JANUARY / FEBRUARY 2005

AROUND HARVARD

This article originally appeared in the December 2004 Harvard Women’s Health Watch and is provided courtesy of Harvard Health Publications.

How to treat troublesome fibroids

The options for treating fibroids are numerous and varied. Here’s help in finding what’s best for you.

Every year in the United States, thousands of women undergo hysterectomies and other procedures to treat fibroids — fibrous growths that develop from muscle cells of the uterus. The most important thing to know about fibroids is that they’re not cancerous, and they don’t put you at risk for cancer. Indeed, unless they cause symptoms, they usually don’t need to be treated. About 30% of women of reproductive age are bothered by fibroids, which typically appear between the ages of 35 and 50. African American women are diagnosed with them two to three times more often than Caucasian or Asian women.

Although fibroids aren’t life threatening, their symptoms can drastically alter a woman’s quality of life. In the mid-1990s, hysterectomy was among the first treatments considered. Within 10 years. a number of less drastic options became available. Having more choices gives women greater control over their treatment, and their clinicians more opportunity to individualize care. The information below is meant to help you start a conversation with your gynecologist about the approach that best fits your situation.

Fibroid symptoms
Fibroids are often found incidentally during a routine pelvic exam or during imaging procedures for other reasons. Although most are “silent,” or asymptomatic, some cause heavy bleeding that can result in anemia and, less often, pelvic pain. The size and location of fibroids determine how bothersome they are and may suggest what can be done about them.

Fibroids range in size from smaller than a pea to larger than a grapefruit. A very large fibroid can distend the abdomen; the uterus may grow to the size of a second-trimester pregnancy. Such fibroids can press against the bowel or bladder, causing constipation or frequent urination. Fibroids may also interfere with fertility. But the biggest complaint about these benign growths is the heavy, often clot-studded bleeding that can make a woman a virtual prisoner in her home during her periods. Such excessive menstrual bleeding is called menorrhagia.

Where do fibroids come from?
No one knows exactly what causes fibroids (also called leiomyomas and myomas). But their growth — though not necessarily their cause — is related to estrogen and possibly progesterone. Several things suggest their dependence on hormones: Fibroids seldom occur before the first menstrual period; pregnancy can spur their growth; and they often shrink after menopause. Faulty genes may play a role, possibly accelerating the growth of uterine muscle cells. Abnormalities in uterine blood vessels may also be involved.

Types of fibroids Fibroids are classified by their location. A woman may have more than one type. Intramural fibroids, the most common type, grow within the uterine wall (A) and may get big enough to distort the shape of the uterus and place pressure on surrounding tissues. Unless they become very large, they can simply be watched. Intramural fibroids can cause back and pelvic pain, heavy menstrual flow, and a frequent urge to urinate. Submucosal fibroids are the least common type of fibroid. They start just under the uterine lining (endometrium) and may protrude into the uterine cavity (B). Some are pedunculated, meaning they grow on a stalk (C). Submucosal fibroids can cause heavy bleeding. Subserosal fibroids grow under the outer surface of the uterus (D), sometimes on a stalk (E). They usually don’t cause bleeding problems but may cause pain from pressure.

Treatment approaches
Fibroids can be treated with medications — the usual first approach — and with surgery, often using minimally invasive techniques that remove or destroy the fibroids. Some new therapies are promising, although their safety and effectiveness over the long term remain unproven. The only permanent fix for fibroids is hysterectomy, which takes out the entire uterus. Hysterectomy also ends childbearing and thus may have psychological as well as medical ramifications. Its use has declined in the past decade or so as less-invasive approaches have been developed.

Depending on the size, location, type, and number of fibroids, one or more treatments may be appropriate for you. The first step in determining your options is a thorough evaluation, starting with your gynecologist. Fibroids are usually diagnosed during a pelvic exam and confirmed with an ultrasound. Other procedures such as MRI or hysteroscopy (examining the uterine cavity with a small optical device inserted through the cervix) can provide additional information about a fibroid’s location and characteristics.

Medical management
Depending on the severity of your symptoms and your age, you may want to simply wait out your fibroids, since they’re likely to shrink and cause less trouble after menopause. Also, you may want to give medications a try before considering an invasive procedure. As you “watch and wait,” your clinician will probably want to monitor the size of your fibroids at regular intervals.

GnRH agonists. The mainstay of medical treatment is drug therapy with a gonadotropin-releasing hormone (GnRH) agonist such as leuprolide (Lupron), which suppresses estrogen production and produces a false (and temporary) menopause that reduces blood flow to the fibroids and shrinks them. Unfortunately, this is only while the drug is being given. These medications can also bring on menopausal symptoms such as hot flashes, vaginal dryness, and bone loss. Consequently, they’re generally not used for longer than six months. Fibroids usually return once the drug is stopped. The best candidates for treatment are women who need only a short-term “bridge” to menopause, when fibroids often recede. A GnRH agonist may also be prescribed before surgery to shrink fibroids and reduce anemia from bleeding.

Hormonal agents such as birth control pills, progestins, and danazol (Danocrine) are sometimes prescribed to help control bleeding, but their usefulness in treating fibroids has not been established. Some women get relief from heavy bleeding by using an intrauterine device that releases progestins (levonorgestrel-releasing intrauterine system). Nonsteroidal anti-inflammatory drugs (NSAIDs) may help with pain. For anemia caused by heavy bleeding, women may be advised to increase their intake of iron, through diet, supplements, or both.

Surgical treatments
There are several approaches to surgical removal of fibroids.

Hysterectomy. This surgery removes the uterus (usually with the cervix). A woman will need to decide about removal of the ovaries and fallopian tubes. Performed through an incision in the lower abdomen or possibly through the vagina, hysterectomy is major surgery, requiring anesthesia and four to eight weeks of recovery time.

This approach completely eliminates fibroids and their symptoms, as well as a woman’s fertility and periods. It’s a reasonable option for women who have completed childbearing and don’t want to wait until menopause for their symptoms to subside. The procedure has been shown to be safe and effective and has a low complication rate. Sexual functioning improves for some after hysterectomy. Studies suggest that most women are satisfied with their decision to undergo the procedure.

Myomectomy. This procedure removes only the fibroid or fibroids. It preserves the uterus and is an option for women who may want to have children, although in some cases they will be advised to deliver by cesarean section.

Abdominal myomectomy is performed under general anesthesia and involves taking out fibroids individually, usually through a horizontal incision in the lower abdomen. Most fibroids can be removed this way. Recovery time is similar to hysterectomy.

Smaller fibroids that grow on the inside wall of the uterus may be removed less invasively with hysteroscopic myomectomy. In this procedure, a small viewing device called a hysteroscope is introduced into the uterus via the vagina, allowing the surgeon to see the uterine wall. Recovery time is shorter than abdominal surgery, and fertility rates following hysteroscopic myomectomy are excellent. Surgeons must be specially trained to perform this procedure.

Another option (for fibroids on the outer surface of the uterus) is laparoscopic myomectomy, which involves inserting a small tube into the pelvic region through a tiny incision near the navel, allowing the surgeon to locate and remove the fibroids.

One disadvantage of myomectomy is that fibroids often return, and new ones may develop. Research suggests that up to 25% of women require another surgery within a few years of undergoing the first.

Uterine artery embolization
Uterine artery embolization (UAE) is another procedure used in treating fibroids. As a treatment for postpartum and other traumatic pelvic bleeding, UAE has been around for more than 20 years. Since the mid-1990s, it’s been employed for fibroid treatment. The idea is to shrink fibroids by cutting off their blood supply. Before the procedure, the pelvic area is imaged (preferably with MRI) to rule out other causes of symptoms, such as an ovarian tumor. This also helps ascertain the size, location, and types of fibroids involved. Some, such as those that grow on a stalk, don’t respond well to UAE.

In the procedure room, an interventional radiologist threads a catheter into the uterine artery by way of the groin and takes an x-ray using contrast dye to see the arteries feeding the uterus. Sand-sized particles of a synthetic material are then fed through the catheter into the uterine artery on one side of the uterus. The particles concentrate in the vessels surrounding the fibroid, cutting off its blood supply and eventually destroying it. The procedure is repeated on the other side.

UAE is generally considered safe and effective. The procedure takes less than an hour and requires no general anesthesia; it may involve one night in the hospital. Data indicate that over 90% of women will get relief from their symptoms after UAE. The main side effect is cramping abdominal pain immediately following the procedure. This can be treated with intravenous painkillers and usually resolves within a few hours.

Serious complications from UAE are rare (less than 1%). There have been reports of buttock and leg pain, hemorrhage, permanent loss of periods, and migration of particles to other tissues. Surgical removal of sloughed off fibroid tissue may be needed if it gets stuck in the cervix on its way out of the body.

UAE for fibroids was first performed in 1995, so there is no long-term data on its effects on fertility and pregnancy outcomes. Although women have become pregnant following UAE, groups such as the American College of Obstetricians and Gynecologists and the Society of Interventional Radiologists say that there’s too little data thus far to reassure women who may want a pregnancy. Research should provide some answers in the future, but until then, myomectomy is probably the better choice for women who need fibroid treatment but may later want to become pregnant.

Uterine artery embolization

New approaches
A newly approved device uses a combination of MRI imaging and focused electron beams to zero in on and destroy fibroid tissue. The treatment is for women who have completed child bearing or don’t intend to become pregnant.

Some gynecologists are looking into other ways of interrupting fibroids’ blood supply, as UAE does, but without having to inject foreign material into the body. In laparoscopic uterine artery occlusion, the clinician places a small clip or clamp on the uterine artery during a laparoscopic procedure. Another technique involves no incision and approaches the artery through the vagina to apply a clamp. The clamp may need to be in place for only a few hours to treat the fibroid; blood flow returns to the artery when the clamp is removed.

Fibroids are common, benign, and may require no treatment. But for those that do, many therapies are available. Not all of them are appropriate for every woman, so see your physician to discuss your options.

Copyright 2006 Harvard Medical International