Treatment of uterine fibroids

Do all fibroids require treatment?

Not usually, because most patients with fibroids do not have symptoms. However, individuals with fibroids should have regular checkups to see if the fibroids are changing in size, to discuss any symptoms with their doctor, or to discuss if they are planning to get pregnant.

When is surgery considered?

Surgery is considered when fibroids cause significant symptoms. Surgery should not be considered to treat infertility until other factors that could be causing infertility to have been thoroughly evaluated.

Is surgery the only treatment?

Some fibroids are affected by levels of the hormone estrogen and can be managed with medicine. These medicines may temporarily preclude fertility and have undesirable side effects but can improve some of the symptoms. For instance, gonadotropin-releasing hormone (GnRH) analog injections can cause hot flashes,vaginal dryness, mood changes, and bone thinning. Birth control pills can cause breast tenderness and less commonly blood clots. Progestins can cause bloating and abnormal bleeding from the uterus. Other, nonsurgical treatments are less common and include uterine artery embolization (UAE) and high-intensity focused ultrasound (HiFU) which are reserved for those who have finished having children. Herbal and homeopathic therapies have not been shown to improve symptoms caused by fibroids.

What kind of surgery?

For individuals who wish to get pregnant, surgical removal of the fibroids through a surgery called a myomectomy is often the best option.

How is myomectomy done? Is there a minimally invasive approach?

There are different types of myomectomies that can be done. The type used depends on the location and size of the fibroids. All surgery on the uterus carries the risk of scarring and adhesions which can affect future fertility. Each also carries the risk of excessive bleeding, which may require blood transfusions or, when life-threatening, a hysterectomy (surgical removal of the uterus).

Abdominal myomectomy (Laparotomy)

With this method, the surgeon makes an incision (surgical cut) in the abdomen. The cut can be 5 inches long or more. It is usually used to remove tumors on the outer surface of the uterus and surrounding organs. This surgery may require a short hospital stay and up to 4-6 weeks of recovery at home.

Laparoscopic myomectomy

The surgeon places a lighted telescope (laparoscope) into the abdomen through a small cut (usually less than ½ an inch) near the belly button. He/she uses surgical instruments placed through other small incisions in the abdomen to remove the fibroids. Patients can be sent home from the hospital the day of the procedure or within 24 hours. Recovery time is usually 2-7 days.

Hysteroscopic myomectomy

This procedure is used for fibroids found inside the lining of the uterus. The doctor inserts a lighted telescope (hysteroscope) into the uterus through the vagina. He/she fills the uterus with fluid to inflate the uterus. Surgical instruments are inserted through a sheath in the hysteroscope to remove the fibroids. Generally, patients are sent home on the day of surgery and can return to their normal activities within a few days. Serious complications are rare and include damage or scarring to the inside cavity of the uterus, electrolyte imbalance (changes in the minerals in the blood system), puncturing the uterus, and bleeding.

Robotic-assisted myomectomy

During a robotic procedure, a doctor places a telescope into the abdomen at or above the navel. Up to five other small incisions are made to hold the instruments to remove the fibroids. The instruments are controlled using robotic instruments. For more information about robotic surgery, please see the ASRM fact sheet titled Robotic surgery. Patients usually go home the same day or within 24 hours. Recovery time is between a few days and a week.

When can I start trying to get pregnant after a myomectomy?

Although recovery time varies with the type of surgery and typically is short, the uterus needs time to heal, and it may be 1-6 months before you are given the green light to attempt pregnancy.

What is the chance that the fibroids will return after surgery?

This risk of new fibroids growing back after surgery is about 30% over 10 years. Individuals with more than one fibroid are more likely to have fibroids return than those with a single fibroid.

Are there other treatment options if I don’t want to get pregnant?

Myolysis

Another laparoscopic technique called myolysis involves burning the fibroids through heat and cold energy via needles or lasers. Also known as Radiofrequency ablation.

MrgFUS

A method which does not involve an incision is called MRI- guided focused ultrasonic treatment (MrgFUS). As this is a relatively new technology, there is limited information about long-term outcomes. At this time, MrgFUS cannot be recommended for individuals hoping to maintain or improve their fertility.

Uterine artery embolization

Uterine artery embolization is performed by a radiologist. It involves injecting small particles into the uterine blood vessels to clog the small blood vessels that supply the fibroids. This cuts off the blood supply and causes the fibroids to shrink. Patients generally experience several days of pain after the procedure. Fibroid volume shrinks by 40-50%, and most women experience relief from their symptoms. At this time, it is not recommended for individuals wanting to get pregnant in the future.

Hysterectomy

About half of all hysterectomies (surgical removal of the uterus) are done to treat uterine fibroids. Hysterectomy is most appropriate for those with symptoms who do not wish to get pregnant later. Hysterectomy can be done through the abdomen, the vagina, or using a laparoscope. Recovery time is usually 2-6 weeks. Hysterectomy can have consequences on sexuality, psychological well-being, and health. It is important to discuss these potential issues with your healthcare provider.