Fibroid Basics: Treatment

The most appropriate treatment for uterine fibroids depends on the severity and type of symptoms, size, number, and location of fibroids, and the patient's desire for preservation of fertility. Treatment options include:

  • Watchful waiting - Fortunately, most fibroids do not cause symptoms and can be managed with observation, an annual physical exam and ultrasound to check for growth.
  • Medications - usually tried first for patients with symptoms, especially those with abnormal bleeding.
    • NSAIDs - Non steroidal anti-inflammatory drugs such as motrin (ibuprofen) or naprosyn. These drugs can be effective in reducing heavy menstrual bleeding and cramping. Little if any effect on uterine size and bulk related symptoms.
    • Iron supplements for those with anemia.
    • Birth Control Pills / Progestins - hormonal treatments that can be effective in controlling bleeding by diminishing the endometrium (endometrial atrophy). Birth control pills can also help regulate dysfunctional uterine bleeding due to anovulation. Little effect on bulk related symptoms.
    • GnRH agonists - ex. Lupron, induce a chemical menopause with a low estrogen state. Since fibroid growth is estrogen dependent this therapy decreases the size of individual fibroids and the overall uterine size by ~50%. Also stops menstrual flow (amenorrhea). Potential side effects include menopausal symptoms of hot flashes, vaginal dryness, and irritability. Long term use can lead to bone loss (osteoporosis) and therefore treatment is usually limited to 3-6 months. Unfortunately, rapid regrowth of fibroids occurs within six months of cessation. Typically used prior to planned hysterectomy or myomectomy.
    • Herbal and Nutritional alternatives - Blue cohosh, black cohosh, milk thistle, wild yam, bee pollen, and shark cartilage have all been suggested to be helpful in managing fibroid symptoms. While there is certainly a high level of interest in these alternatives, there is no published data supporting their use for the treatment of fibroids.
  • MR Guided Focused Ultrasound – A new, non-invasive, outpatient procedure that uses high doses of focused ultrasound waves to destroy uterine fibroids, without affecting the other tissues around the fibroid. The procedure is conducted in an MRI scanner which helps the physician "see" inside the body to guide and continuously monitor the treatment.

    The focused ultrasound energy is directed at a small volume of the fibroid, raising its temperature high enough to cause thermal ablation (killing of the cells) without impacting other tissues. Pulses of energy are repeated until the entire volume is treated. Because the heated volume of tissue is small, multiple pulses are required and the procedure lasts three-four hours depending on the size and number of fibroids treated. The FDA approved the treatment on 10-22-04. Although promising for the treatment of fibroids, and other tumors, the availability is quite limited in the US at this time. The treatment is not intended for women wishing to preserve fertility. Visit Insightec's web site for more info on MRgFUS.

  • Uterine Fibroid Embolization (UFE) - Medical therapy fails to control symptoms in up to 2/3 patients with abnormal bleeding and a higher percentage in those with bulk type symptoms. A now well established alternative to surgical therapy is uterine fibroid embolization. Using imaging guided angiographic techniques an Interventional Radiolgist blocks (embolizes) the blood supply to the fibroids which shrink, causing the symptoms to resolve. This treatment preserves the uterus and potential fertility. More info on UFE.
  • Surgery - Patients who fail medical management, and are not candidates for UFE, may be offered more invasive surgical treatments, typically hysterectomy or myomectomy.
    • Hysterectomy - the surgical removal of the uterus and is the predominant invasive treatment for fibroids, accounting for 225,000 operations per year in the U.S. While this is the only definitive cure for fibroids many have suggested that hysterectomy is radical therapy and should be a last resort for a benign condition such as fibroids. The uterus is most commonly removed through an abdominal incision-abdominal hysterectomy. When feasible a vaginal hysterectomy is preferable, allowing a more rapid recovery. Laparoscopically assisted vaginal hysterectomy (LAVH) uses a laparoscope to facilitate removal of the uterus through the vagina. Laparoscopic supracervical hysterectomy (LSH) spares the cervix and allows removal of the uterus through small incisions. All types of hysterectomy involve removal of the uterus and are obviously only an option for women not planning future pregnancies.
    • Myomectomy - the removal of one or more fibroids while leaving the uterus intact and is frequently used in those women desiring to preserve their fertility. Estimates range from 37-45,000 myomectomies per year in the U.S. Different techniques are available including using a hysteroscope to remove fibroids under the inside uterine lining (submucous). A laparoscope can sometimes be used to remove fibroids under the outside lining (subserosal) of the uterus. An abdominal myomectomy is performed through an abdominal incision with removal of the fibroids followed by suturing of the defect in the uterine wall. In general, myomectomies are effective in about 80% of patients with abnormally heavy bleeding (menorrhagia). Over time fibroids can recur in 25-50% of cases and require an additional major procedure in 10% of patients.
    • Myolysis - the obliteration of fibroids by delivering electric current, laser, or thermal energy through needles inserted into the fibroids during laparoscopy. Reserved for perimenopausal or postreproductive women as uterine rupture during pregnancy has been reported following myolysis, due to weakening of the uterine wall.
    • Endometrial ablation - the intentional destruction of the inner lining (endometrium) of the uterus performed to eliminate abnormal menstrual bleeding. This can be accomplished using a hysteroscope to cut away and cauterize the endometrium (rollerball), or by applying heat (hot water balloon or microwave energy). These techniques can be useful for treating dysfunctional uterine bleeding, but are ineffective for bleeding caused by fibroids.

Basics | Symptoms | Diagnosis | Treatment

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