How can fibroids be treated?

In general treatment is only required if the fibroids are causing symptoms. The fact that fibroids are found during routine examination does not generally mean that action is indicated although you may wish to have check ups for reassurance that the fibroids are not enlarging unduly. When there are small fibroids and heavy periods, medical treatment should still be considered before resorting to surgery.

If fibroids become particularly large they may require surgical removal.Gynaecologistsgenerally assess the size of the uterus by comparing it to the size expected during a pregnancy. As an approximate guide, if the uterine size is larger than 18 weeks size, surgery is probably indicated. In younger women who wish to retain their fertility, the fibroids can be shelled out of the womb (myomectomy). If fertility is not a re quisite, hysterectomy (hysterectomy) is likely to be the preferred operation. It has been estimated that once in every hundred myomectomies uncontrollable bleeding occurs and in such circumstances hysterectomy becomes necessary as a life-saving procedure.

GnRH analogues (gonadotrophins) reduce oestrogen and progesterone levels and they are frequently used to reduce the size of the fibroids pre-operatively. On average, fibroids will be reduced by about a third of their size after three months and perhaps by a half after six months. GnRH analogues can be used by themselves for a maximum of six months as there is a risk of bone thinning (osteoporosis) and the oestrogen protection against arterial disease would also be lost (23). If myomectomy is not performed the fibroids rapidly return to their pre-treatment size. There has been recent suggestion that GnRH analogues could be continued for more than six months provided oestrogen is replaced in the form of HRT (HRT-Add-Back); early studies indicate that the oestrogen replacement does not reduce the benefits of the GnRH on fibroid size. GnRH analogues are expensive, precluding long-term use unless there are exceptional circumstances. When fibroids are associated with heavy periods, GnRH analogues for a few months pre-operatively will provide two advantages: In addition to shrinking the size of the fibroids, they should stop the periods, allowing anaemia to be corrected thus reducing the likely requirement for blood transfusion.

Uterine artery embolisation is a new treatment for fibroids. The uterine arteries provide about 50% of the blood supply to the uterus. A fine catheter is introduced into an artery in the right groin. Poly Vinyl Alcohol particles are placed into the uterine arteries, under x-ray control, with the objective of starving the blood supply to the fibroids. The starved fibroids should then disappear or become smaller. After the procedure there may be pain and for three or four weeks there may be bleeding. Patients usually stay in hospital for a couple of days and may return to work after two weeks.

Data from the Royal Surrey County Hospital trial of 30 patients have achieved successful ongoing pregnancies with no obvious problems to date. Success rates of 85% are being achieved. A few patients stop seeing their periods. The main complication of fibroid embolisation is infection requiring hysterectomy in about 1% of cases.

Twenty patients have become pregnant following fibroid embolisation with no obvious problems to date. Deaths from fibroid embolisation (1:2500) are uncommon and appear to be less than for hysterectomy (1:1600). Fibroid embolisation is still undergoing trials to determine its benefits and risks.

The long-term results of uterine artery embolisation are awaited.

Minimal access surgery is an option in the treatment of fibroids. The laparoscopic route is applicable to sub-serous fibroids and hysteroscopy for sub-mucosal fibroids.

MRI-guided focused ultrasound treatment of uterine fibroids is a further new minimally invasive technique. Research into its place and value is being assessed.

Uterine Artery Embolisation is associated with less complications than hysterectomy. About 1 in 4 women having UAE require further treatment. Both treatments are safe and effective over the medium term. The choice of treatment is a matter of personal preference.0703 UAE is cheaper than hysterectomy even allowing for repeat procedures. UAE is cost effective for those women who prefer uterine conservation.0704

Temporary uterine artery occlusion for treatment of menorrhagia and uterine fibroids using an incisionless Doppler-guided transvaginal clamp provides a relatively simple means to treat fibroids. This technique is under development.0604

 

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