Fibromi

Quanto sono comuni i fibromi?

Fibroids are common. It is difficult to know exactly how common they are as many women won't have any symptoms, and so may not know they have fibroids. Probably at least 1 in 2 women develop one or more fibroids in their lifetime, and probably more. They usually develop in women aged 30-50 and can sometimes run in families. It is common to have several fibroids of various sizes, although some women just have one.

Women from an Afro-Caribbean origin usually have a higher risk of developing fibroids. They also tend to be larger, occur at an earlier age and are more likely to cause symptoms in Afro-Caribbean women.

Fibroids are also more common in women who are overweight. This is thought to be due to the higher oestrogen levels that occur in obese and overweight women.

Fibroids can increase in size, decrease in size or even go away with time. They can occur anywhere in the womb and are named according to where they grow:

Intramural fibroids

Questi crescono all'interno del tessuto muscolare dell'utero. Questo è il luogo più comune in cui si formano i fibromi.

Fibromi sottosierosi

Crescono dalla parete esterna dell'utero (grembo) verso il bacino.

Submucous fibroids

I fibromi sottosierosi crescono dalla parete interna verso la cavità dell'utero.

Pedunculated fibroids

Crescono dalla parete dell'utero e vi sono attaccati tramite un peduncolo stretto.

Come appaiono i fibromi?

Utero con fibromi

Fibroid symptoms

Most women who have fibroids are not aware that they have them as they do not have any symptoms. Sometimes one is found during a routine examination (pelvic examination) by a doctor or by chance during a scan which you may have for another reason. Symptoms may include:

Mestruazioni abbondanti o più dolorose

Fibroids do not disturb the menstrual cycle but bleeding is often heavier than usual, sometimes with more pain. This can lead to bassi livelli di ferro e anemia which will be diagnosed by a blood test. This is easily treated with iron tablets.

Bloating or swelling

Se un fibroma è grande, potresti avvertire disagio o gonfiore nella parte inferiore dell'addome. Alcune donne sperimentano dolore lombare a causa dei loro fibromi.

Sintomi della vescica o dell'intestino

Occasionally, a fibroid may press on the bladder which lies in front of the womb (uterus). You may then pass urine more often than usual. Rarely, pressure on the bowel (which lies behind the womb) may cause stipsi.

Dolore durante i rapporti sessuali

Se i fibromi crescono vicino alla vagina o al collo dell'utero (cervice), questo può causare disagio durante i rapporti sessuali.

Miscarriage or infertility

If the fibroids grow into the cavity of the womb they can sometimes block the Fallopian tubes or interfere with implantation. This can cause problems conceiving, although this is not common. Very rarely, fibroids can be a cause of miscarriages.

Problems during pregnancy

Having one or more fibroids does not cause any problems in the vast majority of women when they are pregnant. Occasionally, you may have pain or discomfort from your fibroid. This may be caused by the fibroid growing too large for its blood supply or twisting, if the fibroid has a stalk (also called pedunculated).

However, fibroids can be associated with an increased risk of having a taglio cesareo, the baby lying bottom-first rather than head-first (breech) and early labour. Your doctor will advise you further if you are pregnant and have fibroids.

Cosa causa i fibromi?

A fibroid is an overgrowth of smooth muscle cells, and other cells from the lining of the womb (uterus). The womb is mainly made of smooth muscle. It is not clear why fibroids develop. Fibroids are sensitive to oestrogen and progesterone, the female hormones that are made in the ovary.

Fibroids tend to swell when levels of female hormones are high - for example, during pregnancy. They also shrink when levels are low - after the menopause. This shrinkage of the fibroids after the menopausa may be delayed if you take terapia ormonale sostitutiva (HRT).

See the separate article called What's the link between hair relaxers and fibroids?

Come vengono diagnosticati i fibromi?

Some fibroids can be felt during an internal (vaginal) examination by a doctor. Usually an ecografia is done to confirm the diagnosis and to rule out other causes of any symptoms. If periods are heavy, a blood test would usually be done to check you are not anaemic.

Trattamento dei fibromi

If your fibroids are not causing any symptoms they do not usually require treatment. Many women choose not to have treatment if they have symptoms that are not too bad. After the menopause, fibroids often shrink and symptoms tend to go or ease. You can change your mind and consider treatment options if symptoms become worse. Your doctor may advise you to have a repeat scan to assess the growth and size of your fibroids.

Farmaci per i fibromi

The following medicines are used to treat heavy periods whatever the cause, including heavy periods that are caused by fibroids. Treating fibroids this way can help to ease symptoms. These medicines may not work so well if your fibroids are large. However, one or more of the following may be worth a try if your periods are heavy and the fibroids are small:

Tranexamic acid

This is taken 3-4 times a day, for the duration of each period. Tranexamic acid works by reducing the breakdown of blood clots in the womb (uterus).

Medicinali antinfiammatori

Medicines such as ibuprofen and mefenamic acid. Medicinali antinfiammatori also help to ease period pain. They are taken for a few days at the time of your period. They work by reducing the high level of a chemical (prostaglandin) in the lining of the womb. Prostaglandin seems to contribute to heavy and painful periods.

La pillola contraccettiva orale combinata (COC)

La pillola contraccettiva orale combinata (COC) may help you to have lighter periods and can often help with period pain too. If you are unable to take this, the pillola contraccettiva a base di solo progestinico (POP) may help. Although there is little evidence for the POP, it seems to help, especially if it makes your periods lighter or stops them altogether.

Il sistema intrauterino al levonorgestrel (LNG-IUS)

This is a plastic device that sits inside the womb, originally used as a contraceptive. It is inserted into the womb and slowly releases a regular small amount of progestogen hormone called levonorgestrel. Il sistema intrauterino al levonorgestrel (LNG-IUS) works by making the lining of the womb very thin, so bleeding is lighter. However, it can sometimes be difficult to insert into the womb in women with fibroids.

Progestogen tablets

You can take compresse di progestinico at certain times in your cycle or have the progestogen-only injection. L'iniezione, solitamente utilizzata per la contraccezione, tende a ridurre o interrompere il ciclo mestruale.

Farmaci per ridurre i fibromi

Some women are given a gonadotrophin-releasing hormone (GnRH) analogue. This is a hormone medicine that causes you to have a very low level of oestrogen in your body. Fibroids shrink if the level of oestrogen falls. This can ease heavy periods and pressure symptoms due to fibroids.

However, a low oestrogen level can cause symptoms similar to going through the menopause (hot flushes, etc). It may also increase the risk factor of 'thinning' of the bones (osteoporosi). Pertanto, questo trattamento viene somministrato per un massimo di sei mesi.

GnRH analogues, such as goserelin or leuprorelin acetate, are often prescribed for three to four months before having an operation. This will make it easier to remove fibroids. Sometimes a low dose of HRT is also given to reduce the incidence of menopausal side-effects.

A medicine called ulipristal acetate (UPA) works by blocking the effects of the hormone progesterone. Progesterone is thought to play a role in fibroid development, so (by blocking progesterone) this medicine shrinks fibroids.

The National Institute for Health and Care Excellence (NICE) has recommended a combination drug called relugolix-estradiol-norethisterone acetate as an option for treating moderate to severe symptoms of uterine fibroids in adults of reproductive age.

Relugolix is a gonadotropin-releasing hormone (GnRH) receptor antagonist, so works like the medication above. This is then combined with the oestrogen, estradiol, to reduce symptoms related to lowered levels of oestrogen, and the progestogen, norethisterone, to counteract estradiol-induced thickening of the wall. This combination has been shown to work well in reducing bleeding. It also has other benefits such as:

• Evitare l'intervento chirurgico. Questo preserva l'utero.

• Può essere assunto per via orale.

• Non ha molti effetti collaterali.

Other medication that work as GnRH antagonists, like the above, have recently been approved- it is best to talk to your specialist doctor about whether any of these are appropriate for you.

Chirurgia e altri trattamenti operativi

Esistono diverse operazioni disponibili per rimuovere e trattare i fibromi.

Isterectomia

This is the traditional and most common type of treatment for fibroids which cause symptoms. Isterectomia is the removal of the womb. This can be done by making a bikini line scar in the lower tummy (abdomen). Or, if the fibroids are small enough, the womb can be removed through keyhole (laparoscopic) surgery in the tummy, or through the vagina so there are no scars. A hysterectomy may be a good option for women who have completed their family.

Myomectomy

This is a possible alternative, especially in women who may wish to have children in the future. In this operation, the fibroids are removed and the womb is left. This procedure is not always possible. This operation can be done through a cut (incision) in the abdomen, via keyhole surgery (laparoscopically) or through the vagina (hysteroscopically).

The type of operation depends on the size, number and position of the fibroids. It is fairly common for a fibroid to occur again (recur) after a myomectomy. There is a risk of very heavy bleeding with this operation. Your surgeon should advise you that a hysterectomy may be needed if that situation arises.

Uterine artery embolisation

This procedure is done by a specially trained X-ray doctor (radiologist) rather than a surgeon. It involves putting a thin flexible tube (a catheter) into a blood vessel (artery) in the leg. It is guided, using X-ray pictures, to an artery in the womb that supplies the fibroid. Once there, a substance that blocks the artery is injected through the catheter. As the artery supplying the fibroid becomes blocked it means the fibroid loses its blood supply and so the fibroid shrinks.

Il processo completo di riduzione dei fibromi richiede circa 6-9 mesi, ma la maggior parte delle donne nota un miglioramento significativo dei sintomi entro tre mesi. C'è una buona probabilità di successo con questa procedura, ma quasi una donna su tre avrà bisogno di ulteriori trattamenti.

Myolysis

Ciò significa ridurre i fibromi in qualche modo chirurgicamente. Ci sono diversi modi per ottenere questo, tra cui i seguenti:

• Endometrial ablation: this procedure involves removing the lining of the womb. This can be done by different methods - for example, using laser energy, a heated wire loop or by microwave heating. This method is usually only recommended for fibroids close to the inner lining of the womb. Treatment can be done either through a tube passed through the vagina, or can be guided through the skin by Risonanza magnetica.

• MRI-guided focused ultrasound: this treatment sends pulses of high-power ultrasound through the skin of the lower abdomen. It is targeted at the fibroid, using the magnetic resonance (MRI) scanner. It is effective but there is no research yet on the long-term outcome for women trying to conceive.

• Ultrasuoni focalizzati ad alta intensità guidati da ultrasuoni: questo trattamento è guidato da ultrasuoni.

Morcellation for fibroids

Laparoscopic surgery with power morcellation allows uterine fibroids to be cut into smaller pieces. This allows them to be removed via keyhole surgery. Hysteroscopic morcellation aims to remove submucosal fibroids, using a telescopic instrument inserted into the womb through the vagina.

The National Institute for Health and Care Excellence (NICE) has looked at the risks and benefits of both procedures. They highlight the risk of possible serious complications with both procedures. Therefore they recommend that:

• La morcellazione elettrica non dovrebbe essere utilizzata per le donne che hanno più di 50 anni o sono in postmenopausa.

• For women under 50 or who have not gone through the menopause, power morcellation should not be carried out except in special circumstances.

• La morcellazione isteroscopica dovrebbe essere eseguita solo in circostanze speciali.

Puoi leggere di più sulle raccomandazioni di NICE nella sezione di lettura aggiuntiva qui sotto.

See the separate leaflet called Menorrhagia Surgery for more information.

Quali sono le complicazioni dei fibromi?

Molti fibromi non causano alcun problema di salute. Tuttavia, le possibili complicazioni dei fibromi includono:

• articolo sull'anemia da carenza di ferro due to heavy bleeding.

• Large fibroids may push on the surrounding organs and pressure against the bladder may cause infezioni ricorrenti del tratto urinario (UTI) oppure urinary retention.

• Problems with fertility (this is rare).

• Problems during pregnancy, including aborto spontaneo oppure un travaglio prematuro.

• Twisting (torsion) of a fibroid may interfere with the blood supply to the fibroid and cause severe lower abdominal or pelvic pain.

Qual è il risultato (prognosi)?

The outcome of fibroids is unpredictable. Fibroids tend to persist until the menopause when they usually shrink. Shrinkage may be limited by taking hormone replacement therapy (HRT). A few fibroids may shrink before the menopause.