Uterine fibroids are the most common benign tumors of the female reproductive organs, commonly found in women of childbearing age, 30 to 50 years old, and are masses formed by the proliferation of uterine smooth muscle cells. Uterine fibroids are traditionally classified into submucosal fibroids, interstitial fibroids and subplasma fibroids according to the location of the fibroids.
What are the symptoms of fibroids?
The symptoms of fibroids often vary depending on the location, size, growth rate, secondary degeneration and comorbidities of the fibroids. However, there are many asymptomatic patients.
Abnormal uterine bleeding is mainly caused by interstitial and submucosal fibroids. Excessive menstrual flow or prolonged menstrual periods can occur alone or in combination. Menstrual abnormalities tend to occur with interstitial fibroids, while submucosal fibroids often present with irregular bleeding. Subplasmalemmal fibroids rarely cause uterine bleeding. It is worth mentioning that submucosal fibroids can lead to chronic endometritis and cause constant bleeding, sometimes very heavy bleeding and loss of a large amount of blood in a short period of time resulting in severe anemia, causing the patient to seek urgent medical attention and possibly requiring blood transfusion treatment.
This is why early detection is important. A mass in the lower abdomen is often another major symptom in patients with fibroids, and sometimes may be the only symptom of fibroids. Because the uterus and fibroids are pushed upward, they are easily palpable by the patient and are often mistakenly thought to be gaining weight or thought to be pregnant. Sometimes it can be a feeling of lower abdominal swelling or back pain, but it is not very serious.
If the fibroids are red and degenerative, the abdominal pain may be severe and accompanied by fever, often after pregnancy. If you are pregnant with fibroids, you are at risk of this and the management after its appearance is relatively conservative. Acute severe abdominal pain also occurs in cases of torsion of the subplasmalemma or axial torsion of the uterus.
In cases of severe and progressively increasing dysmenorrhea, it is often due to fibroids complicated by adenomyosis or endometriosis. Uterine fibroids compress surrounding organs and cause compression symptoms, for example, compression of the bladder may cause frequent urination or difficulty in urination, urinary retention, etc. Compression of the rectum may cause constipation or even difficulty in defecation. Compression of the pelvic veins may cause lower limb edema.
The symptoms of compression are more significant in the premenstrual period, which is due to the congestion and swelling of uterine fibroids. Long-term abnormal uterine bleeding without timely treatment can lead to anemia, resulting in physical weakness, panic and dizziness, etc. If the anemia is severe, it is not suitable for immediate surgical treatment and needs to be replaced first. Some patients with fibroids have hypertension, and according to some people, most of those with fibroids combined with hypertension (except those with a history of hypertension) return to normal after removal of the fibroids.
How can fibroids be detected early?
On the one hand, if you have the above clinical symptoms, you should go to the hospital in time for early detection. On the other hand is regular physical examination. Ultrasound examination is more common in China now. It can identify fibroids with an accuracy rate of up to 93.1%. It can show the enlarged uterus with irregular shape; the number, location, size and whether the fibroids are uniform or liquefied cystic lesions within the fibroids; and whether there is pressure on other organs around the performance.
Ultrasound examination can help diagnose leiomyoma, differentiate whether it is degenerative or malignant, and also help identify ovarian tumor or other pelvic masses. Pelvic CT, pelvic MRI are not routinely used to examine fibroids, but if a patient has a uterine mass detected by CT and MRI during other examinations, suggesting fibroids, ultrasound can be done for further examination.
Another rare clinical presentation of fibroids is infertility.
However, many infertility patients are combined with fibroids. Uterine fibroids also become a problem for them. According to statistics the prevalence of fibroids in infertile women can be 5-13%, of which probably only 2-3% of them fibroids may be the only cause of impaired fertility. Factors such as the composition, size, location and number of fibroids may affect female fertility and pregnancy complications.
This may be due to compression of the endometrium caused by fibroids, resulting in altered endometrial tolerance, abnormal uterine contraction, abnormal blood vessel formation and abnormal endometrial development. Fibroids can cause atrophy of the endometrial glands, fibroids can also lead to enlargement of the uterine cavity, and fibroids in specific areas may cause anatomical changes and narrowing of the fallopian tubes or cervix that interfere with the passage of sperm and fertilized eggs. However, the current evidence has not demonstrated a direct causal relationship between fibroids and infertility.
There are many studies on the impact of uterine fibroids on assisted reproductive outcomes. Assisted reproductive techniques include mainly artificial insemination and IVF. It is generally accepted that submucosal fibroids have no adverse effect on the outcome of assisted reproduction, and myomectomy is not usually required for this purpose. However, if submucosal fibroids are found during other procedures, they can be removed together, at least to reduce the patient’s psychological stress and the risk of future surgery.
There is a consensus that submucosal fibroids can affect the morphology of the uterine cavity and have a significant negative impact on fertility. In cases of unexplained infertility combined with submucosal fibroids, hysteroscopic myomectomy can significantly improve pregnancy rates. IVF in patients with submucosal fibroids is associated with a significant decrease in clinical pregnancy and live birth rates.
Since submucosal myomectomy is beneficial in improving pregnancy rates, we strongly recommend hospitalization for hysteroscopic electrosurgery in patients with submucosal fibroids. The impact of intermural fibroids on fertility and outcome of assisted reproductive treatment is inconclusive. It is generally accepted that interstitial fibroids over 3-100 px are recommended for removal before the start of assisted reproductive treatment, even if they do not affect the morphology of the uterine cavity.
Treatment of uterine fibroids includes pharmacological and surgical treatment.
Medication is mainly used to lower estrogen levels, to make the patient amenorrheic and to inhibit the growth of the fibroids, but certainly not to make them disappear. Surgical treatment mainly includes open myomectomy, laparoscopic myomectomy, transvaginal myomectomy, total hysterectomy, interventional treatment, etc. When fibroids are combined with infertility or fertility requirements, the treatment needs to be careful and the only option available is myomectomy. The options for transvaginal myomectomy are relatively narrow.
Although laparoscopic myomectomy has the advantages of minimal adhesions and trauma, it should be performed by a physician with better laparoscopic suturing skills; otherwise, there is an increased risk of uterine rupture during subsequent pregnancies. Open hysterectomy is suitable for those with multiple fibroids, and some believe that open surgery is needed when the fibroids are greater than 10.
Open surgery allows for the removal of small, invisible fibroids, and the suturing of the uterus can be quite tight and firm. In addition, fibroids can lead to embryo implantation failure or recurrent miscarriage. For those who have repeatedly failed in vitro fertilization, if no other cause can be found and fibroids are the only factor, a myomectomy may be considered.
When can I get pregnant after fibroid surgery? This needs to be studied further in a large sample. Currently, it is believed that pregnancy is usually possible 3-6 months after subplasmic fibroids, more than 1 year after interstitial fibroids, and after submucosal fibroids when the hysteroscopy is repeated and normal.