Uterine fibroids

In this episode of PodMD, Australian-trained gynaecologist Dr Alison Bryant-Smith will be discussing fibroids, including what fibroids are, how a patient would typically present with fibroids, how they are investigated, the treatment options are available, the likelihood of recurrence, when to refer and more.


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  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Alison Bryant-Smith

    Alison is an Australian-trained gynaecologist, with expertise in advanced laparoscopic surgery. Melbourne born and bred, she completed medical school at The University of Melbourne, then obstetrics and gynaecology training through The Royal Women’s Hospital, including several years working in London at Guy’s and St Thomas. It was here that her interest in keyhole surgery was piqued. She then moved to Sydney, and completed a two year laparoscopic surgery Fellowship with esteemed A/Prof Alan Lam.

    Since moving back to Melbourne, she has juggled three public appointments, while being integral in establishing Maven (pronounced ‘May-ven’) Centre: multidisciplinary consulting suites within Sunshine Private Hospital.

    Today we will be discussing the topic of uterine fibroids.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Alison, thanks for talking with us on PodMD today.

    Alison : Thank you for having me. To start, I’d like to acknowledge that we’re recording this podcast on the lands of the Wurundjeri people, and I’d like to acknowledge them as Traditional Owners. I’d also like to pay my respects to their Elders, past present and emerging. I’d also like to acknowledge that in today’s podcast, for brevity’s sake, I’ll use the word ‘woman’, and pronouns ‘she and her’ to refer to any patient who was assigned female at birth.

    Question 1
    The topic of today’s discussion is uterine fibroids. Alison, can you describe for our listeners what fibroids are?

    Alison: Fibroids are the most common pelvic growth in women, and are benign overgrowths of the uterine muscle, or ‘myometrium’.

    They only really occur during a woman’s reproductive years, as fibroids grow under the influence of oestrogen.

    It’s challenging to determine the incidence, as many fibroids are asymptomatic. As a rough rule of thumb, approximately 1 in 4 women of reproductive age will have symptomatic fibroids, and an additional 2 in 4 will have asymptomatic fibroids.

    One key risk factor is increasing age, up until menopause. Towards menopause, fibroids tend to be both more numerous, and larger in size. Hence, they become increasingly problematic in women in their 40s and 50s.

    In addition to increasing age, other risk factors for fibroids include: Asian or African ethnicity, early menarche, and nulliparity

    Question 2
    How would a patient with fibroids typically present?

    Alison: The symptoms caused by a fibroid are almost entirely dependent on where the fibroid is growing, in relation to the uterine muscle and cavity. The three main locations that fibroids grow are analogous to the three main cellular layers of the uterus:
    – ‘sub-mucosal’ fibroids grow under the mucosa, or inner cell layer of the uterus
    – ‘intra-mural’ fibroids grow within the muscular walls of the uterus, called the ‘myometrium’
    – ‘sub-serosal’ fibroids grow under the thin layer of epithelial cells that covers the outside of the uterus, which is called the serosa

    I’ll go through each of these three in turn, as a fibroid’s location helps to explain both its symptoms and signs, plus guide management.
    ‘Sub-mucosal’ fibroids grow on the inside of the uterus, and protrude into the uterine cavity. In so doing, they increase the surface area of the uterine lining, and often lead to heavy menstrual bleeding.

    Because sub-mucosal fibroids distort the shape of the uterine cavity, they can also impact both fertility and obstetric outcomes. We know that submucosal fibroids are associated with: lower conception rates, lower embryo implantation rates, and higher miscarriage rates. Should a woman with a submucosal fibroid have a pregnancy that continues beyond the second trimester, there is a higher likelihood of intra-uterine growth restriction, malpresentation of the baby (such as breech presentation), and pre-term birth.

    In contrast to sub-mucosal fibroids, which protrude into and distort the uterine cavity, ‘intra-mural’ fibroids (as the name implies) grow mostly within the wall of the uterus. If they grow large enough to distort the uterine cavity, they can also lead to heavy and / or prolonged periods. In addition, intramural fibroids can lead to so-called ‘pressure symptoms’, such as: abdominal distension, urinary frequency (if they are on the front of the uterus, and are pressing onto the bladder), and constipation (if they are growing at the back of the uterus, and pressing down onto the rectum). In extreme cases, large intramural fibroids can press down onto the ureters (causing hydronephrosis), or the pelvic veins (leading to venous thromboembolism).

    The third main type of fibroid is ‘sub-serosal’ fibroids: those that grow on the outside of the uterus, under the uterine serosa. Small submucosal fibroids are often asymptomatic: they don’t tend to distort the uterine cavity, so don’t cause heavy periods, fertility or obstetric issues. However, when large, submucosal fibroids can cause pressure symptoms, which I’ve just outlined: abdominal distension, urinary frequency and constipation and so on.
    In terms of the signs that a GP may find due to fibroids, the most obvious one will be abdominal distension and an enlarged uterus on abdominal examination. Keep in mind that uteri are normally about the size of a closed fist, and often not easily palpable on abdominal examination. In contrast, in thin patients with several large sub-serosal fibroids, an enlarged uterus may be felt even up above the umbilicus or beyond, and individual fibroids may even be palpated on top of the uterus.

    So, to summarise:
    – Fibroids that grow on the inside of the uterus and often distort the uterine cavity are called sub-mucosal fibroids, and often lead to heavy periods, in addition to fertility and obstetric complications
    – Fibroids that grow in the uterine muscle are called intramural fibroids, and can lead to heavy periods and so-called ‘pressure symptoms’
    – Fibroids that grow on the outside of the uterus are called subserosal fibroids. When they do cause symptoms, they tend to cause pressure symptoms

    Question 3
    How should fibroids be investigated?

    Alison: The key investigation for fibroids is a transvaginal ultrasound. A T/V ultrasound should be considered for any woman who presents with symptoms suggestive of fibroids, such as:
    – Heavy menstrual bleeding
    – Prolonged periods (ie. periods lasting more than seven days)
    – Trouble conceiving
    – Miscarriage
    – Abdominal distension
    – Urinary frequency
    – And / or constipation

    A good quality T/V ultrasound will outline:
    – The number of fibroids
    – Each fibroid’s size, type (ie. sub-mucosal, intra-mural, or sub-serosal), and laterality (whether it is on the left, right, front, or back side of the uterus)

    This information helps to clarify to what extent a patient’s symptoms can be attributed to their fibroids.

    It also helps to guide us, as gynaecological surgeons, as to how best to excise the fibroids: using a vaginal approach and hysteroscopy for submucosal fibroids, using keyhole surgery (ie. a laparoscopic myomectomy) or even an open approach (via a laparotomy) if needed.

    If a basic transvaginal ultrasound doesn’t provide this level of detail, we (gynaecologists) may order a higher-quality ultrasound, through a radiology practice that specialises in women’s imaging.

    In some circumstances, an MRI may be needed. Indications to order an MRI include:
    – If the patient has huge or numerous fibroids, such that the ultrasound waves from a transvaginal probe can’t penetrate far enough way to provide detailed information about all of a patient’s fibroids. If this is the case, a good ultrasound report should suggest in its conclusion that an MRI may be beneficial
    – Any suspicious findings on ultrasound, suggestive of an underlying malignancy marauding as a fibroid
    – A patient who declines a transvaginal ultrasound
    – Morbidly obese patients, in whom a transvaginal ultrasound has proven inadequate

    In addition to ultrasound +/- MRI, an endometrial biopsy is needed, if the patient has heavy menstrual bleeding. It can sometimes be challenging to differentiate on imaging between a benign fibroid and uterine cancer, and uterine cancer often presents with abnormal uterine bleeding. Hence, when we’re seeing a patient with fibroids and heavy periods, we gynaecologists will often perform an endometrial biopsy in the rooms.

    So in summary:
    – transvaginal ultrasound is vital when investigating fibroids.
    – Pelvic MRI is occasionally indicated
    – and gynaecologists should consider performing an endometrial biopsy for any woman who has heavy periods, in whom uterine cancer needs to be excluded.

    Question 4
    What are the treatment options

    Alison: Broadly speaking, treatment options can be broken down into:
    – Expectant management
    – Symptomatic management
    – Medical management
    – Interventional radiology
    – and surgery,
    which I’ll talk through in turn.

    There are several factors that gynaecologists take into consideration, when discussing management options with patients. These factors include:
    Whether or not the patient has symptoms
    – The severity of those symptoms
    – What management has already been trialled
    – Where the patient is at, in terms of menopause: are they pre-, peri- or post-menopausal?
    – Whether or not the patient wants to retain their fertility
    – Whether or not the patient wants to retain their uterus

    This may seem like a strange distinction, but some women feel strongly about retaining their uterus, even when their childbearing years are a thing of the past. There may be underlying cultural beliefs that she will feel like ‘less of a woman’ if she has a hysterectomy.

    First off: expectant management. This is appropriate for women who have asymptomatic fibroids. (For example, they may have had some fibroids found on imaging which was performed for another indication.) Of note, the American College of Obstetrics and Gynaecology considers that asymptomatic fibroids warrant surgical excision if they are of “significant concern” (quote unquote) to the patient. This would principally be to definitively exclude a uterine cancer marauding as a benign fibroid.

    Expectant management may also be appropriate if a patient is peri-menopausal. If the patient has mild symptoms, and they want to avoid more aggressive management, they may want simply to ‘ride it out’ until they go through menopause. After menopause, fibroids tend to shrink down and any related symptoms improve.

    As to what expectant management involves? The jury is out. The American College suggests an annual ultrasound, in order to detect any abnormal growth or suspicious changes. For anxious women in particular, this would be prudent.

    Moving on now to symptomatic management, which I imagine is bread and butter for GPs. For example, women who have heavy periods and resultant iron-deficiency anaemia warrant either oral and / or IV iron supplementation.

    It’s normally at this point in proceedings that a GP refers a patient to see us gynaecologists, for consideration of medical management, interventional radiology and / or surgical excision.

    In terms of medical management, first-line medical management includes some combination of:
    – Tranexamic acid which lightens periods by about 40%
    – The combined oral contraceptive pill, which lightens periods by about 50%
    – And / or a Mirena IUD, which lightens periods by about 80%

    Second-line medical management includes a six-month course of a GnRH agonist, such as goserelin (‘Zoladex’) monthly injection or nafarelin (‘synarel’) BD nasal spray. These medications put women into a temporary menopause. This has several benefits, including:
    – Stopping their periods, which enables iron stores to build up pre-op
    – And shrinking fibroids by about 40%, which may help to relieve pressure symptoms temporarily

    The down-sides of ‘Zoladex’ and ‘Synarel’ are menopausal side-effects, such as hot flushes, and the potential for irreversible osteoporosis if taken for longer than six months. These risks can be mitigated by prescribing an add-back medication such as ‘tibolone’ to be taken at the same time, which adds back a smidge of oestrogen to minimise the hot flushes.

    Interventional radiology options for fibroids include uterine artery embolisation (or UAE). Similar to a coronary angiogram, this procedure is performed by interventional radiologists via vascular access at the patient’s groin. The arteries supplying the offending fibroids are identified, and an embolic agent introduced to block off that blood supply. The fibroids will then undergo ischaemic necrosis, and related symptoms should slowly resolve over the following months.

    Moving on from IR to surgical management, which involves an operation to either remove the fibroids and retain the uterus (a ‘myomectomy’), or an operation to remove the uterus and fibroids en bloc (a ‘hysterectomy’). Myomectomies can be performed through the vagina (for submucosal fibroids), laparoscopically, or using an open approach.

    From a GP’s point-of-view:
    – Please start iron supplementation and TXA in any patients with fibroid-related heavy menstrual bleeding and iron deficiency
    – Then refer any patients with symptomatic fibroids to your preferred gynaecologist. We can then work out which management options are appropriate, and talk the patient through the pros and cons of those options.

    Question 5
    Have there been any developments in the management of fibroids over the last few years?

    Alison: Two things that spring to mind are: the development of a polypill for fibroids; and the widespread adoption of contained extraction systems to remove large fibroids through small keyhole surgery excisions.

    First off: the holy grail of the medical management of fibroids – a tablet that shrinks fibroids, improves heavy periods, and can be taken indefinitely. The medical management I’ve already mentioned (iron supplements, the contraceptive pill, tranexamic acid) helps manage heavy periods, but doesn’t actually treat the root cause – problematic sub-mucosal fibroids, which will continue to grow.

    A new medication was released onto the local market in late 2023, which combines three different active ingredients: relugolix, estradiol, and norethisterone. Relugolix is a GnRH antagonist, which puts women into a temporary menopause, leading to both temporary cessation of periods, and shrinking of fibroids. The oestradiol helps mitigate the related hot flushes, and the norethisterone protects the endometrium from what would otherwise be unopposed oestrogen. Sold under the brand name ‘Ryeqo’ (which is spelt R Y E Q O), this once-daily tablet is licensed for women of reproductive age who experience moderate to severe fibroid-related symptoms. Unlike GnRH agonists ‘Zoladex’ and ‘Synarel’, Ryeqo can be taken indefinitely until menopause. Bone mineral density is maintained (at least in the medium-term studies completed to date). The main downside of Ryeqo is the out-of-pocket cost, which is approximately $130 per month.

    The second recent innovation has been the development of so-called ‘contained extraction systems’, which enable us keyhole surgeons to safely remove large fibroids through small laparoscopic incisions. Basically, we shell the fibroid out from the surrounding uterine muscle laparoscopically, then place it into a bag in the patient’s abdomen. We bring the bag and fibroid up to the umbilical incision, then chop the fibroid up into small pieces and remove it. Having the fibroid contained inside a bag during that process theoretically reduces the risk of small fragments of fibroids being flung around the abdominal cavity.

    Question 6
    Are there any warning signs a GP can look out for?

    Alison: One risk that is always in the back of our minds is that what is thought to be a benign fibroid on ultrasound actually turns out to be a rare form of uterine cancer, called a leiomyosarcoma (or LMS). While rare, it can be quite hard to differentiate between fibroids and LMS on ultrasound.
    Warning signs that make LMS more likely include:
    – Increasing age, particularly if a “fibroid” (quote unquote) is getting larger after menopause
    – The patient having a history of pelvic radiation (eg. radiotherapy for bowel cancer)
    – African ethnicity
    – Tamoxifen use
    – Any suspicious findings on ultrasound

    As benign gynaecologists, if there are any concerns about possible malignancy, we would routinely order a pelvic MRI, and a serum lactate dehydrogenase, then liaise with our gynae-oncology colleagues, who may deem it appropriate to take over management.

    Question 7
    What is the likelihood of fibroids recurring?

    Alison: Certain women seem to be prone to fibroids, for the reasons mentioned previously, many of which are unmodifiable risk factors: African or Asian ethnicity, increasing age, early menarche etc. Hence, fibroids do tend to recur in these women.
    Even if women have had a myomectomy, we can never guarantee that we have removed all of their fibroids. We can remove the obvious fibroids, but there are likely to be many microscopic little seeds of fibroids that we can neither see nor feel, that will continue to grow until the woman goes through menopause.

    Question 8
    When should a GP refer?

    Alison: Any woman who is troubled by fibroid-related symptoms would benefit from talking through their options with a gynaecologist. Even asymptomatic women may want to undertake surgical excision, as this is the only way we can be sure that what has been seen on ultrasound is definitely a benign process.

    Question 9
    What role does the GP play in the treatment of the condition?

    Alison: There are several ways that GPs can play a vital role in helping women manage their fibroids. These include:
    – Requesting a transvaginal ultrasound for any woman with possible fibroid-related symptoms (eg. heavy periods, abdominal distension, fertility issues)
    – Initiating symptomatic management of heavy menstrual bleeding (eg. iron supplementation)

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on fibroids.

    Alison: 1. Transvaginal ultrasound is the cornerstone investigation for fibroids. If a basic ultrasound doesn’t provide detailed information about the number, size and location of fibroids, please request a detailed ultrasound through a provider that specialises in women’s imaging.

    2. Fibroids should shrink down after menopause. A “fibroid” (in inverted commas) that continues to enlarge after menopause may actually be a malignancy, and warrants immediate referral to a gynaecologist.

    3. The size and location of fibroids determines not only the patient’s symptoms and signs, but also the appropriate surgical approach: hysteroscopy for submucosal fibroids, and laparoscopic or open for intramural or subserosal fibroids.

    Thanks for your time and the insights you’ve provided.

    Alison: Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.