Uterine fibroids or myomas are benign (non-cancerous) tumours of the muscle cells of the uterus. These are produced due to a localized overgrowth of the smooth muscle and connective tissue of the uterus and can cause a variety of symptoms. They are hormone dependant tumours found in about 20%- 30% Indian women. They are usually found in the age group of 30- 50 years but can actually present at any age.
The exact cause of development of fibroids is unknown and it is postulated that they are multi-factorial in origin. However, it is well accepted that the development and growth of the fibroids is dependent on the influence of the hormones Estrogen and Progesterone.
What are the options for Uterine Fibroid Treatment ?
Not all uterine fibroids will need to be treated. Sometimes, if the fibroids are very small and not causing any symptoms, the doctor may suggest a watchful approach with just a regular monitoring to assess the size and growth of the fibroids and a treatment may be offered if they grow to an extent where they are causing problems with the periods, pressure effects or are likely to cause adverse reproductive outcomes.
It is important to bear in mind that fibroids are non cancerous and usually regress after menopause. Rarely, when there is rapid growth of the fibroids in a short span of time or in post menopausal women, it may raise the suspicion of malignant (Cancerous) transformation of fibroid and an immediate intervention is then suggested. It must be remembered however, that malignant transformation occurs in only 0.25% of fibroids and hence merely the presence of fibroids should not trigger a panic reaction for cancerous growth.
Factors governing the treatment approach:
The treatment of Uterine Fibroid may vary greatly from one woman to another based on a number of factors:
- Age of the woman
- Desire for future fertility
- Presence and type of symptoms
- Severity of symptoms
- Motivation for regular follow up in case of conservative approach
Non Surgical Approach – Generally speaking , a conservative approach with non-surgical intervention is preferred in cases where the fibroids are small, symptoms are mild and where surgery is not preferable eg in young/unmarried girls with small fibroids or women who are poor surgical candidates due to medical /personal reasons.
Surgical Approach – Occasionally, it may be considered necessary to undertake a surgical intervention in cases where:
- The bleeding is excessively heavy/prolonged
- Fibroids are causing excessive pain or pressure effects over urinary bladder or rectum
- If there are pregnancy losses/ complications or difficulty in conceiving due to location and size of the fibroids
- If the fibroids continue to cause problems inspite of medical treatment
- If there is rapid growth of fibroids, especially in post-menopausal women.
Non Surgical Treatment for Fibroids:
These are suggested to treat the symptoms and/or arrest the growth of fibroids. These may or may not help in shrinkage of the existing size and the treatment needs to be modified periodically based upon the response. It should be remembered that these methods are to be used under proper medical supervision and guidance only. The various options available are:
- NSAID’s- Ibuprofen, Mefenamic acid etc are available as oral medications taken during periods to control the pain and bleeding due to fibroids. They act by reducing the formation of prostaglandins. However, they do not provide contraception and hence additional contraceptive precautions should be continued by women who do not desire pregnancy.
- Tranexamic Acid Tablets – These can also be used to minimize bleeding and are taken thrice daily during the periods only. No contraceptive benefits.
- Combined Oral Contraceptives – These are given in the form of oral tablets taken continuously for 21 days starting from the 1st or 2nd day of period. They provide contraception, reduce pain and bleeding during periods but have not been shown to decrease the size of the fibroids significantly.
- Progestogens – These may be given in the form of oral tablets from day 5th today 25th of the menstrual cycle or may be taken as injection once every 3 months. They work by reducing the growth of the lining of the uterus and thus reducing the blood loss during periods. However, they may have unpleasant side-effects like nausea, water retention, acne, bloated sensation etc and the injectable progestogens may cause irregular bleeding occasionally. The oral progestogens do not provide reliable contraception but the injectibles can give the contraceptive benefits.
- Levonorgestrel Intrauterine system (LNG-IUS) – This is a T –shaped device that is inserted into the uterus and causes a regular release of the progestogen levonorgestrel into the body. This leads to thinning of the uterine lining and thus reduces blood loss during periods. The side effects are that sometimes it may cause complete stoppage of periods temporarily or there may be irregular bleeding for a few months. The other side effects of progestogens may also be there. But usually, it is well accepted by women and can significantly reduce blood loss.
- Gonadotropin Releasing Hormone analogues – These are hormonal agents that are given in the form of injections and they act by altering the production of gonadotropins (FSH & LH) from the Pituitary gland in the brain. This ultimately affects the production of Estrogen and Progesterone from the ovaries and may lead to a slight shrinkage of the size of the fibroids thus decreasing the symptoms. The side effects are menopausal effects like Hot flashes, vaginal dryness, sweating etc. Sometimes they may also increase your risk of osteoporosis and need to be supplemented by Hormone replacement therapy as add-back to prevent complications.
- Selective Progesterone Receptor Modulator – Various oral medications like Mifepristone and Ulipristal have been introduced to reduce the size and symptoms of the fibroids. The Ulipristal tablet needs to be taken once daily for 3 months on prescription by a Gynaecologist and it has been shown to reduce the size of fibroids. Unlike GnRH analogues, they do not cause menopausal symptoms or decrease in bone density but you should use a barrier method for contraception while you are taking these.
Surgical Treatment for Fibroids:
Various types of surgeries can be done if the fibroids are not responding to the medical management or if they are unsuitable for medical management. These include:
- Hysteroscopy and Myomectomy- This involves introducing a thin telescopic instrument called Hysteroscope into the uterus through the vagina & Cervix. The fibroids which are bulging into the cavity of the uterus can be removed by cutting thin slices and removing through the operative Hysteroscope/resectoscope. This method is suitable for the fibroids which are bulging 50% or more into the cavity of the uterus and causing symptoms. It is done under General anaesthesia and does not involve any incision or stitches because the surgery is conducted through the natural orifice of vagina & Cervix. There may be cramps and mild pain for a couple of days after the surgery.
- Abdominal / Laparoscopic Myomectomy – In this method, the fibroids are removed by giving a cut over the abdomen and exposing the uterus and the fibroids, thereby operating on them and removing the fibroids, followed by repair of the uterus. Laparoscopic method involves tiny keyhole incisions over the abdomen for the surgery and the fibroids are then extracted after morcellation through these incisions only. However, nowadays, this method is not preferred due to possibility of dissemination of undiagnosed cancer in the fibroid and hence Laparoscopic myomectomy is performed only after detailed discussion between the doctor and the patient/attendants.
In both Hysteroscopic and Abdominal/Laparoscopic Myomectomy, only the fibroids are removed and the uterus is retained in the woman.
- Hysterectomy – This procedure involves removal of the entire uterus alongwith the fibroids and hence it is reserved only for cases in which future fertility is not desired. Hysterectomy can be done vaginally/ abdominally or laparoscopically depending on the size, number and location of the fibroids. The most important side effect of course, is inability to bear children in future, apart from the usual risk of inadvertent injury to other organs, excessive bleeding during the surgery or infection. All these are generally well managed under experienced surgeons and it is a safe and reliable procedure.
Minimally Invasive Techniques:
- Uterine Artery Embolisation – In this, the uterine arteries i.e the main arteries supplying blood to the uterus, are blocked by special substances introduced under ultrasound guidance. This reduces blood loss during periods but may be associated with severe pain abdomen for a few days after the procedure. The outcome of future pregnancy may also be compromised.
- MRI Guided Percutaneous Laser or Focused Ultrasound – These are procedures done under MRI guidance where special laser technique or High intensity Ultrasound waves are used to target and destroy one fibroid at a time. They avoid the need for surgery but are time consuming, require repeated sittings and maybe done only at advanced centres under specialized care. They are still not widely available and the longterm risks and benefits are under study.
Whatever form of treatment option you choose, it should always be done in consultation with a Gynaecologist and you should comply with the necessary instructions and precautions as advised. In the end, it is your body but it is important to trust the doctor and have a detailed, rational discussion whenever you are unclear about any aspect of the treatment of Uterine Fibroid.
The Author, Dr. Smita Vats is practising as a Consultant Gynaecologist and Laparoscopic Surgeon in Gurgaon.She is one of the Best Gynaecologist in Gurgaon and a visiting consultant at various esteemed Hospitals in Gurgaon including Artemis Hospital, Cloud nine Hospital, Paras Hospital & GNH Hospital Gurgaon.
For the Best Uterine Fibroid Treatment in Gurgaon Consult Dr. Smita Vats.