Fibroids

A graduate from the Obafemi Awolowo University in Nigeria, Mr. Odejinmi became a consultant in the UK in 2001, having trained at the Royal London and St Bartholomew's hospital, the Royal Free, and the University College hospitals in London. His current NHS Practice is at Whipps Cross University Hospital , where he is the lead Gynaecologist within the department. He sees private patients at Holly House hospital and the BUPA Roding Hospital in Essex. He has a special interest in advanced Laparoscopic (Keyhole) surgery.

Fibroids are the commonest benign tumour (growth) of the female genital tract. They are present in up to 25-30% of the population, being 2-3 times more common in Afro-Caribbean women, and tend to occur at an early age. They tend to occur in women who have not had children and in those who are overweight.

Uterine Fibroids
Fibroid	Fibroids at Laparoscopy	Different Locations of Fibroids

The cause of fibroids is unknown but it is thought they are due to a number of interacting factors: genetic, hormonal and environmental. Fibroids tend to run in families and where they do, cause similar symptoms.

The majority of fibroids do not cause symptoms, but where they do they may cause

This is the presenting symptom in up to 25% of women, though a direct relationship between the two cannot always be demonstrated, and sometimes removal of the fibroids may not improve fertility. It has been shown however that removal of fibroids that interrupt the cavity of the womb and interfere with implantation does improve fertility.

Fibroid symptoms sometimes depend on their size and location

Locations include:

When women have symptoms as described above or are unable to conceive they should seek advice from a specialist through their general practitioner. In the first instance they will need to have a pelvic examination and depending on the findings will need to have further tests.

Investigations

The first investigation is usually a blood test to indirectly investigate iron levels as heavy bleeding from fibroids may lead to anaemia. Women are often then sent off for an ultrasound scan that will help to note the presence of fibroids the location and the size. This is not possible in all cases and in these circumstances an MRI scan may be necessary or women may be advised to have a hysteroscopy; which is a test that can be carried out with or without anaesthetic and involves a “telescope” with a camera inserted into the womb to see inside. A laparoscopy where the “telescope” is inserted through the belly button (umbilicus) is used to visualise the abdominal contents of the pelvis.

Treatment options

As the majority of fibroids are without symptoms, the fact that they are there does not mean that treatment is required. However, for women with symptoms a number of options are available. Treatment depends on the presenting symptoms and the desire for fertility, and is broadly divided into: surgical management, medical management, uterine artery embolisation, or ultrasound treatment.

Historically an hysterectomy was the definitive management of fibroids but for the majority of women uterus conserving treatment is available.

Myomectomy: this involves the removal of individual fibroids. This can be carried out either through a cut on the “tummy” (abdomen) or if there are not that many or they are not that large it can be carried out with the laparoscope. The laparoscopic approach has the advantage of an earlier recovery, less need for pain killers and less risk of adhesion formation (adhesions occur in up to 90% of women who have the conventional operation compared to 43% of women with the laparoscope) Adhesions are scar tissue which forms between tissues as a result of an operation. For some women these adhesions may be severe and in themselves lead to infertility if they affect the tubes.

Sometimes when the fibroids are within the cavity of the womb it is possible to remove them with the hysteroscope this is usually done as a day case procedure but sometimes requires more than one occasion to remove the fibroid completely. For appropriate women this has been shown to increase the chances of pregnancy and for those who have had recurrent miscarriages it is also helpful.

Where surgery is performed for heavy periods 80% of women improve, for fertility and up to 60% of patients conceive in the first year. However, up to 10% of women will have no alleviation of symptoms and between 10-20% of women may need to have a hysterectomy within 5 to 10 years because of either recurrence of fibroids or recurrence of symptoms.

For women who have completed their families and have disturbing symptoms from fibroids, an hysterectomy may be the treatment of choice particularly for heavy periods as it has a 100% success rate and there is no risk of recurrence of fibroids.

In women where fertility is not an immediate issue, medication is available to shrink the fibroids. The advantage of this is that women avoid an operation; however the fibroids only shrink, remain in place and may increase in size when the medication is stopped. Medication is also limited by side effects. If contraception as well as treatment for fibroids is desired a Mirena intrauterine system may be used. This is like a “coil” (intrauterine contraceptive device) but contains hormones that are known to shrink fibroids and only needs to be changed every 5 years.

This is another technique for shrinking fibroids. With this procedure the blood supply to the fibroids is cut off under radiological guidance. It relieves symptoms in up to 80% of women and shrinkage of fibroids is by 40-60%. Complications include pain, infection and vaginal expulsion of fibroids to mention a few. Though pregnancy has been reported after this procedure it is not primarily aimed at women who desire pregnancy.

Although alternative therapies are under investigation none have been shown to have significant effect. A healthy diet including fruit and vegetables is beneficial and women who are overweight are advised of the benefits of weight loss.

‘In the UK, for those coming into the profession today, times have changed and so has the face of post graduate medical education.” says Mr Odejinmi. “This makes it increasingly difficult now to embark on a career in obstetrics and gynaecology, but for those with UK experience and postgraduate medical qualifications, it is still possible to get into the system. It also helps if you have participated in research or published.”

Mr Odejinmi recently returned from the Sudan where he was involved in the first ever advanced laparoscopy course, imparting advanced laparoscopic skills to consultant gynaecologists in Sudan. A similar programme is planned for Nigeria later this year.

Mr Jimi F Odejinmi
Consultant Gynaecologist and Obstetrician
Whipps Cross University Hospital London
Dr_jimi_gynaecologist@yahoo.co.uk