Fibroids – What you need to know

About one-third of Canadian womxn will develop uterine fibroids by the age of 30. The number climbs to seven out of 10 by the time womxn reach 50. These benign (non-cancerous) tumors grow in the uterus, or off of the uterus on stalks within the pelvic cavity. They can range in size from as small as a pea to as large as a grapefruit. Some womxn may never know they have them unless they are caught by a routine exam, and they may never cause adverse effects in their day-to-day life. 

However, for some womxn fibroids can have some severe symptoms, including: pelvic pain, heavy menstrual bleeding, bleeding for longer than seven days, low iron (anemia), large clots, pain in the legs or back, pain during sex, and a higher risk of infertility.   For symptomatic womxn, 20% to 50% experience a considerable social and economic impact on their lives. 

Since fibroids affect such a large number of womxn, they ought to be classified as important health concern – right? Yet, the reality is very little research has been successful in determining the cause of these tumors, or keeping track of their numbers. Medical researchers have a long way to go to better understand fibroids, and perfect less invasive procedures to remove them or lessen their effects on womxn’s reproductive health. 

Fibroids themselves are not dangerous, since they are non-cancerous in nature. However, the resulting symptoms can be extremely dangerous. Severe anemia might require multiple blood transfusions. Fibroids might prevent a womxn from becoming pregnant, or a pregnancy might be lost due to miscarriage.  Severe pelvic pain might mean missed days at work or social engagements.

As a course of action, womxn are often told that if the fibroids are not causing any discomfort or issue, they can be left alone. It is believed that fibroids may shrink a little after menopause, but can still cause problems because the tumor may calcify and harden. 

Choosing to remove fibroids might mean removing the uterus as well. One in four Canadian womxn over the age of 45 have had a hysterectomy, and at least one third of those did so because of fibroids.  Hysterectomy is rare in younger womxn, but for those experiencing extreme pain from fibroids, endometriosis, or adenomyosis, a hysterectomy can provide relief from a lifetime of future pain. 

Fibroids Affect Black Womxn Disproportionately

Black womxn are nearly guaranteed to have fibroids in their lifetime – the likelihood of a black woman having fibroids by the time she is 50 years old is a staggering 90%. They are also much more likely to have recurring fibroids or suffer from complications from them. 

We don’t know enough about why fibroids develop in the first place, why black women get them more frequently and with more severity than other races, and exactly how they affect fertility.

Fibroids affect fertility

Depending on where they are located within the uterus, fibroids can prevent implantation of an embryo, and can cause problems with the ability to become pregnant or can result in miscarriage. They can also prevent conception by obstructing the fallopian tubes, which will not allow the embryo to pass into the uterine cavity and implant on the endometrial lining.

Fibroids can also cause problems during pregnancy. These include placental abruption (detachment of the placenta, causing bleeding and loss of pregnancy, or pre-term birth), abnormal growth of the pregnancy occurring from fibroids affecting blood flow or the size of the fibroids, preventing the baby from growing properly, pre-term labor. Early labor may lead to an early delivery of the baby, and result in possible developmental problems for the child.

Active monitoring might be dangerous

Womxn are frequently told that if the fibroids are not causing any severe symptoms, they can be left alone. Womxn are left thinking that they don’t need to treat them until or unless there is a problem – by the time they become a problem, however, many doctors are only able to remove them through invasive, open procedures, frequently recommending hysterectomy over myomectomy (fibroid removal).

“Fibroids will continue to grow,” says Dr. Natalya Danilyants. “That’s a very important point. A lot of patients that come see me with very big fibroids, they have known about these fibroids for many years, but they were told ‘Just leave them; if they don’t bother you, don’t bother them,’ but that’s not the right approach. Eventually, these fibroids are going to cause symptoms. For women who are planning to have children, you don’t want to wait to get to the point where your fibroids are large. Those large fibroids can cause irreversible damage to the uterus.”

If you have a concern about fibroids, ask your doctor for an ultrasound, to get a better idea of where the fibroid is growing, how quickly, and how big it is currently. Also, be sure to tell your doctor about any symptoms you’re experiencing: fatigue, pelvic pain, pain during sex, excessive bleeding – and whether these things are new, or getting worse. A baseline is important in any health care concern – but especially so with fibroids that will keep on growing and might become problematic. 

See your doctor if you have:

  • Pelvic pain that doesn’t go away
  • Overly heavy, prolonged or painful periods
  • Spotting or bleeding between periods
  • Difficulty emptying your bladder
  • Unexplained low red blood cell count (anemia)

Choosing to be child-free

When it comes to choosing a form of contraception that suits our needs, for most women it’s a case of trial and error.  Using the birth control pill can be tricky to remember to take at the same time every day, and gives some women intolerable side effects.  Condoms are easy enough to use, but are a bit fiddly in the throes of passion, and might give some women an allergic reaction or cause discomfort. The Depo-Provera shot is safe and convenient, but does cause some negative side effects like nausea or wonky menstrual cycles, and it needs to be repeated every three months. Hormonal intrauterine devices (IUDs) are long-lasting, effective birth control, which has the added benefit of reducing the flow of your period (score!). It does require an office procedure with your ObGyn, and it can cause some pain and cramping initially, and for several months following insertion. 

Tubal ligation is an effective form of contraception and it is considered permanent. A person could, however, get pregnant in the future with in vitro fertilization. Depending on the technique used and the age of the woman, the 10-year failure rate is under five per cent. Tubal ligation also may carry other benefits including reducing the risk of ovarian cancer, depending on the technique used.

For women and femmes who choose to remain child free, tubal ligation is a popular, permanent choice. Being granted access to the procedure, however, is a challenge with which many women under 30 struggle

For young patients, a gynecologist might recommend an IUD because there is a chance of regretting the decision in the future if something permanent like tubal ligation is chosen. Studies have estimated that the rate of regret for tubal ligation can be somewhere between four and 20 per cent, and is higher in women under the age of 30. 

But there’s an important distinction to be made here:  the rate of regret is higher among women who have already had children and wish to have more; the rate of regret of women among who have never wanted children is very low (six per cent). 

In a recent interview with CityNews, a leading gynecologist explained the disparity. “Women who want child-free living don’t change their minds,” says Dr. Dustin Cotescu, Family Planning Specialist at McMaster University. “People who have one or two children may decide later that they would like to have more. People might think that they’re causing harm in performing a tubal on a woman with no children; in fact those women are at lower risk of regret.” 

The push-back is so common that some child-free people have termed the experience of discussing their desire for tubal ligation and being faced with these dismissive phrases as being “bingo-ed”.  From the patronizing “you’re too young to make such a permanent decision,” to the delaying “you might change your mind,” to the downright paternalistic “what if you meet a man who wants kids,” all of these comments ignore the person’s gender identity, sexual identity, and most importantly, body autonomy and personal choice.

The reality remains, the choice should be up to the patient. Medicine, at its best, is meant to be shared decision making, and the decision for a tubal ligation is no exception. If you are convinced you desire a child-free life, it might be prudent to prepare yourself with research, answers to common health professional “bingo” statements, and firm up your resolve. It is your body, after all, and your choice. 

The official stance of the Society of Obstetricians and Gynecologists of Canada is that if you are fully informed on the risks, benefits, and alternatives, and you still choose a tubal ligation, then a doctor should offer this to you regardless of your age or if you’ve had children before. In practice, however, many women report being unable to access the surgery, largely through delays or redirections from their health care professionals.