Updated on 30.10.2016.
Evidence based unbiased information
Uterine fibroids –
Alternative treatment to hysterectomy or myomectomy
This is a laparoscopic picture of a lady with infertility showing multiple (seven) good sized fibroids. Myomectomy or hysterectomy was not performed and she was treated conservatively. She became pregnant soon and had delivered a healthy baby. Mere presence of fibroids does not cause infertility.
Uterine fibroids (tumours) are found in about 20% of women of the reproductive age. While more than 50% of women with fibroids remain asymptomatic the rest would have various symptoms including serious and debilitating ones. Women with fibroids are often worried about the risk of malignancy (cancerous changes) in fibroids. Hysterectomy or myomectomy has been done for years to treat fibroids, however, many other excellent treatment modalities are also available. All those issues have been discussed in this article.
Uterine fibroids – Alternative treatment
to hysterectomy or myomectomy
Uterine fibroids are found in about 20% of women of the reproductive age. More than 50% of women with fibroids remain asymptomatic. The symptoms associated with uterine fibroids include menorrhagia (regular heavy periods, 30 to 50%), metrorrhagia (irregular uterine bleeding), dysmenorrhoea (painful periods), anaemia, pelvic/abdominal pain/discomfort, abdominal swelling, pressure symptoms (bladder– increased frequency, urgency, stress incontinence, difficulty voiding, retention; bowel– constipation), infertility (rare), miscarriage (rare) etc. The risk of malignancy (cancerous changes) in a fibroid is low (about 0.5% or 1 in 200). In pregnancy fibroids are associated with large for dates, pain abdomen, fetal growth restriction, preterm labour, obstructed labour, post-partum haemorrhage etc.
While more than 50% of women with fibroids remain asymptomatic, the rest might require treatment. Surgical treatment in the form of hysterectomy (removal of the uterus) or myomectomy (removal of fibroid) has been widely used. But these are associated with increased morbidity and non-surgical treatment might be a suitable alternative in a number of cases. The advantages of non-surgical treatment are avoidance of surgery and its associated morbidity. In recent years some new non-surgical treatment modalities became available.
The non-surgical options that are available/have been tried to treat fibroids include explanation, reassurance and monitoring if asymptomatic; iron to treat any anaemia; tranexamic acid + mefenamic acid to treat any heavy periods; analgesics to treat any pain; progestogens, gestrinone, anti-progestogens, danazol, GnRH analogues, combination of GnRH analogues and oral contraceptive pill, levonorgestrel releasing intrauterine system (Mirena), uterine artery embolisation etc.
Progestogens have been found to be ineffective in reducing the size of the fibroid.
Gestrinone has been found to be ineffective in reducing the size of the fibroid.
Many studies have shown a reduction of fibroid size with long-term high-dose anti-progestogens like mifepristone (RU486), however, the hormonal effects are undesirable.
Danazol reduces the size of the fibroid, but it cannot be used long-term because of its side effects, the androgenic ones in particular.
The side effects of danazol include weight gain (commonest), muscle cramps, decreased breast size, hot flushes, mood change, oily skin and hair, depression, sweating, edema, change in appetite, acne, weakness, hirsutism, decreased libido, nausea, headache, dizziness, insomnia, skin rashes, increased libido, hoarseness of voice (could be permanent), atrophic vaginitis, decrease in HDL-Cholesterol (60%) , decrease in HDL2 subfraction (80%), decrease in LDL (40%), decreased HDL/LDL ratio, alterations in liver enzymes (so contraindicated in liver disease) etc.
Combination of a GnRH analogue and the oral contraceptive pill
The combination of a GnRH analogue and the oral contraceptive pill has proved ineffective, with eventual growth of tumour beyond the pre-treatment size.
Levonorgestrel releasing IUS (Mirena)
Mirena has been shown to reduce the growth of fibroids significantly after 6-18 months of use, due to levonorgestrel-induced effects on insulin-like endometrial growth factors and their binding proteins. It is already gaining popularity in the treatment of menorrhagia, which might occur with fibroids as well in the future. Its main side effect is irregular vaginal spotting during the first 4-6 months after its insertion.
GnRH analogues have been shown to reduce the size of the fibroid by 50% within 3 months of therapy. Women with the largest fibroids are likely to experience the greatest shrinkage, though complete regression has only been noted in small tumours. Shrinkage of the fibroid occurs because of hypo-estrogenism. Treatment is usually given for 3-6 months to reach a significant reduction in tumour size. Tumour re-growth up to 90% of the original size may occur within 3 months of treatment discontinuation.
The major problems of long-term use of GnRH analogues include hypo-estrogenic side effects (menopausal symptoms – hot flushes, night sweats, dryness of vagina, atrophic vaginitis, superficial dyspareunia, reduced libido etc) and bone mineral loss leading to an increased risk of osteoporosis (3 to 5% loss in vertebral trabecular bone density of the lumbar spine detected by CT scan following 6 months treatment).
The use of add-back HRT in combination with GnRH analogues reduces menopausal symptoms and helps protect against bone mineral loss. Tumour regression, however, may not be as pronounced as with the GnRH analogue alone. A prospective open trial assessing the long-term benefits of giving leuprolide acetate with tibolone has reported initial significant regression in tumour size within 6 months followed by tumour re-growth, though not back to the original size. The other disadvantages include worsening of symptoms due to initial stimulation and pain from degeneration.
GnRH analogues definitely have a role in the management of fibroids in specific situations for short-term treatment and alleviation of symptoms, use in women close to the average menopausal age, and presurgical treatment to reduce the size and vascularity of the fibroids. The presurgical treatment has several potential advantages e.g. reduced menorrhagia leading to increased haemoglobin levels, possible avoidance of hysterectomy, reduced intra-operative blood loss, making pfannenstiel and smaller incisions possible, technically easier operation with less tissue trauma and injury, possibility of vaginal hysterectomy and easier endoscopic surgery. It is argued that as the fibroid capsule becomes less evident and tumours do not shell out easily making the removal more difficult, the perceived benefit may be questionable in case of myomectomy. A randomised trial did not find any advantage in laparoscopic myomectomy. Although the fibroids were significantly reduced in size, operating time was significantly prolonged.
Uterine artery embolisation
Uterine artery embolisation to treat fibroids has been introduced relatively recently. It is mainly carried out by interventional Radiologists via the bilateral percutaneous femoral artery route, locating the uterine arteries, using local anaesthesia and intravenous sedation under fluoroscopic guidance. Injection of polyvinyl alcohol particles followed by gelatin sponge pledgets causes thrombosis and occlusion of the uterine arteries. Recently, a single femoral approach using a single catheter has been developed.
It substantially reduces fibroid size up to 65% and gives symptomatic relief in 90% of women within 2 months. Fibroid re-growth does not seem to be a common problem. It has even been advocated by some as a first-line treatment.
The complication rates are low and include haemorrhage, false aneurysm, sepsis, pyometra, ischaemia, gangrene and neurological damage.
It is indicated in women with symptomatic fibroids, fibroid re-growth following myomectomy or other treatment, where the surgery is potentially difficult, and women who decline blood transfusion and surgery.
The advantages include: performed under light sedation, short hospital stay (few hours) and well-tolerated procedure.
The disadvantages include: carried out by Radiologists who might perform it without gynaecological assessment, general anaesthesia is occasionally required, post-procedure pain or cramp, haematoma at puncture site, spasm of branches of iliac artery particularly following pretreatment with GnRH analogues, arterial dissection, infection, fibroid discharge, vaginal expulsion of fibroid, cannot be used in women with coagulation disorders and not yet recommended in nulliparous women (effects of devascularisation on subsequent fertility not known). Its role in post-menopausal women with fibroid-related symptoms has not been addressed.
Non-surgical treatment of fibroids is a suitable alternative to hysterectomy or myomectomy. Explanation, reassurance and monitoring if asymptomatic (>50%); iron to treat any anaemia; transexamic acid + mefenamic acid to treat any heavy periods; analgesics to treat any pain could be used in a number cases. GnRH analogues have been used successfully for the treatment of fibroids. Its main drawback is unacceptable side effects limiting its long-term use. Mirena is effective and can be used long-term. The new technique of uterine artery embolisation has been shown to be promising. It is only available in specialist centres and is still part of an ongoing evaluation process.
1. CD-ROM for Part 2 MRCOG: Paul S. Obstetrics & Gynaecology for Part 2 MRCOG, 3rd edition, Medidea, UK, 2006
2. Akande V, Jenkins J. Surgical vs medical treatment for uterine fibroids. In: Liberman BA, Shaw RW, Sutton CJG eds. Advances in Obstetric and Gynaecology Issue 18. Oxford:TMG Healthcare Communication 2000:7-14.
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