Fibroids are very common, non-cancerous overgrowths of the muscle of the uterus. They can cause various symptoms, including heavy periods and subfertility (as discussed in a previous blog post). In addition, fibroids can also cause so-called ‘pressure symptoms’, which include constipation, having to urinate more often, and abdominal distension. Management options for such symptoms include observation, medications, and surgery. Read on for an exploration of these issues, and an outline of what you can do if your fibroids are putting you (and your pelvis) under undue pressure!
What are ‘pressure symptoms’, and which types of fibroids cause them?
Broadly speaking, the three most common types of fibroids are distinguished based on their location in relation to the muscle of the uterus. As you can see in the diagram below:
– Fibroids are white growths, that can occur in various places in relation to the muscle of the uterus (or the ‘myometrium’, shown in red in the diagram below)
– ‘Submucosal’ fibroids grow under the internal lining of the uterine cavity, and can distort the shape of the cavity (causing subfertility and obstetric issues, as discussed in a previous blog post). They can also lead to heavy periods.
– ‘Intramural’ fibroids grow within the muscle of the uterus, and can cause heavy periods; they can also cause ‘pressure symptoms’ if very big / numerous.
– ‘Subserosal’ fibroids grow on the outside surface of the uterus, which is called the ‘serosa’. They can protrude in any direction, for example forwards (pressing onto the bladder), or backwards (pressing onto the large bowel). Subserosal fibroids that are on a thin stalk (like an apple on a stalk) are called ‘pedunculated’ fibroids.
If there are several large intramural and / or subserosal fibroids, the size of the whole uterus can be significantly larger than normal. On average, the size of a uterus that doesn’t have any fibroids is about the size of a clenched fist. As you develop more and more, larger and larger fibroids, the total size of the uterus can get significantly larger: equivalent to being a few months’ pregnant! As an extreme example, the largest fibroid ever removed from a live patient weighed over 46kg!
Depending on how many intramural and / or subserosal fibroids you have, and where they are located in your uterus (eg. front / back / top / sides), they can cause various different symptoms. It’s a bit like the old real estate mantra of “location, location, location”: where your fibroids are located in your uterus impacts on the kinds of symptoms you’re likely to experience.
Fibroids that grow on the back of the uterus, and protrude into the so-called ‘Pouch of Douglas’ (the anatomical area between the back of the uterus and the front of the large bowel) can cause bowel symptoms. When they press onto the large bowel, fibroids can distort the lumen (or internal channel) of the large bowel, and cause constipation. Imagine that the large bowel is cylindrical, like an empty roll of toilet paper. If fibroids press onto this cylinder, distorting its shape and / or limiting its diameter, it can make it hard to force poo through that narrowing. This can lead to constipation, as you need to strain to force poo past this narrow point.
On the other hand, if your fibroids are located at the front of your uterus, they may press onto your bladder (where urine is stored). This may mean you can’t store as much urine as you used to be able to, and you need to urinate smaller amounts of urine more often: what is called ‘urinary frequency’.
Fibroids can (rarely) block the urethra, which is the tube urine goes through on its journey from the bladder to the toilet bowl. If this happens, fibroids can lead to blockage of this outflow tract, and urinary retention (an inability to pass urine).
Pelvic pressure / heaviness
If you have several large intramural and / or subserosal fibroids, the total size of your uterus (whose total dimensions include your fibroids) can be much bigger than normal. A normal uterus without any fibroids is about the size of your clenched fist. Add in several large fibroids, and your uterus may come up above your belly button, or even beyond!
The sheer weight of your ‘multi-fibroid’ uterus can lead to the gradual development of a sense of pelvic pressure. This is often described as a sense of heaviness, or vague discomfort. Imagine having a ten pin bowling ball inside your tummy, instead of a tennis ball, and can envisage how such symptoms develop!
Bloating / distension
Just as a large ‘multi-fibroid’ uterus can press down on your pelvis when you’re upright (causing pelvic pressure and a sense of general heaviness), it can also press forwards onto your tummy wall (towards your belly button). This can lead to a feeling of constant bloating, or ‘abdominal distension’. You may notice that you need to let out your belts to accommodate your larger tummy, or even go up a clothes size or three.
If particularly large, that bowling ball of a multi-fibroid uterus can also press upwards, onto your stomach (where food is digested after it is swallowed). That can limit the space inside the stomach, leading to you feeling ‘full’ after eating less food than you used to be able to – what is called ‘early satiety’.
Rare but extreme symptoms
In extreme cases, the sheer weight of a multi-fibroid uterus can press onto the major blood vessels that sit behind it, and make you prone to forming blood clots within those blood vessels – what is called ‘venous thromboembolism’ (VTE). Worst case scenario, these blood clots can flick off, and be swept into the blood vessels in the lungs, causing blockages there – known as a ‘pulmonary embolus’ (PE).
Very rarely, large fibroids can press onto the ureters, which are the tubes that carry urine from the kidneys into the bladder. This can cause blockage and swelling of the urinary system, which may cause hydronephrosis (swelling of the urine tubes inside the kidneys) or hydroureter (swelling of the ureters).
Broadly speaking, the treatment of many medical conditions can be broken down into ‘conservative’ (or ‘expectant’), medical, or surgical. Fibroids are no exception!
Fibroids tend to shrink down after menopause. So if you are approaching menopause (the average age of which is 52yo), and you have mild symptoms, you may choose a ‘watch and wait’ approach. If your symptoms persist, or you want to confirm that your fibroids are definitely benign (non-cancerous), you may opt for more proactive (medical or surgical) management.
If your fibroids are causing troubling constipation, taking regular laxatives may help. However, this is really just a stop-gap measure, and doesn’t treat the underlying cause of your constipation, which is fibroids pressing onto the large bowel.
Urinating more often
Similarly, if ‘urinary frequency’ is troubling you, you may find scheduling more regular trips to the bathroom to empty your bladder helpful. However, this is really just managing an annoying symptom, and won’t treat the underlying cause of your urinary frequency.
According to Maven Centre’s resident dietician, Dr Steph Pirotta, diet alone cannot ‘cure’ fibroids. However, a well-balanced diet may ease many of the symptoms of your fibroids, or help reduce the risk of them occurring again. Evidence in this area is ongoing, with more robust evidence-based trials needed. To date, research supports having a diet rich in wholefoods (such as fruit, vegetables and wholegrains), low in saturated fat, and with lower alcohol intake of alcohol is recommended. Use of different teas such as peppermint tea, caffeinated drinks like coffee, enjoying dairy or dairy alternatives like soy and inclusion of fish have mixed results. Dietary recommendations are very much dependent on personal circumstance and working with a dietitian in the field of fibroids is the best foot forward.
Management with medicines
Unfortunately, there are no ‘silver bullet’ medicines that can magically solve all of the different problems fibroids can cause. In particular, medical management of fibroids that are causing pressure symptoms is rather limited.
The contraceptive Pill
While the combined oral contraceptive pill (COCP) can lighten periods by about 50%, it doesn’t shrink fibroids, nor slow their growth. So unfortunately being on the COCP won’t help to relieve pressure symptoms.
In late 2022, an exciting new medication was approved by the Australian government’s Therapeutic Goods Administration (TGA). Called ‘Ryeqo’ (pronounced ‘REE-ECHO’), it is a single tablet that is a combination of three different medicines: relugolix (to turn off your ovaries, put you into a temporary menopause, and shrink your fibroids), estradiol (an estrogen supplement, to reduce the hot flushes that can occur with relugolix), and norethisterone (a progesterone supplement, to reduce the risk of endometrial cancer due to estradiol). While a relatively new drug, trials (admittedly sponsored by the company who make ‘Ryeqo’) are promising: 70% of patients stop having periods; the uterus of patients taking ‘Ryeqo’ shrinks by about 15%; and it can be taken indefinitely until menopause. The main downside is the cost: it retails at approximately $135 / month. In addition, there are not yet studies about the possible long-term implications of being on ‘Ryeqo’: watch this space!
Goserelin / nafarelin
So-called ‘GnRH agonists’ are a family of medicines that turn off your ovaries, and put you into a temporary menopause. Goserelin (‘Zoladex’) is given as a monthly injection into your tummy; nafarelin (‘Synarel’) is a twice-a-day nasal spray. GnRH agonists shrink fibroids down by about 40%, so may significantly improve any pressure symptoms.
However, they are really strong drugs, and have significant side-effects (mainly hot flushes). A notable downside is that they can only be prescribed for a total of six months: any longer, and they may cause irreversible osteoporosis. Hence, these medications tend to be used in very specific situations: eg. prior to a planned surgery to remove your fibroids, in order to provide temporary symptomatic relief and / or enable keyhole surgery (rather than requiring surgery through a large cut).
The mainstay of management for fibroids that are causing pressure symptoms is an operation to remove the fibroid(s), with or without also removing your uterus (that contains said fibroids).
Surgical excision is the only way to definitively confirm that your fibroids are, indeed, non-cancerous, as it allows the pathologist (the doctor in the laboratory) to look at your fibroids under the microscope, and confirm that they are benign (non-cancerous).
‘Ectomy’ means ‘cutting out’, and ‘myoma’ is the technical term for a fibroid. So ‘myomectomy’ means surgical cutting out of a fibroid: the uterus is left inside, and you are still able to fall pregnant and carry a baby. As discussed above, fibroids that cause pressure symptoms tend to be ‘subserosal’ (on the outside of the uterus) or ‘intramural’ (inside the muscular wall of the uterus). Hence, surgery to remove them approaches them from above the uterus.
The next decision for you and your gynaecologist to make is whether your myomectomy can be performed using keyhole surgery (a ‘laparoscopic myomectomy’), or whether it needs to be performed through a single large cut in your tummy (an ‘open’ or ‘abdominal’ myomectomy). Gynaecologists take many factors into account to guide this decision, such as: the size of your fibroids; the location of your fibroid(s) (front / back / top of the uterus); the number of fibroids you have; and your gynaecologist’s surgical skills and expertise. This is a very individualised discussion, based on your particular circumstances.
Maven Centre’s advanced laparoscopic gynaecological surgeons, Dr Sneha Parghi and Dr Alison Bryant-Smith have completed additional training, to enable them to perform laparoscopic myomectomy in appropriate patients.
The most definitive treatment option for fibroids that are causing pressure symptoms is hysterectomy: permanent surgical removal of the uterus (and the fibroids contained therein). Clearly, having your uterus removed means that you will never be able to carry a baby. So this should only be considered if you are 110% sure that you will never want to do so.
If you are tossing up between having a myomectomy, and having a hysterectomy, a considered discussion of the pros and cons of each option is needed, with a gynaecologist who can perform both operations. Somewhat counter-intuitively, a laparoscopic hysterectomy (keyhole surgery to remove the whole uterus plus fibroids) is actually a slightly safer operation than a laparoscopic myomectomy (that removes the fibroids and retains the uterus), due to lower average blood loss.
Frequently asked questions (FAQs)
Is there anything you can do to slow the speed with which fibroids grow?
As mentioned above, there is limited evidence that dietary changes may slow the speed with which fibroids grow: for example, optimising your green tea intake. However this will just slow the worsening of your pressure symptoms: it won’t actually make your symptoms any better.
In order to actively shrink your fibroids, strong medications or surgery is needed, as discussed above.
Do fibroids ever shrink of their own accord?
Fibroids grow under the influence of oestrogen (the main female hormone). After menopause, when the ovaries turn off and oestrogen levels plummet, fibroids normally shrink down significantly. Unfortunately, it can take many years for them to shrink down enough for pressure symptoms to improve.
Can all fibroid operations be done using keyhole surgery?
As outlined above, there are various different surgical approaches to remove fibroids: hysteroscopic (through the vagina) for ‘submucosal’ fibroids that impinge on the inside of the uterine cavity; laparoscopic (keyhole surgery); and ‘open’ (or ‘abdominal’) through a single large scar. If your fibroids are causing annoying symptoms, schedule an appointment with a gynaecological surgeon, to discuss which surgical approach is most relevant for you.
Can fibroids cause chronic pelvic pain?
As outlined above, large fibroids can cause a sense of pelvic pressure, heaviness, or discomfort. Very rarely, when they outgrow their blood supply and start to die (due to a lack of oxygen and nutrients, a process called ‘red degeneration’), they can cause several days to weeks of acute pelvic pain.
Fibroids are unlikely to be a cause of chronic pelvic pain (pain that lasts over six months). If you are known to have fibroids, and are experiencing chronic pelvic pain, please consult with your local gynaecologist and / or pain specialist (such as Dr Megan Eddy). Other possible causes of chronic pelvic pain (such as endometriosis) may need to be excluded and / or treated.
Do all fibroids need to be treated?
No! The vast majority of women have many small (< 2cm) fibroids on their uterus by the time they are in their 40s. Your fibroids only need to be treated if they are causing you troublesome symptoms, such as heavy periods, pressure symptoms, and / or fertility or obstetric issues.
As mentioned in this blog post, the only way to guarantee that your fibroids were benign (non-cancerous) is to remove them surgically. Interestingly, the American College of Obstetricians and Gynaecologists (ACOG) supports the surgical removal of fibroids that aren’t causing any symptoms at all, if removing them assuages patients’ anxiety about the fact that their fibroids may actually be cancerous (which is very rare).
Can fibroids be cancerous?
Very rarely, what is thought to be a fibroid on ultrasound may actually be a cancer of the uterine muscle, called a ‘leiomyosarcoma’ (or LMS). The odds of your fibroid actually being a cancer are approximately:
– 1 in 550 (if you are aged between 25 – 29yo)
– 1 in 500 (if you are 30 – 34yo)
– 1 in 370 (if you are 35 – 39yo)
– 1 in 400 (if you are 40 – 44yo)
– 1 in 300 (if you are 45 – 49yo)
– 1 in 210 (if you are 50 – 54yo)
– 1 in 150 (if you are 55 – 64yo)
– 1 in 120 (if you are 65 – 74yo)
– 1 in 100 (if you are 75yo or older)
As you can see, the risk of a ‘fibroid’ actually being cancerous increases as women get older. If you’re worried about your ‘fibroid’ being cancerous, please consult with your gynaecologist about additional testing that can be performed (a ‘lactate dehydrogenase’ blood test and an MRI), and about the pros and cons of surgical excision to confirm that your fibroid is benign.
Fibroids are extremely common overgrowths of the uterine muscle. When they are several big intramural and / or subserosal fibroids, they can cause pressure symptoms such as constipation, urinary frequency, constant bloating, and pelvic heaviness.
If you’re experiencing such symptoms, there is no need to suffer in silence! Please consult with an advanced laparoscopic gynaecological surgeon (such as Dr Alison Bryant-Smith or Dr Sneha Parghi) to discuss your treatment options!
Women experience so many different stressors these days, from career, to family, to societal expectations: don’t let your fibroids add to the other pressures you’re already managing!