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Unless fibroids are causing excessive bleeding, significant discomfort or bladder problems, a fibroid treatment is usually not necessary. A woman with fibroids should be evaluated periodically by her health care provider. The visit should include questions about fibroid symptoms and abdominal and pelvic examinations to assess uterine size. Routine pelvic ultrasounds have very little clinical benefit for women without symptoms. Fibroids are likely to increase in size each year until menopause. Changes in fibroid size should not be an indication for a fibroid procedure unless accompanied by disabling symptoms.
Currently, the medical treatments available for fibroids can make symptoms better temporarily but they do not make the fibroids go away. For women with heavy bleeding, it is worth trying a medical treatment before undergoing a surgical procedure. Women with pressure symptoms caused by large fibroids will not benefit from any medicines currently available. On the horizon are several promising, new drugs that will treat the fibroids themselves not just the symptoms.
Oral contraceptive pills and
Progestational agents (Provera®, medroxyprogesterone acetate)
Women with heavy menstrual periods and fibroids are often prescribed hormonal medications to try to reduce bleeding and regulate the menstrual cycle. The medications will not cause fibroids to shrink nor will it cause them to grow at a faster rate. If the medication has not improved your bleeding after three months, consult with your doctor. Women over the age of 35 who smoke should not use oral contraceptive pills.
GnRH agonists (Lupron®)
GnRH agonists are a class of medications that temporarily shrinks fibroids and stops heavy bleeding by blocking production of the female hormone estrogen. Lupron is the most well known of these drugs. Although Lupron can improve fibroid symptoms, it causes unpleasant, menopausal symptoms such as hot flashes and, with long-term use, leads to bone loss.
Lupron should be recommended only in very specific circumstances. For example, a woman with very heavy bleeding and profound anemia will likely need a blood transfusion at the time of surgery. However, if she uses lupron for 2-3 months before surgery to make her periods temporarily stop and an iron supplement, the anemia will improve and the need for a blood transfusion will be reduced. In rare instances, a woman with huge fibroids(>10-12 cm) may be encouraged by her doctor to use lupron prior to surgery. Importantly, lupron should not be used solely for the purpose of shrinking fibroids unless surgery is planned because the fibroids will re-grow to their original size and symptoms will return as soon as the lupron is discontinued.
Intrauterine Devices (IUD)
Although IUD's are typically used to prevent pregnancy, they have non-contraceptive benefits as well. An IUD that releases a small amount of hormone into the uterine cavity has been shown to decrease bleeding related to uterine fibroids. An IUD can be inserted during a routine office appointment. Ask you doctor for more information about this option.
Myomectomy is an operation in which fibroids are removed from within the uterus. Stitches are used to bring the walls of the uterus back together. For women with symptomatic fibroids who desire future childbearing, myomectomy is the best treatment option.
Myomectomy is a very effective treatment, but fibroids can re-grow. The younger a woman is and the more fibroids present at the time of myomectomy, the more likely she is to develop fibroids in the future. Women nearing menopause are the least likely to have problems from fibroids again.
A myomectomy can be performed several different ways. Depending on the size, number and location of your fibroids, you may be eligible for an abdominal myomectomy, a laparoscopic myomectomy or a hysteroscopic myomectomy.
Hysterectomy is a major surgical procedure in which the uterus (womb) is removed. Many women choose hysterectomy to definitively resolve their fibroid symptoms. After hysterectomy, menstrual bleeding stops, pelvic pressure is relieved, frequent urination improves and new fibroids cannot grow. A woman can no longer become pregnant after a hysterectomy.
There are several different surgical approaches. A vaginal hysterectomy involves removing the uterus through an incision in the vagina. An abdominal hysterectomy is performed through an incision on the lower abdomen. A laparoscopic hysterectomy is accomplished through four tiny incisions on the abdomen. The type of hysterectomy will depend on the size of the uterus and several other factors.
The ovaries are not necessarily removed during a hysterectomy. Women should discuss the pros and cons of ovarian removal with their physicians.
What about my ovaries?
Uterine artery embolization is a relatively new treatment alternative to open surgery for symptomatic fibroids. Embolization means blocking the blood flow to the fibroid. By stopping the blood flow, the fibroid begins to die and shrink in size. This will often decrease menstrual bleeding and symptoms of pain, pressure, urinary frequency or constipation.
The procedure is performed in the radiology department of the hospital. A doctor of Interventional Radiology will perform the procedure. The night before the treatment you should have nothing to eat or drink after midnight. You may take any medications that you usually take in the morning with a small sip of water. No aspirin, advil, motrin or ibuprofen should be taken for 5 days before the procedure. All of these medicines can thin your blood. (If you take coumadin, plavix, lovenox, glucophage or heparin, please speak to your doctor about when to stop these medicines.) See How To Prepare For Your Arteriogram for further general information. The procedure takes approximately two hours.
During the procedure, an intravenous line is started prior to beginning the procedure. You will then be sedated and are awake but sleepy throughout the procedure. A needle is placed in an artery in your leg, at the groin crease. A small catheter is then placed into the artery and dye is injected while x-rays are performed to get pictures of the arteries (arteriogram) that supply the uterine fibroid(s). The catheter is then used to select these arteries and particles are used to block the flow of blood. The particles are called polyvinyl alcohol and are the size of a grain of sand. These are mixed with contrast and injected slowly while we watch to assure that they go only to the fibroid. It takes several minutes to block arterial flow. After the left and right uterine arteries are embolized, a repeat arteriogram is performed to confirm the completion of the procedure. The catheter is removed and pressure is held over this area for approximately 15 minutes. After the exam you must be on bed rest for six hours lying flat with your leg straight. The amount of pain that women experience is variable. The most significant pain usually occurs immediately following the procedure and over the next 6 hours. Our patients report this pain to be similar to menstrual cramps. Some patients experience no pain. Patients usually stay overnight in the hospital, so that we can monitor the arterial access site and provide adequate pain control. Patients are discharged home the next morning. Most patients can return to full activity in a week.
Please see the Uterine Artery Embolization home instructions for more information.
What can I expect?
When blood flow to the fibroid is blocked the fibroid will have no oxygen and will begin to die. This process happens over days to months. During this time the fibroid shrinks by approximately 40-50 % and the uterus by approximately 30-40 %. Our experience and the literature suggest that 80-90% of patients will have improvement of symptoms. For some patients this form of treatment is ineffective. Serious complications occur in less then 4 % of patients. These include injury to a vessel, uterine infection, blood clots and injury of the ovaries.
UAE has been performed for 7 years during which time there have been many studies that confirm its utility as a primary treatment for uterine fibroids in suitable patients. Longer-term studies are currently underway. At the UCSF Comprehensive Fibroid Center, physicians will help patients choose the treatment option right for them.