Management of Uterine Fibroids: What Women Need to Know

By John C. Lipman, MD, FSIR

Uterine fibroids are benign, non-cancerous tumors made up of smooth muscle cells and fibrous tissue. They affect one in three women of childbearing age and as many as 80 percent of African-American adult women. The incidence of these tumors increases with age, with peak prevalence seen in women in their forties.

Most women who have fibroids are asymptomatic and typically do not require any treatment. The one exception to this is the patient who has a central fibroid that has prevented her from getting pregnant or caused her to miscarry.

Fibroids can be as small as a pea and grow to be as large as a melon. While their precise etiology is unknown, fibroids grow with estrogen (and progesterone) stimulation. That is why they often grow rapidly in women who are pregnant and why they tend not to be an issue once a woman reaches menopause.

Fibroids are categorized by their location in the uterus. There are three types of fibroids:

  1. Submucosal: located underneath the uterine lining
  2. Intramural: involving the muscular portion of the uterus
  3. Subserosal: located underneath the outer covering of the uterus

When fibroids become symptomatic, they usually consist of three main symptoms:

  • Fibroids are the most common cause of abnormally heavy periods. Women often need to change more than eight pads per day and sometimes more frequently than every hour. They can report blood gushing out like a running faucet, often with large blood clots. When women bleed like this, they lose a lot of iron and hemoglobin, which are important in carrying oxygen from the lungs to the tissues of the body. The result is a chronic iron deficiency anemia, which can be insidious as it often occurs gradually over many months. Symptoms of anemia include being very tired or weak, particularly during menstruation, episodes of lightheadedness or dizziness, headaches, chewing/craving ice, heart palpitations, even hair loss.
  • Pelvic pain from fibroids can occur anywhere in the abdomen or pelvic area and can radiate in to the hips, groin, buttocks, and even down the legs. Pelvic pressure or bloating commonly felt as tight-fitting clothes is particularly noteworthy in and around the time of menstruation.
  • Increased urinary frequency and nocturia (waking up at night to urinate) occur from fibroids that compress the bladder preventing it from filling to capacity.

How Are Fibroids Treated?

The treatment of fibroids often starts with medical therapy. These first-line therapies usually have limited, short-term value. However, there are a number of newer agents being investigated at the progesterone or estrogen receptor (and even gene) level that likely will improve the medical therapy for fibroids (ulipristal acetate). In the past, when medical therapy failed, this was often the next option.

  • Hormonal therapy: oral contraceptives, IUD, implant
  • Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen), or tranexamic acid

Surgery

There are two main surgical therapies: a myomectomy, or the removal of some of the fibroids surgically, or hysterectomy, a surgical removal of the entire uterus.

A myomectomy is usually reserved for women who remain interested in future fertility. It is important to understand, however, that a myomectomy does diminish a woman’s fertility, and if the surgeon runs into too much bleeding or cannot fix the uterine defects caused by fibroid removal, a hysterectomy may still need to be performed. These risks need to be factored into any decision regarding which treatment option is best. The most significant shortcoming of myomectomy is that the surgeon often cannot remove all of the fibroids present in the uterus. This will leave living fibroids in the uterus following the myomectomy surgery, which will grow and in time (often within 3 to 5 years) the patient will need a second procedure.

By age 60, one of every three women in this country will have already lost her uterus. Hysterectomy is the second most common surgery performed in the United States. This is rather surprising because half of the population is male. What is also surprising is that despite their benign composition, fibroids are the most common reason women undergo hysterectomy. Most women struggling with fibroids never hear any other option besides surgery. While hysterectomy does end a woman’s suffering from fibroids, the price of losing her uterus is often underestimated by physician and patient alike. Women who undergo hysterectomy can struggle psychologically (like a man being castrated), sexually (loss of libido, loss of orgasm), and have increased bone loss, which increases her risk for osteoporosis and pathologic fracture. The average age women undergo hysterectomy is younger than 40 years; with some women even under 30 years. Due to this and the inherent surgical risks and often long surgical recovery, hysterectomy should be a treatment of last resort rather than a first and only option given as it is done most commonly today.

Uterine Fibroid Embolization or Uterine Artery Embolization

There is one other treatment option that offers women the relief of symptoms, enables them to avoid surgery entirely, and allows them to keep their uterus. This procedure has been performed for over 20 years, but has languished in relative obscurity. It is called Uterine Fibroid Embolization (UFE) or Uterine Artery Embolization (UAE) and performed by interventional radiologists, a subspecialty of radiology that also suffers from anonymity.

Uterine Fibroid Embolization is performed on an outpatient basis. The procedure typically takes 30-45 minutes with a 4 to 5 hour recovery and a total recovery of 5 days. It is performed under X-ray guidance; a tiny catheter is steered into each uterine artery, which is accessed from the femoral artery in the groin. This artery branches like a tree with the fibroids representing the leaves. Tiny inert particles are injected, which cut off the blood supply to the fibroids while sparing the normal uterine blood flow. Without a blood supply, all of the fibroids die, resulting in significant improvement and/or complete resolution of the symptoms by the time patients are seen in follow-up 3 months after the procedure.

Any woman who has been told she is a candidate for hysterectomy should also be a candidate for UFE. It does not matter how big or how many fibroids she has. It also does not matter where the fibroids are located. Compared to surgery, UFE is safer, less invasive, less expensive, has a much shorter recovery, and allows women to keep her uterus.1 To learn more about fibroids and the UFE procedure, please visit http://www.AtlantaFibroidCenter.com.

Reference:

  1. EMMY Trial reference: Hehenkamp WJ et al. UFE vs. Hysterectomy in the treatment of symptomatic uterine fibroids. Am J Obstet Gynecol 2005; 193: 1618-1629.

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