MiddletownJournal.com

If you aren't experiencing symptoms caused by your fibroids, you may not need any treatment. And, if your symptoms aren't severe, you may decide you can put up with them. This may be especially true if you're close to menopause—a time when fibroids shrink and symptoms resolve. It's important to discuss all your options with your health care professional and consider his or her recommendations when weighing your treatment options.

You may want to try the "watch and wait approach," where your health care professional periodically evaluates the size of your fibroids during routine pelvic exams and discusses how much discomfort you're feeling or how the symptoms may be disrupting your lifestyle.

Fibroids that don't cause symptoms rarely need therapy unless they get big enough to affect other structures in the pelvic area, such as the kidneys or the ureter (the tube leading from the bladder to the outside of the body).

The need for treatment and the type of treatment you choose depends on the size and position of the fibroids, as well as any symptoms they're causing, your age and whether or not you want to have children in the future. Even with a variety of treatment options available, new fibroids usually grow back to some degree in the years following most treatments. No treatment—except hysterectomy—can guarantee that fibroids won't recur. The more fibroids you have, the more likely they are to recur after treatment.

If bleeding is your major symptom, some women opt for managing this symptom with medication (called "medical treatment") before surgery, or as a way to delay surgery if they're close to menopause (because fibroids generally shrink and cause few or no problems after menopause).

Medical Treatment Options for Fibroids

• GnRH agonists Gonadotropin-releasing hormone (GnRH) agonists, including Lupron (leuprolide), Synarel (nafarelin nasal) and Zoladex (goserelin), temporarily shrink fibroids by blocking estrogen production, which stimulates their growth. They are mainly used in women close to menopause or to shrink fibroids before removing them surgically or to correct anemia caused by heavy bleeding associated with fibroids.

  GnRH agonists are considered a short-term treatment because by blocking estrogen production they trigger menopausal symptoms caused by estrogen depletion, such as hot flashes, vaginal dryness and bone loss. The usual course of treatment is three to six months and it may be combined with estrogen and/or progesterone hormones to minimize menopausal symptoms. Once this medication is stopped, fibroids usually grow back to near pre-treatment size or larger within several months.

• Oral contraceptives (OCs). While OCs do not treat fibroids, they may be recommended to manage heavy bleeding caused by fibroids or for women who experience irregular ovulation in addition to fibroids.

Minimally Invasive Treatment Options

• Uterine artery embolization (UAE). This minimally-invasive, non-surgical therapy treats all fibroids at the same time. UAE is a radiological procedure that involves placing a small catheter (a thin tube) into an artery in the leg and guiding it via x-rays to the arteries in the uterus. Then, tiny particles similar in size to a grain of sand are injected through the catheter and into the artery. As they move toward the uterus, they obstruct the blood supply to the fibroids. Without an adequate blood supply, the fibroids shrink. The uterus is spared, however, because an alternate blood supply develops to support it. UAE relieves symptoms in up to 90 percent of women who choose the procedure.

  UAE takes about one hour to perform and is typically performed by an interventional radiologist. It requires no general anesthesia or prolonged hospital stay. Most women are back to their normal activities in seven to 10 days.

  While this treatment option leaves your uterus intact, it's not recommended for women who wish to become pregnant in the future.

  Outcome for UAE—the rate of fibroid recurrence after the procedure—is about the same as fibroid recurrence after myomectomy, a surgical procedure described below. A five-year follow up study of UAE found that symptoms recurred in about 25 percent of the women, most who required another procedure. UAE and hysterectomy are about the same in terms of safety—major complications are rare.

  Potential complications include embolization particles traveling to other sites in the body, such as the ovaries, causing premature ovarian failure. In addition, allergic reaction, urinary tract infection, and a low-grade fever and fatigue that may last for a week or less, also may occur.

• Endometrial ablation. While this technique is not indicated for treating fibroids, it is used to reduce or eliminate heavy periods that may be caused by fibroids. Endometrial ablation uses electrical energy, heat or cold to destroy the lining of the uterus. It is performed on an outpatient basis; only offered as a treatment option to women who have finished childbearing. While it is possible to become pregnant after having endometrial ablation, potential risks to the mother's and the baby's health exist. Using a reliable form of contraception after having ablation is important.

Surgical Options for Fibroids

• Hysterectomy. About 30 percent of all hysterectomies in the U.S. are performed to treat fibroids. A hysterectomy offers the only real cure because it completely removes the uterus.

  However, hysterectomy is major surgery, requiring between two and eight weeks of recovery, depending on the type of surgery performed. Hospital stays and recovery times can vary based on the type of procedure used and the extent of the surgery performed. Because your uterus and, sometimes, your ovaries, are removed, it is not an option if you want to become pregnant. Even if you're finished having children, you should be aware of other options to treat fibroid symptoms so you can make a treatment decision that best fits your needs.

  If you and your health care professional decide that a hysterectomy is the best choice for you, you may have several options about how the procedure is performed:

  • Abdominal hysterectomy, in which the uterus is removed through an incision in the abdomen. It is generally used for large pelvic tumors or suspected cancer because this procedure allows the surgeon to see and manipulate the pelvic organs more easily.

  • Vaginal hysterectomy, in which the uterus is removed through the vagina. This approach is best when the uterus isn't enlarged or dropped (prolapsed).

  • Laparoscopically assisted vaginal hysterectomy (LAVH), in which a surgeon uses a laparoscope (a small telescope) inserted through the abdomen to see the inside of your pelvis. A LAVH is less invasive than an abdominal hysterectomy, but more invasive than a vaginal hysterectomy. However, this procedure is often limited in availability because not enough surgeons have experience performing laparoscopic hysterectomies. It is also not an option for women with a very large uterus.

In addition, you'll want to know that there also are several types of hysterectomies, defined by which organs are removed. Deciding which the type of surgery and how it will be performed that makes most sense for you depends in part on the size of your uterus, the size of your fibroid(s), your medical history and other factors that your health care professional should explain to you.

Other Surgical Options

• Myomectomy. This procedure removes only the fibroids, leaving the uterus intact, which can preserve fertility. The procedure is performed through an incision in the abdomen (a laparotomy), which requires general anesthesia, or by laparoscopy (similar to a laparotomy but using a smaller incision). A full recovery from laparotomy can take up to six weeks and two weeks from laparoscopy. Your health care professional will decide which procedure to use based on the size of the fibroids as well as whether they are superficial or deep (which is too difficult for laparoscopy).

A hysteroscopic myomectomy is performed through the vagina and requires no incision. It is appropriate only for women whose fibroids are in the endometrial canal. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed through the vagina into the uterine cavity. A wire loop carrying electrical current is then used to shave off the fibroid.

Myomectomy can be more complicated than hysterectomy. Risks include:

• Greater blood loss and need for transfusion

• Risk of damage to the uterus and other pelvic structures

• Scarring of the uterus that may affect fertility

Also, as with other treatment options except for hysterectomy, fibroids often grow back, requiring more surgery.

• Myolysis. This procedure involves using a laser, radiofrequency energy or freezing via a probe applied during laparoscopy to cut off the blood supply to a fibroid, destroying it. Because the procedure causes scarring, called adhesions, in the uterus, it's not a preferred method of many gynecologists. Most women who undergo myolysis go home the same day and are able to perform all normal activities within a week. Newer myolysis technology features guided magnetic ultrasound energy aimed more precisely at the fibroid. It doesn't require an incision, but the process can take a long time. Damage to nearby organs is a risk of this procedure.