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Treatment

Most fibroids cause no symptoms, do not interfere with pregnancy, and do not need to be treated.

If your fibroids cause mild symptoms, they may require no treatment either. Your doctor should simply keep an eye on them to see if they are growing.

Fibroids require treatment when they are extremely large, making it impossible to get pregnant, or causing symptoms which substantially reduce your quality of life. Which treatment is right for you will depend on the size and location of your fibroid(s), your age and how close you are to menopause, and whether or not you would like to get pregnant.

Treatment options include:

  • Surgery
  • Drugs
  • Medicated IUD
  • High-intensity focused ultrasound

Surgery

There are three main procedures used to surgically remove fibroids: myomectomy, hysterectomy and uterine fibroid embolization. To learn more about these procedures, click on the links below.

Drugs

Drugs are often used to reduce the size of fibroids. Drugs may also be recommended before surgery to make the surgery less difficult.

GnRH agonists
Gonadotropin-releasing hormone (GnRH) agonists are used to shrink fibroids. These drugs reduce estrogen and progesterone levels, reducing the blood flow to the fibroids, and making them smaller. Women who use these drugs will have their periods stop and will temporarily experience other symptoms of menopause, such as hot flashes, vaginal dryness and headaches.

These drugs can also cause substantial bone loss (see our Osteoporosis section). Because estrogen levels drop dramatically, the bone loss can be severe. GnRH agonists can make surgery safer and easier but, to avoid osteoporosis, they should not be used for more than three to six months.

Lupron is the most commonly used drug in this class. It is given by monthly injection in your doctor's office. After you stop taking the drug, your period will return to normal in one to three months. If you do not have one of the other treatments described in this section, the fibroids will also return to their original size within a few months.

Androgens
Androgens are often referred to as male hormones. Synthetic androgens can slow or stop the growth of fibroids and relieve the symptoms. Drugs such as danazol can reduce the size of the fibroids and the uterus, and stop menstruation and anemia. However, the side effects make many women reluctant to take them. Potential side effects include weight gain, depression, anxiety, oily skin and hair, deepening of the voice, headaches, fatigue, hair loss, growth of facial and body hair, blood clots and liver problems.

Birth control hormones
Birth control hormones (in the form of birth control pills, a skin patch or a vaginal ring) can help control heavy menstrual bleeding. However, they do not shrink fibroids.

Medicated IUD

Putting a medicated intra-uterine device (IUD) into the uterus can decrease a woman’s blood flow and reduce the size of her fibroids. This new treatment is one way of avoiding surgery. Medicated IUDs are not suitable for women whose uteruses are greater than 12-week size.

High-Intensity Focused Ultrasound

High-intensity focused ultrasound is a new, non-invasive outpatient procedure, which uses MRI to locate fibroids and then directs high-intensity ultrasound energy to destroy the fibroids. This procedure was approved as a treatment for uterine fibroids in the US in 2004; however, it is not yet available in Canada.

Myomectomy

Myomectomy is an operation that removes fibroids while leaving the uterus intact. It usually requires abdominal surgery but can sometimes be done using less invasive techniques, such as laparoscopy and hysteroscopy.

Myomectomy is the treatment of choice for women who wish to get pregnant in the future as it can potentially improve a woman’s fertility. However, many women continue to have trouble conceiving following the procedure. Long-term studies of women attempting to get pregnant after myomectomy show pregnancy rates of 40 to 60 percent. After myomectomy, a cesarean section may be required for delivery.

Drugs called gonadotropin-releasing hormone (GnRH) agonists are often given in the months before surgery, to shrink a large fibroid and minimize the amount of bleeding when it is removed.

Abdominal Myomectomy

Abdominal surgery, using general anesthetic, is usually required for a myomectomy. A horizontal bikini-line incision, 13 to 18 centimetres (five to eight inches) in length, is preferred but larger fibroids may require a vertical incision.

In a small fraction of myomectomies, it becomes too difficult to remove fibroids without removing the uterus or causing heavy bleeding. Hysterectomy may be required in about one percent of myomectomies. Your surgeon should discuss this possibility with you before surgery.

Blood transfusions are sometimes required during this procedure. The need for a transfusion increases with the size of the fibroid, and transfusion rates range from five to 25 percent.

Bleeding and abdominal pain are expected, and women typically stay in hospital for two to four days after the surgery. It may take six to eight weeks for a full recovery, depending on your lifestyle and activity level.

Between 20 and 40 percent of women have some complications after a myomectomy but these are usually mild, most commonly a post-operative fever. Serious complications, such as a puncture of the uterine wall or an infection, are uncommon. Abdominal myomectomy can leave scars on the uterus, which can cause abdominal pain. They can also make future surgery more complicated and can, in rare cases, reduce a woman's fertility.

Laparoscopic Myomectomy

Women with smaller fibroids on the outside of the uterus may have them removed by laparoscopic surgery, particularly if they are attached by a thin stalk of tissue (pedunculated). The laparoscope is inserted through small incisions in the abdomen, in and around the belly button. Guided by a fibreoptic camera, the surgeon removes the fibroid(s), using laser surgery or a more traditional incision. A laparoscopic myomectomy is usually day surgery and requires one to two weeks of recovery time.

Hysteroscopic Myomectomy

A hysteroscopic myomectomy uses a long, slender scope, called a hysteroscope, to remove the fibroid. This procedure is only appropriate for women who have fibroids on the inner wall of the uterus (submucosal fibroids). These fibroids are the type most likely to cause uterine bleeding.

A local or general anesthetic may be used. The uterus is filled with fluid and the hysteroscope is inserted through the cervix into the uterus. This device guides the physician to the fibroid, which is then removed in pieces with a wire loop. Sometimes a second procedure is needed to remove the entire fibroid.

The greatest advantage of hysteroscopic myomectomy is the quick recovery time. It is usually done as day surgery, and a woman can resume her normal activities in a few days. After surgery, most women experience some pain and bleeding, but the pain can generally be managed with oral pain medication.

If your pain is severe or your bleeding is heavy and bright red, you should contact your doctor and return to the hospital emergency room immediately. The risks of this procedure include bleeding and infection, but these complications are rare.

Assuming that it is done correctly and there are no complications, a hysteroscopic myomectomy should not interfere with a woman’s fertility. Pregnancy rates have been high among women who had this procedure to remove a fibroid that was causing fertility problems.

Endometrial Ablation

In some circumstances, hysteroscopic myomectomy is combined with another technique called endometrial ablation. During this procedure, the uterine lining (the endometrium) is destroyed, permanently stopping menstrual bleeding and preventing future pregnancy. This procedure is used when there is heavy bleeding and multiple fibroids. It is a more permanent solution for women who have completed childbearing. One study reported that after six years, only eight percent of women required followup treatment.

Endometrial ablation can be done using one of a variety of energy sources, including laser, microwave, electric current, heated fluid or freezing.

Gonadotropin-releasing hormone (GnRH) agonists are sometimes used for a few months before the procedure, to thin the endometrium and reduce the size of the fibroids. The side effects of this medication include symptoms similar to menopause, including hot flashes, mood swings, vaginal dryness, headaches, insomnia and weight gain. GnRH-a therapy can also weaken your bones.

Eighty to 90 percent of myomectomies successfully relieve or reduce fibroid symptoms. The procedure does not stop remnants of fibroids or other new fibroids from growing. It is estimated that about 20 percent of women will require another surgery within 10 years. Women in their mid- to late-40s occasionally experience menopause as a side effect.

Advantages:

  • successful at relieving symptoms in 80 to 90 percent of cases
  • preserves the uterus
  • may allow future pregnancy
  • can be used for large fibroids, in some cases
  • best established procedure for treating fibroids while saving the uterus
  • for hysteroscopic myomectomy:
    • relatively quick recovery time
    • minimal pain

Disadvantages:

  • fibroids may re-grow and require further surgery
  • relatively high risk of minor complications
  • drugs to shrink the fibroid may be recommended; these drugs cause bone mineral loss
  • chance of infection
  • for abdominal myomectomy:
    • requires extensive surgery
    • lengthy recovery time
    • may require blood transfusion

Hysterectomy

A hysterectomy is an operation to remove the uterus, including the fibroids. If your ovaries are also removed, the operation will cause you to have early menopause. Preserving the ovaries will allow your normal hormonal cycle to continue (although you will no longer have your period). Occasionally, a woman in her mid- to late 40s may experience the symptoms of menopause as a side effect of a hysterectomy even when her ovaries are not removed.

The Possibility of a Hysterectomy

For women who have very large fibroids and/or severe symptoms and who do not wish to have (more) children, this can be a good option, because it can offer a permanent solution to an often painful problem. However, even when a woman does not want children, a hysterectomy can be a difficult choice. It is a major surgery, which carries with it the risk of minor and more serious complications.

Hysterectomy is not necessarily your only option. Talk to your doctor about why this procedure is being recommended and about other options. Ask about alternative procedures, like uterine fibroid embolization. If you are not comfortable with your doctor’s advice, get a second opinion. Talk about what your quality of life would be like if you decide to avoid the surgery and wait for menopause, when declining hormone levels may shrink the fibroid(s) and relieve your symptoms. If you do want to have (more) children, ask what options are available and whether your current fibroids would be likely to interfere with a pregnancy. The more information you have, the more well-informed your decision will be.

Sixty thousand hysterectomies are performed in Canada each year and the most common reason for this surgery is fibroids. There is a great deal of debate about how many of these hysterectomies are necessary. While this procedure is often not necessary, this does not mean that it is always a bad treatment option. Sometimes hysterectomy is the best option, and sometimes it is the only option that will relieve your pain.

If your discussions with your doctor(s) lead you to this conclusion, it is reasonable for you to feel afraid or to feel a sense of loss. You may wish to ask your doctor to refer you to a counsellor, or you may wish to check some of the online discussion forums for women who have had or are going to have a hysterectomy. If you do have a hysterectomy, be patient with yourself. Be aware that it may take time to recover emotionally as well as physically.

The Surgery

A total hysterectomy involves the removal of the cervix; a subtotal hysterectomy does not. You should discuss which procedure is best for you with your doctor; however, if you have never had an abnormal Pap smear, there is little reason to remove the cervix.

A hysterectomy can be done through an incision in the abdomen or through the vagina. The Society of Obstetricians and Gynaecologists of Canada says a vaginal hysterectomy is preferable, when possible, since it has a lower rate of complications and damage to surrounding tissues. This may not be possible with a very large fibroid. Drugs called gonadotropin-releasing hormone (GnRH) agonists are often used for large fibroids to decrease bleeding and make the surgery easier. These drugs are given in the months before surgery.

A hysterectomy is done with a general anesthetic. Antibiotics are usually given in advance to prevent infection. The procedure takes several hours and may require two to four days in hospital.

Blood transfusions are sometimes used during this procedure. The need for transfusion increases with the size of the fibroid. Transfusions are needed in five to 25 percent of cases.

Afterwards

Up to 43 percent of women may have some complications, most commonly, infection or post-operative fever, but serious complications are uncommon. Bleeding and abdominal pain are expected.

It usually takes six to eight weeks for a full recovery. While you recover, be sure to get plenty of rest and avoid lifting. If possible, ask friends and family to help you with household tasks.

The procedure prevents the future regrowth of fibroids and substantially improves the quality of life for most women with fibroids. In a study of women who had a hysterectomy, 93 percent reported that the procedure met or exceeded their expectations.

Some women are concerned about the impact of a hysterectomy on their sex lives. One study, which was based on the experiences of 1100 women who had had hysterectomies (to treat a variety of conditions, not just fibroids), found that the number of women regularly engaging in sexual activity after the surgery increased, and the number of women who said they never had orgasms decreased. It is true that some women report that their orgasms feel different and less intense after hysterectomy; however, for the majority of women, the relief from fibroid symptoms that hysterectomy brings improves their sex lives.

Advantages:

  • completely and permanently resolves symptoms
  • can treat even very large and difficult fibroids
  • most women have no complications

Disadvantages:

  • extensive surgery, requires general anesthetic
  • abdominal hysterectomy requires large incision
  • lengthy recovery time
  • prevents pregnancy
  • removal of the uterus may be emotionally distressing
  • relatively high risk of minor complications
  • drugs to shrink the fibroid may be recommended; these drugs cause bone mineral loss
  • potential complications include: needing blood transfusion, infection, bowel injury, bladder injury, blood clot
  • Long-term risks include difficulty urinating, weakened pelvic floor muscles and pelvic prolapse, scar tissue (adhesions) in the pelvic area

Uterine Fibroid Embolization

Uterine fibroid embolization (UFE) is a new procedure for treating fibroids. Rather than physically removing the fibroid, this procedure blocks (or at least reduces) the blood flow to the fibroid. Fibroids may regrow in the years following the procedure. UFE preserves the uterus, but there are several unanswered questions about UFE’s long-term effects. For example, we do not know if it will have any negative effects on a woman's ability to have a child; because of this, UFE is only appropriate for women who wish to maintain their fertility who would otherwise require a hysterectomy.

The procedure is performed by a radiologist. Women are usually mildly sedated but not unconscious during the procedure.

A small incision (approx 5 mm) is made in the groin, and a tiny tube (catheter) is threaded into the nearby artery. The radiologist uses x-ray to guide the catheter through the artery to the uterus. Fibroids depend on the uterine arteries for nourishment, and literally suck up much of the blood supply from these vessels. When the tube reaches the artery that supplies blood to the uterus, a mixture of tiny plastic particles and x-ray dye is injected. This mixture flows into the fibroid(s), where the plastic beads pile up until they block the blood supply. The flow of particles is carefully monitored, by watching the flow of dye with x-ray equipment.

The procedure takes between 40 minutes and three hours. A woman is exposed to about the same amount of radiation as a person having a barium enema. This is not enough to cause symptoms or long-term side effects.

Afterwards

Because UFE restricts the blood flow to the uterus, it can cause severe cramping, which normally peaks in the first 24 hours after the procedure. Women usually stay in hospital overnight and receive pain medication intravenously. Anti-nausea medication may also be given if you are feeling nauseous. Most women return home on the second day and receive adequate pain control with oral medications. One to two weeks is usually required for a full recovery.

UFE successfully shrinks between 48 and 78 percent of fibroids. About 85 percent of women report that their symptoms improve as a result of the procedure. Five years after the procedure, 70 percent reported that their symptoms were still under control.

If a woman's fibroids are located adjacent to the lining of the uterus (endometrium), she may experience vaginal bleeding for a couple of weeks, and bits of fibroid tissue may be visible in the blood flow. Many women who have UFE have post-embolization syndrome, which consists of fever, extreme fatigue, pain, nausea and vomiting. One to five percent of women experience major complications. In some cases, women who develop an infection require a hysterectomy.

A number of participants in trials of UFE have become pregnant and given birth after the procedure. However, the number of women involved in these trials is too small to determine whether UFE influences fertility. Occasionally, women in their 40s experience menopause as a side effect of this procedure.

Advantages:

  • appears to be successful at relieving symptoms in about 85 percent of cases
  • preserves the uterus
  • simple procedure
  • does not require general anesthetic or incision
  • quick recovery time

Disadvantages:

  • 20 percent of women who have UFE later need another UFE or a hysterectomy
  • within six years, fibroids return in 27% of women
  • not recommended for women who wish to get pregnant
  • possible to get a delayed infection within a year of the procedure
  • long-term effects unknown
  • not widely available
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