Management of Fibroids

Fibroids without any symptoms.

Fibroids that are not causing heavy bleeding or discomfort can be just monitored rather than treated.. It is necessary to have regular check-ups. Fibroids usually continue to increase in size till menopause though the rate of growth may vary from patient to patient.

Treatment of Fibroids.

If the Fibroids are not causing any problems, they don’t need treatment. It is necessary to get regular sonographies done to monitor the growth of the Fibroids . Treatment depends on several factors including the severity of the symptoms, the size and position of the Fibroids, age and whether or not the woman desires to have children in the future.

Drug treatments – GnRH analogues

GnRH analogues are drugs which reduce oestrogen levels in the body and create a temperory menopause like state , as a result of which the Fibroids shrink. When taken for six months, GnRH analogues can reduce the size of Fibroids significantly and also stop menstrual bleeding and pelvic pain. But GnRH analogues should not be taken for more than six months as they have a number of side effects. These include menopause-like symptoms such as hot flushes, vaginal dryness and bone loss (osteoporosis).

Once the drug injections are stopped , Fibroids begin to grow again. GnRH analogues are most commonly used to reduce the size of Fibroids before surgery or to build up the haemoglobin in severely anaemic patients prior to surgery. In some cases they are used as a temporary treatment for women who are nearing the menopause, when Fibroids begin to shrink naturally.

Surgical and non-surgical procedures

The main treatments for Fibroids are:

Myomectomy (removing Fibroids only while leaving the womb intact) which maybe an abdominal or laparoscopic procedure.. Hysterectomy (removing the womb completely )

Uterine artery embolisation (blocking the blood supply to the Fibroids)

Abdominal Myomectomy

Laparotomy is an open surgery to remove Fibroids. This can help to removal intramural Fibroids (Fibroids in the wall of the womb) and in the outer layer of the womb (subserosal Fibroids) A cut is made on the abdominal wall which maybe a bikini cut or a vertical one in order to gain access to the uterus. The uterus is then inspected and all Fibroids are shelled out. Once the Fibroids have been removed, the uterus and abdomen are stitched up.

The operation requires general or spinal anesthesia and requires hospitalization for a few days. The recovery and rest following this procedure is about a month. There is a 10 –25 % chance of recurrence of Fibroids. Most women can become pregnant after a myomectomy, but in certain cases scarring in the womb can cause fertility problems. The advantage of this procedure is that the womb is left intact and the woman can have children. Complications are excessive bleeding during the operation that can lead to an emergency hysterectomy. Also Infection and damage to surrounding organs can occur..

There is a possibility of weakening of the wall of the uterus and scarring may cause complications during pregnancy such as rupturing of the uterus wall.

Laparoscopic Myomectomy

Laparoscopic (endoscopic) surgery is also known as Keyhole surgery to remove Fibroids. This procedure is helpful for less than four Fibroids and Fibroids that are less than 10cm in size though larger Fibroids can be removed in expert hands. A laparoscope (telescope) is inserted into the womb through a tiny cut in the abdomen. Other small cuts are made in the same area to insert instruments that help remove the Fibroids, make them into small pieces so that they can be removed out through a small cut .

This procedure is done under general anesthesia and requires hospitalization for a day or two. The recovery period is much lesser than abdominal myomectomy. Rest for one to two weeks is advisable. Laparoscopic myomectomy does not usually interfere with fertility. This procedure is less invasive than other surgical options; small abdominal scars and little scarring inside the womb. Unexpected complications may require an abdominal myomectomy or emergency hysterectomy.

There may be an increased risk of uterine rupture during pregnancy if the laparoscopic stitching of the gap in the womb is not done well, as this is a lot more difficult then stitching during open surgery.

Hysteroscopic Myomectomy

Hysteroscopic myomectomy is the procedure to remove small submucous Fibroids. A small hysteroscope (telescope) is inserted into the womb through the vagina and cervix. A laser or wire loop or versapoint is then inserted through the hysteroscope to shave off the Fibroids. This can be done under general or local anesthesia and the patient is usually able to go home the same day. Hysteroscopic myomectomy does not usually interfere with fertility.

The advantage of this technique is that there are no cuts on the abdomen and the recovery is less than a week.. The patient can retain the uterus and can have children. There can be complications such as bleeding. There is a chance of infection, damage to surrounding organs and fluid overload as the fluid used to distend the womb gets absorbed into the system.

There is a chance of possible weakening of the uterine wall and scarring which may cause complications during pregnancy such as rupturing of the uterus.

Uterine Artery Embolisation

This is a procedure that blocks the blood supply to the Fibroids and hence the Fibroids shrink with time. The radiologist passes a fine tube into the right and left uterine arteries ,usually through the thigh and injects a dye to locate the arteries that are feeding the Fibroids. A special substance is then injected to block (embolise) the blood supply.

This is done under a local anesthesia and hospitalization for a few days is required. Post procedure rest for about a week or two is required. Some women have become pregnant after embolisation, but it can also lead to ovarian failure.

This procedure is minimally invasive, no incisions are needed and patients have a short recovery period. However there is a risk of infection, ovarian failure due to reduction in blood supply and radiation exposure.

Hysterectomy

Hysterectomy is removal of the uterus (womb) permanently. In some cases, as in women who are near menopause or who have many other problems such as endometriosis etc the fallopian tubes and ovaries are also removed.

This procedure can be used to remove all types of Fibroids. It is done if Fibroids are very large or cause problems that cannot be treated in other ways in women who have completed their family.

The uterus is removed either through a cut in the abdomen (if Fibroids are large) or through the vagina (if Fibroids are small). Both are major operations. Hospitalization for about 5-7 days is necessary. Rest for about 4-6 weeks following the procedure is recommended.. Since hysterectomy is removal of the uterus, the patient will not be able to have children.

This is a permanent treatment for the Fibroids and they will never recur or grow. There is also a possibility of damage to the patient’s bladder or bowel, infection, risk of bleeding heavily during or after the operation.

New Techniques: such as focus ultrasound and MR guided focused ultrasound which are non invasive, non surgical techniques to reduce the size of Fibroids are still in early stages of use. In the future they may be used as a simple method for treatment of Fibroids.

Conclusion:

There is no efficient and permanent non surgical treatment available.

Since Fibroids may be found in women of all ages from those in 20’s to those in their 50’s, it is good for all women to have regular gynaecological check ups.