Key content
Fibroids are the most common uterine growth and there is an
increasing range of options for their management.
Management options are affected by the woman’s symptoms, age,
desire to conceive and local resources.
Pharmacological agents are effective in alleviating symptoms and
may improve women’s quality of life.
Interventional radiology procedures may prevent the need
for hysterectomy.
Conventional surgical procedures and minimal access surgery are
important in management of fibroids.
Learning objectives
To understand the options available for the management of
uterine fibroids.
To create awareness of radiological techniques, such as uterine
artery embolisation and magnetic resonance imaging-guided
focused ultrasonography, that preserve the uterus.
To understand the use of pharmacological agents in the reduction
of menstrual blood loss and fibroid size.
Ethical issues
Is it ethical to offer new minimally invasive treatment options for
fibroids to older women who wish to retain potential fertility?
Keywords: fibroid / infertility / leiomyomata / leiomyoma /
menorrhagia due to fibroids
Introduction
Uterine fibroids (leiomyomata) are the most common benign
tumours in women, with a lifetime prevalence of around
30%. These tumours are overgrowths of smooth muscle and
connective tissue that are hormone dependent. Each fibroid
arises from a single cell. Fibroids may be solitary, multiple or
diffuse. There is a genetic predisposition to the development
of leiomyomata; they are more common in black women
than in white women, with a ratio of between 3 and 9:1.
Other risk factors for developing fibroids include being
overweight and nulliparity.1,2 The majority of fibroids do not
cause any symptoms but one in four women with fibroids are
symptomatic.2 The symptoms depend on the location and
size of the fibroid and include heavy menstrual bleeding, pain
during periods and intercourse, a dragging sensation in the
lower abdomen and urinary or defecation problems.3
Fibroids rarely present before menarche and usually regress
after menopause.3,4 They can cause concern in women of
reproductive age because of heavy, irregular menstrual
bleeding and pain, which can have a negative impact on a
woman’s life and warrants intervention.3,4 Treatment options
include nonsurgical methods (pharmacological, uterine
artery embolisation [UAE], magnetic resonance imaging
[MRI]-guided focused ultrasound [MRgFUS]), minimally
invasive surgery (hysteroscopic myomectomy, laparoscopic
myomectomy), and open surgery (myomectomy or
hysterectomy). The choice of treatment has to be tailored
for each patient according to their wishes, the type and
location of the fibroid, and associated symptoms and
availability of service. Figure 1 shows the locations where
fibroids can be found in the uterus.
In women who are asymptomatic or with bearable
symptoms, expectant management may be acceptable.
Many women with fibroids have successful pregnancies.
Pharmacological treatment
Pharmacological options are available for short-term use to
treat problems associated with fibroids. These options were
used more frequently in the following situations:
in perimenopausal women whose problems were likely to
resolve with the onset of the menopause
in women who were not suitable for surgery and in some
women receiving fertility treatment
preoperatively to reduce the size of the fibroid and to
reduce menstrual bleeding to improve haemoglobin levels
before surgery. Ulipristal acetate (UA) and
gonadotrophin-releasing hormone (GnRH) analogues
may be used prior to surgery for a fibroid uterus.
Nonhormonal treatment for heavy periods
associated with fibroids
Tranexamic acid is frequently used in treating heavy
menstrual bleeding in women who have uterine fibroids.
Tranexamic acid is an antifibrinolytic drug that reduces
menstrual loss. A review of the use of tranexamic acid in
women with fibroids concluded that it may reduce
menorrhagia as well as perioperative blood loss in
myomectomy.10 Necrosis and infarcts in fibroids (especially
in large fibroids) have been reported following use of
tranexamic acid.
Levonorgestrel intrauterine system
The levonorgestrel intrauterine system (LNG-IUS) has been
widely accepted as an effective treatment of heavy menstrual
bleeding. There is general agreement among several reviews
that use of the LNG-IUS in women with fibroids is successful
in reducing menstrual blood loss, increasing haemoglobin
and relieving symptoms.14–17 There are conflicting results
regarding its effect on fibroid or uterine volume and device
expulsion rates. Jiang et al.17 reported no effect on fibroid
volume but a decrease in uterine volume; however,
Sangkomkamhang et al.16 and Kim and Seong15 reported
no change in both uterine and fibroid volume. Zapata et al.14
and Kim and Seong15 reported higher device expulsion rates
that appear to increase with uterine volume. However, Jiang
et al.17 reported low expulsion rates. An online survey for the
Uterine Bleeding and Pain Women’s Research Study found
that 10.3% of women in the UK and France used the
LNG-IUS for menorrhagia associated with fibroids.4
The LNG-IUS reduces menstrual blood loss from
fibroids by inducing endometrial atrophy. A review by
Sangkomkamhang et al.16 included a randomised controlled
trial of 58 women assigned to either a combined oral
contraceptives treatment group (n = 29) or a LNG-IUS
(n = 29) treatment group. The trial showed that the LNG-IUS
was more effective than combined oral contraceptives in
reducing menstrual blood loss and improving haemoglobin
levels.18 The LNG-IUS group showed an increase in
haemoglobin levels from 9.7 1.9 g/dL to 11.7 1.2 g/dL
(P <0.001) and a reduced number of days of menstrual loss.18
Gonadotropin-releasing hormone analogues
GnRH analogues were approved by the Food and Drug
Administration in 1995 for preoperative management of
uterine fibroids. GnRH analogue treatment induces a menopausal state with low estrogen levels that may result in
intolerable side effects and bone loss. The hypoestrogenic side
effects could be minimised by adding low dose estrogen and
progestin or tibolone after initial phase of downregulation.
Progesterone-mediated medical treatment
Selective progesterone-receptor modulators
Mifepristone
Ulipristal acetate
Aromatase inhibitors
Uterine artery embolisation
MRI-guided focused ultrasonography
Surgical treatments of fibroids
Surgical management of uterine fibroids may be required in
women with severe pressure symptoms, unresponsiveness to
other therapies (medical, UAE) or in large pedunculated
subserosal or submucous fibroids. Surgical treatment can be
either hysterectomy or myomectomy. The size and location
of the fibroid in the uterus and the desire for future fertility
affects the choice of surgical procedure. Hysteroscopic,
laparoscopic, vaginal or laparotomy routes may be used to
remove fibroids. Myomectomy may alleviate symptoms in
most women with uterine fibroids but complications (e.g.
severe haemorrhage that is difficult to control), may lead to
hysterectomy. The need for careful counselling prior to
surgical interventions cannot be overemphasised.45,46
Myomectomy
Hysteroscopic myomectomy
ESGE and FIGO classifications for submucous myomas
ESGE classification FIGO classification
Type 0: no myometrial involvement, entirely in endometrium (pedunculated) Submucosal 0 Pedunculated (intracavity)
1 <50% intramural
Type 1:
<50% myometrial extension (sessile)
<90° angle of myoma surface to uterine wall
2 ≥50% intramural
Others 3 Contact endometrium (100% intramural)
4 Intramural
Type II:
≥50% myometrial extension (sessile)
≥90° angle of myoma surface to uterine wall
5 Subserosal ≥50% intramural
6 Subserosal <50% intramural
7 Subserosal pedunculated
8 Others (cervical or parasitic
Conclusion
There is good evidence to support the following suggestions
for fibroid uterus management:
Medical management and noninvasive techniques (UAE,
MRgFUS) are effective in alleviating the symptoms
associated with uterine fibroids.
New technologies that have been recently introduced
without adequate assessment require further research
regarding long-term outcomes, especially in the context
of future fertility.
The surgical options can be considered after careful
selection of patients with informed choice.
For hysteroscopic myomectomy, traditional resection is
still the gold standard for submucous fibroids.
There have been reports of successful pregnancies after
UAE and MRgFUS, but further randomised trials are
needed to prove the safety of these treatments in young
women where future fertility is desired.