What are my options now that I have been diagnosed with fibroids?
by William H. Catherino, MD, PhD
Like many women in their 20’s to 40’s, you have heard from your care provider that you have fibroids. Depending upon how heavy your menstrual periods are or how much pain you are feeling, you may have different goals for therapy. Fortunately, you have many options to treat your symptoms, and it is important for you to consider all of your options before making the best decision for you. For most of these options, you can try one and switch to another, so when in doubt, choose the option that has the least impact on your life.
Therapies Directed at Your Symptoms
Watchful waiting: If you know you have fibroids, but your symptoms are manageable at home without involving medicine or surgery, it is reasonable to check in with your care provider regularly and otherwise continue to manage your symptoms as you have been doing. It is possible that your symptoms will get worse over time, so regular re-assessment is important to be sure that your fibroids are not disrupting your life. If your periods become heavy, anemia can occur. Seek medical care if this happens.
Birth control pills: Birth control pills are often prescribed for women who have heavy periods in order to decrease the amount of bleeding associated with their periods. While this therapy does decrease normal menstrual bleeding, unfortunately it does not treat the fibroids, and symptoms may start to worsen over time despite using birth control pills. This therapy does not treat the fibroids, so they may continue to grow, and any pain or pressure that you feel will not be treated either.
Other hormonal therapies: Hormone-releasing IUDs, pills that only contain progesterone-like compounds, implants, and other hormonal methods will have a similar effect on bleeding, but do not treat the fibroid directly. As a result, while menstrual bleeding may improve initially, they also may worsen over time. Also, pain and pressure will not be treated.
Tranexamic acid: This medicine regulates the way that blood clots, and can lower the amount of blood that is lost from the normal menstrual period and from fibroids. It does not treat the fibroid directly, however, and will not address pain and pressure.
Endometrial ablation: This out-patient surgery essentially destroys the part of the womb that is involved with menstruation. The procedure is quick and requires a few visits, but it can be expensive and does not cure the fibroids. As a result, additional treatment in the future may be required. Also, if you plan on having children in the future, this is not an option to consider, since it destroys the tissue required for pregnancy.
Therapies that Treat Fibroids
Anti-hormonal therapies: There are two major classes of medicines that block the impact of hormones on fibroid growth: gonadotrophin-releasing hormone (GnRH) agonists/antagonists and selective progesterone receptor modulators. In the United States, currently only GnRH-agonists are available for fibroid treatment. All of these therapies decrease fibroid size and heavy menstrual bleeding. Consult with your health care provider to determine whether such medicines will work well for you.
Uterine artery embolization: Under X-ray guidance, a small tube is placed near the fibroid, and small beads are released into the nearby blood vessels to block blood flow to the fibroids. This causes the fibroids to shrink, and improves symptoms. However, surrounding tissue may be impacted, and as a result this option may not be best for women who want to have children in the future.
MRI-guided high frequency ultrasound: This therapy uses a focused ultrasound to heat up the fibroids an MRI machine to monitor the spread of the heat so that surrounding tissues (such as blood vessels, nerves, and normal uterine tissue) are protected. No incisions are needed. Specialized equipment and training are required, however, and may not be available locally. Finally, this therapy may not be covered by insurance, so be sure to check before proceeding with this option.
Radiofrequency ablation: A probe is placed into the fibroid either during a surgical procedure or using local anesthesia and going through the normal skin. The tip of the probe is then heated up to destroy normal myometrial tissue. While the tip is monitored, potential damage to surrounding tissues may be difficult to detect and prevent.
Myomectomy: The surgical procedure where the fibroids are removed from the uterus, leaving the uterus inside of you. It may be performed inside the uterus (called a hysteroscopic myomectomy), or through the abdomen as a laparoscopic surgery, a robotic surgery, or a laparotomy (where a larger incision is used to make the uterus more accessible. Robotic surgery has certain benefits to the surgeon, but typically the quality of the surgery is not better than either a laparoscopic surgery or surgery by laparotomy).
Hysterectomy: This is the surgical removal of the uterus, with all fibroids. While curative, it also eliminates the possibility of future child-bearing, and may result in other long-term side-effects such as inability to hold urine when coughing or sneezing, and potentially bulging of tissues out of the vagina. Given the wide array of alternatives, hysterectomy should be the last option once all other options are either not right for you or have failed.
Receiving a diagnosis of uterine fibroids can initially be frightening, but it is important to know that the likelihood of any associated cancer is very low, and that there are many options to relieve symptoms associated with uterine fibroids. Hysterectomy, while certainly a good option for some women, is not the required option for all women. It is important to discuss your options with your healthcare provider, and if your preferred option is not available locally, consider asking your provider to work with someone who can provide the intervention that you want. There are many more details to consider with each therapy, so work with your healthcare provider to educate both of you on the best therapeutic option that is best for you.
Ultimately, you are in control of your healthcare and will have to address the benefits and risks of whichever course you choose. Work with your providers to tailor the option that works best at the moment, and should your choice become less effective over time, be aware that you have other alternatives that might provide greater relief. Also, talk to your peers and share your stories about which therapies worked or did not work for you and why. You are not alone.