In this episode of PodMD, Obstetrician and Advanced Gynaecological Surgeon Dr Nargis Noori will be discussing the topic of uterine fibroids. We discuss what a fibroid is, the different types of fibroids, causes of fibroids, and more.
- Transcript
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*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 back to the PodMD studio Dr Nargis Noori.
Dr Noori is a Minimally Invasive Obstetrician and Advanced Gynaecological Surgeon providing care in Westmead.
After graduating with Honours in Medical Science, Nargis completed her medical degree at the University of Sydney. She then pursued specialist training in Obstetrics and Gynaecology through placements at Nepean Hospital, Westmead Hospital and Orange Base Hospital. Dr Noori has broad clinical experience in managing a variety of patients with complex conditions.
She is dedicated to offering her patients an experience rooted in empathy and understanding, consistently prioritising exceptional care in pregnancy and gynaecological health.
*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.
Today we’ll be discussing the topic of uterine fibroids. Nargis, thanks for talking with us on PodMD today again.
Nargis: Thank you again for having me.
The topic of today’s discussion is uterine fibroids. Nargis, can you describe for our listeners what a fibroid is?
Nargis: Sure. So fibroids are non-cancerous, usually, births within the muscle wall of the uterus. Women usually develop fibroids during their reproductive years. And it’s estimated that up to 80% of women will develop fibroids at some point. It’s important to know majority will be asymptomatic and majority are benign.
Question 1
Perfect. And what are the different types of fibroids?Nargis: Fibroids can be classified depending on their location within the uterus. So, there’s four types really that we see. Subserosal fibroids, these grow on the outside surface of the uterus. They’re usually not connected to the endometrium and as they get bigger, tend to cause more of the pressure symptoms that we see in patients.
The same goes with pedunculated fibroids. These grow as a completely separate attachment to the uterus, usually attached to the uterus by a vascular stalk.
Submucosal fibroids grow on the inside of the uterus, so within the endometrium. These, when they get quite large, can cause a lot of issues with either fertility or heavy menstrual bleeding.
And intramural fibroids, which grow on the muscular wall of the uterus. As they get bigger, they can also have a submucosal component depending on how big they actually end up getting.
Question 2
And what causes fibroids, Nargis?Nargis: So the exact cause of fibroids is still quite unknown. However, we do think hormones, including estrogen and progesterone, will promote their growth. There are definitely some people who are more at risk of developing fibroids. So for instance, those who are at the later end of their reproductive years, like 35 and over, patients who have started their periods at a younger age than average, those who have never been pregnant, so nulliparous women, and obesity seems to be another risk factor for getting fibroids.
Question 3
What are some fertility or pregnancy-related risks?Nargis: Most women with fibroids are able to become pregnant and have a completely normal pregnancy. And I think that’s quite important to note as we do see a lot of patients with fibroids in early pregnancy or in the preconception space that are quite worried about whether or not they need treatment for them. Those that have infertility as a result of fibroids are usually secondary to the size and the location of the fibroid. So in particular, those submucosal fibroids that take up majority of the cavity, we definitely see a lot of issues with both fertility and in the pregnancy stages.
The main risks that we see when patients are pregnant with fibroids include so early miscarriage, again, if there’s a large, if they’re large enough and if they’re impinging on the endometrial cavity. There are risks with premature labour and premature birth for the same reason. We also see an increased risk of malpresentation, so babies that are in breech or transverse or oblique positions, again, due to the fibroid distorting the endometrial cavity. In these circumstances, this then increases your risk of needing a cesarean section.
And then for those patients that end up having a cesarean section, depending on, again, where the fibroid is and how big it is, the caesarean section itself can be a little bit more complicated or increased or associated with increased risk of bleeding. And I guess the other risk in pregnancy with fibroids is pain. So, a lot of the times what we end up seeing is something called degenerative pain, as the fibroid is not getting as much vascular supply because of the pregnancy. This causes a lot of pain and we’re quite limited with the analgesia that we’re able to prescribe for these patients as well.
Question 4
Are there any treatment options to shrink the size of fibroids?Nargis: So there are ways of shrinking the fibroid. However, these modalities, unfortunately, are not always able to be offered to all patients for various reasons. So GnRH agonists like Zoladex can shrink fibroids. However, their major limitation is the side effect profile, and they’re mainly used preoperatively. So a lot of the time with large fibroids that we end up doing myomectomies on, I would prescribe a GnRH agonist for about three months prior just to make it a little bit smaller to make the myomectomy somewhat easier.
The other modality that can treat fibroids or help that’s a little bit less invasive is uterine artery embolisation. So this is performed by interventional radiologists, and it’s also important to note that not all interventional radiologists do this, so it can be a little bit tricky with respect to an access point of view. This in itself has some disadvantages as well. For example, we do see that some patients have more pain as a result of uterine artery embolisation. Also, there is this potential risk because you’re affecting the vascular supply to the fibroid that you end up affecting the supply to the ovaries and causing a primary ovarian insufficiency type picture. So again, it’s not really a great option for young patients or fertility patients.
So there are some avenues for shrinking the fibroid. They’re not long-term solutions, unfortunately, and it’s important that we counsel the patients about their side effects and risks. and then take a very individualised approach depending on their goals of treatment.
Question 5
And when should a GP refer?Nargis: I think like with many conditions, referral is dependent on the severity of the symptoms and other associated issues. So the big one that we tend to see is heavy menstrual bleeding. So fibroids, again, especially the intramural or submucosal fibroids that cause heavy bleeding, especially those that don’t respond well to hormonal therapy, definitely warrant a referral. Patients with severe pressure symptoms, so this is due to the size of the fibroids, they can present with pain. A change in bowel habit, if the fibroid is kind of putting pressure on the bowel, whether that’s constipation or pain during a bowel motion. Issues with bladder control, whether it’s incontinence, urgency or frequency, I think they definitely warrant specialist review.
A growing fibroid can be of concern, especially in older women. Although the risk of sarcoma in a fibroid is very low, this risk does slowly increase with age. And I guess infertility is the other big reason for referral, especially in the context of a known fibroid. If they’ve had issues with falling, with conceiving, sometimes it might be worthwhile looking to see if the fibroid is contributing and whether something like a myomectomy would be beneficial in that patient.
Question 6
Perfect. 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 uterine fibroids?Nargis: Sure. Thank you again for having me. I think fibroids are, it’s important to note that fibroids are very common, but they are often silent, and recognising how common and usually benign they are helps reduce unnecessary anxiety around the diagnosis.
The other important thing to note is that symptoms do depend on the size and the location of the fibroid. So intramural or submucosal fibroids can cause heavy bleeding, whereas the subserosal or pedunculated ones might cause more of a pressure type symptom. And the majority of them may be completely asymptomatic, so I think understanding this distinction can help guide when to seek specialist referral.
And finally, I think as with most things, management needs to be very individualised and treatment will depend on symptoms, fertility goals, and the fibroid’s characteristics.
Thanks again for your time and the insights you’ve provided, Nargis.
Nargis: No problem. Thank you.
