Appropriate treatment depends on the size and location of the fibroids, as well as the severity of symptoms. If a woman is not experiencing symptoms, her doctor will most likely suggest "watchful waiting" – checking the fibroid at annual gynecologic examinations and monitoring for symptoms.
If symptoms develop, there are a number of treatment options:
- Uterine fibroid embolization, a nonsurgical treatment that causes the fibroid to shrink
- MR-guided focused ultrasound, a new nonsurgical treatment available in limited locations
- Drug therapy, including non-steroidal anti-inflammatory drugs (NSAIDs), birth-control pills and hormone therapy
- Surgical treatments, including myomectomy (surgical removal of the fibroids) and hysterectomy (surgical removal of the uterus)
Uterine Fibroid Embolization (UFE)
Known medically as uterine artery embolization, this approach to the treatment of fibroids blocks the arteries that supply blood to the fibroids causing them to shrink. It is a minimally invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated – drowsy and feeling no pain.
Fibroid embolization is performed by an interventional radiologist, a physician who is specially trained to perform this and other minimally invasive procedures.
The interventional radiologist makes a small nick in the skin (less than one-quarter of an inch) in the groin to access the femoral artery, and inserts a tiny tube (catheter) into the artery. Local anesthesia is used so the needle puncture is not painful. The catheter is guided through the artery to the uterus while the interventional radiologist guides the process of the procedure using a moving X-ray (flouroscopy).
The interventional radiologist injects tiny plastic particles the size of grains of sand into the artery that is supplying blood to the fibroid tumor. This cuts off the blood flow and causes the tumor (or tumors) to shrink. The artery on the other side of the uterus is then treated. The skin puncture where the catheter was inserted is cleaned and covered with a bandage.
Fibroid embolization usually requires a hospital stay of one night. Pain-killing medications and drugs that control swelling typically are prescribed following the procedure to treat cramping and pain. Fever sometimes occurs after embolization and is usually treated with acetaminophen. Many women resume light activities in a few days and the majority of women are able to return to normal activities within one week.
While embolization to treat uterine fibroids has been performed since 1995, embolization of arteries in the uterus is not new. It has been used successfully by interventional radiologists for more than 20 years to treat heavy bleeding after childbirth.
Expected Results
- On average, 90 percent of women who had the procedure experience significant or total relief of heavy bleeding. The procedure is about 85 percent effective for pain.
- The procedure is effective for multiple fibroids and large fibroids.
- Recurrence of treated fibroids is very rare. Short- and mid-term data show UFE to be very effective with a very low rate of recurrence. Long-term (10 year) data are being collected and not yet available; but in one study in which patients were followed for six years, no fibroid that had been embolized re-grew.
Fertility
There have been numerous reports of pregnancies following uterine fibroid embolization, however prospective studies are needed to determine the effects of UFE on the ability of a woman to have children. One study comparing the fertility of women who had uterine fibroid embolization with those who had myomectomy showed similar numbers of successful pregnancies. However, this study has not yet been confirmed by other investigators.
Less than 2 percent of patients have entered menopause as a result of UFE. This is more likely to occur if the woman is in her mid-forties or older and is already nearing menopause
Side Effects/Complications
Fibroid embolization is considered to be very safe; however, there are some associated risks, as there are with almost any medical procedure. Most women experience moderate to severe pain and cramping in the first several hours following the procedure. Some experience nausea and fever. These symptoms can be controlled with appropriate medications. A small number of patients have experienced infection, which usually can be controlled with antibiotics. It also has been reported that there is a 1 percent chance of injury to the uterus, potentially leading to hysterectomy. These complication rates are lower than those of hysterectomy and myomectomy. A small number of patients have entered into menopause after embolization. This is more likely to occur if the woman is in her mid-forties or older, and is already nearing menopause. Myomectomy and hysterectomy also carry risks, including infection and bleeding leading to transfusion. Patients who undergo myomectomy may develop adhesions causing tissue and organs in the abdomen to fuse together, which can lead to infertility. In addition, the recovery time is much longer for hysterectomy and myomectomy, generally one to two months.
You should talk to your doctor about possible risks of any procedure you may choose.
Magnetic Resonance Guided Focused Ultrasound
Magnetic resonance guided focused ultrasound (MRGFU) is a noninvasive outpatient, procedure that uses high-intensity focused ultrasound waves to ablate (destroy) the fibroid tissue. During the procedure, an interventional radiologist uses magnetic resonance imaging (MRI) to see inside the body to deliver the treatment directly to the fibroid. The procedure is FDA approved for treating uterine fibroids, but is under investigation for the treatment of breast, prostate, brain and bone cancer.
MRI scans identify the tissue in the body to treat and are used to plan each patient's procedure. MRIs provide a three-dimensional view of the targeted tissue, allowing for precise focusing and delivery of the ultrasound energy. MRIs also enable the physician to monitor tissue temperature in real-time to ensure adequate but safe heating of the target. Immediate imaging of the treated area following MRGFU helps the physician determine if the treatment was successful.
The ultrasound energy used in MRGFU can pass through skin, muscle, fat and other soft tissues. High-intensity ultrasound energy that is directed to the fibroid heats up the tissue and destroys it. This method of tissue destruction is called thermal ablation.
Treatment Option: Drug Therapy
Drug therapy is usually tried first. This might include:
- the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) or naproxen sodium (Naprosyn)
- birth-control pills
- hormone therapy
In some patients, symptoms are controlled with these treatments and no other therapy is required. However, some hormone therapies can have risks and side effects (menopausal symptoms, erratic or no menstruation, bloating, moodiness) when used long term, and generally are used temporarily.
A newer group of drugs being used for fibroids are hormones known as GnRH analogues, which are administered by injection by the gynecologist. These synthetic (man-made) hormones act like the hormones that are naturally produced by the body and reduce the level of estrogen. The result is reduced blood flow to the uterus and, therefore, to the fibroids, decreasing the size of both. Some physicians recommend these hormones prior to surgery to reduce the size of the fibroids and make them easier to remove. The effectiveness of the hormones is considered temporary as studies show that when the therapy is stopped, fibroids re-grow to their original size in four to six months. The GnRH hormones also may cause side effects that mimic menopause, including hot flashes, vaginal dryness, mood swings and a decrease in bone density (osteoporosis).
Surgical Treatments: Myomectomy
Myomectomy is a surgical procedure that removes visible fibroids from the uterine wall. Myomectomy, like UFE, leaves the uterus in place and may, therefore, preserve the woman's ability to have children. There are several ways to perform myomectomy, including hysteroscopic myomectomy, laparoscopic myomectomy and abdominal myomectomy.
Although myomectomy is successful in controlling symptoms about 80 percent of the time, the more fibroids there are in a patient's uterus, the less successful the surgery generally is. In addition, fibroids grow back several years after myomectomy in 10 percent to 30 percent of cases.
Hysteroscopic Myomectomy:
Hysteroscopic myomectomy is used only for fibroids that are just under the lining of the uterus and that protrude into the uterine cavity. There is no need for a surgical incision. The doctor inserts a flexible scope (hysteroscope) into the uterus through the vagina and cervix and removes the fibroids using special surgical tools fitted to the scope. Usually this is an outpatient procedure performed while the patient is under anesthesia and not conscious.
Laparoscopic Myomectomy:
Laparoscopic myomectomy may be used if the fibroid is on the outside of the uterus. Small incisions are made so the doctor can insert a probe with a tiny camera attached and another probe fitted with surgical instruments inside the abdominal cavity and remove the tumors. It is performed while the patient is under general anesthesia and not conscious. The average recovery time is about two weeks.
Abdominal Myomectomy:
This is a surgical procedure, in which an incision is made in the abdomen to access the uterus, and another incision is made in the uterus to remove the tumor. Once the fibroids are removed, the uterus is stitched closed. The patient is given general anesthesia and is not conscious for this procedure, which requires a several-day hospital stay. Typical recovery is four to six weeks.
Surgical Treatments: Hysterectomy
Approximately one-third of the more than half-million hysterectomies performed in the United States each year are due to fibroids.
In a hysterectomy, the uterus is removed in an open surgical procedure. This operation is considered major surgery and is performed while the patient is under general anesthesia. It requires three to four days of hospitalization, and the average recovery period is about six weeks. Some women are candidates for a newer, laparoscopic procedure. The recovery time for this procedure is considerably shorter.
Hysterectomy is the most common current therapy for women who have fibroids. It is typically performed in women who have completed their childbearing years or who understand that after the procedure, they cannot become pregnant.
Reprinted with permission of the Society of Interventional Radiology © 2004, www.SIRweb.org. All rights reserved.