Fibroid Facts for Females
Fibroids are the most common benign smooth muscle tumor of the uterus and the most common indication for hysterectomy in the United States.  Fibroids are found in over three-quarters of all hysterectomy specimens, even when the indication for surgery was not fibroids.  Fibroids are discovered in 40% of all women by age 35 and 70% by age 50, and are more common in black women.

Symptoms
The presence of fibroids within the uterus may produce no symptoms at all or may lead to excessive and irregular menstrual bleeding and/or pelvic and abdominal pain.  For some women, these symptoms can be debilitating.

You can’t make an asymptomatic woman with fibroids feel better by treating her; so, unless there is a rapid change in fibroid size, a woman with no symptoms needs no treatment.

Treatment
There are many treatment options for fibroids, and which is chosen depends upon a woman’s desire for pregnancy, her desire to keep her uterus, her symptom severity, and the location and size of the fibroids within her uterus.  The appropriate type of procedure: should be discussed with a woman by a gynecologist who is skilled in all these procedures. 

Medication options:  Medical therapy can, and should, always be the first approach to the management of fibroids symptoms. Oral contraceptive pills and progestin-type drugs will almost always control abnormal bleeding from fibroids, but will do nothing to reduce their size. A medication that will reduce fibroid size works only while the medication is taken, and fibroids will re-grow after the medication is stopped.  So, this latter medication is used to reduce fibroid size or stop uterine bleeding in preparation for surgical removal.   A new class of medications called selected progesterone receptor modulators are in development and should be a source for treatment in the future.

Uterine Fibroid Embolization (UFE):  This is a procedure that can permanently reduce fibroid size without surgery.  A woman’s appropriateness for this procedure will depend upon her symptoms, fibroid size and location, and her desire for future pregnancy, since this procedure is not recommended if future pregnancy is desired.  This procedure is done by a specially trained radiologist and involves injecting material which will cut off blood supply to the fibroid.  Over the course of a few months the fibroid will decrease to about one-half of its original size.  Women are usually kept in the hospital overnight in case they feel pain while the fibroid degenerates.  This procedure does not eliminate the fibroids, but most women will have a decrease in their symptoms.  A woman’s gynecologist or an Interventional Radiologist can determine her appropriateness for uterine fibroid embolization.

Magnetic Resonance Imaging Guided Focused Ultrasound:  This procedure can also reduce fibroid size, and therefore a woman’s symptoms, without surgery.  It is relatively new and is only available in approximately 30 center in the United States.  Its appropriateness is also determined by fibroid size and location and involves focusing high-frequency ultrasound waves into the fibroids to produce heat and to destroy them.  This procedure, like UFE, can only reduce fibroid size without removing them, and studies to-date indicate that the size-reduction is less than that achieved with UFE.

Myomectomy:  This less invasive type of surgery removes the fibroids themselves and can be performed, depending upon fibroid size and location, with minimally-invasive techniques such as hysteroscopy and laparoscopy, or, if necessary, an open abdominal procedure.  Myomectomies are the preferred procedure for those women wishing to preserve their ability to get pregnant.  After myomectomy, fibroids can recur, because each fibroid comes from a single individual uterine muscle cell. 

Hysterectomy:  This is the only procedure that completely removes all fibroids with no chance for recurrence, and with the permanent relief of symptoms.  The entire uterus is removed during this procedure.  Fortunately, those gynecologists skilled in vaginal and laparoscopic procedures can remove even very large uteri without making a large incision.  These minimally invasive vaginal and laparoscopic procedures markedly shorten hospital stay and post-operative recovery time and can even be done in the out-patient setting.  Many women can resume normal activity within a week of so after vaginal and laparoscopic hysterectomy.

Summary
Patient choice should play a significant role in deciding a treatment option for uterine fibroids.  Medication therapy will almost always relieve abnormal bleeding   Imaging studies such as ultrasound and magnetic resonance imaging (MRI) can be used to guide surgical and non-surgical treatment strategies.   Non-surgical options, like UFE, can greatly decrease symptoms.  Myomectomy is the treatment of choice for symptomatic fibroids in a woman wishing to retain her uterus for child-bearing.  Women should be well informed and question their healthcare provider if hysterectomy is the first and only option offered. 

MUSC has developed a Virtual Fibroid Center.  With the exception of MRI focused ultrasound, all other treatment options are available through MUSC Women’s Services.  Call 843-792-5300 for information or for an appointment with one of MUSC’s GYN physicians.

by:  Donald L. Fylstra, M.D.

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