Understanding Uterine Fibroids
Fibroids are benign smooth muscle tumours of the uterus. They are classified by location - which determines symptoms and appropriate treatment:
FIGO fibroid classification (leiomyoma subclassification):
- Type 0 (completely intracavitary pedunculated submucosal): Protruding into the uterine cavity on a stalk
- Type 1 (partially intracavitary submucosal): >50% in the cavity
- Type 2 (submucosal): <50% in the cavity
- Types 3-5 (intramural): Ranging from abutting the cavity to entirely within the myometrium
- Types 6-7 (subserosal): Projecting towards the serosa - pedunculated or sessile
Symptoms by fibroid location:
- Submucosal (Types 0-2): Heavy menstrual bleeding, irregular bleeding, infertility, recurrent miscarriage - the most clinically significant types for symptoms
- Intramural (Types 3-5): Heavy periods, pelvic pressure, bladder symptoms, dyspareunia; large intramural fibroids impair implantation
- Subserosal (Types 6-7): Pelvic pressure, urinary frequency, constipation; rarely cause heavy bleeding; large pedunculated fibroids occasionally undergo torsion
Fibroid growth: Fibroids are oestrogen-dependent - they grow during reproductive years and typically regress after menopause. GnRH analogues (Zoladex, Decapeptyl) and ulipristal acetate can temporarily shrink fibroids before surgery, improving surgical conditions.
Treatment Options for Uterine Fibroids
Hysteroscopic Myomectomy (for submucosal fibroids Types 0-2):
- Resectoscope introduced through the cervix without any incisions
- FIGO Type 0-1 fibroids: complete resection in a single procedure
- Type 2 fibroids: may require staged resection
- Day case or 1-night admission; return to work in 1-2 weeks
- Highly effective for heavy bleeding and fertility improvement
Laparoscopic Myomectomy (for intramural and subserosal fibroids):
- 3-4 small port incisions; fibroids removed through a morcellator retrieval bag (contained power morcellation for safety)
- Uterine wall meticulously repaired in layers laparoscopically - requires advanced suturing skill
- Preserves the uterus; suitable for women wishing future pregnancy
- Hospital: 1-2 nights; recovery: 2-4 weeks vs. 4-6 weeks open myomectomy
- Fertility outcome: conception rates 50-60% within 2 years post-laparoscopic myomectomy; caesarean section recommended for delivery after myomectomy involving deep myometrial repair
Robotic Myomectomy:
- da Vinci robot assistance for large or multiple intramural fibroids - superior suturing precision for myometrial repair
- Available at select partner hospitals
Open Myomectomy (laparotomy):
- Reserved for: very large fibroids (>15-18 cm), multiple fibroids making laparoscopic morcellation impractical, or when anatomy precludes laparoscopic access
- Pfannenstiel incision; 3-5 nights hospital; 6 weeks recovery
Uterine Artery Embolisation (UAE):
- Interventional radiology procedure: catheter via femoral artery; particles injected into uterine arteries - fibroids devascularised and infarct/shrink
- Fibroid volume reduction: 30-60% at 6 months; symptom relief in 85% of women
- No incisions; 1-2 night admission; return to work: 1-2 weeks
- Not recommended for women planning future pregnancy (risk of uterine ischaemia affecting endometrial receptivity)
- Ideal for women with multiple fibroids, or post-menopausal women seeking alternatives to surgery
Fertility After Fibroid Treatment
Fibroid treatment selection in women wishing to conceive must carefully balance fibroid removal effectiveness against impact on uterine integrity and endometrial function:
Hysteroscopic myomectomy:
- Best option for submucosal fibroids impairing implantation
- No effect on uterine wall integrity - no restriction on subsequent delivery mode
- Improves clinical pregnancy rates in women with submucosal fibroids undergoing IVF
Laparoscopic myomectomy:
- Removes intramural and subserosal fibroids; uterus preserved
- Deep myometrial repair: caesarean delivery recommended for subsequent pregnancy (uterine rupture risk during labour - low but present after full-thickness myometrial repair)
- Time to conception: wait 3-6 months post-op for uterine healing before attempting conception
UAE - not recommended if future pregnancy desired:
- May impair endometrial blood supply and ovarian reserve
- Pregnancy after UAE is associated with higher preterm delivery and miscarriage rates
- Women wishing to conceive should choose myomectomy over UAE
Pre-operative MRI: Essential for planning all fibroid surgeries - accurately maps fibroid number, size, location, depth, and relationship to the endometrial cavity. MRI data directly guides the decision between hysteroscopic, laparoscopic, or open approach for each patient.
Cost comparison: Hysteroscopic myomectomy Turkey: -3,500-6,000; UK private: -7,000-12,000. Laparoscopic myomectomy Turkey: -5,500-9,000; UK private: -12,000-20,000. UAE Turkey: -4,000-7,000; UK private: -9,000-15,000.