Uterine fibroids: It not only causes heavy periods but can also affect a woman’s fertility

Chen Liling couldn’t understand why she constantly felt lethargic, breathless, and had heart palpitations. She was then in her early thirties and thought she simply needed to rest more. But her health didn’t improve – it turns out she had uterine fibroids.

A full body check-up in 2015 first revealed she had severe anaemia, likely caused by her heavy periods. She then saw a gynaecologist for help. 

“They found out that I had a very big fibroid that was causing the uterus to bleed excessively every month,” Chen said. Her doctor also discovered several smaller fibroids.

At 31, Chen underwent myomectomy, a procedure involving making an incision at the abdomen, to remove all the fibroids.

The fibroids, however, returned last year, when Chen turned 40. This time, there were five times more fibroids than the first time, combining to make up the size of a five-month-old foetus. The growths filled her whole uterus.

Unlike the previous time where her periods were excessively heavy, Chen’s periods were normal. However, she noticed that her lower abdomen had been getting steadily bigger since the start of the year and becoming very hard to the touch.

The real-estate agent, who is single, also experienced frequent gastric and stomach pain, and bloatedness, from the fibroids pushing her stomach upwards, as well as increased urination from the pressure of the fibroids against her bladder.  

WHAT ARE UTERINE FIBROIDS?

Uterine fibroids are non-cancerous growths consisting of smooth muscle cells and fibrous connective tissue, originating from the muscle layer of the uterus, said Dr Harvard Lin, an obstetrician, gynaecologist and urogynaecologist at Asia Obstetrics & Gynaecology Centre.

The Johns Hopkins Medicine website said that fibroids do not increase a woman’s risk for uterine cancer.

Uterine fibroids appear most commonly in the wall of the uterus, where they can grow larger and stretch the uterus. They can also form outside the uterus, in the middle layer of the uterine wall, and in rare cases, in the cervix.

Fibroids can appear alone or in groups, and range in size, from as small as a grain of rice to as big as a melon, he added.

According to Dr Jessie Phoon, an obstetrician and gynaecologist at Mount Elizabeth Fertility Centre, “one in three women have fibroids”.  

Of the women who have fibroids, the condition goes undetected in 40-60 per cent of them, according to the Singhealth website. This is often because the fibroids pose no problems or show no symptoms.

Some women only discover they have fibroids by accident during a pelvic exam or pelvic ultrasound, said Dr Lin.

Symptoms of uterine fibroids include:

• Heavy or frequent menstruation
• Anaemia from heavy menstruation
• Pelvic pain and pressure on the bladder or bowel, leading to frequent urination or constipation
• Swelling in the lower abdomen caused by larger fibroids enlarging the uterus
• Pain or discomfort during sex
• Lower back pain or discomfort

The doctors CNA Women spoke to said the symptoms and severity of fibroids can vary widely and are dependent on size, quantity and location.

HORMONES AND OTHER RISK FACTORS

Dr Lin said fibroids are most common among women between 30 and 50 years, the reproductive years.

Their cause is likely to be hormonal, said Dr Phoon: “Uterine fibroids tend to grow under a hormonal environment.”

Dr Lin added that as fibroids are oestrogen- and progesterone-sensitive, hormonal fluctuations during your menstrual cycle can affect their size.

Likewise, elevated hormone levels during pregnancy or hormonal medications like oral contraceptives, may increase a woman’s risk of developing fibroids.

Fibroids shrink after menopause when oestrogen and progesterone decrease significantly, but “they can still be an issue, sometimes causing pain and unusual bleeding”, said Dr Lin.

The risk of developing fibroids increases with age, and women who gave birth to their first child at 35 years or older are at a higher risk. Interestingly, women who have never given birth also have a high risk of developing uterine fibroids.

Even though pregnancy is a risk factor in fibroid development, Dr Lin said that some epidemiological studies have found that being pregnant can reduce the risk of fibroids due to the womb shrinking after delivery.

Genetics plays a role too – if your mother had fibroids, you are three times more likely to get them, according to the United States government’s Office on Women’s Health.

A study by the University of California last year found that African-American and East Asian women (those from China, Japan and Korea), have a higher risk of developing fibroids than women of other ethnicities, possibly due to a genetic predisposition that affects how oestrogen is metabolised by the body.

“[Asian women] also tend to develop fibroids at a younger age, and the fibroids that they develop may be larger and more numerous,” added Dr Lin.

Another factor is obesity. The risk could be two to three times greater than average. “Obesity is associated with higher levels of oestrogen, which may contribute to fibroid growth,” said Dr Lin.

THE LINK BETWEEN FIBROIDS AND FERTILITY 

Uterine fibroids may affect one’s reproductive health, said Dr Phoon.

For example, large fibroids located near the fallopian tube or cervix can hinder conception as they physically obstruct the passage of the sperm, Dr Lin explained.

Fibroids located within the uterine wall may alter uterine contractions and impair the movement of sperm, or interfere with transporting the embryo to the implantation site, he added.

At the same time, large fibroids can also cause reduced blood flow and oxygen to the uterine lining, which can impair its healthy development for successful implantation. It can also cause “irregular menstrual bleeding which makes timing of ovulation difficult”, said Dr Lin. 

Removing the fibroid then improves the overall health of the uterus, making it more conducive for pregnancy.

However, not all women who have uterine fibroids will struggle with infertility. If the fibroids are located on the outer surface of the uterus, the chances for a successful term pregnancy are high, said Dr Phoon.

During pregnancy, if a woman’s fibroids get larger, it could lead to an increased risk of a caesarean section as the foetus may not be able to turn head-down for birth.

Other complications include labour not being able to progress, placental abruption (when the placenta detaches from the wall of the uterus, leading to heavy bleeding in the mother and depriving the foetus of oxygen) and even pre-term delivery, Dr Lin said.

TREATMENT FOR FIBROIDS

Besides size and location, treatment options are determined by “the severity of symptoms, the patient’s age and their desire for future fertility”, said Dr Lin.

If the fibroids are small and you have no significant symptoms, your doctor may choose to monitor them for the time being.

Alternatively, non-steroidal anti-inflammatory medication like ibuprofen can be prescribed to relieve menstrual cramps and pelvic pain associated with fibroids.

In some cases, hormonal medication such as progestin-releasing intrauterine devices (IUDs) can reduce menstrual bleeding while gonadotropin-releasing hormone (GnRH) agonists can reduce the size of fibroids, said Dr Lin. These are often used in the short-term to manage symptoms before surgery or during the pre-operative period. 

Non-invasive and minimally invasive options may also be recommended, such as MRI-guided high-intensity focused ultrasound, and uterine artery embolisation (UAE), said Dr Phoon.

The former employs magnetic resonance imaging to locate the fibroids and then uses focused ultrasound energy to heat and destroy them. UAE involves injecting tiny particles into the blood vessels that lead to the uterus. This cuts off blood flow to the fibroids, causing them to shrink.

Surgery is also an option. There’s morcellation, where the fibroid is cut into smaller pieces, enabling it to be easily removed via the vagina, through laparoscopy or small incisions on the abdomen.

In myomectomy, which Chen did, the fibroids are removed while preserving the uterus. “This is used to treat bleeding, infertility, pain and pressure caused by the fibroids, and is an option for women who want to retain their fertility or avoid a hysterectomy,” said Dr Lin.

In severe situations, hysterectomy is the only permanent solution for uterine fibroids. It is a surgical removal of the uterus and may include the ovaries as well.

“This is recommended for women who have large or multiple fibroids, or have severe symptoms that do not respond to other treatments, or in rare cases, women who develop fibroids after menopause,” said Dr Lin.

WILL THE FIBROIDS RECUR?

Both doctors said that uterine fibroids cannot be prevented from forming or recurring.

Besides going for regular pelvic exams, the only things a woman can do is to eat healthily – a diet rich in fruit, vegetables and fibre, and to maintain a healthy body weight, advised Dr Lin.

Ultimately, it would be best to develop a plan with your doctor, allowing him/her to evaluate the situation and determine if fibroids removal is necessary, said Dr Phoon.