What are the treatment options for fibroids and which one is suitable for me?

The choice of treatment depends on the type and severity of symptoms, as well as the size and location of fibroids. Below is a general discussion of different treatment options. Please see specific pages for uterine fibroid embolisation and hysterectomy.


Medical Therapy

Mirena IUD

Endometrial ablation

Hysteroscopic resection

Hysterectomy

Myomectomy

Uterine fibroid embolization(UFE)

MRgFU

Medical Therapy

Non-steroidal anti-inflammatory drugs (e.g. Naprosyn), birth control pills, or progesterone agents maybe used to control heavy periods. However these treatments do not reduce the size of the fibroids. Gonadotropin Releasing Hormone (GnRH) agonist is used to control bleeding and it may slightly reduce size of the uterus and fibroid. However, due to its common side effects such as hot flashes, mood changes and osteoporosis, its use is usually limited to 6 months. Fibroids usually regrow after GnRH agonists are stopped.

Cyclokapron reduces heavy period by enhancing clotting ability. The side effects are deep venous thrombosis (DVT) and pulmonary embolism (clots in the lung).

Mirena IUD (Intrauterine Device)

The device is inserted in the rooms of your GP or gynaecologists. It is only helpful for heavy period. It does not reduce the size of the fibroids. When fibroids are large and distorting the cavity, it may be difficult to insert and remove the device. Sometimes device may not stay in. In some women, heavy bleeding could be converted to prolonged spotting which could be quite annoying as well.

Endometrial ablation

The procedure is performed under general anaesthetic in an operating theatre. It uses heat energy to destroy the inner lining of the uterus. You may no longer have menstrual period. However, the treatment dose not shrink the fibroid and therefore will not relieve symptoms related to the bulk of the fibroids, such as urinary symptoms.

If your uterine cavity is distorted by fibroid, the procedure may not be successful due to lack of effective contact between the heating device and the lining of the uterus.

Hysteroscopic resection

This is usually a general anaesthetic procedure performed in operating theatre. The procedure is much less invasive than hysterectomy. The procedure is only suitable for small fibroids protruding into the cavity of the uterus. They are removed with the aid of a camera through the vagina and cervix.

Hysterectomy

Traditionally when conservative treatments failed or were unsuitable, hysterectomy(removal of the uterus) is offered to women. However, hysterectomy is a major surgery that requires 5-6 weeks of recovery, carries the risks of a major surgery and is associated long-term adverse effects (See separate sections on "Hysterectomy" and "Why should you consider alternatives to hysterectomy?").

Myomectomy

This is a surgical operation to remove one or a few fibroids. This is offered to women who wish to retain the uterus and fertility. It is possible only for a small number of fibroids in suitable locations. It is technically more demanding to the surgeon, takes longer time to perform, more likely to require blood transfusion and requires 5-6 weeks for recovery. Sometimes myomectomy is converted to hysterectomy if the surgeon is unable to control the bleeding or reconstruct the uterus.

Myomectomy improves heavy menses in 70-80% of patients. Development of adhesion (internal scarring of the abdomen) is a potential side effect. Recurrence of fibroids occurs in 40-50% of women*.

The recovery is quicker with laparoscopic myomectomy, but the surgical risks are not lower. Laparoscopic surgery is technically more demanding and there is a steep learning curve for the surgeons. Due to limited access and visualization, and it can be more risky in terms of injuries to blood vessels, bowel, bladder and ureter. Whether laparoscopic surgery is the right choice for you depend on the reason for your hysterectomy, your desire for quick recovery, as well as skill and the experience of the surgeon.

* Reference: Chapter 9, Williams Gynaecology 2008.

Uterine fibroid embolization(UFE)

Uterine fibroid embolization(UFE) is a non-surgical alternative to hysterectomy. It is minimally invasive, but highly effective in reducing heavy period, shrinking fibroids and relieving period pain. Studies have shown that UFE is as effective as hysterectomy in improving the women's quality of life. Please see separate sections on "Uterine Fibroid Embolisation", "Hysterectomy vs UFE" and "Patient Testimonials".

Magnetic Resonance Imaging Guided Focused Ultrasound (MRgFU)

Advantage:
Painless. Non-invasive. Outpatient.

Disadvantage:
Long treatment time on the MRI machine.
High equipment cost and staff cost ( radiographer, nurse, supervising radiologist).
Viable fibroid tissue left behind becomes nidus for regrowth.
Only small fraction of suitable patients
No Medicare nor health fund rebate, and therefore there will be no rebatable doctors' fee, theatre banding charges and in-hospital bed fee.
Currently only available in Melbourne.

Exclusion criteria:
Obesity >120 kg or 250lbs
Pedunculated fibroid
Abdominal scar
Desire future pregnancy
Fibroid volume >900mL or more than 7 fibroid
Submucosal fibroid > 3cm
Adenomyosis
Bright T2 and/or vascular fibroids
Calcified fibroid
Longer then 3 hours of treatment time

Safety concerns:
Abdominal scar distort ultrasound beam and can cause skin injury and ineffective heating of fibroids.
Fibroids too close to skin can cause skin burns.
Fibroids too close to bone cause overheating and nerve damage.
Fibroids too close to bowel cause thermal injury.
Subserosal fibroid < 3cm in size may cause thermal injury to adjacent tissue, because focal ablation zone is 2.5cm along its beam.
Submucosal fibroid > 3cm may slough off and cause cervical obstruction.

Efficacy concerns:
8cm fibroid takes 3 hours to treat.
T2 bright/vascular fibroids difficult to heat, may not respond.
Heterogenous/sepatated/non-perfused fibroids do not respond well
Calcified fibroid difficult to heat up. It may refocus ultrasound and cause thermal injury to non-target organs.

MRgFU UFE
Size and number fibroid Limited Any size and numbers
Desire pregnancy Maybe suitable Maybe suitable
Adenomyosis Not suitable Effective
T2 bright Heterougenous Hypervscular Less effective Effective
Calcification Nontarget energy reflection Not affected
Abdominal scarring Skin injury Not affected
Obesity, thick uneven abdominal fat Less effective Not affected
Target deeper than 12 cm Not effective Not affected
Too close to bone Nerve damage Not affected
Too close to skin Skin injury Not affected

UFE and MRgFU are not competitive, but complementary.
There are cases not suitable for UFE but suitable for MRgFU, and vice versa.