Fibroids in plain language
Fibroids are non-cancerous growths of the muscle of the womb. They are very common, particularly from the late thirties onwards, and many women have them without knowing. They range from the size of a pea to the size of a melon, and they are named by where they sit in the womb, which affects both the symptoms they cause and the way they can be treated.
- On a stalk (pedunculated)
- Cavity of the womb
- Within the muscle wall (intramural)
- On the outer surface (subserosal)
- Bulging into the cavity (submucosal)
- Cervix (neck of the womb)
Symptoms
Many fibroids cause no symptoms. When they do, the most common are:
- heavy or prolonged periods, sometimes leading to anaemia and tiredness
- a feeling of pressure, swelling or fullness in the lower abdomen
- needing to pass urine often, or constipation, from pressure on the bladder or bowel
- pelvic pain or pain during sex
- difficulty conceiving or miscarriage, particularly with fibroids that bulge into the cavity of the womb
How I assess fibroids
I begin with your history and, with your permission, an examination. At Parkside Hospital and the CRP Clinic I can perform an ultrasound scan during the consultation, so we can usually discuss what it shows at the same visit. The scan shows how many fibroids there are, their size and their position. Before surgery, and particularly for large or numerous fibroids, I usually arrange an MRI scan to map them precisely and to look for features that need further thought.
Treatment options
The right treatment depends on your symptoms, the size, number and position of the fibroids, whether you hope to become pregnant and your own preferences. I will set out each reasonable option, including no treatment, give you my recommendation and leave the decision with you.
- No treatment. If fibroids are not causing problems, regular review may be all that is needed.
- Medical treatment. Non-hormonal medicines that reduce bleeding, hormonal treatments including the hormonal coil, and medicines that temporarily shrink fibroids before surgery can help, depending on the type and position of the fibroids.
- Hysteroscopic removal. Fibroids that bulge into the cavity of the womb can often be removed through the cervix with a hysteroscope, without any incisions on the abdomen. You can read more on the hysteroscopy page.
- Myomectomy. Removing the fibroids while keeping the womb, by keyhole, robotic or, occasionally, open surgery.
- Uterine artery embolisation. A procedure carried out by an interventional radiologist, which blocks the blood supply to the fibroids so that they shrink. I can refer you to discuss it.
- Hysterectomy. For women who do not want a future pregnancy, removing the womb, usually by keyhole surgery. It ends periods and the symptoms that come from fibroids in the womb, although it does not treat pain from other causes. The hysterectomy page explains the choices.
Large and complex fibroids
Many women are told that their fibroids are too large or too numerous for anything other than open surgery, or that a hysterectomy is the only option. Complex cases of this kind are a large part of my practice, and I am often able to offer a keyhole or robotic myomectomy instead.
Robotic surgery is particularly helpful here, and it is my preferred approach for myomectomy. The Royal College of Obstetricians and Gynaecologists notes that robotic surgery is well established for myomectomy, and that surgeons prefer it for complex operations [9].
The three-dimensional view, magnified up to ten times, and the wristed instruments allow me to remove fibroids deep in the wall of the womb and then repair the muscle carefully in layers, which is important for its strength in any future pregnancy. Whether keyhole surgery is possible depends on the size, number and position of your fibroids, and I will tell you honestly what your scans show.
Morcellation: the risks and how I reduce them
To remove a large fibroid through small incisions, it is cut into smaller pieces (morcellation). This carries risks that you should know about, and they are the reason for the precautions I take.
Rarely, something that appears to be a fibroid turns out to be a cancer of the muscle called a sarcoma. Tests before surgery cannot rule this out completely.
The risk rises with age. For women under 50, it is between about 1 in 1,250 and 1 in 300; for women aged 50 to 59, between about 1 in 300 and 1 in 160; and for women aged 60 and over, between about 1 in 280 and 1 in 65 [10]. The ranges are wide because the studies behind them differ. The risk is higher around and after the menopause, which on average comes at about 51.
When a hidden sarcoma was cut up without a bag, the cancer was more likely to come back inside the abdomen: in about 4 in 10 women, compared with about 1 in 10 when it was removed whole. More women died of it too, although these studies were small [1].
Small pieces of fibroid left behind can also attach inside the abdomen and grow, often several years later (parasitic fibroids). A review of the published cases found this in between about 1 in 1,000 and 1 in 100 women after morcellation [2]. Fragments of the lining of the womb can be spread in the same way: after morcellation without a bag, another review found new endometriosis in about 1 in 70 women [3]. These are less serious than a cancer, but can need another operation.
Parasitic fibroids can also form without any surgery, from a fibroid on a stalk that takes a blood supply from nearby organs, and we have published such a case [4].
For all these reasons, I only cut up fibroids inside a protective bag, which keeps the pieces together (contained morcellation). We moved early to this, around 2014, when the US Food and Drug Administration (FDA) first warned that cutting up the womb or fibroids without a bag could spread a hidden cancer. In 2020 the FDA advised that this should only ever be done inside a bag [5].
In the two trials of cutting up fibroids inside a bag at keyhole myomectomy, no tears in the bag were reported, although both trials were small [6]. The bag reduces, but does not remove, the risk of spreading tissue.
In 2018 a colleague and I surveyed hospitals across the UK on how they assess and explain these risks [7]. We found that practice varied, which is why I take these precautions so seriously.
UK guidance advises against morcellation for women over 50 or after the menopause, when the risk is higher [10]. Before you decide, I will explain how the risk applies to you, taking into account your age, your scans and any concerning findings, and discuss other ways of removing the tissue if morcellation is not suitable.
Adenomyosis
Adenomyosis, in which tissue similar to the lining of the womb grows into its muscle wall, causes similar symptoms to fibroids, such as heavy, painful periods, and the two often occur together. It is treated differently, and the adenomyosis page explains how it is diagnosed and treated.
What surgery involves and recovery
A keyhole or robotic myomectomy is carried out under general anaesthetic through several small incisions. I remove the fibroids, repair the muscle of the womb and then remove the fibroid tissue through one of the incisions using contained morcellation. Most women stay one night in hospital and return to desk-based work after about three to four weeks, avoiding heavy lifting for around six weeks.
The main risks are bleeding, which occasionally needs a blood transfusion, infection, injury to nearby organs and, rarely, the need to convert to open surgery or, very rarely, to remove the womb to control bleeding.
In rare cases, a hernia can form at one of the small incisions. A case report by my colleagues and me shows how serious this can be: after a keyhole myomectomy, a hernia at one of the small incisions caused a blockage of the bowel [8].
Because of cases like this, I take particular care closing the incisions, especially the larger one at the navel through which the fibroid tissue is removed. I close the strong layer of the abdominal wall beneath it (the sheath) with extra-strong, long-lasting dissolvable stitches, to help prevent a hernia. I will explain how these risks apply to you.
If you hope to become pregnant, I will advise you on how long to wait and on whether a planned caesarean birth would be wiser.
The womb tearing in a later pregnancy (uterine rupture) is rare after a myomectomy: a review of 31 studies covering more than 13,000 pregnancies found it in about 3 in every 1,000, with no difference between keyhole, robotic and open operations, although the chance appears higher when the cavity of the womb was opened during the operation [11]. Careful technique, and in my experience the precision of the robot, reduce the chance of opening the cavity; when it has been opened, that is one of the reasons I sometimes advise a planned caesarean.
