What Are the Treatment Options for Fibroids?
If you need treatment for fibroids, there are many options available to you. Your choices should be guided by the medical problems the fibroids are causing, your desire to have children, and your feelings and thoughts about your body, surgery or about other options. I think it is important for you to know all the options available. Even if some treatments do not apply at the current time, your condition or symptoms may change. If you understand the potential for future symptoms and problems, as well as the alternative means of treatment available, much of the mystery of fibroids will disappear.
Can “Watchful Waiting” Be Used to Keep an Eye on My Fibroids?
Although most women will have fibroids during their lifetime, only a small number of them will ever need treatment. The vast majority of women with fibroids are unaware of them until their doctor feels them at the time of a routine pelvic exam. Some women have very minor symptoms, which are not bothersome at all. If that is the case for you, then no treatment is necessary and then I consider “watchful waiting” to be the primary option.
It is not possible for either you or your doctor to predict whether your fibroids will grow in the future or whether you will go on to develop new symptoms. A study of women with fibroids 2 months pregnancy size or larger, found that 77% of women choosing “watchful waiting” had no significant changes in bleeding, pain or bothersome symptoms at the end of a year. Also, they had no changes in their mental health, general health or ability to do physical activity. However, 23% of the women were bothered by symptoms to the point that they chose to have a hysterectomy during the course of the year.
Based on this study, women with fibroids that cause only mild or moderate problems “watchful waiting” may enable surgery to be postponed or entirely avoided. Women who are close to menopause might choose “watchful waiting” because there is less time to develop new symptoms and after menopause bleeding will stop and fibroids shrink about 50%.
The cause of the growth of fibroids is not well understood, and the rate of growth is unpredictable. Most fibroids never grow; others grow gradually over the course of many years; and some seem to go through growth spurts and then may stop growing entirely. The only way to know what is happening is to have a pelvic examination on a regular basis. I usually examine women with fibroids every three to six months. If the fibroid grows during that time period, the growth will be discovered early, and a number of options short of hysterectomy, should still be available. If the fibroid continues growing, I usually do exams more frequently, generally every month until the growth stops. Ultrasound, a simple test that uses sound waves to make a picture, can also be used to determine the size of the fibroids.
Over the years, a number of women have come to my office with extreme symptoms due to uterine fibroids. Some of these women had fibroids that were very large (the size of a full-term pregnancy), some had severe bleeding that caused a very low blood count (hemoglobin of 4- 6, when 12 is normal), and some had fibroids that blocked the bladder and required a visit to the emergency room where a urinary catheter was inserted.
All of these intelligent women were aware that they had fibroids. However, they had put off treatment after numerous doctors (as many as 7 in one woman’s case) told them that the only remedy was a hysterectomy. Some of the women had not yet had children and wanted a family. Many felt strongly about keeping the body parts they were born with, and others feared a hysterectomy. They didn’t want or medically need a hysterectomy, so they just stopped seeing doctors.
However, these women tolerated terrible symptoms and allowed fibroids to control their lives. Some were unable to leave the house every month when the bleeding was heavy. Some were so weak and tired they weren’t able to function at work or at home. Some reported having strangers asking them “when the baby is due”. Most were consumed with worry about their health and about what was going to happen to them.
My sense is that these women accommodated to their symptoms over time.
“Well, I am bleeding heavily but not much heavier than last month.”
“Well, the fibroids are larger but not that much larger than 6 months ago.”
The problem is that “normal” had been forgotten, and slow growth or a slow increase in bleeding can be deceptive. Following a myomectomy, these women often say “I forgot how good it feels to have a fibroid-free life” or “I feel like a new person”.
It is important to consider, however, that treatment options may be limited when the fibroids grow very large or if a woman has a very low blood count. For instance, laparoscopic or robotic myomectomy is not possible if the uterus is so large that there is not enough room to fit the robotic instruments in the abdomen. Some interventional radiologists do not recommend uterine artery embolization for very large fibroids because they think the procedure is not likely to be successful. Severe anemia may require either iron infusions or, rarely, even a blood transfusion before anesthesia and surgery can proceed safely.
Watchful waiting is an excellent solution for many women with fibroids. Some fibroids don’t grow, and some even shrink before menopause. After menopause most fibroids will shrink and bleeding will stop. My advice, however, is to continue to search for a gynecologist who has experience with managing fibroids on a regular basis, who can help you with the “watching,” and who is experienced at treatment options including myomectomy in case surgery becomes necessary.
In my practice, I like to see women with bothersome fibroids on a regular basis. This usually means every 3-6 months. I review their symptoms and examine them during these visits. We monitor blood counts when bleeding gets heavier. We reevaluate treatment options if symptoms get worse or if the patient has reached the end of her rope. So, watchful waiting is fine, but have someone help you “watch”.
What if Fibroids Cause Bothersome Symptoms?
Fibroids may sometimes grow large enough to cause frequent urination, constant discomfort, pressure, and even pain. And, while not dangerous, the discomfort may lead you to choose surgery as treatment for fibroids. Two added notes: very large fibroids may partially block blood flowing from the legs back to the heart. This can lead to swelling of the legs and some discomfort. Very rarely, it can also lead to formation of blood clots in the legs that can be dangerous and this can be a good reason to get treatment. If you have very large fibroids, it is important that you not sit for prolonged periods of time so that clots have less chance to form. Also, very rarely large fibroids may block the flow of urine out of the kidneys and, even more rarely, this can cause kidney damage. If your doctor thinks the fibroids are close to the ureters on pelvic examination then this can easily be evaluated with either ultrasound or X-ray of the ureters.
What If You Have Large Fibroids?
Doctors have been taught that if a woman has fibroids the size of a large grapefruit (a three month pregnant uterus) or larger, she would be at risk for other health problems. This reason-the future possibility of problems-simply does not make sense to me. If you have a large fibroid and you are feeling fine, I can’t see the need for you to undergo surgery. It is actually unlikely that your large fibroid will ever go on to cause you any bothersome symptoms.
Doctors also feel that large fibroids make it very difficult to perform a thorough pelvic examination and fear that a less than optimum pelvic examination can result in missing an early diagnosis of ovarian cancer. Unfortunately, ovarian cancer is extremely difficult to diagnose in the early stages, with or without fibroids, even with the most sophisticated and expensive testing (see A Gynecologist’s Second Opinion: http://www.gynsecondopinion.com/ – Ovarian Cancer chapter) .
This is a frustrating and difficult reality for us all. Usually, by the time a gynecologist can feel an abnormality of the ovary during the pelvic exam, the disease has already spread. It is also common for gynecologists to not be able to feel every patient’s ovaries because of the size of the ovaries, the position of the ovaries, or the weight of the patient. It would make no sense to recommend a hysterectomy to every woman whose ovaries were unable to be felt by her gynecologist. And no study has ever shown that removal of a uterus enlarged with fibroids will make any difference in the early detection of ovarian cancer.
Another argument for aggressive surgery relates to the belief that the risks and complications of surgery are greater if the surgery is delayed and the uterus grows larger. As shown in a study at the University of Iowa College of Medicine, the complication rate for women who have hysterectomies for large fibroids is no different from that for women with small fibroids.
Also, a myomectomy may be safely performed on a woman with large fibroids. Drs. Stanley West , Reginald Ruiz and I published an article in the August, 2005 issue of Obstetrics and Gynecology reviewing the results of 91 women with uterine fibroids larger than a four month sized pregnant uterus operated on by Dr. West. The results compare very favorably to other studies of women who had a hysterectomy for large fibroids.
Many patients with uterine fibroids need no treatment. Surgery is only reasonable if you have symptoms that truly warrant the risk, time, stress, and money that an operation entails. But, if you need surgery it can be performed safely by a gynecologist experienced in fibroid surgery.
Can You Take Medication for Fibroids?
Unfortunately, there are no medications currently available that are able to prevent the formation of fibroids or permanently shrink them once they are present. Medicines are often used to buy time or reduce symptoms. For some women, medication allows a more relaxed time period to prepare emotionally and physically before treatment. Medications may also temporarily reduce the size of the fibroids enough to allow for a less invasive surgery with a quicker recovery. For some women who are approaching menopause, the “bought time” may lead them right into menopause, when the natural loss of estrogen and progesterone shrinks the fibroids.
Lupron (injectable) and Synarel (nasal spray) are two of the medications that work by temporarily shutting off the ovaries’ ability to make estrogen and progesterone, and menstrual periods temporarily cease. Since estrogen and progesterone are some of the substances necessary for fibroids to grow, the lack of hormones causes fibroids to shrink. These medications take about two weeks to begin shrinking the fibroids, and the full effect is seen after three months. At that time, most fibroids will decrease in size by about 35% of their volume. The shrinking effect is maintained for as long as you use the medication, but there is rarely any further shrinkage after the third month of treatment.
Heavy bleeding goes away in almost all women by about 6 months. However, if the medication is stopped, the ovaries begin to produce hormones again and the fibroids return to their original size and bleeding returns within 3-6 months. Therefore, the medication has no permanent effect and is primarily used to reduce symptoms and allow time to bring your blood count back to normal and plan treatment. In addition, long-term use of these medications is limited by their side effects and the risk of osteoporosis. Side-effects occur in 95% of women treated with Lupron; 78% have hot flushes, 32% have vaginal dryness and 55% have headaches on and off for a few weeks. Muscle or joint pain, trouble sleeping, fluid retention, fragile emotions, depression and decreased libido can also happen but are less common. Importantly, significant bone loss can occur if treatment continues for 6 months or more.
The FDA has approved the use of Lupron for 6 months or less. Use for any longer time is considered “off-label use” and the risks should be discussed with your doctor.
After the first three months of therapy, low doses of estrogen and progestins (called add-back therapy) may be taken with Lupron in order to decrease side-effects and bone loss. However, a study of Lupron used for 6 years found a wide range of bone loss among different women, so the effects of this treatment for individual women is not predictable and should be monitored closely.
Can Lupron Be Used Before Surgery?
Because Lupron stops heavy bleeding, women who are treated for 3 to 4 months before surgery will have higher blood counts but still have a similar risk of needing a blood transfusion. Some surgeons use Lupron before a hysterectomy to shrink the uterus so that the hysterectomy might possibly be performed through a vaginal incision rather than an abdominal incision.
Can Lupron Be Used as Temporary Treatment for Women Approaching Menopause?
A woman with symptoms from fibroids who is approaching menopause can use Lupron or Synarel until menopause begins. Then the natural supply of estrogen will cease, and the fibroids will remain small without any medication. After the first three months, low doses of estrogen and progestins may be taken to reduce side-effects, but it is important to measure bone density. However, because the exact age of natural menopause is unpredictable and we have no way to test when it will occur, long-term Lupron can turn into an expensive proposition-$2,000 per year-and is usually not covered by medical insurance. But, for some women, this treatment plan may be useful.
Can Progesterone-Blocking Medication Treat Fibroids?
Contrary to what many women have heard, progesterone can make fibroids grow. Under the microscope, fibroid cells seem to be growing the fastest during the part of the menstrual cycle when progesterone levels are naturally highest. Treatment with the progesterone-blocking drugs Mefipristone (RU-486) or Asoprisnil shrinks fibroids and stops heavy bleeding in most women. However, Mefipristone can cause over-growth of the uterine lining cells (endometrial hyperplasia) in about one quarter of women. There is some concern that this over-growth could lead to pre-cancer or cancer of the lining cells, although this has not been seen in preliminary studies. Asoprisnil is currently undergoing FDA review following its recent clinical trials.
I am including the abstracts:
Low-dose mifepristone for uterine leiomyomata.
Authors: Eisinger SH, Meldrum S, Fiscella K, le Roux HD, Guzick DS.
Obstet Gynecol. 2003 Feb;101(2):243-50
OBJECTIVE: To compare the effect of 5 and 10 mg of mifepristone on uterine leiomyoma size and symptoms, and to measure side effects.
METHODS: Forty premenopausal women with large, symptomatic leiomyomata were randomized to receive either 5 or 10 mg of mifepristone daily for 6 months in an open-label study. Uterine volume was measured at bimonthly intervals by sonography. Serum concentrations of hemoglobin levels, follicle-stimulating hormone, and liver enzymes were obtained, and endometrial samples, symptoms, and menstrual bleeding were also assessed.
RESULTS: Nineteen of 20 subjects taking 5 mg and all 20 subjects taking 10 mg completed all 6 months of the study. Mean uterine volume shrank by 48% (P <.001) in the 5-mg group and 49% (P <.001) in the 10-mg group, a nonsignificant difference. Leiomyoma-related symptoms were comparably reduced in both groups. Amenorrhea occurred in 60-65% of both groups. Hemoglobin levels increased by 2.5 g/dL in anemic subjects. The incidence of hot flashes increased significantly over baseline in the 10-mg group but not in the 5-mg group. Simple endometrial hyperplasia occurred in 28% of all subjects, with no difference between groups. No atypical hyperplasia was noted.
CONCLUSION: Mifepristone in doses of 5 mg or 10 mg results in comparable leiomyoma regression, improvement in symptoms, and few side effects. Further study is needed to assess the long-term safety and efficacy of low-dose mifepristone.
Asoprisnil (J867): a selective progesterone receptor modulator for gynecological therapy.
Authors: DeManno D, Elger W, Garg R, Lee R, Schneider B, Hess-Stumpp H, Schubert G, Chwalisz K.
Steroids. 2003 Nov;68(10-13):1019-32.
TAP Pharmaceutical Products Inc., 675 N. Field Drive , 600452, Lake Forest , IL , USA
Asoprisnil is a novel selective steroid receptor modulator that shows unique pharmacodynamic effects in animal models and humans. Asoprisnil, its major metabolite J912, and structurally related compounds represent a new class of progesterone receptor (PR) ligands that exhibit partial agonist and antagonist activities in vivo. Asoprisnil demonstrates a high degree of receptor and tissue selectivity, with high-binding affinity for PR, moderate affinity for glucocorticoid receptor (GR), low affinity for androgen receptor (AR), and no binding affinity for estrogen or mineralocorticoid receptors. In the rabbit endometrium, both asoprisnil and J912 induce partial agonist and antagonist effects. Asoprisnil induces mucification of the guinea pig vagina and has pronounced anti-uterotrophic effects in normal and ovariectomized guinea pigs. Unlike antiprogestins, asoprisnil shows only marginal labor-inducing activity during mid-pregnancy and is completely ineffective in inducing preterm parturition in the guinea pig. Asoprisnil exhibits only marginal antiglucocorticoid activity in transactivation in vitro assays and animal models. In male rats, asoprisnil showed weak androgenic and anti-androgenic properties. In toxicological studies in female cynomolgus monkeys, asoprisnil treatment abolished menstrual cyclicity and endometrial atrophy. Early clinical studies of asoprisnil in normal volunteers demonstrated a dose-dependent suppression of menstruation irrespective of the effects on ovulation, with no change in basal estrogen concentrations and no antiglucocorticoid effects. Unlike progestins, asoprisnil does not induce breakthrough bleeding. With favorable safety and tolerability profiles thus far, asoprisnil appears promising as a novel treatment of gynecological disorders, such as uterine fibroids and endometriosis.
Can a Progestin-Releasing IUD Treat Heavy Bleeding from Fibroids?
Women who have a uterus with fibroids smaller than 12 weeks size and a normal size uterine cavity may get relief from heavy bleeding by using a progestin-releasing intra-uterine device (Mirena). The progesterone in the IUD thins the uterine lining cells, so the cells bleed less. One study showed that by 3 months, 85% of women returned to normal bleeding, and heavy bleeding and anemia were cured in virtually all women at the end of one year.
Can Alternative Medicine Be Used to Treat Fibroids?
Unfortunately, there are few studies of alternative treatments for fibroids. However, one very small study compared fibroid growth in women treated with Chinese Medicine, body therapy and guided imagery with women treated with non-steroidal anti-inflammatory medications (NSAIDs), progestins, or oral contraceptive pills. After 6 months, ultrasounds showed that fibroids stopped growing or shrank in 59% of the women treated with the combination of alternative medicines, but in only 8% of the other women. Another study reported treatment of 110 women with fibroids smaller than 10 cm. (4.5 inches) with the Chinese herbal medicine Kuei-chih-fu-ling-wan. Fifteen of the 110 (14%) women requested and had a hysterectomy during the study. However, fibroids went away in 19% of the other women, got smaller in 43%, did not change in 34% and grew in 4%. Heavy bleeding improved in 95% and severe cramping improved in 94%. The Chinese Medicine doctor with whom I work tells me that he has success with small fibroids (less than 2 inches), but not with fibroids larger than that. So, this treatment may work for women with small fibroids who wish to prevent the fibroids from growing and causing more symptoms. In any case, it is important to work with a reputable alternative medicine practitioner who can direct your care.
Are There Any Other Promising Medications on the Horizon?
Pirfenidone is a new, not yet available, medication that blocks the growth of existing fibroids and may stop the formation of new fibroids. Although the exact mechanism of action is not known, pirfenidone affects the production of collagen, a major component of fibroids. Other effects of pirfenidone on cell growth factors may also be important. Studies are now under way to evaluate how fibroids respond to this new drug and to evaluate its side effects. In the future, women with small fibroids may be able to take pirfenidone, or a medication like it, to prevent fibroid growth and avoid any other need for treatment.
By William H. Parker, MD
Clinical Professor, Obstetrics and Gynecology, UCLA School of Medicine
Director of Minimally Invasive Gynecologic Surgery, UCLA Medical Center, Santa Monica
Page last updated: November 26, 2013