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What to do about fibroids

JUL 2008

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New options for managing troublesome fibroids continue to appear. Here's help in finding what's best for you.

Every year in the United States, hundreds of thousands of women undergo treatments and procedures (including as many as 200,000 hysterectomies) because of fibroids. About 25% to 30% of reproductive-age women have symptoms caused by these rubbery noncancerous growths that form in the walls of the uterus, usually between the ages of 35 and 50. Many more women have fibroids but no symptoms. African American women are three times more likely to develop symptomatic fibroids than women of other ethnic groups, and typically do so at an earlier age.

Fibroids can drastically alter a woman's quality of life. For example, a very large fibroid can expand the uterus to the size of a second-trimester pregnancy and press against the bowel or bladder, causing constipation or frequent urination. Fibroids are also occasionally associated with infertility, miscarriage, and premature labor. But the most common complaint is heavy, often clot-studded menstrual bleeding, called menorrhagia (if a pad or tampon is soaked through every hour) or hypermenorrhagia (if two or more tampons or pads are soaked through every hour), which can make a woman a virtual prisoner in her home during her periods. Such heavy bleeding can also cause iron-deficiency anemia.

No one knows exactly what causes fibroids. Genes that accelerate the growth of uterine muscle cells may play a role. Abnormalities in uterine blood vessels may also be involved. The presence of estrogen and possibly progesterone seems to be important in some way: fibroids seldom occur before the first menstrual period, pregnancy can spur their growth, and they usually shrink after menopause.

Until the late 1990s, hysterectomy was often among the first treatments considered. Since then, less-invasive therapies have become more available, and more is known about the options for managing different types of fibroids. Women now have more choices for their treatment, and clinicians can better individualize care.

Types of fibroids

Fibroids are classified by location. They are generally multiple, and you can have more than one type. The most common type, intramural fibroids, grow within the uterine wall and sometimes cause heavy menstrual flow, a frequent urge to urinate, and, in some cases, back and pelvic pain. Submucosal fibroids, the least common type, start under the uterine lining (endometrium) and may protrude into the uterine cavity. They can cause heavy bleeding and are most closely linked to fertility problems. Some fibroids are pedunculated, meaning that they grow on a stalk. Subserosal fibroids grow on the outer surface of the uterus, sometimes on a stalk. They usually don't cause bleeding but may cause pressure. Rarely, they can twist or degenerate and will be painful.

Treatment approaches

Fibroids are often found during a routine pelvic exam or imaging procedures performed for other reasons. If they don't cause symptoms — heavy bleeding, pressure, or pain — and aren't implicated in infertility, fibroids usually don't require treatment. When there are symptoms, they can be managed with medications (the usual first approach) or with surgery, using minimally invasive techniques where possible.

The first step in determining your options is a thorough evaluation, starting with your gynecologist. She or he can often feel fibroids on a pelvic exam but may use imaging techniques to get more precise information, which is critical for planning treatment. For example, transvaginal ultrasound can help assess the size of fibroids that extend into the uterine cavity (intracavitary fibroids); the addition of 3-D imaging can determine their location precisely. This is important because intracavitary fibroids can cause infertility. Other potentially useful imaging techniques include magnetic resonance imaging (MRI) and sonohysterogram (ultrasound with a saline infusion into the uterine cavity). Your clinician may also examine the uterine cavity with a small optical device (hysteroscope) inserted through the cervix.

If you're relatively young and symptoms aren't severe, you may simply wait out your fibroids, since they're likely to shrink after menopause. As you "watch and wait," your clinician will monitor them at regular intervals. Development and growth of fibroids isn't unusual in premenopausal women, but in postmenopausal women, a new or enlarging mass may indicate a malignancy and should be followed up.

Medications

If your symptoms preclude waiting until menopause, there are other options, surgical and pharmaceutical. For mild pain, your clinician may suggest over-the-counter analgesics, including acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Motrin, Advil). For anemia caused by heavy bleeding, you may be advised to increase your iron intake through diet, supplements, or both.

No medication can prevent fibroids or guarantee that they won't return. But there are prescription drugs that shrink fibroids and reduce bleeding. The most important classes of prescription drugs are the following:

GnRH agonists. Gonadotropin-releasing hormone (GnRH) agonists such as leuprolide (Lupron) suppress ovarian estrogen production and produce a temporary false menopause that reduces blood flow to fibroids and shrinks them. Fibroids usually grow back once the drug is stopped. These medications are rarely used for more than six months, because they can bring on menopausal symptoms, including hot flashes and vaginal dryness — as well as depression, joint pain, bone loss, and sleep problems. The best candidates for GnRH treatment are women who need only a short-term "bridge" to menopause, when fibroids tend to recede, or respite from periods to build up their blood count. A GnRH agonist may also be prescribed before surgery to shrink fibroids.

Hormonal agents. Birth control pills, the androgen drug danazol (Danocrine), or medroxyprogesterone acetate (Depo-Provera) may be prescribed to help control bleeding. Mifepristone (RU-486) blocks progesterone, shrinking fibroids and reducing bleeding. (Researchers are developing other drugs in this class, called selective progesterone receptor modulators, or SPRMs.) Early studies suggested that RU-486 might cause overgrowth of uterine cells, but lowering the dose appears to solve that problem. Raloxifene (Evista) helps shrink fibroids but is prescribed only for postmenopausal women. Some women get relief from heavy bleeding by using a progestin-releasing intrauterine device (Mirena).

Surgery

For more severe symptoms, you may want to consider surgery. Your decision will depend largely on whether you've completed childbearing and, if you have, whether you are willing to wait for menopause. The two most common surgeries are these:

Myomectomy. This operation removes only the fibroid (or fibroids). It preserves the uterus, so it's the best option for women who may want to have children (although they may be advised to deliver by cesarean section).

Depending on the type, size, and location of the fibroid(s), myomectomy may be performed through a standard abdominal incision or — less invasively — via laparoscopy, where small incisions and video-aided instruments are used. The surgeon may also employ a technique called hysteroscopy. In this procedure, a hysteroscope equipped with instruments for removing the fibroids is introduced into the uterus through the vagina and may be used for fibroids that protrude into the uterine cavity. Surgeons must be specially trained to perform this operation. Recovery time is shorter in hysteroscopic and laparoscopic procedures than in abdominal myomectomy, and fertility rates are excellent.

One disadvantage of myomectomy is that adhesions may form. (Adhesions are a type of scar tissue that forms on pelvic organs and binds them to each other.) Another is that fibroids may recur, since the uterus isn't removed. Among women undergoing myomectomy, 10% to 33% require a second surgery within five years.

Hysterectomy. The uterus is removed through an incision in the lower abdomen, through the vagina, or laparoscopically. This completely eliminates fibroids and their symptoms.

Hysterectomy is safe and effective and has a low complication rate. Nevertheless, it's major surgery that requires anesthesia and — depending on the particular procedure — two to six weeks of recovery time. Women who have had a hysterectomy are at greater risk for urinary incontinence and reach menopause an average of two years earlier.

Studies suggest that most women are satisfied with their decision to have the procedure. But hysterectomy ends periods and childbearing, so you need to consider psychological as well as medical ramifications.

Selected resources

Center for Uterine FibroidsBrigham and Women's Hospital, Boston800-722-5520, operator 525-4434 (toll-free)www.fibroids.net

National Uterine Fibroids Foundation800-874-7247 (toll-free)www.nuff.org

Society of Interventional Radiology800-488-7284 (toll-free)www.sirweb.org/patPub/uterine.shtml

Uterine artery embolization

Uterine artery embolization (UAE) — also known as uterine fibroid embolization — is a minimally invasive procedure that shrinks fibroids by cutting off their blood supply. UAE has been around since the early 1980s as a treatment for postpartum and other traumatic pelvic bleeding. Since 1995, it's been used to treat fibroids and has become increasingly popular.

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. During the procedure, an interventional radiologist inserts a catheter through a small nick in the skin (at the groin) into the femoral artery. Using contrast dye x-ray imaging, the catheter is guided into one of the two arteries that supply the uterus (the uterine arteries). Sand-sized particles made of a synthetic material are then injected into the uterine artery. The particles concentrate in the blood vessels feeding the fibroid (see illustration), cutting off its blood supply and eventually shrinking it. Both uterine arteries can usually be treated during the same catheterization.

Uterine artery embolization

During the procedure, an interventional radiologist threads a catheter into the uterine artery by way of the groin, using real-time x-ray imaging, and releases tiny particles into the artery on one side of the uterus. The particles accumulate in the blood vessels feeding the fibroid, cutting off its blood supply. Then the procedure is repeated on the other side.

UAE is performed under local anesthesia and takes less than an hour. It can be performed on an outpatient basis but usually requires a one-night hospital stay to monitor for post-embolization syndrome (pelvic pain and cramping, nausea, vomiting, fever, and general discomfort). Serious cramping during the first 12 to 24 hours after UAE is common and treated with oral or intravenous painkillers. Some women experience a bloody discharge for two weeks to several months following the procedure.

Serious complications are rare (less than 1%). There is some concern about damage to the ovaries from migrating particles. A few women have suffered a temporary or even permanent disruption of ovarian function. The risk is greater after age 45. In some cases, sloughed-off fibroid tissue becomes stuck in the cervix on its way out of the body and has to be removed surgically.

UAE is an option for a woman who doesn't want or can't have surgery, or who would like to preserve her uterus. It generally isn't recommended for women wanting to conceive after treatment: pregnancy rates are lower — and pregnancy complication rates are higher — following UAE than after myomectomy.

UAE is most effective for fibroids that are not pedunculated (growing on a stalk). Surveys show that 85% to 90% of women are satisfied with the results up to three years after the procedure. It's faster than hysterectomy and involves a shorter hospital stay and less recovery time. Quality of life scores are similar for the two procedures. But follow-up data indicate that 20% to 24% of women undergoing UAE will need surgery (hysterectomy or myomectomy) within a couple of years.

Some gynecologists are looking for ways to interrupt the blood supply of fibroids without injecting 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 requires no incision at all; the surgeon approaches the artery through the vagina to apply a clamp, which stays in place for a few hours and shrinks the fibroid. Blood flow returns to the artery when the clamp is removed.

Magnetic resonance–guided ultrasound

Magnetic resonance–guided focused ultrasound surgery (MRgFUS) is a noninvasive technique that works by heating and shrinking the fibroid with high-intensity ultrasound waves. MRI is used to visualize the fibroid and monitor temperature changes in the tissue during the procedure.

The device used to perform MRgFUS (the ExAblate 2000) gained FDA approval in 2004, so there's little information on its long-term safety and effectiveness. Two- and three-year follow-up studies suggest that MRgFUS helps reduce symptoms, but it hasn't been compared directly with hysterectomy, myomectomy, or UAE.

How does MRgFUS work?

The patient lies on her stomach on a table inside the MRI scanner, positioned over a transducer that emits high-intensity ultrasound energy and focuses it on a tiny area of the fibroid. Each such "sonication" heats and destroys a small amount of tissue; multiple sonications are required for each fibroid. The patient is sedated but fully awake during the procedure, which takes three hours, on average. Patients can go home shortly afterward and usually return to normal activities the next day.

MRgFUS is not recommended for multiple small fibroids, pedunculated fibroids, or fibroids located deep in the pelvis, behind bowel loops, or close to the sacral nerves in the lower spine. Although it is approved only for women not concerned about preserving their fertility, some pregnancies have occurred following MRgFUS. The procedure isn't widely available and may not be covered by insurance. For now, it should be considered promising but still unproven.