Many women in their thirties (and sometimes younger) begin to have symptoms of fibroid tumors (medically known as leiomyomas). Fibroid tumors are extremely common, usually circular or oval-shaped solid tumors that arise from the smooth muscle tissue in the uterine wall or its support ligaments. Less than 1% of these tumors are cancerous, and most of the time the symptoms are mild. Although not dangerous, they can cause abnormal bleeding, pain, or size-related problems and are a leading reason for hysterectomy. Recent data indicate that near age fifty, 70 percent of Caucasian women and more than 80 percent of African American women have evidence of fibroids on ultrasound. While it is surprising how common these tumors are, the bright side is they usually shrink dramatically after menopause.
Most medical treatments of fibroids will preserve fertility, but if a surgical option is determined to be needed, the plan will be pivotal around the issue of future fertility. The most common reason to treat fibroids is abnormal vaginal bleeding. Fibroid tumors in the wall or lining of the uterus may cause more blood to circulate into the uterus, causing heavy periods. Age-related hormonal changes that may cause irregular periods (often the case in the late 40s or perimenopause) can also result in an uneven build-up in the uterine lining, aggravating the problem. A thickened uterine lining may need to be tested or biopsied before treatment can start.
If the uterus is not markedly enlarged, the most common treatments involve the use of progesterone or progestins (synthetic progesterone-like medications) to thin the uterine lining, which tends to help bleeding related to the fibroids. The birth control pill and other forms of hormonal contraception (such as the vaginal ring or the IUD containing progestin) may reduce abnormal bleeding associated with fibroids. These methods can be extremely effective in lessening PMS, perimenopausal symptoms and cramps, as well. There are several medications that can be used to lower estrogens and/or progesterone in the body, which generally causes the fibroids to shrink. Because these medications (such as DepoLupron) are relatively expensive and may cause menopause-like side effects, they are usually used only temporarily.
Some women have small fibroids that may be accessible from the inside of the uterine cavity. A minor surgery known as hysteroscopy may be used with an instrument to cut out the tumor(s). This simple approach is usually an outpatient procedure, does not require an incision, and fertility may be maintained.
In some cases, as long as there is no future plan to try to become pregnant, noninvasive surgical procedures may also be used to permanently thin the lining of the uterus, or reduce its blood supply (i.e, a procedure known as endometrial ablation). While this procedure does not eliminate the fibroids, the most bothersome symptom (bleeding) is often markedly improved. This procedure requires no incision or stitches, and in some instances may be performed in the office setting under local anesthesia.
Another conservative treatment method is called uterine artery embolization (UAE). This minimally invasive procedure is usually performed by a radiologist and involves injecting tiny beads in the uterine blood vessels by way of an artery in the upper thigh (similar to a heart catherization) in order to block the blood supply to the fibroid. The dramatic reduction in the uterine blood flow will cause the fibroids to shrink, often reducing period bleeding as well. The procedure usually does require an overnight hospital stay, but only requires a very small incision.
There is a growing interest in using MRI and ultrasound imaging to locate and treat fibroids with almost any imaginable energy source, such as ultrasound energy or microwaves. Most of these relatively non-invasive procedures are very early in their development and are not yet commonly performed.
Surgical removal techniques are still the most commonly used approaches and involve removing the tumors or the uterus, depending on the desire to maintain fertility. A myomectomy is a surgical procedure to remove the fibroids from the uterus. This operation may be performed using laparoscopic techniques (outpatient, with tiny incisions) or in the case of multiple, very large tumors, a traditional incision may be required. Pregnancy is usually possible after myomectomy, but if the uterus has been deeply incised, a cesarean section may be recommended for delivery.
Hysterectomy is the most common approach to symptomatic fibroids, but again, this depends on the woman’s desire for a future pregnancy. Newer laparoscopic hysterectomy techniques have lessened the need for large, painful incisions and often only require an overnight stay (or less) in the hospital. Some women opt to maintain the integrity of their cervix (having only the body of the uterus removed), and this may allow a quicker recovery. Having a hysterectomy does not usually mean that the ovaries need to be removed. Recent data indicating health benefits associated with ovarian function has encouraged surgeons not to remove normal ovaries in the woman at low risk for ovarian cancer at the time of hysterectomy until after age 65.
Fibroid tumors are so common it is unusual not to have them, but most affected women will not need aggressive treatments.
Medical
- Hormonal contraceptives (Pills, ring, IUD, etc)
- Progestins (synthetic or natural progesterone agents)
- Hormone-suppressing agents
Minimally invasive options
Fertility preserving:
- Hysteroscopic removal
- Laparoscopic removal
- Targeted fibroid destruction
Non-fertility preserving:
- Endometrial ablation
- Uterine artery embolization
- Minimally invasive hysterectomy
Traditional surgical options
Fertility preserving:
- Abdominal myomectomy
Non-fertility preserving:
- Abdominal hysterectomy
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