Treating Fibroids
Fibroids usually don't need to be treated unless they are causing symptoms like bleeding, pelvic pressure, or increased uterine size. But medications may be prescribed to shrink troublesome fibroids, or surgery may be required when symptoms are severe. The most common treatment for those with large fibroids or severe symptoms is a hysterectomy, or surgical removal of the uterus. In fact, fibroids are the most common reason for hysterectomies, with about 200,000 women in the U.S. getting the surgery every year to treat fibroids.
This section discusses:
Drugs
Medications may be used as a first-line treatment for fibroids. The most effective are gonadotropin-releasing hormone (GnRH) agonists, which include Lupron, Synarel, and Zoladex. These suppress estrogen, creating a menopauselike state. Since fibroids are dependent on estrogen for their development and growth, lowering estrogen supply helps to shrink the size of fibroids and an enlarged uterus, which can reduce pelvic pressure and bleeding symptoms. Once the treatment is stopped, fibroids rapidly regrow, and the uterus expands once again.
These medications can't be used indefinitely, since long-term use can significantly decrease bone density and increase the risk of osteoporosis. Because of this, GnRH agonists are used only for a short period in women nearing menopause, or for one month to three months prior to surgery in order to shrink fibroids in preparation for their removal.
A combination of GnRH agonists and low doses of estrogen and progesterone (to add back some of the suppressed hormones) is being studied to see if it can reduce bone loss and extend the time women can take the drugs. Preliminary data suggest that a combination protocol may be safe for up to two years if GnRH agonists are given alone first to allow the uterus to shrink and if the hormone dose is low (equivalent to hormone replacement therapy doses). Other medical therapies such as mifepristone, GnRH antagonists, and raloxifene are being investigated to determine how effectively they induce uterine shrinkage and stop menstrual periods.
Surgery
There are a variety of ways a hysterectomy can be performed, including through an abdominal incision, through the vagina, or through an incision in the bellybutton (laparoscopically). The risks and long-term outcomes of these surgeries are generally the same. However, women who have the vaginal or laparoscopic hysterectomies spend less time in the hospital and return to their normal activities sooner. The type of hysterectomy chosen depends on the size of the uterus, a woman's medical history, and the skills of her surgeon. Although a hysterectomy can require several days in the hospital and several weeks of recuperation, it has the advantage of being a guaranteed cure for fibroids. But it's obviously not an option for women planning future pregnancies.
In extremely rare cases (about 1 in 1,000), fibroids can become malignant. Those that are large or rapidly growing are more likely to be cancerous. Since it's impossible to determine whether a fibroid is indeed cancerous without removing the fibroid and uterus, hysterectomies may be the preferred method of treatment in those with extremely large or rapidly growing fibroids. Postmenopausal women who continue to be plagued by fibroid symptoms, especially if they aren't taking hormone replacement therapy, may also be good candidates for hysterectomies since those fibroids that grow independent of estrogen have a greater likelihood of being malignant.
Other surgical approaches include:
Focused Ultrasound Treatment
In 2004, the Food and Drug Administration approved a device called ExAblate 2000, which uses MRI-guided ultrasound to target and destroy fibroids. It's intended only for premenopausal women who have completed childbearing. Unlike any other treatment, other than the use of medications, focused ultrasound is completely noninvasive. The therapy focuses ultrasound energy to destroy the fibroid tissue. The technique is very accurate, given that a real-time MRI is performed during the procedure to map out and confirm that the ultrasound waves are targeting the fibroid precisely.
Because this treatment is still being investigated for long-term outcomes, insurers may not cover it.
Myomectomy
A surgical procedure to remove just the fibroid, called a myomectomy, can be performed on those wishing to preserve their fertility. About 34,000 myomectomies are performed yearly in the United States. Most myomectomies are performed through an abdominal incision into the uterus, although certain submucosal fibroids can be removed through the vagina without an abdominal incision using a procedure called hysteroscopic myomectomy. This technique is performed by gently dilating the cervix and inserting a hysteroscope into the uterus. The fibroid is then shaved away by the surgeon, typically using an electrified wire loop. The small fibroid pieces are removed through the dilated cervix. It is primarily useful for pregnant women with bleeding or other problems related to the fibroids since it preserves the size of the uterus.
Certain fibroids may be removed through a small bellybutton incision in a laparoscopic myomectomy. A camera is inserted through a 5-10mm incision in the bellybutton and two or three additional incisions are made on the abdomen to allow for long laparoscopic instruments to be inserted and used. The fibroid is grasped and freed, and cut into small pieces so that it can be removed. The incision on the uterus is then sutured in the traditional fashion, using the long laparoscopic instruments.
In general, myomectomy diminishes bleeding in approximately 80 percent of patients presenting with this symptom. But there is a significant risk of recurrence of fibroids after myomectomy; in some studies about 25 to 50 percent of women who had myomectomies wound up with a recurrence of fibroids within 10 years, and up to 10 percent required a second surgery.
Thermomyolysis, Cryomyolysis, and Uterine Artery Embolization
Other laparoscopic techniques being studied include thermomyolysis, which delivers an electric current to a fibroid to destroy it, and cryomyolysis, which involves freezing the fibroid. For both procedures, a laparoscopy is performed and a probe that either heats or freezes the tissue is directly inserted into the targeted fibroid. These procedures are still being investigated for long-term outcomes and are not widely available.
A newer minimally invasive procedure to treat fibroids, called uterine artery embolization, is a radiological alternative to surgery that involves placing a catheter into a leg artery and guiding the catheter via X-ray images to the arteries of the uterus. A solution containing grain-size polyvinyl particles is then injected into the tubing to deliver the particles directly to the major blood vessels that feed the fibroids to cut off the blood flow to these vessels. Women usually require only an overnight hospital stay and have a much shorter recuperation. A recent randomized study found that embolization improved the quality of life of fibroid sufferers as much as surgery. However, about 20 percent of those who had the less invasive technique wound up having to repeat the procedure or undergo surgery for persistent fibroids. In women close to the age of menopause, this procedure can lead to an absence of periods and loss of ovarian function. The safety of the procedure in women who later wish to become pregnant has not been demonstrated.
advertisement
