Fibroids treatment

Medical treatmentSurgical treatmentEmbolizationCombined treatmentsPre-interventional examinations

Fibroid center.

1. Medical treatment

The development and growth of fibroids are under the influence of sex hormones secreted by the ovaries, as shown by increased growth during the reproductive years but low in pre-puberty and menopause. On the other hand some patients have higher hormone levels in the blood (estrogens), for example in cases of obesity. However these patients develop more fibroids than others proving the influence of estrogen as one of the known growth factors.

Medical treatment involves the administration of drugs that block the action of hormones secreted by the ovaries of fibroids.

GnRH agonists (Decapeptyl ®, Zoladex ® ...) : They are probably the most effective medical treatment by blocking the production of ovarian hormones and causing a state of transitory menopause. The decrease in volume of fibroids can vary from 20 to 70%. The maximum effect of the decrease in uterine size occurs between 8 and 12 weeks after the start of treatment. However, after stop of treatment, fibroids can return to their original size within six months, so this is not a definitive treatment. Side effects with agonists are those of estrogen deprivation: vasomotor symptoms (hot flushes) and decreased bone mass. This problem can be anticipated by the administration of bone protective drugs.

Progesterone intrauterine device (IUD) (Mirena ®) : Fibroids often cause heavy periods with large amounts of blood loss. Progesterone IUDs act on increased blood flow by releasing a daily dose of hormone which prevents endometrial proliferation, resulting in a reduction in the duration and quantity of the blood loss. However, no reduction in size of the fibroids is obtained, therefore IUD only treats the symptom and not the cause.

2. Surgical treatment

The majority of patients who have fibroids do not require surgery, surgical indication exists for fibroids with vaginal hemorrhage, necrosis, increase in volume, for fibroids which interfere with the function of reproduction (miscarriages, infertility), or cause bothersome symptoms by compression of adjacent organs.

A. The two main types of surgical operation

Two types of operation are possible: remove only the fibroid (myomectomy), leaving the uterus in place or remove the entire uterus (hysterectomy).

Indications to remove only the fibroids and leaving the uterus in place are :

• Fibroids that cause unique complication in a young woman desiring children.
• Infertility or recurrent miscarriages. It is then necessary because the fibroid causes compression of a fallopian tube or deformation of the uterine cavity that may hinder the establishment or development of the egg.
• Torsion of a pedunculated fibroid.
• Very heavy periods and / or abdominal pain in patients wishing to preserve their uterus.

However it should be noted that after the removal of a fibroid recurrence is possible in 25-50% of cases and more often with younger women (same type of reccurence as agonist treatments).

The removal of a fibroid alone, compared with the removal of the entire uterus is therefore questionable for woman who does not want children any more, after 40 years, especially because the complications and the difficulty of the surgery are roughly equivalent for one or other of the operations.

B. The two different possible way to perform for the surgery :

• Open surgery: the traditional way to operate, the surgery is performed by a large scar from 15 to 20 centimeters in the abdomen.
• By laparoscopy: this is a more innovative way, the surgeon is working on a video screen via a camera and special instruments that are entered into the abdomen through small scars (half a centimeter wide). This technique is more difficult for large fibroids and in case of heavy bleeding during the operation.

Conventional surgery scars

Laparoscopy scars

Laparoscopy has several advantages compared with conventional surgery :

• Small scars
• Reduced postoperative pain
• Shorter duration of hospitalization
• Lower overall cost

3. Fibroid Embolization

The uterine fibroid embolization by interventional radiology is routinely performed since many years (embolization unit). With more than 50,000 women treated in the world, this technique has proven to be effective as an alternative to hysterectomy and myomectomy.

4. Combined treatments: embolization and surgery at the same time

When fibroids cause no heavy symptoms and have no particular complication, annual monitoring by ultrasound may be sufficient.
On the other hand, if treatment is necessary, more and more women seek a solution that allows them to keep their uterus especially if pregnancy is desired. However, even in patients who do not wish to maintain their fertility there is a growing demand to preserve the uterus. In this sense, as described above, two possibilities exists: arterial embolization of the fibroma or surgical excision.

Arterial embolization is performed as a routine technique for many years and allows control of symptoms in 80% of cases with low rates of intraoperative and postoperative complications (2-3%). However, spontaneous expulsion, from the vagina, of dead fibroid tissue frequently occurs after several days or even weeks after embolization, sometimes accompanied by superinfection or smelly vaginal discharge which may significantly alter the medium-term quality of patients' lives. On the other hand, in about 1% of cases, complete removal of the uterus (hysterectomy) should be performed due to persistent pain, infection or necrosis.

Surgical myomectomy alone, when performed without embolization, can cause very important bleeding which are sometimes difficult to manage and require that the surgeon is obliged to perform an hysterectomy to stop the bleeding. Although several techniques can reduce blood loss (vaso-constrictor drugs, ligature around the uterine arteries ...) but these techniques are restrictive because have a too short half-life or a difficult access to uterine vessels in the case of voluminous fibroids. On the other hand, when the laparoscopic approach is chosen, the main causes of complications are bleeding.

The combined techniques : To avoid these problems, several teams have proposed to perform a preoperative embolization of fibroids to minimize blood loss, facilitate surgery and thus reduce the major complications especially in the removal of uterine fibroids of important volume. Patients who may benefit from this technique must have symptomatic fibroids and / or fibroids whose presence is a proven factor infertility, and / or wish to keep their uterus. At least one symptom must be present: menorrhagia, pelvic pain, abnormal compression (urine, weight, constipation).

5. Investigations and pre-interventional examinations

The following basic investigations must be carried out before combined treatment :

• Gynecological clinical examination
• Cervical pap smear
• Gynecological ultrasound examination
• Nuclear magnetic resonance of the pelvis
• Classic Pre-operative bloodtest
• Consultation with gynecologist and radiologist to explain the method, the advantages, disadvantages and side effects, and obtain informed consent of patients