Treatment of uterine fibroids

First, let’s understand what this formation actually is in a woman’s body. A fibroid (myoma) is a benign growth in the muscular layer of the uterus. Since it is benign, this diagnosis should not cause concern.

Small fibroids are found in almost every fourth woman. In most cases, fibroids do not cause harm and are asymptomatic. They do not produce any symptoms and are often discovered incidentally.

Only a small number of fibroids require close monitoring and, in some cases, surgical treatment. There are three types of fibroids:

• Subserosal fibroid – located in the outer muscular layer of the uterus; it grows outward into the abdominal cavity.
• Intramural fibroid – located within the uterine wall and grows by expanding the muscular layer.
• Submucosal fibroid – located and growing directly into the uterine cavity.

Symptoms

The presence of symptoms depends, of course, on the size and location of the fibroid. The main symptoms are pain and bleeding. At the same time, each fibroid has its own characteristics. If a fibroid grows toward the abdominal cavity (subserosal), it usually does not cause any symptoms and is detected only on ultrasound, especially when it is small.

However, location is very important. For example, a fibroid located on the outer posterior side of the uterus may press on the bladder or the rectum. In such cases, symptoms naturally develop more quickly.

In any case, pain and bleeding are the main symptoms. This may include pain during sexual intercourse or persistent, exhausting pain in the lower abdomen; however, in such cases, it may also indicate the presence of another condition.

If a fibroid separates the uterine wall (intramural fibroid), it more often causes pain because it affects and stretches the nerve endings running through the uterus. A fibroid growing into the uterine cavity (submucosal fibroid) most often causes bleeding.

Fibroids can lead to heavy bleeding. But how do we understand whether the bleeding is heavy? We usually ask the patient how much blood loss she has per day. If a woman’s menstruation lasts more than 7 days and she needs to use more than 5 pads per day, this is definitely considered abnormal bleeding.

In such cases, it is necessary to consult a doctor. However, there can be many causes of bleeding, and it is not always related to fibroids. Heavy bleeding can lead to anemia, meaning iron deficiency in a woman’s body, which results in weakness, lethargy, fatigue, and pale skin.

Surgical treatment of uterine fibroids

If a fibroid grows into the uterine cavity, surgical treatment is recommended even for small sizes. Such fibroids interfere with proper endometrial contraction and uterine function and themselves cause significant bleeding. They also interfere with pregnancy. Therefore, even a small submucosal fibroid is usually recommended for removal.

In this case, hysteroscopic surgery is performed. This means there is no need for open surgery; a hysteroscope is used to enter the uterine cavity and remove the fibroid. For large fibroids, removal in a single procedure is not always possible in all medical centers.

In our clinic, we use advanced modern equipment and can remove fibroids up to 4–5 cm in a single procedure. Fibroids that partially grow into the cavity are also removed hysteroscopically.

However, if most of the fibroid is located outside the uterine cavity, it cannot be reached with a hysteroscope. In such cases, it is monitored rather than immediately operated on. There is no need for immediate surgery. This is a benign formation with no malignant cells. Many women become anxious when they learn they have a 2–3 cm fibroid, but in most cases, observation is sufficient.

Usually, I invite the patient for a follow-up after 3 months for small fibroids to assess whether it is growing. Since we do not know when it started growing or its growth rate, monitoring is important.

If within 3 months it grows from 3 cm to 5–6 cm, then surgical treatment is considered. If no change is observed, the next follow-up is scheduled in 6 months. If there are still no changes, it is considered a stable fibroid and can be monitored once a year if there are no symptoms.

Currently, in our clinic, surgical removal of subserosal and intramural fibroids is performed using laparoscopy. We do not use open surgery (laparotomy).

Fibroids are successfully treated with laparoscopic techniques. Since this is a minimally invasive (closed) surgery, recovery is faster, rehabilitation time is shorter, and the risk of adhesions is lower.

If the fibroid is located within the uterine wall, surgical intervention is usually recommended when it reaches 5 cm.

Fibroids and pregnancy

Small intramural fibroids are usually not a problem for pregnancy. Yes, they may grow during pregnancy, but in 98% of cases they increase only by 1–2 cm and then decrease again after childbirth.

Sometimes a woman may become pregnant with a 4 cm pedunculated subserosal fibroid. In such cases, we monitor it, but there is a risk of torsion or necrosis of the fibroid’s stalk, which may require surgery — although this is rare.

Submucosal fibroids usually lead to miscarriage. Therefore, if a woman is planning pregnancy, submucosal intrauterine fibroids should be removed first before conception.

After surgery on an intrauterine or intramural fibroid, at least 6 months are required for uterine healing, and only after that pregnancy is possible.

As a reproductive specialist, I would like to emphasize that age plays a very important role. There is no need to rush into surgery, for example, if you are 38 years old and planning your first pregnancy.

First, ovarian reserve should be evaluated. If the reserve is reduced, or if there have been difficulties conceiving, reproductive specialists often proceed as follows:

We first perform IVF, freeze embryos, then remove the fibroid, wait 6 months for recovery, and then transfer the embryos into the uterus. This is important because the preparation and recovery period can take time, and ovarian reserve may decrease during this time.

In cases of fibroids, age factors, and infertility history, treatment decisions should be made together with a reproductive surgeon to determine whether immediate surgery is needed or whether embryo preservation should be done first.

Cesarean section and fibroids

Is fibroid an indication for cesarean section? No, it is not. If the fibroid is not located in the cervical canal or does not obstruct the birth canal, vaginal delivery is possible.

Often during cesarean section, women request removal of fibroids at the same time. This decision is individual and depends on the surgeon’s skills, size, and location of the fibroid.

Since fibroids are highly vascular tumors, and blood vessels are significantly enlarged during pregnancy, removing a fibroid during cesarean section can cause significant bleeding. Therefore, the doctor carefully weighs all risks and benefits.