Overview

Uterine fibroids are benign growths of the uterus. These growths are of smooth muscle origin and are non-cancerous. Uterine fibroids commonly affect women of reproductive age, and prepubertal girls are not affected by uterine fibroids. Uterine fibroids are also known as uterine leiomyomas or uterine myomas.^1,2,3 

Uterine fibroids are the most common non-cancerous growths in women. Evidence states that over 80% of women of black origin and at least 70% of women of white origin would have had at least one uterine fibroid by the time they are 50 years old.^4,5 This means that by the onset of menopause, over 70% of women would have had uterine fibroids in their lifetime.^6,7 Despite this proportion of women who would have had uterine fibroids in their lifetime, many women do not know that they have fibroids because they usually do not present with symptoms, i.e. are asymptomatic, or the symptoms develop very slowly over the years, leaving them undiagnosed.^8,9 

About 25% of women present with symptoms of fibroids.^10,11 Uterine fibroids cause a range of symptoms, the most common of which is heavy menstrual bleeding that can lead to anaemia and fatigue over a long period. Other symptoms include:

• Painful periods
• Abdominal pain
• Abdominal swelling
• Painful sexual intercourse
• Pelvic discomfort or pain
• Lower back pain
• The frequent need to urinate
• Constipation

In pregnancy, it can lead to infertility, recurrent pregnancy loss, preterm labour and obstruction of labour.^2,4,5 Some of these symptoms are severe enough to require treatment and hospital admission in 15% to 30% of women.^10,11

Treatments for uterine fibroids

Treatment is usually required for symptomatic uterine fibroids. This treatment focuses on alleviating or completely eliminating the symptoms to improve the woman’s quality of life. 

Treatment of uterine fibroids can be medical or surgical. Medical treatment involves the use of medications such as hormonal medications, for example,  gonadotropin-releasing hormone (GnRH) agonists, oral contraceptives, selective progesterone receptor modulators, levonorgestrel-releasing intrauterine system and non-hormonal medications e.g. nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid and vitamin D. 

Surgical treatment can be a myomectomy, uterine artery embolisation (UAE) or a hysterectomy. ^12,13,14 The choice of the type of treatment takes into consideration several factors such as: 

• The size, number and location of the fibroids
• The age of the woman
• The type and severity of symptoms
• The desire of the woman to preserve her fertility
• The health practitioner’s expertise
• Access to treatment is available

The ideal treatment option for uterine fibroids is an option that relieves signs and symptoms, leads to a sustained reduction in the size of fibroids, preserves fertility if that is a desired outcome for the woman and avoids harm to the woman.^12,13

Recurrence of uterine fibroids post-treatment

Despite the goal of available treatment options being to obliterate uterine fibroids, uterine fibroids have been found to recur after treatment in some women, and this recurrence is associated with some defined factors. The risk of recurrence is associated with: 

• The number, size, type and location of fibroids
• Age
• Surgical option
• Presence of pelvic disease
• Postoperative delivery has also been implicated in the risk of recurrence^{3, 15, 16}

Recurrence of fibroids is usually associated with recurrence of previously resolved symptoms such as abdominal, pelvic and lower back pain and/or discomfort, heavy menstrual bleeding, blood transfusions secondary to anaemia, and increased costs in purchasing sanitary towels.¹⁷ Recurrence of uterine fibroids after treatment can be a difficult diagnosis to cope with, and it can lead to a significant toll on the physical, emotional and mental well-being, as well as the overall quality of life of the woman. There are several risk factors associated with the recurrence of fibroids after treatment. These factors will be discussed below.

Risk factors for uterine fibroid recurrence

Type of treatment

Myomectomy versus hysterectomy

Myomectomy is the surgical removal of uterine fibroids, with the preservation of the uterus. An estimated 15% to 33% of fibroids have been found to recur after myomectomy. An estimated 10% of women who have a myomectomy will undergo a hysterectomy in five to ten years.¹⁸

Myomectomy can be open (abdominal), laparoscopic and hysteroscopic. Higher rates of recurrence have occurred following laparoscopic myomectomy when compared to open myomectomy.¹⁶ An estimated 33% of uterine fibroids have been reported to recur following myomectomy via laparoscopy.¹⁹

Uterine artery embolisation

Uterine artery embolisation is a minimally invasive procedure which injects embolic agents to interrupt the blood supply of the uterus, leading to the killing of the fibroids. However, this procedure can disrupt the function of the uterus and ovaries. It is contraindicated in pregnancy, suspected cancer, and active pelvic infection.¹⁹ Uterine fibroids have been found to recur at a 20% higher rate following uterine artery embolisation compared to myomectomy.²⁰

Length of time post-treatment

The more years post-uterine fibroid surgical removal has been associated with the higher the risk of recurrence of fibroids. Recurrence rates of 10.6% - 15.3%, 31.7% - 43.8%, and 51.4% - 62.1% occurred after one, three and five years post-laparoscopic myomectomy, respectively. ^16,19

Postoperative infection

Infection following myomectomy has been identified as a risk factor for the recurrence of uterine fibroids. This may be due to inflammation of the uterine cells, which can lead to an increase in the proliferation of smooth muscle and fibrous connective tissue. This leads to a disruption of the uterine function and an increase in the risk of recurrence.²¹

Uterine fibroid characteristics

Number and size of fibroids

The presence of multiple fibroids poses a higher risk of recurrence compared to single fibroids. The smaller the fibroid, the higher the chance of the fibroid being missed during surgery, leading to the fibroid's growth post-operatively. In a study by Nezhat, the number of fibroids and depth of penetration were associated with recurrence. Women who experienced recurrence had between 4 to 6 fibroids, while women with 2 fibroids had no recurrence. Small fibroids are difficult to locate during myomectomy and have a high chance of recurrence because they were not removed.^{19, 22}

Location of fibroids

Uterine fibroids can be located in the muscular wall of the uterus (intramural), in the inner lining of the uterine cavity and project inwards (submucosal), in the outer lining of the uterus and project outwards (subserosal). Recurrence rates for subserosal and intramural uterine fibroids were reported as 11.8% and 44.9%, respectively.^{19, 22}

Being pregnant after surgery

Evidence suggests that there are higher rates of recurrence of uterine fibroids in women who did not become pregnant after fibroid removal surgery. In the study by Kotani et al, women who became pregnant after myomectomy had lower rates of recurrence compared to women who were not pregnant.¹⁶ The recurrence rate of women who were not pregnant following a myomectomy was 40.5%.¹⁶

Menarche

Age of menarche (the time of a girl’s first period) less than 13 years was associated with a higher rate of recurrence. In early menarche, sexual maturation and oestrogen levels peak earlier than their peers, menstrual periods are more frequent, and these factors influence the growth of fibroids. ^{21, 22}

Prevention of uterine fibroid recurrence post-treatment

Preoperative management

A detailed preoperative examination should be carried out to have an in-depth understanding of the size, type, and number of fibroids. This may require the use of colour Doppler ultrasonography. ²³

Lifestyle modifications

Lifestyle modifications target myometrial stiffness that has been implicated in the disease propagation of uterine fibroids. These include: 

• Reducing consumption of red meat
• Limiting alcohol intake
• Using vitamin D supplementation
• Including green tea extract in your diet
• Increasing physical activity
• Maintaining a healthy weight
• Avoiding the use of external sources of hormones^{24, 25}

Hysterectomy

A hysterectomy is the complete removal of the uterus. This permanently prevents the recurrence of fibroids. However, there are concerns, especially as it relates to fertility and for women who still want to keep their uterus.²⁶

Summary

Uterine fibroids are a common benign growth found in many women and can cause debilitating symptoms. Treatment options can be medical or surgical. Surgical options are more common than medical therapy because they are more successful in removing fibroids. Despite the success of surgical options, recurrence of fibroids has been found to occur in some women. These recurrences have been attributed to certain risk factors. Identification of these risk factors is important in preventing the recurrence of uterine fibroids in women.