Uterine fibroids are benign tumors of the uterus. Usually the diagnosis is made by physical examination confirmed by either ultrasound or MRI examination. Once diagnosed, the growth of fibroids may be monitored by physical examination.
Fibroids that are not causing symptoms don’t require treatment, other than periodic examinations by a gynecologist or other gynecologic care provider.
When treatment is required, several non-surgical and surgical treatment options are available. Treatment options include:
- Uterine Artery Embolization (UAE)
- Medication for uterine fibroids
- Hysteroscopy and endometrial ablation
- MR-guided Focused Ultrasound
Once symptoms of uterine fibroids develop, medications may help control symptoms. For cramping and pain, anti-inflammatory medications may be used, which may also help with heavy bleeding. Heavy bleeding may be somewhat reduced by use of an oral non-hormonal medication, such as Lysteda.
There are a range of hormonal agents that can be effective at reducing menstrual bleeding while also providing birth control. These include birth control pills, oral or implantable progesterone, and progesterone-releasing IUDs (such as a Mirena IUD).
Another drug occasionally used to block the production of hormones is leuprolide acetate (Lupron), which is given by injection either once a month or every three months. It usually stops or greatly reduces menstrual bleeding during use. This drug may cause hot flashes and mood changes in some patients, similar to those experienced in menopause. A potentially more serious side effect of these medications is osteoporosis (bone density loss). Use of this medication is typically limited to 6 months.
Selective progesterone receptor agonists are a new class of drugs being used to treat fibroids in Europe. As of 2017, none are yet approved for this purpose in the U.S. These drugs markedly reduce or completely stop menstrual bleeding while they are used. They do require the patient to take a pill every day.
Hysteroscopy is a procedure in which a fiber-optic scope is advanced into the uterus through the vagina and the cervix. It is used to diagnose the cause of abnormal bleeding. If fibroids are small enough and not buried in the uterine wall, fibroids may also be removed during hysteroscopy. Removal of fibroids during hysteroscopy is a treatment option for 10-15% of patients.
Endometrial ablation, a procedure that intentionally destroys the uterine lining, may also be performed at the time of hysteroscopy. This procedure is intended to permanently stop menstrual bleeding and prevent future pregnancy.
Hysteroscopy and endometrial ablation can be performed safely and effectively. Patients are typically administered general anesthesia, but can be discharged on the same day as surgery and may return to normal activities within a few days.
One of the newer treatments for fibroids is magnetic resonance (MR)-guided focused ultrasound therapy. This treatment uses high-intensity ultrasound energy to heat up portions of the fibroid tissue. The procedure is done with the patient in an MR scanner on a table fitted with a special ultrasound device. The procedure takes several hours to complete.
The advantage of this treatment is that it is completely non-invasive. The procedure generally provides moderate symptom improvement in the short run, although its long-term outcome is not yet known. It appears likely that it will not be as effective as uterine artery embolization for most patients.
Usually only one or two fibroids are treated with magnetic resonance-guided focused ultrasound and therefore a limited number of women are good candidates for the treatment. In addition, the fibroids usually are not completely treated. This may predispose fibroids to re-grow and symptoms to return over time.
MR-guided focused ultrasound is only available in a limited number of centers in the U.S., and it is not offered at MedStar Georgetown University Hospital or any other MedStar facility. Unfortunately, most insurance companies do not currently reimburse for this treatment.
Myomectomy is an operation in which one or more fibroids are removed, leaving the rest of the uterus in place. This procedure is most commonly used in women who trying to become pregnant or who wish to become pregnant in the near future. Long-term studies of myomectomy patients that attempted pregnancy have shown pregnancy rates between 40 and 60%.
Fibroids may regrow after myomectomy, with recurrence rates of between 20 to 25% by five years after treatment. The procedure may cause pelvic scarring, which may contribute to future fertility problems. While bleeding and other surgical complications is somewhat higher than with hysterectomy, myomectomy is generally safe and is successful in controlling symptoms in about 80 to 90% of women.
The surgical removal of the uterus is called a hysterectomy. This surgery is effective in treating all fibroid cases in which heavy bleeding is the primary symptom. Usually, it also resolves pain or urinary symptoms. It is a safe procedure, with a very low complication rate in experienced hands. It has traditionally been the standard therapy for fibroids that fail to respond medical therapy in women who do not wish to have future children. Recent studies have shown that the patient’s health-related quality of life after hysterectomy is normal for most patients within a few months of the surgery.
Traditionally, hysterectomy requires a standard surgical incision and a recovery time of four to six weeks. However, minimally-invasive approaches are often possible. Hysterectomy may be performed using laparoscopic or robotic techniques. These incisions are much smaller and recovery usually requires about 2 weeks.
If the uterus is not too large, another approach called a vaginal hysterectomy may be possible. During a vaginal hysterectomy, the uterus is detached and then removed through the vaginal vault. This approach is typically feasible only for women who have had previous vaginal deliveries.
When less invasive approaches are used to perform a hysterectomy, one risk is that a malignant tumor is more likely to be overlooked. However, malignant uterine tumors are very rare and the benefits of less invasive approaches typically outweigh this risk. Your gynecologic surgeon will discuss the risks and benefits of the suggested approach with you prior to the procedure.