Most uterine fibroids do not cause any symptoms and do not require treatment. Studies show that 3-7% of untreated fibroids will shrink over time. Most women find that their fibroids shrink at menopause and that any symptoms they were experiencing disappear. Women who are close to menopause may therefore decide not to have surgical treatment, and wait to see if symptoms improve after menopause. If you are watching and waiting it is important that you do so with regular follow up. A fibroid that is rapidly growing requires prompt investigation to rule out a cancer. And if you wish to avoid surgery, it is important to know that fibroids do grow- you will want to act before the fibroids become too large, while you still have more treatment options.
In all cases, look after your health, and make sure that you are not developing iron deficiency anemia Treatment of fibroids is highly individual, and depends on the symptoms you are experiencing, the size and location of the fibroids, your age, and your desire to preserve your fertility or not. For women who are experiencing symptoms, the treatment of fibroids has improved substantially in recent years. It used to be common practice for women with fibroids to undergo removal of the uterus and sometimes the ovaries (hysterectomy). Now there are other options, although hysterectomy is still recommended in some cases. If your fibroids are small, it may be recommended that you treat the symptoms you are experiencing, rather than the fibroids themselves. If you are taking any medications that contain estrogen, your doctor may recommend that you stop taking these, or change medications.
Medications
Birth control
Your doctor may recommend a low-dose, progestin-only birth control method, to help reduce menstrual bleeding. These could be oral contraceptives, or an intrauterine device (IUD). An IUD is a common method of birth control, consisting of a T-shaped device which is inserted into your uterus. The device releases levonorgestrel, a type of progestin which counteracts the effects of estrogen in the same way that other progestin therapies do. The IUD can provide continuous therapy for five years or until it is removed by a health care provider. The IUD is a very effective therapy for heavy menstrual bleeding or pain because it stops menstruation.
Tranexamic acid
Tranexamic acid is a non-hormonal oral treatment that may be prescribed to reduce heavy bleeding. It does not cause any shrinkage in the fibroids.
Selective progesterone receptor modulators (SPRM)
Progesterone is required for fibroid growth, and drugs that block the receptor for progesterone may be used to treat fibroids. Ulipristal acetate is an SPRM that is available in Canada. It is taken as an oral medication that blocks progesterone, effectively reducing fibroid size and related symptoms. It may be used prior to surgery, or as an alternative to surgery.
GnRH agonists
Your health care provider may recommend a GnRH agonist (or gonadotropin releasing hormone agonist). This hormone, given by injection or nasal spray, will cause you to stop menstruating. The use of GnRH agonists cause fibroids to shrink by up to 50% within the first 3 months. However, the side effects of this type of medication tend to be similar to symptoms you might experience in menopause: loss of bone mineral density, hot flashes, mood swings, vaginal dryness, smaller breasts and headaches. Therefore, for long-term use, your doctor will recommend that you “add back” some estrogen to prevent these side-effects.
Danazol
Danazol is chemically similar to testosterone and lowers estrogen levels. It is associated with a 20-25% reduction in the size of fibroids. While this is a modest reduction, it may reduce heavy menstrual bleeding associated with fibroids. Danazol can cause weight gain and acne.
Pain relief
Over-the-counter anti-inflammatory medication (NSAIDs) is often effective in treating the pain caused by fibroids. These medications are inexpensive and non-addictive.
If you are taking an NSAID such as ibuprofen or naproxen sodium and aren’t getting much pain relief, you may want to try again. The most important thing to remember is that unlike other pain medications, NSAIDs do not block existing pain. Instead, they block the production of prostaglandins, which produce the pain. You must take the medication before the prostaglandins are produced — start taking the medication before you expect the pain to start — and you must keep on taking it every six hours around the clock to ensure it works effectively.
However, for some patients, long term use of NSAIDs may result in side effects such as stomach ulcers and bleeding. Let your doctor know when you are taking any over-the-counter medication.
Nonsurgical interventions
Uterine artery embolization
Uterine artery embolization (UAE) may be an option for some women with fibroids. This treatment is only available in centres that have specialized equipment and trained individuals for interventional radiology. This is most likely to be limited to major medical centres. In UAE, a cannula is introduced into the blood vessels that go to the uterus, and a small “plug” is placed to block off the blood supply to the fibroid. UAE can be quite effective for bleeding symptoms, but is less effective for symptoms related to the size of a very large fibroid uterus. There is pain in the days after treatment, and it is not effective for all women. There can be complications of the procedure, including infection, or damage to other pelvic organs.
High Frequency Ultrasound
MRI-guided focused high intensity ultrasound is a more recent treatment that is available in some centres. The ultrasound energy is used to disrupt the uterine fibroid.
Surgical options
Hysteroscopic surgery
Fibroids that protrude into the interior of the uterus can be removed with a relatively minor procedure, hysteroscopy. In this procedure no incisions are made in the abdominal wall. A slender tube is inserted though the vagina and into the uterine cavity. The fibroid can be visualized using a small camera, and the fibroid mechanically broken down and safely removed. Most women go home the same day and have a rapid return to normal activities.
Hysterectomy
In women who do not intend to become pregnant, hysterectomy is an effective, permanent treatment for fibroids. If your fibroids are not causing symptoms, hysterectomy is not recommended. Hysterectomy can be performed through an abdominal incision, laparoscopy, or by vaginal route.
Myomectomy
Myomectomy is a laparoscopic surgical procedure that removes fibroids. It is an effective treatment for the treatment of abnormal uterine bleeding caused by fibroids. Myomectomy is an alternative to hysterectomy for women who wish to keep their uterus. The surgery is associated with a higher risk of blood loss, and a longer operation time, but a lower risk of injury to the ureter. Incisions may leave scar tissue. If you undergo a myomectomy, there is a 15% chance that you will have fibroids again. Risk of recurrence is associated with age, number of fibroids before the procedure, size of the uterus, the presence of other disease, and childbirth. Of all women who have a myomectomy, 10% will go on require a hysterectomy within 5 to 10 years. The surgery can be performed under general anesthetic or spinal anesthetic. You may also undergo a procedure called ‘endometrial ablation’ at the same time, which destroys the lining of your uterus.
Preparation for surgery
Before you undergo surgery for fibroids, your doctor will evaluate your health and prepare you for the procedure. It is important to correct any iron deficiency anemia you may have, prior to surgery. You may also be prescribed a medication to help shrink your fibroids before removal. Ask what your surgical options are, and be sure to communicate your wishes to your doctor – particularly if you wish to preserve your fertility. It is not always possible to have “key hole” surgery, but “minimally invasive” procedures, when they can be safely offered, may enable you to return to your usual activities much more quickly. In most cases the ovaries can be safely preserved, whatever surgery is planned. Removing the fallopian tubes (salpingectomy) at the time of surgery in a woman who has completed child bearing may reduce the long term chances of ever developing ovarian cancer. It does not cause menopause and this procedure does not add surgical complexity.