1) How are fibroids treated?
There isn’t one way of treating fibroids. The options can vary from simple ones like supportive treatment to radical treatment such as hysterectomy. There are many important factors to consider such as age, size and location of fibroids, fertility aspirations and more importantly your symptoms and your wishes.
2) How big do the fibroids have to be before they need to be removed?
There is no hard and fast rule about size. Surgery is deferred unless an individual fibroid is larger than 4-6cm in size or the uterus is larger than 12 weeks of pregnancy. Even smaller fibroids can cause severe symptoms particularly if they are submucous and may need removal.
3) When Fibroids needs to be removed?
Once symptomatic, most fibroids need to be surgically removed. Removal of fibroid is recommended in women with symptoms of Abnormal Uterine bleeding, Pain during menstruation, Pressure symptoms or Infertility.
4) What are the treatment options for fibroids ?
Surgery is not the only way to treat fibroids. All the options are described below:
Hormones: The simplest form of treatment is to start the Oral Contraceptive Pill to regulate the oral contraceptive pill. If there is breakthrough bleeding, progesterone tablets could be used to stabilize the endometrium. GnRH analogues can be used to stop periods and also to shrink the fibroids before surgery.
Mirena Intrauterine System (IUS) : is a hormonal IUD which secretes a small amount (20 microgm) of progesterone hormone per day within the uterus. This works very well in small to medium sized fibroid uterus where the cavity is not affected by fibroids. Effect of Mirena lasts for 4 to 5 years. It is also a very effective method of contraception.
Tranexamic Acid: tablets can be used for reducing the amount of bleeding. It will typically cut down the blood loss by about 50%. Haematinics and iron supplements can be used to correct anaemia.
Ullipristal Acetate (Esmya): Ulipristal acetate, a selective progesterone receptor modulator (SPRM), has emerged as an effective medication in decreasing menstrual blood loss and myoma size when used in the short term. Ulipristal acetate reduces the size of uterine fibroids in women who have not yet started menopause by blocking the effects of progesterone. It is used by some women for as long as 3 months before surgical fibroid removal; other women take the drug in repeated courses, with time off between courses.
But In early February 2018, the The European Medicines Agencyconcluded that there is a risk for rare but serious liver injury with ulipristal acetate for the treatment of uterine fibroids, and measures were implemented to minimize the risk.Many countries have Suspended the usage of ulipristal acetate for uterine fibroids after theEuropean Medicines Agencyreview of liver injury risk.
Endometrial Ablation: is an operation to destroy the lining of your womb (endometrium) using an energy source and replace it with a scar tissue so there will be little or no menstrual bleeding. This works better if the uterine cavity is normal with no submucous fibroids
Uterine Artery Embolization: This is a procedure where blood supply to the fibroids is blocked using silicon pellets. It is performed under short general anesthesia or sedation. It is about 50 - 70% effective in reducing mass related symptoms and 60 -80% effective in improving bleeding related symptoms. The main risks are pain for the first few days, risk of infection, vaginal discharge and recurrence of symptoms. Very large fibroids enlarged above the level umbilicus are not suitable for this procedure. There is also a very small risk of ovarian blood supply being affected and premature menopause. Hence this procedure is usually performed for women in their forties when fertility is no longer desired.
High intensity Focused Ultrasound: MRgFUS& HIFU (Magnetic Resonance Ultrasound Guided) uses MRI and ultrasound to find your fibroids and then to apply ultrasound-generated energy to heat the fibroids up in order to destroy them. This procedure aims to relieve symptoms caused by fibroids. Fibroid volume may be shrunk by 20 % after 4 months. MRgFUS is suitable for small fibroids (larger than 3 cm and less than 10 cm) of average size less than 7 cm where the high intensity ultrasound energy does not pass through the bowel or bladder on its way to reach the fibroids. It is NOT recommended for women who still want children and in 6 or more symptomatic fibroids. As we are not getting tissue for histopathology rarely malignant tumours likeLeiomyosarcoma can be missed.
Hysteroscopic Resection of Fibroid (Hysteroscopic Myomectomy): This procedure is ideally suited for submucous fibroids where the fibroids have grown within the uterine cavity. It is performed as a day case procedure under general anesthesia. A hysteroscope (camera) is inserted through the neck of the womb (cervix) and fibroids are resected under direct vision using an electrical wire loop. View Video
Myomectomy: Myomectomy is an operation performed to surgically remove the fibroids. This can be performed laparoscopically (key-hole surgery) in almost all cases.
Hysterectomy is reserved for very large and multiple fibroids or where fertility is no longer desired. Hysterectomy can also be performed as a key-hole procedure in almost all cases.
5) When you require hysterectomy for Fibroids?
Hysterectomy in fibroid condition is recommended only when:
You want a permanent solution to your fibroid problem.
You no longer want to have children or near or pass menopause.
The fibroids are large and cause heavy bleeding.
All other alternatives for fibroids have failed.
One of the most important factors in helping you choose appropriate medical care is your full understanding of the reasons for treatment, the risks, and the potential benefits for you. If hysterectomy has been suggested to you as an option, you should carefully weigh the potential benefits and risks so that you are able to make a comfortable and informed decision about whether hysterectomy is right for you.
6) Can you recommend one treatment option over all the others?
One treatment may not suit all women with fibroids. Consultation with an experienced Gynecologist will allow you to assess various factors and come to a decision regarding the optimal option for you.