Women's health

I’m a women’s health expert – here’s what you need to know about fibroids

Dr Karen Tang, gynaecologist and gynaecologic surgeon, talks fibroids and explains what we need to know about this challenging condition.

Fibroids explained – from symptoms to treatment

First things first, what are fibroids?

Fibroids are benign tumours of the uterus. They’re extremely common – it’s probably the most common tumour there is. And even though not everyone has bad symptoms, they can wreak a lot of havoc.

80% of black women and 70% of white women have fibroids, yet no one seems to know anything about them.

It’s outrageous when you think about. If 80% of men had a tumour that made them hemorrhage once a month, caused severe pain, made them look like they were pregnant, and caused infertility – we would be calling it an epidemic and throwing so much funding and awareness at it!

What are the symptoms?

Fibroid symptoms are typically split into pain, bleeding, and bulk.

Fibroids can bleed a lot, so that’s a key symptom.

For pain – this mostly come with periods, but they can sometimes be painful all the time. If fibroids grow very fast, they can actually outgrow their blood supply and die – this can be really painful. This sometimes happens in pregnancy because pregnancy hormones stimulate fibroids to grow fast. This can be super painful and even cause contractions and some complications for the pregnancy.

The third category is bulk symptoms. This is almost a pregnancy-like feeling where the fibroid pushes on your bladder and you have to pee all the time. It can also push on your rectum so you have constipation – you literally feel and look like you’re pregnant.

A fourth ‘unofficial’ category of symptoms for fibroids can be related to fertility.

Fibroids can block the cavity of the uterus and cause problems getting pregnant. They can also increase the risk of a miscarriage if the pregnancy implants on the fibroid.

How important is age?

Fibroids grow over time during the reproductive years and tend to become more problematic for someone in their 30s to 50s – that’s the key time when we start to see someone come in for bad bleeding and pain.

It’s rare to have someone in their teens or twenties to have fibroids – or who knows that they have them – most of the women that we’re seeing for treatments are in the perimenopause age range.

Part of that is just because they grow over time. When we’re getting to menopause, this is probably when they’re at their largest.

How does menopause affect fibroids?

As we approach menopause, it’s common to have irregular cycles – we’re not ovulating as regularly so the normal hormone patterns that keep periods regular and predictable are all out of whack.

When this is combined with the fibroids, it leads to really uncontrolled bleeding and even more pain. It is the terrible coinciding of the fluctuating hormones in perimenopause and the growth of the fibroids being at their peak.

The positive news is that, usually after menopause and oestrogen levels are lower, fibroids do tend to shrink. They’re stimulated by hormones, like oestrogen and progesterone. Once the ovaries have quieted, fibroids do tend to get smaller. They may not completely disappear, but they might become so small that we don’t notice them anymore.

Are there instances where fibroids can return after menopause?

This is actually really important. If a fibroid seems like it’s growing after menopause, that is concerning for potentially cancerous fibroids.

There is something called leiomyosarcoma. This is basically a cancerous muscle tumour of the uterus that looks identical to fibroids. It’s very hard to distinguish them from normal fibroids, even on imaging studies.

The clues that maybe something is not just a regular fibroid are if the fibroid is growing when someone is post-menopausal – that’s always a little bit of a warning sign. They should be getting smaller, not bigger.

Be reassured that these are very rare, and is pretty much only seen in post-menopausal women. It affects almost nobody in their 30s or younger.

But, please do see your doctor or gynaecologist if you’re post-menopausal, the fibroids feel like they’re growing again or if they start bleeding.

The other thing to bear in mind is that, if you do have fibroids, they seem to push back the onset of menopause. I have patients with fibroids that are 59 and still having periods.

Will HRT make fibroids worse?

It’s not clear. It’s not a known huge risk, but any time you’re giving any oestrogen or progesterone, it’s possible it can increase the risk a tiny bit.

In my book, It’s not hysteria, I talk about birth control pills – these are actually a much higher dose than what HRT is. With HRT – we’re just trying to increase hormones to a level where you’re not having symptoms. Birth control doses are much higher because you’re trying to suppress the ovaries.

In general, the progesterone of the birth control pill lightens period bleeding so we often give progesterone to people with fibroids to help suppress the heavy bleeding symptoms.

We don’t tend to notice major growth of the fibroids when someone is on birth control and HRT is a much lower dose. It’s not something that should reawaken everything.

But, if someone were to start bleeding again or feel like something is growing again while taking HRT, it’s important to talk to a doctor or gynaecologist.

Do we know what causes fibroids?

One interesting fact – the cells are all genetically identical so maybe there is some genetic issue that sparks their growth. They do tend to run in families too, so there’s something genetic about it… we just don’t know what that is.

As I mentioned earlier, 80% of black women and 70% of white women have fibroids. There are a lot of questions as to why black women are more likely to have them.

One interesting thing that came up recently was the use of hair relaxers. Their use is more common among black women and it’s been suggested recently that these hair relaxers can increase the risk of uterine cancer – and maybe even breast cancer as well.

These hair relaxers act as an endocrine disruptor – they function almost in a hormone signalling pattern. They can stimulate hormonally-responsive things like tumours and cancers. It was found that some of the phthalates in the hair relaxers can increase the risk of both fibroids and uterine cancer.

There’s vitamin D deficiency too. This is known to increase the risk of fibroids. Giving extra vitamin D doesn’t seem to particularly help with preventing fibroids but, sometimes if someone is very deficient in vitamin D, giving them vitamin D back might slightly decrease the risk of fibroid growth.

It’s one of those things that, again, we just don’t know enough about where fibroids come from to prevent them or keep them from coming back.

How are fibroids diagnosed?

Usually we start with a pelvic ultrasound, which is an imaging tool using soundwaves to make pictures of the fibroids. Those are easy and inexpensive to do and have no radiation exposure. It’s a good first line tool.

The treatment will depend on where the fibroids are located in the uterus – for example are they in the cavity or are they on the outside of the uterus? Imaging can also help us to learn how big the fibroids are and how many of them there is. We have to map them to figure out what’s best. There are some treatments where you can go in through the vagina with a camera and shave them down or there are the surgeries where you go through the abdomen to remove the fibroids. So knowing where they are and how many is important.

MRIs are better at getting the exact detail of where they are. For surgeries of fibroids, in the US at least, we’ll get an MRI to get a really clear map of where they are so that we don’t miss any.

That’s basically it. There’s no blood test but, if you are bleeding like crazy, we want to make sure you’re not anaemic. But there’s no other diagnostic test. It’s all done through imaging.

What are the treatment options for fibroids?

Not knowing the root cause means we can only really respond to the symptoms – or physically try and remove the fibroids once they’re there.

The only thing that completely gets rid of them and prevents them from coming back is doing a hysterectomy. Obviously a lot of women aren’t ready for that if they still want to maintain their fertility or they just don’t want to have a hysterectomy.

There are a few other options that are starting to become more widely used across the US (and may eventually be available in the UK).

One of them is called Acessa. This uses radiofrequency energy to destroy the fibroids. This is done surgically, either laparoscopically (through the abdomen) or through the vagina. It’s where you place thin needle probes into the fibroids and pulse energy to heat and destroy them.

These surgeries seem to be very effective – they really help with bleeding and shrink the fibroids. The limitations are that there’s not enough data on what happens in pregnancy. We don’t recommend it if someone wants to get pregnant, because we’re not quite sure how it affects the uterus.

The fibroids can also come back. Even if you destroy the ones that are there, new ones can pop up later.

Other surgeries can be more invasivem as you have to fully cut the fibroids out. This can be a really major surgery that takes a long time and the patient can bleed a lot. The other alternative is a hysterectomy.

There’s also uterine fibroid embolisation, which is done by radiologists where they go through a vein in the wrist or groin and then block the blood vessels that feed the fibroids.