The Treatment of Fibroids

While hysterectomies are still commonly performed for fibroids, this is by no means the only treatment option!  For patients without uncomfortable symptoms, management of fibroids is "expectant."  This means that no action is necessary unless fibroid size, number, or symptoms increase significantly.

Despite the claims of recent ads, however, there are no foods that make fibroids vanish like magic.  In fact, there are no foods or drugs that make fibroids "vanish" at all. 

Because fibroids are estrogen dependent, some clinicians wonder whether dietary phytoestrogens such as those found in soy or flax might increase fibroid size or number; this has not been proven, however.  Phytoestrogens are weak estrogens that act differently on different organs; they are not believed to have any effects on the uterus.  Good general nutritional habits with low dietary fat and alcohol consumption can only help. Alcohol and dietary fat are substances that interfere with the liver's role in breaking down the body's estrogen.  High fiber diets are also recommended for symptom relief.

There are some medications that may help reduce the symptoms or size of fibroids, either as an initial therapy or as a presurgical therapy. 

Over-the-Counter (Non-prescription) Medications:

Non-steroidal anti-inflammatory drugs (NSAIDs): Although their mechanism for doing so is unknown, NSAIDs such as ibuprofen (e.g. Motrin©, Advil©, and Nuprin©) or naproxen (e.g. Anaprox© or Naprosen©) have been shown to decrease the amount of menstrual blood loss.  NSAIDs are also well known to decrease uterine cramping.

Prescription Medications:

GnRH Agonists: These injectable medicines (e.g. Lupron©, Synarel©, and Zoladex©) are considered the mainstay used to decrease fibroid size, generally before surgery.  They work by causing a medical menopause.  They cause the ovaries to stop producing estrogen and progesterone.  While this does cause fibroids to shrink, it also starts all the complications of menopause from menopausal symptoms (including hot flashes, night sweats, sleep disturbances, vaginal dryness, etc.) to increased risk for diseases and disorders such as osteoporosis and elevated cholesterol.  In addition, fibroids tend to regrow when the medicine is stopped.  Therefore, this treatment is only recommended for short-term therapy (3 to 6 months) in perimenopausal women trying to avoid surgery or in women planning to have surgery to achieve some tumor shrinkage beforehand.

Progesterone:  Progesterone is sometimes prescribed to treat the bleeding associated with fibroids.  There are many different doses, brands, formulations, and preparations.

There are now several minimally invasive procedures designed to treat fibroids as well. Different types of endometrial ablation aim to destroy tissue in the lining of the uterus to stop bleeding.  Long-term studies (up to three years after these procedures) show that most women resume having normal periods, about 15%--40% no longer have periods, and the procedure fails in 10% to 20% of patients. Different techniques have different results. As a result, women who elect to have this procedure should be sure beforehand that they do not want to have any other children, but on the other hand, they cannot rely on this procedure for contraception.  Women who have menorrhagia or severe periods that interfere with their daily activities are good candidates for this procedure. This is usually defined as periods lasting longer than 7 days or requiring 15 or more sanitary napkins per day.

Uterine Artery Embolization (UAE) is a relatively new, minimally invasive procedure designed for certain women with large or numerous fibroids who are symptomatic.  Its goal is to eliminate the need for hysterectomy in a large percentage of women with fibroids.  It is similar to cardiac angiography performed by interventional radiologists on an outpatient basis. A thin catheter is inserted into the major artery of the leg (the femoral artery) and threaded to the uterine artery.  Tiny spongy particles are then injected into the uterine artery, obstructing blood flow to the uterus.  This causes fibroid tissue death and reduced fibroid size as a result.  The uterus itself usually gets sufficient blood flow (and thus oxygen) from other sources and can therefore survive.   After the procedure, women may experience cramping, labor-like pain for 24 hours.  The recovery period is 3-7 days. 

This procedure is generally restricted to women who are not interested in or able to have subsequent pregnancies; the effect of this procedure on fertility is unknown.  There are women who have gone on to have normal pregnancies after UAE, however. One to 2% of women who have had it went into early menopause as a result of reduced blood supply to the ovaries.  In addition, a small percentage of UAE patients required hysterectomy after complications. 

There are several surgical treatments for fibroids depending upon the patient's individual circumstances, particularly her plans for future fertility and the size, number, and location of her fibroids.  A myomectomy is an operation to remove only the fibroid(s) and leaves the remainder of the uterus intact.  This is the preferred procedure for women who want to preserve their ability to become pregnant.  Myomectomies can be done through a hysteroscope (inserted through the vagina into the uterus) using anesthesia. This approach works best for fibroids on the inside of the uterine cavity.  Myomectomy can also be done through a laparoscope (a camera inserted through a "band-aid cut" incision beneath the belly button) using anesthesia as an outpatient.  The laparoscopic approach works best for small fibroids on the outside of the uterus.  If a laparotomy is required, a "bikini cut" abdominal incision is necessary as is general anesthesia, an in-patient stay, and a longer recovery time.  What many women do not realize is that this type of surgery can be more complicated than a hysterectomy, especially if there are several fibroids.  The major downside of choosing myomectomy is that fibroids can grow back and new ones can form.  Many women who have a myomectomy wind up having a subsequent hysterectomy, although it may be many years later.  On average, however, recurrence takes about 7 premenopausal years.

A hysterectomy refers to removal of the entire uterus; it is the only treatment that eliminates fibroids completely and prevents regrowth.  Depending upon the size of the fibroid uterus and other factors, a hysterectomy may be performed vaginally, by a technique called "laparoscopically assisted vaginal hysterectomy" (LAVH), or through an abdominal approach.  If a patient is near or past menopause, her doctor may also recommend a complete hysterectomy, which is called a hysterectomy with bilateral salpingoophorectomy. This means removal of the uterus, fallopian tubes and ovaries.  The ovaries stop functioning with menopause and yet are then at increased risk for ovarian cancer, an insidious disease with no screening tests.  The prevailing thinking is that if you are having surgery anyway to remove the uterus, you may as well remove the ovaries preventively.

Created: 8/20/2003  -  Donnica Moore, M.D.