women s health issues
Uterine Fibroids
Treatment of Fibroids
Medications to relieve symptoms or shrink fibroids Sometimes surgery to remove the entire uterus or only the fibroids Sometimes procedures to destroy the fibroids For most women who have fibroids but no bothersome symptoms or other problems, treatment is not required. They are reexamined every 6 to 12 months so that doctors can determine whether symptoms are worsening or lessening and whether fibroids are growing. Such periodic monitoring is sometimes called watchful waiting. Several treatment options, including medications and surgery, are available if bleeding or other symptoms worsen or if fibroids enlarge substantially. A few medications may be used to relieve symptoms or to shrink fibroids, but their effects are only temporary. No medication can treat fibroids so that they permanently resolve. Medications used to treat fibroids may be hormonal or nonhormonal. The first medications given are usually those that decrease bleeding, are easy to use, and are well-tolerated, including Estrogen-progestin contraceptives Progestins (for example, alevonorgestrel-releasing intrauterine device [IUD]) Tranexamic acid Nonsteroidal anti-inflammatory drugs (NSAIDs) Hormone Therapy for Menopause None Tranexamic acidworks by preventing blood clots (which are made by the body to help stop bleeding) from breaking down as quickly. As a result, bleeding decreases. Nonsteroidal anti-inflammatory drugs (NSAIDs)may relieve pain but may not reduce bleeding. Other medications that are sometimes used to treat symptomatic fibroids include Gonadotropin-releasing hormone (GnRH) analogs Antiprogestins Selectiveestrogenreceptor modulators (SERMs) Danazol are used if other medications have not been effective, bleeding is persistent, and the woman has Overview of Anemia (too few red blood cells in the blood). GnRH analogs are either agonists (such as The medications may be taken as a pill, injected, or implanted as a pellet under the skin.Nafarelin, another GnRH agonist, can be used as a nasal spray. GnRH agonists are usually taken for less than 6 months. If taken for a long time, they may reduce bone density and increase the risk of Osteoporosis . Low doses of Within 6 months after GnRH agonists are stopped, fibroids may become as large as they were before treatment. Antiprogestins,such asmifepristoneand related medications, inhibit the activity of the hormoneprogesterone. As a result, the uterus and fibroids shrink. Selective estrogen receptor modulators (SERMs),such asraloxifeneand related medications, reverse some ofestrogen’seffects. They may not be as effective as other medications. Danazol(a synthetic hormone related totestosterone) inhibits the activity ofestrogenandprogesterone. It is rarely used and has many side effects, such as weight gain, acne, increased body hair (hirsutism), swollen ankles, loss of scalp hair, vaginal dryness, and lowering of the voice. Several minimally invasive procedures are available to treat fibroids. These are usually used if medications are not effective and a woman does not want surgery or has health reasons why she should not have surgery. After having one of these procedures, women should not become pregnant. Whether pregnancy after these procedures is safe is unclear. Foruterine artery embolization,doctors use an anesthetic to numb a small area of the thigh and make a small puncture hole or incision there. Then, they insert a thin, flexible tube (catheter) through the incision into the main artery of the thigh (femoral artery). The catheter is threaded to the arteries that supply blood to the fibroid, and small synthetic particles are injected. The particles travel to the small arteries supplying the fibroid and block them. As a result, the fibroid dies, then shrinks. Most of the rest of the uterus appears to be unaffected. However, whether the fibroid will regrow (because blocked arteries reopen or new arteries form) is unknown. After uterine artery embolization, most women have pain and cramping in the pelvis, nausea, vomiting, fever, fatigue, and muscle aches. These symptoms develop within 48 hours after the procedure and gradually lessen over 7 days. An infection may develop in the uterus or surrounding tissues. Women recover more quickly after this procedure than after a hysterectomy or myomectomy, but they tend to have more complications and more return visits to the doctor. If fibroids continue to be a problem or grow back after embolization, hysterectomy is recommended. Magnetic resonance-guided focused ultrasound surgeryuses sound waves to destroy fibroids. Surgery is usually considered for women who have any of the following: Fibroids that are rapidly enlarging Bleeding that continues or recurs despite treatment with medications or minimally invasive procedures Severe or persistent pain Large fibroids that cause problems, such as the need to urinate frequently, constipation, pain during sexual intercourse, or blockage of the urinary tract For women who want to conceive, fibroids that have caused infertility or repeated miscarriages If women do not want to have any more children or want a definitive cure, Treatment may be a good option. Several types of surgery can be done. The recommended surgery depends on the size, number, and location of fibroids. However, before making a decision about treatment, women should talk to their doctor about the problems that can result from each type of surgery so that they can make an informed decision. Surgery to remove fibroids traditionally involves one of the following: Treatment : Myomectomy:Only the fibroid or fibroids are removed. In contrast to a hysterectomy, most women who have a myomectomy can have children. Also, some women feel psychologically better when they keep their uterus. However, after myomectomy, new fibroids may grow, and about 25% of women have a hysterectomy about 4 to 8 years later. Forhysterectomy,surgeons may use one of the following methods: Laparoscopy : Laparotomy:They make an incision that is several inches long in the abdomen. Vaginal hysterectomy:The uterus is removed through the vagina, sometimes assisted by laparoscopy. An incision is made in the vagina. An abdominal incision is not needed. Laparoscopic surgery can be done with robotic assistance. The robot is a device used to control and manipulate surgical instruments inserted with the laparoscope. The laparoscope sends a three-dimensional image of the body's interior to a console. Surgeons sit at a console to view this image, and a computer translates their hand movements into precise movements of the surgical instruments. Formyomectomy,surgeons may use Hysteroscopy: Surgeons insert a telescope-like lighted device (hysteroscope) through the vagina into the uterus. Using instruments inserted through this tube, surgeons can cut tissue and remove fibroids on the inside of the uterus. Laparoscopy Laparotomy Laparoscopy and hysteroscopy are outpatient procedures, and recovery is faster than recovery after laparotomy. However, sometimes removing fibroids using laparoscopy or hysteroscopy may be difficult or impossible—for example, when there are many fibroids, when they are very large, or when they are embedded deeply in the wall of the uterus. In such cases, doctors do a laparotomy. Hysterectomy may be preferred to myomectomy or may be required for several reasons: The woman does not desire future childbearing. After myomectomy, fibroids may begin to grow again. Women have disorders that make removal of fibroids harder. These disorders include Endometriosis and abnormal bands of scar tissue in the uterus or pelvis (adhesions). Hysterectomy may reduce the risks of developing new or worse disorders, especially if a woman has risk factors for a particular disorder. These disorders include endometriosis, cervical cancer, and endometrial cancer (cancer of the lining of the uterine cavity). For example, women who have Lynch syndrome are at increased risk of endometrial cancer. Other treatments have been ineffective. may be done during myomectomy or hysterectomy. For this procedure, surgeons cut the fibroids or uterine tissue into small pieces so that the pieces can be removed through a smaller incision. Rarely, women with fibroids have Cancer of the Uterus that is unsuspected and undiagnosed. If morcellation is done in such women, the cancer cells may be spread into the abdomen and pelvis. In such cases, cancer can develop in other locations. Doctors can use surgical techniques to prevent tissue from being spread, such as using a bag to catch all of the pieces of the fibroid and remove them from the body. Before surgery for fibroids, women should evaluated for uterine cancer if they have any concerning symptoms and they should be informed of the very small risk of spreading cancerous cells if morcellation is done. Radiofrequency fibroid ablationcan be used during hysteroscopy or laparoscopy to destroy, rather than remove, fibroids. Doctors insert a needle that transmits an electrical current or heat into the fibroid to destroy its core. After these treatments, fibroids may grow back. In such cases, another treatment or a hysterectomy may be recommended. Choice of treatment for fibroids depends on the woman's situation, but women and their doctors may discuss the choice based on the following general guidelines: If the fibroids do not cause any symptoms: No treatment but continue to follow up with a doctor. If a woman is going through or has passed through menopause: Undergo evaluation for uterine cancer if there is abnormal uterine bleeding and, if results are normal, continue to follow up with a doctor to see if symptoms resolve, which usually happens as fibroids decrease in size after menopause. If fibroids cause symptoms: Start with medications for most women, unless surgery is likely to be much more effective (such as for fibroids that are very large or for intracavitary submucosal fibroids). If medications are not effective, doctors treat with a minimally invasive procedure or surgery. If fibroids cause infertility: Undergo myomectomy to remove fibroids. If symptoms are severe and other treatments are ineffective, particularly if a woman does not want to become pregnant: Have a hysterectomy, possibly preceded by treatment with medications. 