Treatment Options For Uterine Fibroids

Your individual situation will determine the treatment plan your doctor creates for you. Your overall health, age, number, and size of fibroids will be some of the factors that will influence your treatment plan. If you are diagnosed with uterine fibroids but are not experiencing any symptoms, no treatment is required.

Lifestyle Choices

There is no known cause of fibroids, however, we do know some factors that assist them to grow and multiply. Striving to avoid these factors may have an impact on their growth and number.

Eating healthy and avoiding foods that interfere with the balance of estrogen in the body.
Getting enough sleep.
Avoiding personal care products that contain additives that alter the natural estrogen in the body (like hair relaxers).
Maintaining a healthy weight because excess fat produces estrogen.
Exercising regularly will help maintain a healthy BMI and can relieve stress that plays a part in the production of estrogen.
Vitamin D is linked to the reduction of fibroid growth, so safe sun exposure and/or supplements should be a part of your daily routine.
Iron and Hemoglobin levels should be checked and supplemented as needed for women who experience heavy bleeding (to alleviate anemia symptoms).

Hormones and Other Medications

Usually, hormones and over-the-counter medications are often the first-line treatment options recommend for women who are diagnosed with symptomatic fibroids.

Over-the-counter anti-inflammatory, non-steroidal pain relievers help alleviate mild symptoms (Motrin/Ibuprofen, Naproxen, etc).
Oral Contraceptives/ Progestin-containing IUD/hormonal implant may work to limit fibroid growth by regulating certain hormones.
GnRH antagonists or GnRH agonists are sometimes prescribed for short time spans because they cause a temporary, medically induced menopause. They only work for the time you are taking them, and fibroid growth resumes when the medication is stopped.
SERMs, SPRMs – actively target the body’s estrogen/progesterone receptors and may help shrink fibroids without medically inducing menopause. The most notable SERM (tamoxifen) is often used in the treatment of certain breast cancers, but there is not enough data for their use in fibroids. Unfortunately, the main SPRM (Ulipristal) was discontinued due to liver injury requiring liver transplant in some women.

Surgical Treatment For Fibroids

Myomectomy

This is an invasive surgery done by a gynecologic surgeon with the patient under general anesthesia. Unfortunately, there are typically more fibroids than the surgeon can safely remove. Therefore, there will often be a number of living fibroids in the uterus after the myomectomy surgery. This will often lead to a recurrence of symptoms typically within 5 years (i.e. 11% per year).

Anyone facing a second myomectomy surgery should first be offered a non-surgical option – Uterine Fibroid Embolization procedure (see below). Surgically operating on the uterus will diminish a woman’s fertility due to the adhesions and scar tissue. However, if the patient does become pregnant following myomectomy, a C-section will be required.

There are different surgical approaches to perform a myomectomy:

Open myomectomy is typically performed through a “bikini cut” incision from one hip across horizontally to the other hip in the lower abdomen. Risks for scarring of the uterus and blood loss may be higher with abdominal myomectomies than with the less invasive procedures. Recovery is 6-8 weeks.
Laparoscopic myomectomy is performed through smaller incisions made in the abdomen using special scopes that contain surgical instruments and a tiny camera placed through thin, hollow metallic tubes. The recovery time is quicker than abdominal myomectomy; usually 4-6 weeks. However, due to the size of the enlarged fibroid-filled uterus, myomectomies often cannot be performed laparoscopically. With either laparoscopic or open myomectomy, patients have to realize that they might wake up without their uterus and will be required to sign a medical release attesting to this.
Hysteroscopic myomectomy is done by inserting a scope through the vagina and cervical canal and then utilizing an electrosurgical wire loop to surgically remove the fibroid. This technique can only be used for a very small select group of fibroid patients that only have a certain subset of submucosal fibroids (FIGO Type 0 or 1). Recovery time is a few days.

Hysterectomy

This is the removal of the uterus through surgery. The cervix, ovaries, and fallopian tubes may also be removed. A hysterectomy can be done abdominally, vaginally, or laparoscopically. It also can be done with the assistance of computer robotics.

Abdominal Hysterectomy is the most invasive of hysterectomy techniques and the most commonly performed for fibroids. Depending on how big the uterus is will determine what type of long incision is necessary. For an enlarged uterus up to but not above the belly button (i.e. 16-week pregnant size), the incision is typically horizontal. This will extend from one hip to the other, similar to a c-section, and the uterus and any other reproductive organs may also be extracted. If the uterus extends above the belly button, a vertical incision from breastbone to pubic hairline is usually required. Unfortunately, some cases that start out with a horizontal incision do not allow enough exposure to reach high enough and a vertical incision is then added (the “Upside-down T” incision). Abdominal hysterectomy requires a hospital stay and 6-8 weeks recovery time.
Laparoscopic hysterectomy is less invasive than abdominal hysterectomy surgery and is performed using a laparoscope, a lighted instrument equipped with a camera, and is done through small incisions. The laparoscope is normally lowered through the belly button and a few other incision sites while visually assisting the surgeon in removing the uterus. If the surgeon is using the assistance of a computer with robotics, the technique is the same but the computer’s robotic arms are holding the instruments instead of the surgeon.
Vaginal hysterectomy – with the assistance of a laparoscope, the surgeon accesses the uterus through a small incision in the vagina and using special instruments, removes the uterus through the vagina. The cervix, ovaries, and fallopian tubes may be removed as well. This is rarely able to be done in women with symptomatic fibroids due to the uterine enlargement from these fibroids. Recovery time is about 4-6 weeks.

Surgical risks of hysterectomy include damage to other nearby organs, such as the bladder, ureter, and colon. Other risks include bleeding requiring transfusion, infection/wound issues, side effects to the anesthesia, and blood clots that can form in the legs or pelvis (DVT – deep vein thrombosis) and can travel to the lungs (PE -pulmonary embolus) and even be fatal.

Once the hysterectomy is performed, there are often consequences that the woman may face after recovering from hysterectomy surgery. These can be psychological due to the loss of her womb, like a man being castrated. It can be sexual dysfunction e.g. loss of libido, loss of orgasm. It can be urinary leaking and incontinence. The surgical removal of the enlarged fibroid-filled uterus can weaken the pelvic floor muscles and can cause a woman to permanently leak urine. There is a lot of bone loss after hysterectomy which can lead to osteoporosis, and there is even evidence of increased cardiovascular risk for high blood pressure, heart attack, and stroke.

Non-Surgical Fibroid Treatment

Uterine Fibroid Embolization (UFE)

UFE is an interventional radiology technique to treat uterine fibroids. UFE is a non-surgical, outpatient, a minimally invasive procedure performed by Interventional Radiologists who are physicians that are specifically trained in minimally invasive therapies. UFE is 90% effective in relieving fibroid symptoms and has over 25 years of proven safety and efficacy.

In 2008, UFE was endorsed by the American College of Obstetricians & Gynecologists (ACOG) with the highest level of scientific evidence (Level A). UFE cuts off the blood supplying the fibroids. As the fibroids die, they soften and shrink. As this occurs over days-weeks, the symptoms start to fade away.

UFE does not require a hospital stay. It yields permanent results, but if there is the appearance of new fibroids which become symptomatic, UFE can be repeated. Because UFE treats every fibroid that is in the uterus at the time of the procedure (a significant advantage over myomectomy), the chance of needing a 2nd UFE procedure is very low. The recovery time for someone after a UFE procedure is 5-7 days. Many patients have conceived and given birth after UFE. These births are usually full-term and vaginal. Every insurance company routinely covers UFE; including Medicare and Medicaid.

Uterine Endometrial Ablation

Endometrial ablation is a gynecology technique to treat uterine fibroids. It destroys a layer of the uterine lining and reduces or sometimes stops the flow of menstruation for women that have bleeding NOT due to fibroids (or adenomyosis). Despite the fact that endometrial ablation does not shrink, remove or affect fibroids, many doctors will try (often unsuccessfully) to treat fibroid-related bleeding with ablation. Also, pregnancy is not possible after an ablation procedure.

There are several types of uterine endometrial ablation:

Electrosurgery – Thin trenches are carved into the outside layer of the uterine lining with an instrument that resembles a wire loop that uses heat.
Cryoablation – Guided by ultrasound, the doctor freezes and destroys the outside layer of the uterine lining.
Free-flowing Hot fluid – Heated saline fluid is circulated inside the uterus for about 10 minutes, which destroys the uterine lining. This method is often used on women who have an irregular-shaped uterus.
Heated balloon – a balloon-like device is inserted into the uterus and filled with heated fluid, and the heat destroys the uterine lining.
Microwave – Microwaves are emitted through a device that resembles a wand, heating the outside lining of the uterus, and destroys it.
Radiofrequency – Radio frequencies are emitted through a mesh-like material into the uterus destroying the outermost layer in just a few minutes.

Radiofrequency Ablation For Fibroids

Laparoscopic, ultrasound-guided radiofrequency ablation (LUGRA, brand name – Acessa) is a new, outpatient surgical approach to treating symptomatic fibroids. The very first cases performed were reported in the early 2000s. Many insurance companies do not cover this procedure and consider it experimental. It involves the placement of a stiff hollow needle into a fibroid under ultrasound guidance. Through this needle, an array of electrodes are advanced into the fibroid. Heat is delivered to the fibroid which will destroy it. Over time, the fibroid will soften and shrink.

Like any new technology, there is a learning curve, and the reported adverse event rate is up to 32%. This is not recommended for women with numerous fibroids, women that want to avoid surgery, or for women who might possibly or definitely want future fertility. There is very little long-term data on this new technology and further studies will be needed to prove its safety and efficacy.