The cause is unknown, but seems to respond to the hormones estrogen and progesterone; Fibroids may grow with time or shrink. 

The symptoms are normally heavy bleeding during periods, abdominal heaviness and pain. In large fibroids pressure on the bladder or rectum causes difficulty in urination or constipation respectively. If the woman has no symptoms, nothing need be done, but to observe and follow the patient. During the menopause symptoms will usually become less apparent, or disappear.

When treatment is necessary it may be in the form of medication or surgery.

Medication:

GnRHA – is used only temporarily prior to surgery so as to improve the anaemia status or around the menopausal age group, to tide over the crisis.

GnRHA (gonadotropin released hormone agonist), makes the woman's body produce much lower quantities of estrogen, which makes the fibroid shrink.

Other drugs may be used to treat symptoms of fibroids; however, they are less effective for larger fibroids. These include:

1.       Tranexamic acid – These are taken by the patient from the day of menstrual period starting for up to 4 days.

2.       Anti-inflammatory drugs (mefanamic and ibuprofen) - these medications are taken for a few days during the patient's menstrual period.

3.       The contraceptive pill

4.       LNG-IUS (Levonorgestrel intrauterine system) - this is a plastic device which is placed inside the uterus. LNH-IUS releases progestogen hormone. This hormone stops the lining of the uterus from growing.

5.       There are other medications under research for decreasing the size of fibroids

 Surgeries to treat fibroids:

 1)      Endometrial resection and/or ablation -  Endometrial resection and/or ablation - A small telescope (hysteroscopy) is passed through the cervix, allowing access and visualization of the uterine cavity. If no sub-mucous fibroids or polyps are present, laser or more commonly, electrical energy can be applied to the endometrium, thus destroying the tissue lining the uterus and sealing the blood vessels. The commonly used device, a rollerball is used to roll over the endometrium as the energy is being applied, and the degree of success varies depending upon the operator's skill level. The percentage of women who will never bleed again varies from a reported 30 percent to about 70 percent; while 5-10 percent of procedures may fail, the rest of the patients will experience a significant a decrease in the menstrual flow.

 
Actual removal of the uterine lining (endometrium) is called endometrial resection and if this procedure is accompanied by immediate ablation, the one year amenorrhea rate is reported between 75-89 percent.

2)      Hysterectomy – Is a surgery which involves removing the uterus. This is considered only if the fibroids are very large. Hysterectomy is the surgical removal of the uterus (and fibroids), commonly performed surgical procedure in the treatment of fibroids for those who are done with creating a family and above forty years. Previously done by conventional open surgery or vaginally, now with advanced technology, the removal of uterus or fibroids is simplified with laparoscopy, even if they are very huge. The surgery is done using the laparoscope and small accessory instruments inserted through tiny incisions, because of which the post-operative pain is very much lessened and recuperation, faster.

Advantages of laparoscopy over open surgery

• Small incision: less pain and short recovery time, wounds heal quickly. There is less scarring with better cosmoses.
• The pain is less, so there is less administration of pain medication.
• Reduced bleeding and need of blood transfusion is negligible.
• Two to three days’ stay in the hospital after surgery. Few are discharged on the same day. This enables the patient to return to normal routine life quickly.
• There is reduced chance of infections and contaminations.
• Hysterectomies have possible side-effects of early menopause.

 3)      Myomectomy - Myomectomy is the surgical removal of the fibroids. This can be accomplished through hysteroscopy, laparoscopy, or open procedure. It is also done for preserving future fertility.

• Laparoscopy Myomectomy: The advantage of this is that patients can go home the same or next day. The use of an electric morcellator to remove the fibroid tissue in long strips has made the surgery speedier.
• Minilap Myomectomy: This is another technique pioneered at our center where large multiple fibroids can be removed through a 2 inch bikini incision. Patients can go home the next day after surgery.
• Hysteroscopic Myomectomy: Submucus fibroids are removed by inserting a hysteroscope through the vagina and an electrical loop is used to remove the protruding part.

In the case of a sub-mucous fibroid, the fibroid is completely cleared till the cavity of the uterus returns to its original shape (sub-mucous resection). The procedure is terminated if the patient wants to maintain fertility, if otherwise, then the rest of the uterine lining is resected and ablated.

This technique is performed in an outpatient setting, carries little risk of serious complications (in experienced hands), there is very little if any post-operative discomfort, resumption of activities is immediate, and costs compared to a hysterectomy is much less.

This technique is performed in an outpatient setting, carries little risk of serious complications (in experienced hands), there is very little if any post-operative discomfort, resumption of activities is immediate, and costs compared to a hysterectomy is much less.

Complications of the surgery include: Blood loss leading to a blood transfusion, scar formation around the uterus  and the possible need for cesarean section (uterine rupture).

The operation will not prevent new fibroids from growing.

 4)      Myolysis or "Myoma Coagulation"- This is a technique whereby symptomatic intramural or subserous (large, pressure-producing) fibroids are treated with either electrical energy through needles, or a laser fiber inserted into the fibroids, laparoscopically. (‘laparoscopic’ means through a telescope/tube inserted through the abdomen as opposed to a ‘hysteroscope’ where the telescope is inserted through the cervix)

5)      Uterine Artery Embolization - this treatment stops the fibroid from getting its blood supply. This is a newly described indication for an old radiological technique, in which a catheter is passed from the groin, up to the level of the uterine arteries. An "interventional radiologist", not a gynaecologist, injects an inert material called "polyvinyl alcohol" which obliterates the blood supply to the fibroid(s), much like tea leaves in a strainer.

At this moment only two facilities have announced their involvement in such an investigational study, one in Philadelphia, the other in Los Angeles. Initial observations would suggest that heavy bleeding is controlled in about 90 percent of patients, the Amenorrhea rate is low (25 percent), and fibroid size reduction varies from about 40-80 percent. The procedure in essence, causes the fibroid equivalent of a massive heart attack!!

Most patients require overnight hospitalization for pain control, after which they are discharged on oral pain medication; the post-operative pain medication is required for 3-10 days. At this point in time, cost can be expensive.

6)      Magnetic-resonance-guided percutaneous laser ablation – not being done in India

7)      Magnetic-resonance-guided focused ultrasound surgery – being done in select centers, is a non-invasive intervention (requiring no incision) that uses high intensity focused ultrasound waves to destroy tissue in combination with MRI, which guides and monitors the treatment.

Conclusion:

About one out of 1000 lesions are or become malignant, typically as a leiomyosarcoma  on histology. A sign that a lesion may be malignant is a growth that occurs after menopause.

Early consultation with the doctor when symptomatic, is important to avoid long term complications.