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What treatments are available for uterine fibroids?

I previously discussed the impact that fibroids can have in a woman’s life, primarily that of irregular bleeding, pelvic pain, and infertility.  There are various options for the treatment of fibroids depending on the future fertility plans of the woman.  The guiding question should be whether or not there is or may be any future plans to conceive.   If so, then the only treatment that should really be considered is a myomectomy, a surgical procedure in which the fibroids are removed, leaving the uterus in place.  If childbearing is complete, then there are several other routes which may be chosen.  These could include a myomectomy, hysterectomy, uterine artery embolization, endometrial ablation, or MRI guided focused ultrasound.

Medical (Non-Surgical) Management of Fibroids

I did not mention the use of medications in the above paragraph due to the fact that this is not a good long term option for fibroid treatment, and is only used in a few circumstances.  The medications that are used work by shutting down the ovary temporarily.   This induces a temporary reversible menopause-like situation.  This can be used to reduce bleeding due to fibroids, and help to shrink them by about 30%.  However, this effect only lasts as long as the medication is used, with fibroids returning to their normal size soon after stopping the medication.  Due to the menopause-like situation, this treatment should only be used for short term treatment (<1 year duration) with ultimate definitive therapy.   This is most frequently used in women who are having heavy bleeding, allowing the bleeding to slow or stop down so that her body can recover before ultimately having surgery.

Myomectomy

In a myomectomy, uterine fibroids are surgically removed, leaving the uterus in place.  If fibroids are located primarily within the uterine cavity (submucosal type), then they may be able to be removed with a hysteroscope (small camera) by entering the uterus through the cervical opening.  In most cases, they are removed by making an incision on the outside of the uterus, removing the fibroids, and suturing (sewing) the uterus back together.  In the past, myomectomies were performed through large open incisions in the abdomen, often going side-to-side, but sometimes vertically.  This type of “open” myomectomy has significant drawbacks, including a 2-3 day hospital stay, extended recovery, adhesion (scar tissue) formation, and significant blood loss.  In recent years, there has been a large shift towards performing myomectomies by laparoscopy (through small incisions using cameras).  This “minimally invasive” route offers significant advantages, including less pain, a more cosmetic result with smaller incisions, usually no overnight hospitalization, less bleeding and scar formation, and a much faster recovery.   Before a few years ago, only some selected cases were performed laparoscopically due to the significant increase in difficulty in performing myomectomies laparoscopically.  The introduction of the da Vinci Robotic System for laparoscopic assistance has made a tremendous improvement, allowing nearly any myomectomy to be performed laparoscopically, regardless of size or difficulty.    Our practice specializes in myomectomies and is able to repair and reconstruct the most severely distorted uterus due to fibroids.

Hysterectomy

For some women, they may choose to have a hysterectomy (removal of the uterus) as a treatment for fibroids.  It is for this reason that a hysterectomy has become one of the most common surgeries that a woman may face during her lifetime.  Most hysterectomies can be accomplished by a minimally invasive route, either removing it through the vagina, or laparoscopically through the use of small cameras, or in difficult cases, using Robotic assistance to perform it through a camera.  Rarely is an open incision needed for a hysterectomy.

Uterine Artery Embolization

A uterine artery embolization (UAE) procedure performed by a specially trained radiologist which involves injecting small particles (about the size of a small grain of sand) into the uterine blood vessels. These particles clog the small blood vessels that supply the fibroids, cutting down the blood supply and causing the fibroids to die and degenerate. Fibroid volume shrinks by 40% to 50%, and the majority of patients experience symptomatic relief.  However, patients generally experience several days of pain after the procedure and are usually hospitalized for 1-2 days. Women who are older may at risk of developing early ovarian failure.  Due to the effect on uterine blood flow, this technique is not recommended for women who would like to conceive in the future, and for those who do, there is a slightly higher rate of pregnancy complications.

Endometrial Ablation

An endometrial ablation is a procedure that is intended to treat heavy uterine bleeding in general.  This could be due to fibroids or to other causes.  In this procedure, one of several techniques are used to basically burn or cut out the endometrium (lining of the uterus).  This significantly limits the amount of bleeding that occurs.  An ablation may be effective in treating bleeding due to fibroids, but may often provide only effective treatment for a limited time (perhaps 1-3 years).  Bleeding may return as fibroids continue to grow and enlarge.

 

MRI Guided focused ultrasound

This is a newer approved technique which uses powerful ultrasound waves to destroy the fibroid.  It has only limited availability, and only small studies available with long term follow up.  It is likely most effective for someone with a small number of larger fibroids.  However, due to the lack of long term follow-up results it is not widely recommended and cannot be recommended for anyone wishing to retain their fertility.

In summary, if fertility is still desired, then a myomectomy is the procedure of choice.  Other forms of fibroid treatment should not be undertaken due to known problems with subsequent pregnancies.  If childbearing is not desired, then the woman can make an informed decision with her physician regarding her desires, knowing that each of the above option has both benefits and drawbacks.

Can uterine fibroids affect my fertility?

Uterine fibroids, also called myomas or leiomyomas, are benign (non-cancerous) tumors that arise from the muscle of the uterus.  They are extremely common, with most women developing them at some point in time during their life.  One study found that by the age of 50, that 70% of Caucasians and 80% of African-Americans will have developed fibroids.   There appears to be a genetic link to the development of fibroids, often arising earlier and growing faster in African-Americans.  Fibroids often appear to begin when a woman is in her 20s, and usually grow at a slow rate, only reaching a size large enough to cause symptoms when she is in her 30s-40s.  Because of this, problematic fibroids are the most common indication for a hysterectomy in women.

 

When they reach a large enough size, they can cause symptoms such as heavy or irregular bleeding, infertility, pain, or symptoms of “pressure” by pressing on other pelvic organs.  However, many fibroids can be totally asymptomatic, with the woman not having any problems until they are incidentally seen by an ultrasound or CT scan. 

We classify the location of fibroids as primarily four different types:  1) subserosal- located in the outer-most portion of the wall of the uterus, just underneath the outer surface (the serosa); 2) pedunculated- a type of subserosal fibroid that lies mostly outside of the uterus and only connected by a small stalk of tissue; 3) intramural- found within the main body of uterus; 4) submucosal- In the inner-most portion of the uterus and protruding into the cavity of the uterus. About 55% of fibroids are subserosal or pedunculated; 40% are intramural; and 5% are submucosal.    As fibroids increase in size, they may come to span two or more of these categories.   Typically, submucosal and larger intramural fibroids are responsible for heavy menstrual bleeding.

So do they affect your chance of conceiving?  In short, likely yes, possibly no.   This depends on the location and size of fibroids.   Many studies have tried to determine the right answers to this question, with some progress being made.  Some of the results are still somewhat debated.  Many women with fibroids conceive on their own and they may only be discovered during routine pregnancy ultrasounds.  However, for many women they can play a role in hindering fertility.  It is estimated that fibroids play a role in approximately 5-10% of infertility cases.

There is very good data and it is clear that submucosal fibroids can decrease pregnancy rates by about 35%, and increase miscarriage rates by over 65%.   On the other hand, fibroids that are only of the pedunculated or subserosal type appear to have no effect on fertility or miscarriage.  Fibroids that are intramural do appear to decrease fertility though the scientific data is less clear.  With all categories, however, there likely is an effect of fibroid size and fertility impact.  Subserosal fibroids can enlarge to the point that they become predominantly intramural or even submucosal.  Once this size, they may also impact fertility.

Both the lowered pregnancy rate and increased miscarriage rate is likely due to altered blood flow within the uterus.  The fibroids may serve to divert necessary blood flow away from the uterine cavity where an embryo could implant.

We’ll discuss the treatment options for fibroids in an upcoming blog topic.