The author reports no financial relationships relevant to this article.
Part 1 of this article, in the May 2008 issue, discusses how to counsel patients who are found to have a uterine fibroid.
CASE 1 Menorrhagia with anemia
G.L. is a 44-year-old G2P2 who comes to the office for a second opinion on treatment for menorrhagia and a 10-weeks–size fibroid uterus. She reports that her periods last 8 days, and that for 3 of those days she changes a pad once an hour. Her most recent hemoglobin level was 10.2 g/dL. Her regular gynecologist has recommended abdominal hysterectomy. She would like to avoid major surgery and asks about alternatives. What therapies do you tell her are appropriate?
Most women who have uterine fibroids are asymptomatic or mildly symptomatic; they do not require treatment. In one study, 77% of women choosing observation for their fibroids had no significant changes in bleeding, pain, bothersome symptoms, mental health, general health, or activity after 1 year.1 After menopause, fibroids shrink, and the rate of surgery decreases greatly.2 For women such as these, “watchful waiting” may allow them to avoid treatment indefinitely.
For such women as G.L., however, who develop severe anemia from fibroid-related menorrhagia, treatment is necessary. It also is indicated in the rare case of hydro-nephrosis due to obstruction of the ureter(s) by fibroids, or when menorrhagia, pelvic pain or pressure, or urinary frequency or incontinence compromises quality of life.
The distress experienced by women with symptoms such as these can be severe. In one study, women who chose hysterectomy for fibroid-related symptoms assessed their quality of life as worse than that of women who suffered hypertension, heart disease, chronic lung disease, or arthritis.3
Nevertheless, when symptomatic women were offered hysterectomy as a first and sometimes sole treatment, some chose to adapt to symptoms and stop seeking treatment. In fact, hysterectomy is not the only option. A number of alternatives are available, including:
- medical therapy
- the progesterone-releasing IUD
- endometrial ablation
- hysteroscopic, laparoscopic, and abdominal myomectomy
- uterine artery embolization (UAE).4
With the exception of medical therapy, all of these modalities are described here.
- Most uterine fibroids are asymptomatic, require no treatment, and can be managed by watchful waiting.
- Treatment is indicated when fibroids cause severe anemia and when symptoms interfere with quality of life.
- Hysterectomy is not the only treatment option; alternatives include medical therapy, the progesterone-releasing intrauterine system, endometrial ablation, myomectomy (hysteroscopic, laparoscopic, or abdominal), uterine artery embolization (UAE), and focused ultrasound.
- Contraindications to UAE include active genitourinary infection, genital tract malignancy, reduced immune status, severe vascular disease, allergy to intravenous contrast, or impaired renal function. Relative contraindications include large submucous myomas, pedunculated myomas, recent treatment with gonadotropin-releasing hormone agonists, previous iliac or uterine artery occlusion, or postmenopausal status.
- Myomectomy may be considered even for women who have large uterine fibroids who wish to retain their uterus. Surgical techniques available for abdominal or laparoscopic myomectomy make this procedure safe.
- Women who have intractable symptoms and who have not been helped by other therapies may benefit from hysterectomy. Laparoscopic hysterectomy has the benefits of less postoperative pain, shorter hospital stay, and quicker recovery. If a vaginal hysterectomy is feasible, however, there is no benefit to a laparoscopic hysterectomy.
Progesterone-releasing intrauterine system
In a woman who has fibroids no larger than 12-weeks size and a normal uterine cavity, the levonorgestrel-releasing intrauterine system (IUS) (brand name, Mirena) has been shown to substantially reduce menstrual bleeding.5 Within 3 months, 22 of 26 (85%) women with documented menorrhagia treated in this way had normal bleeding and, by 12 months, 40% of all 76 women studied were amenorrheic.
CASE 1 CONTINUED
You perform an office hysteroscopy on G.L., which reveals a 3-cm, type 1 submucosal fibroid, suggesting, by its size, that the levonorgestrel-releasing IUS is unlikely to relieve her bleeding. What other treatments might be appropriate?
Studies show a reduction in bleeding following hysteroscopic resection of submucous fibroids. One hundred ninety-six consecutive women who had menorrhagia and one or more submucous myomas were followed for an average of 73 months after hysteroscopic myomectomy.6 Sixty-eight percent reported “satisfaction and ability to lead a normal life,” and 32% considered results unsatisfactory.