UTERINE FIBROIDS (3)

What medical treatment? What surgical treatment?

Embolization treatment: for whom?

Uterine fibroid: In brief

Dr. Claude Allouche, Gynecologist Fibromes 8-12 engl
Ahuza Clinic, Raanana
058 726 02 64

Summary:

H) What medical treatment?
I) What surgical treatment?
J) Embolization treatment: for whom?
K) Uterine fibroid (11): In brief

H) UTERINE FIBROID: WHAT MEDICAL TREATMENT?

Treatment will only be considered if the patient shows symptoms (pain or bleeding) or if the fibroids are at risk of complications (compression, torsion). Most of the time, fibroids are small and remain asymptomatic. In these cases, they will simply be monitored regularly with ultrasound.

When treatment is considered, it will depend on the patient's age and desire for pregnancy, the severity of symptoms, the characteristics of the fibroids, and the patient’s overall health.
There are indeed different types of treatment:

  • Medical
  • Surgical
  • Embolization

1/ Medical Treatment

It should be noted that no treatment can permanently eliminate a fibroid. However, some medications can relieve symptoms. This treatment is mainly indicated for women who want to have children or who present with mild to moderate symptoms.

When the doctor opts for medical treatment, several types of medication are available:

A] Progestins

Progestin-based treatments can reduce heavy bleeding. Menorrhagia (heavy periods) is often linked in this context to associated endometrial hypertrophy (increased thickness of the uterine lining).
By their effect, progestins cause endometrial atrophy (thinning of the uterine lining). They have no effect on the size or progression of fibroids. At best, they can temporarily stabilize their growth.

They can be prescribed:

  • Orally from the 15th to the 25th day of the cycle, or from the 5th to the 25th day if a contraceptive effect is desired.
  • Intrauterine: hormonal IUD (Mirena, Kyleena, or Janess): this is the treatment of choice for menorrhagia, with or without fibroids.

B] LH-RH analogs (Decapeptyl, Enantone)

These suppress estrogen production (inducing artificial menopause) and allow for:

  • A reduction or cessation of bleeding after one month of treatment.
  • A reduction of about 50% in fibroid size after three months of treatment.
    These treatments induce temporary menopause, accompanied by symptoms such as hot flashes, decreased libido, and vaginal dryness. They are sometimes used preoperatively to shrink fibroids to facilitate surgery, enabling it to be performed via laparoscopy rather than laparotomy.

C] Tranexamic acid

  • A medication that aims only to reduce heavy bleeding in the case of menorrhagia.
  • Taken during periods or heavy bleeding.
  • Administered orally or intravenously.
  • Exacyl in France, Hexakapron in Israel.

I) UTERINE FIBROID: WHAT SURGICAL TREATMENT?

2/ Surgical Treatment

Surgical treatment of fibroids is primarily indicated for:

  • Women who no longer wish to have children.
  • Those with moderate to severe symptoms (heavy bleeding, compression, large fibroid size, rapid fibroid growth, etc.).
  • Or after the failure of medical treatment.

There are two alternatives: myomectomy and hysterectomy.

A] Myomectomy

  • Involves removing the fibroid while preserving the uterus.
  • Performed under general or epidural anesthesia.
  • It is not a permanent solution, as new fibroids may develop.
  • Preferably used if the patient still wishes to have children.

The surgical approach is chosen based on the fibroids' location, size, number, the patient's age, and desire for pregnancy:

a) Operative Hysteroscopy

  • The preferred indication is for submucosal fibroids, pedunculated, smaller than 3 cm, with a posterior safety wall greater than 5 mm.
  • For fibroids between 3 and 5 cm or with an interstitial component, resection may be incomplete, requiring a second procedure later.

b) Laparoscopy (also called coelioscopy)

  • Used for subserous or intramural fibroids.
  • Less than 8 cm in size.
  • Fewer than 3 fibroids.
    Laparoscopy offers small scars, the ability to explore the pelvis in cases of associated infertility, and a low risk of postoperative adhesions.

c) Laparotomy

  • Opening the abdomen with a transverse or sagittal incision.
  • Reserved for interstitial or subserous fibroids larger than 8 cm or more than 3 in number.

B] Hysterectomy

  • Total removal of the uterus.
  • A radical and definitive treatment, reserved for women who no longer wish to have children and have severe symptoms (bleeding, pain, compression, etc.).
  • Can be performed vaginally, by laparoscopy, or by laparotomy.
    Hysterectomy may be:
    • Total: Also removes the cervix (no more pap smears needed afterward).
    • Subtotal: The cervix is left in place, but requires a normal preoperative pap smear and continued surveillance postoperatively.
    • Conservative: Ovaries are preserved; no more periods, but the patient will not be menopausal unless they were already before surgery.
    • Non-conservative: Ovaries are removed, usually in menopausal or older women or those with associated conditions (cysts, endometriosis, etc.).
      Uterine fibroids are the leading cause of hysterectomy in France.

J) UTERINE FIBROID: EMBOLIZATION TREATMENT: FOR WHOM?

3) Embolization

Arterial embolization is an alternative to surgery when the patient has no desire for pregnancy. The procedure involves blocking the blood vessels feeding the fibroid by injecting microparticles into the uterine arteries under radiological control.
The fibroid, no longer nourished, gradually regresses, alleviating symptoms.

  • Performed by a radiologist in an interventional radiology unit.
  • Using a catheter introduced into the femoral arteries, the radiologist blocks the blood supply to the fibroid by releasing small particles.
    Embolization may be:
  • Preoperative: Reducing the vascularization of fibroids facilitates the surgical procedure by reducing bleeding.
  • Definitive: Reserved for interstitial fibroids, it reduces fibroid size and bleeding, but risks causing early menopause or severe uterine infections.

K) UTERINE FIBROID: IN BRIEF

Uterine fibroids are the most common benign tumors in women, developing on the surface or inside the uterine muscle tissue. They affect 1 in 3 women, most commonly between the ages of 30 and 50.
Factors like heredity and hormones increase the likelihood of fibroids.

There are three types of fibroids, from the inside to the outside of the uterus:

  • Submucosal
  • Intramural
  • Subserous

Most fibroids cause no symptoms and are often discovered incidentally during a routine gynecological exam or an imaging exam done for another reason.
However, they can cause symptoms such as bleeding between periods, heavy periods, frequent urination, pelvic pain, constipation, painful intercourse, anemia, infertility, or miscarriage.

Their progression is unpredictable and hormone-dependent: they can grow during pregnancy but often regress spontaneously after menopause if untreated.

Fibroids are diagnosed primarily through ultrasound.

Treatment is only considered if the patient shows symptoms (pain or bleeding) or if fibroids are at risk of complications (compression, torsion).
Most fibroids are small and asymptomatic, and in these cases, they are simply monitored with regular ultrasound.

When treatment is considered, it depends on the patient's age, desire for pregnancy, the severity of symptoms, the fibroids' characteristics, and the patient’s overall health.

There are several treatment options:

  • Medical: progestins, hormonal IUD, or tranexamic acid.
  • Surgical: myomectomy or hysterectomy via vaginal, laparoscopic, or laparotomic approach.
  • Uterine artery embolization.

If you wish to read more information about uterine fibroids, each element of this summary has been detailed in separate publications.

Other publications on the subject:

  • Uterine fibroid (1): What is it?
  • Uterine fibroids (2): Where can they be located?
  • Uterine fibroid (3): Who, when, how, why?
  • Uterine fibroid (4): Symptoms
  • Uterine fibroid (5): Progression
  • Uterine fibroid (6): How is it diagnosed?
  • Uterine fibroid (7): And during pregnancy?
  • Uterine fibroid (8): What medical treatment?
  • Uterine fibroid (9): What surgical treatment?
  • Uterine fibroid (10): Embolization treatment: for whom?
  • Uterine fibroid (11): In brief.