Dr Ajith.S MD, DGO, DipNB, MRCOG
Professor of OBGYN
Medical College, Pariyaram, Kannur
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Uterine fibroids are present in 20 to 50% of women older than 30 years and 20 to 50% of women with fibroids have symptoms that can be attributed to these tumors. Most fibroids are asymptomatic and don’t require treatment. The most common fibroid related symptoms are caused by the mass effect of an enlarged uterus on adjacent pelvic organs and to excessive menstrual bleeding. The role of fibroid in infertility is controversial. Current evidence suggests sub mucosal and intramural fibroids that distort the uterine cavity can impair the fertility.s
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Symptomatic fibroids need to be treated. Despite the lack of clear evidence of their role in infertility, sub mucosal fibroids, intramural fibroids that distort the uterine cavity, fibroids larger than 5 cm and multiple fibroids are often treated in patients with otherwise unexplained infertility. Few data support uterine size as the sole indication for treatment. Conventional recommendation is to advocate treatment when the uterine size equals or exceeds 12 weeks’ gestation on clinical examination. But this traditional indication based on uterine size has no clinical foundation when examined critically. In patients with asymptomatic fibroids and no reproductive plans, expectant management is an option. This approach entails clinical and ultrasonographic examination at 6 to 12 months intervals to assess uterine size, fibroid growth and number, ovarian size and morphology and to review symptoms. Expectant management may be considered for patients with mild symptoms of menorrhagia and dysmenorrhoea.NSAIDs, Tranexemic acid or low-dose combined pill may be considered depending on the individual patient.
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Medications used in the management of fibroids include GnRH analogs, Mifepristone, Raloxifene and Anastrozole. These medications are shown to reduce the size of the fibroid. They are mainly used prior to surgery or in the perimenopausal patients. Significant side effects prevent the long term use of GnRH analogs. Studies show that Mifepristone reduce the tumor size and improve symptoms, but none of these studies are placebo controlled and the significant side effect was development of endometrial hyperplasia. Better quality clinical trials are needed before recommendations can be made. There is no evidence from the limited number of studies that SERMs reduce the size of fibroids or improve the clinical outcome. Anastrazole is a potent third generation aromatase inhibitor. Estrogen produced insitu by the fibroid can promote cell proliferation and consequently, their on growth. In one study when Anastrazole used at a dose of 1mg per day for thee cycles of 28 days each, it significantly reduced the size of fibroid and improved the symptoms in premenopausal patients and is well tolerated. The reduction in size was not significant enough in patients younger than 40 years.
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Most of the patients with symptomatic fibroids are treated with hysterectomy or myomectomy. Vaginal and Laparoscopic hysterectomies are associated with early recovery and less hospital stay compared to abdominal hysterectomy. Laparoscopic myomectomy is an option for many patients with fibroids. Sub mucosal fibroid is removed through hysteroscope. The use of pericervical tourniquet, intramyometrial vasopressin and analogues and vaginal misoprostol reduce the blood loss during myomectomy.
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The new treatment options for fibroid include Uterine Artery Embolization (UAE), Myolysis, MRI – guided cryotherapy, and MRI – guided High Intensity Focused Ultrasound (HIFU) Surgery (MRgFUS).
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Jacques H Ravina in early 1990s used uterine artery embolization to reduce the bleeding at the time of myomectomy and later in 1993 Ravina and his colleagues used it as the primary treatment of uterine fibroids. UAE is typically performed by an interventional radiologist. It is done under intravenous sedation. Using a femoral approach, a micro catheter is introduced in to the uterine artery. Polyvinyl alcohol foam particles or other occluding agents are then injected. In observational studies there is significant reduction in the uterine volume, a decrease in the excessive menstrual bleeding and a high rate of sustained symptom control (up to 80%) 5 years after the procedure. UAE is less invasive compared to abdominal surgeries and associated with less hospital stay and early recovery. Complication rates were similar in both groups at one year according to one study (REST – Randomized trial of Embolization verses Surgical Treatment for fibroids). Complications generally occurred earlier in the surgical group (at the time of surgery or soon after like infections). Aside from two patients who required immediate hysterectomy because the embolization procedure failed, most of the complications in the embolization group occurred after discharge from the hospital. As compared to surgical group, the embolization group had significantly shorter hospital stay and more rapid resumption of normal activities. But less invasive hysterectomies like VH and Lap hysterectomies were not directly compared with embolization in this study. Before undergoing UAE, the patients should be told that about 20% patients may require further treatment like myomectomy or hysterectomy. Less than 1% patients may develop premature ovarian failure. It remains unclear whether pregnancy outcomes are affected by UAE, since fewer than 150 pregnancies are reported in the literature. Miscarriages, preterm deliveries and post partum hemorrhage (may be due to abnormal placentation) are the reported complications. Myomectomy should be the first line of treatment in patients with symptomatic fibroids and who wish to conceive. Conversely embolization should be offered to patients who are at high surgical risk (previous multiple laparotomies or women with diffuse fibroids in whom myomectomy may not be technically possible). ACOG strongly recommends that women who wish to undergo UAE have a thorough evaluation by a gynecologist to ensure that the procedure is appropriate.
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Myolysis is delivering energy to tumors to desiccate them directly or disrupt their blood supply. It is performed with Nd: YAG laser or bipolar needles through laparoscope. MR guided percutaneous laser ablation is suggested by some. Here under MR image guidance needles are inserted through an area of skin that has been locally anaesthetized, into centre of targeted fibroid. Then laser is used to destroy the fibroid. Potential complications include urinary infections, skin burns and vaginal bleeding. Evidence on safety and efficacy of this procedure is insufficient. MRI guided cryotherapy is another alternative
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MRI guided High Intensity Focused Ultrasound (HIFU) Surgery (MRgFUS) is a newer option in the management of fibroids. FDA has approved it in October 2004. Under MRI guidance high energy ultrasound waves are used to target and destroy the tumors. It is non invasive. HIFU is essentially a thermal ablation technique which utilizes sound waves focused at a point to deliver heat (65 to 95 degree C) to tissue, resulting in tissue necrosis, apoptosis and cell death. This technology is still in the “learning curve” phase of introduction. It is contraindicated if fibroid is close to sensitive organs like bowel or bladder. It is conducted as a day surgery procedure. The MRI is giving real time feedback to make sure surrounding tissues are safe through out the procedure. The 2 year follow up studies have shown that only about 20% patients require further alternate treatment. At present it is recommended to women who have completed their child bearing years. Since the beam is focused at the centre of fibroid it doesn’t affect the endometrium, uterine wall or ovaries. Further studies are needed to know whether it is safe for young women who want to preserve the fertility.
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Now we have new treatment alternatives for management of fibroids. It doesn’t mean that surgery should be used only as second line treatment. The selection of treatment varies with the clinical situation, including patients’ age, her wish to conceive and her treatment preference.
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