomy menopause is 5 years earlier and is the major cause of early use of HRT. Women have to pay at least double prescription charges for HRT as they are charged on each hormone in the medicine.

In a recent study on women's decision-making in choosing UAE for treating symptomatic fibroids most wanted relief from their symptoms and felt that UAE would provide this. They cited quality of life reasons for making their decision: -

Avoiding adverse effects of other treatments

  • Long recovery time from surgery
  • Avoiding surgery
  • Loss of femininity
  • Loss of self-image
  • Loss of sexual image [69]

Myomectomy is normally only offered to younger women wishing to have a family, as the high incidence of fibroid re-growth and adhesions makes hysterectomy inevitable for most women. The procedure takes longer to perform than hysterectomy and has a similar recovery time, which is often unacceptable.  Recently, a number of women have approached FEmISA about fibroid embolisation after fibroid re-growth following myomectomy.  They did not wish to have another myomectomy.

Younger women wishing to become pregnant have a choice between myomectomy and embolisation. Most will be offered myomectomy by the gynaecologist. One Interventional Radiologist in England has 60 patients who have achieved successful pregnancies and births after UFE. There have been a number of clinical studies comparing the two treatments and other larger ones are underway. It would be useful to determine which treatment is better for which types of fibroids and patients.

MR-guided focused ultrasound is a newer technique where high-power ultrasound is used to ablate the fibroid which a number of treatments

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