Dr. Jennie Draper, OB/GYN at Virginia Physicians for Women, explores how patients can collaborate with their doctor to find the best uterine fibroid treatment option for them based on symptoms and treatment goals.
One of the most common reasons a patient visits their OB/GYN outside of a scheduled annual exam is for uterine fibroids. In fact, fibroids may affect up to 70% of women by the time they reach menopause. From visits for heavy or painful periods to problems with pain during intercourse, fibroids can also be discovered during evaluation for infertility or miscarriage. They are the leading indication for hysterectomy in the United States. Fibroids can affect a person’s quality of life in a myriad of ways.
The good news is uterine fibroid treatment has come a long way, including options for women who are considering pregnancy. We have so many options now that can truly make a life-changing difference for someone who is suffering from fibroids. I’d like to answer a few questions that can help patients understand what fibroids are and how they can find the best treatment option for their uterine fibroid symptoms and phase of life.
What are uterine fibroids?
Uterine fibroids are benign (noncancerous) solid tumors that originate from the smooth muscle cells of the uterus. They’re also called leiomyomas or myomas. Fibroids can affect any female of reproductive age, but they are more common in Black women. Each case of fibroids is unique, and treatment can depend on their location within the uterus, the size and number of fibroids, the patient’s symptoms, and whether they are hoping to preserve their fertility.
What are the symptoms of uterine fibroids?
Uterine fibroid symptoms most commonly present as changes in periods, pelvic pain, pelvic pressure, and an enlarged abdomen. Period changes include heavier or longer cycles or worsening cramps. Pelvic pain and pressure can show up during intercourse and lead to changes in more frequent urination or constipation symptoms. Fibroids can also be found during evaluation for infertility and miscarriage.
Not all fibroids are symptomatic. They can also be identified at the time of a routine gynecology visit or due to a primary care referral for further evaluation of anemia as a result of heavy periods.
How are fibroids diagnosed?
Fibroids are diagnosed by ultrasound. Depending on surgical planning, they may require a sonohystogram (saline ultrasound) or MRI for better characterization.
Do fibroids affect fertility or pregnancy?
Not only can fibroids affect fertility, but they can also cause pregnancy complications for individuals who do become pregnant. Fibroids can interfere with the sperm’s ability to meet the egg or with the uterus’ ability for an embryo to be implanted. Pregnancies affected by fibroids are at increased risk for growth restriction of the baby and preterm labor Rarely, fibroids can contribute to placenta abruption which is an emergency when the placenta prematurely separates from the uterus.
However, just because a patient has fibroids does not mean they are the cause of the patient’s infertility or that the fibroids would cause pregnancy complications. In fact, most often fibroids do not affect a person’s ability to become pregnant or maintain a pregnancy. Each patient’s fibroid presentation is unique, and they would need to undergo evaluation to determine the cause of infertility.
What is the main cause of fibroids?
Unfortunately, we still don’t know what causes women to develop fibroids. Estrogen and progesterone are likely to play a role as fibroids tend to shrink with the onset of menopause when these hormones decrease. There also seems to be a genetic link as fibroids tend to run in families.
What is the best treatment for uterine fibroids?
Fibroid treatment is tailored to a patient’s symptoms, the location of the fibroids, and whether the patient has a goal to preserve fertility or not. There is not a best treatment per se but one that is collaborative between the patient and physician. If fibroids are discovered in a patient who is asymptomatic, they may not need treatment at all. Many women who are asymptomatic will elect to expectantly manage: monitor their condition and receive follow-up care if symptoms appear or worsen.
Is medication used to treat fibroids?
Medication is primarily used to help with bleeding symptoms of uterine fibroids. The options can be long-term or limited to short-term as a bridge to surgery. Some patients will respond to any birth control method to reduce periods as well as associated cramps. These include a progestin oral contraceptive pill or progestin-containing IUD.
If a patient is anemic, a medication that reduces bleeding is helpful to make a future surgery safer. These medications come in both pill and injection form. They are called GnRH antagonists, which create a reversible suppression of hormones acting on the fibroids: Orilissa, which contains elagolix, and Myfembree, which contains relugolix. A GnRH antagonist that can temporarily help with bleeding as well as size reduction which can make surgery safer is an injection called depo-lupron.
Tranexamic acid is a non-hormonal medication option that reduces bleeding by blocking the breakdown of blood clots.
Is surgery a good option for fibroids?
If other treatments haven’t worked, surgery can be a good treatment option if fibroids are affecting your quality of life or making it difficult for you to get pregnant. Fibroid surgery is primarily performed to help with bulk symptoms as well as bleeding. The approach to removing fibroids depends on size and location of the fibroids, as well as the desire to bear children.
What are the fibroid surgery options for women who want to preserve their fertility?
For individuals wanting to maintain fertility options, the goal would be to keep their uterus. Here are some options:
Hysteroscopic myomectomy If a fibroid is limited to inside the uterine cavity, a vaginal approach can be taken called a hysteroscopic myomectomy. This is where a camera is inserted into the uterine cavity from a vaginal approach to remove fibroid tissue without any incisions. The advantage is going home the same day.
Abdominal surgery Fibroids that are within the muscle of the uterus or on the outside of the uterus require an abdominal approach to surgery. This includes laparoscopic, robotically-assisted or open-incision depending on size, number and surgeon recommendation. Depending on locations and incisions to the uterus, some women will require cesarean sections for all future deliveries due to the risk of the scar opening during labor. If surgery is performed laparoscopically or robotically, same-day discharge is an option.
What are some minimally invasive or non-invasive options?
There are several treatment options to remove fibroids with minimally invasive or non-invasive procedures.
Acessa procedure The laparoscopic technique Acessa is a minimally invasive option that utilizes radiofrequency energy for thermal ablation of the fibroids. This reduces their size as the fibroids shrink and the surrounding muscle absorbs some of the tissue, resulting in improved symptoms over time. Currently the procedure is not FDA-approved for the treatment of infertility; however, current studies indicate it is likely safe for women desiring pregnancy and vaginal birth in the future. Depending on the fibroid uterus, this technique can be combined with hysteroscopy and/or robotic removal of pedunculated fibroids for maximum result.
Uterine artery embolization Alternative procedures for minimally invasive treatment of fibroids include uterine artery embolization, which is performed by an interventional radiologist. This procedure involves injecting tiny pellets into the uterine vessels by going through a vessel in your arm or groin to decrease blood flow to the uterus. At this time, it’s not clear if this is a safe technique for allowing future pregnancies.
Ultrasound therapy Another option is non-invasive, MRI-guided ultrasound therapy, which uses ultrasound energy to help decrease fibroid size, but may be less effective in fibroid symptom relief.
Is surgery recommended for patients who don’t desire to preserve their fertility?
If a patient has completed childbearing or doesn’t plan to pursue pregnancy, a more definitive uterine fibroid treatment option is to proceed with a hysterectomy: removal of the uterus as well as all fibroids. The reason being unfortunately fibroids can recur after surgery to remove them. A hysterectomy eliminates that risk. Pursuing hysterectomy focuses on removal of the uterus, fibroids and cervix; if ovaries are left in place this will not affect a patient’s current hormonal status.
What size fibroids require surgery?
There are many factors besides size that can determine if surgery is a recommended treatment option for a fibroid patient, including the type and location of the fibroid(s). Fibroids can occur within the uterine cavity (submucosal), in the muscle (intramural), underneath the surface of the uterus (subserosal) or extended from the uterus (pedunculated). A patient can have a single fibroid or many of these tumors, as well as what we call hybrid fibroids: a combination of types.
Submucosal fibroids are notorious for causing heavy bleeding due to occupying space inside the uterus. Surgery is often recommended for these fibroids even though they may be just a few centimeters in size, whereas a patient could have a tumor the size of a grapefruit that isn’t bothersome!
Can fibroids be treated without surgery?
Although fibroids can reduce in size with some non-surgical treatment and will also typically reduce size with menopause, they won’t go away on their own without surgery.
What happens if fibroids go untreated?
Fibroids which run out of their blood supply can degenerate and calcify, becoming harder, which may reduce the symptoms they produce. The fibroids may then stop growing, but they do not spontaneously go away. Most fibroids decrease in size during menopause.
Can fibroids turn into cancer?
Less than 1% of fibroids are cancerous. If you experience any concerning symptoms including rapid growth, you should talk to your doctor. However, the chances of fibroids developing into cancer are slim.
Is there anything you can do to reduce your risk for fibroids?
More research is needed on understanding what causes fibroids and what may help reduce risk. Having healthy lifestyle habits such as exercise and a balanced diet focused on whole foods may help.
Your OB/GYN can help you create a plan for relief.
If you experience any of the uterine fibroid symptoms we mentioned, know that they are not normal and that your OB/GYN is there to help you find relief. I love partnering with each fibroid patient to find the right treatment option for them and to make sure their goals of treatment are acknowledged, whether they include preserving fertility or not. Patients should feel empowered to know about their unique fibroid uterus and play an active role in deciding the fibroid treatment that’s best for them!
Dr. Jennie Draper is an OB/GYN at Virginia Physicians for Women with expertise in treating uterine fibroids. She sees patients at VPFW’s Henrico Doctors’, St. Mary’s, and West Creek offices and delivers babies at Henrico Doctors’ Hospital and St. Mary’s Hospital.
