Fibroids are almost always benign. In many women they go unnoticed; in others they may cause painful periods and heavy and prolonged menstrual bleeding.

Dealing with Fibroids-New Options

Fibroid tumors are the reason for one third of the half million hysterectomies performed annually in the United States. Many of these hysterectomies can be avoided as information on fibroids and new treatment options become available.

Fibroids are a common problem, affecting 25 percent of women over age 35. Fibroids are almost always benign. In many women they go unnoticed; in others they cause symptoms that include painful periods and heavy and prolonged menstrual bleeding that can lead to anemia. When either the size or position of fibroids puts pressure on other abdominal organs they can cause urinary incontinence, constipation or infertility.

There is no specific diagnostic test for fibroids. Large fibroids can often be felt on physical examination, and some physicians use guided ultrasound to locate tumors and to keep track of changes of size.

Treatment Options
The need for treatment depends on the number and size of fibroids and on specific symptoms a woman may be experiencing. In some cases regular checkups to monitor tumor size may be all that's needed. Fibroids are believed to be estrogen dependent and usually shrink after menopause. Sometimes managing symptoms until menopause resolves the problem.

A hysterectomy is often recommended when heavy or prolonged bleeding create a risk of anemia or when enlarged tumors are pressing on the bladder or other organs. Pressure on the bladder may cause urgency, urinary incontinence or kidney problems; pressure on the bowel may result in constipation. In some cases tumors may cause infertility or miscarriage.

Women of childbearing age who still wish to become pregnant should work with their physicians to explore alternatives to hysterectomy. It's always a good idea to seek a second opinion before surgery.

Nonsteroidal antiinflammatory drugs (NSAIDs) such as Advil and Motrin, taken on an ongoing basis, may be prescribed to help reduce blood loss and cramps. Iron supplements are also prescribed if blood loss has caused anemia.

Combination oral contraceptives or depot medroxyprogesterone acetate (DMPA) can substantially reduce bleeding. They can only be used by women who don't wish to become pregnant.

Drugs known as GnRH agonists can shrink fibroids by as much as half. The drugs work by suppressing estrogen production, and side effects include hot flashes, vaginal dryness and bone loss. The side effects are serious enough that these drugs are prescribed for only a short period, usually only three to six months, and tumors enlarge again when they are discontinued.

GnRH agonists are used to control bleeding when a women is close to menopause, and to shrink tumors before a myomectomy, a surgical procedure to remove fibroids.
Myomectomy is an alternative to hysterectomy that involves removing the fibroids while leaving the uterus intact. About 35,000 myomectomies are performed annually, mostly in women of childbearing age who wish to preserve their fertility.

The surgery is most often done as open surgery. Most women who have the surgery later will require a Cesarean section for delivery because of the uterine scar

Myomectomy involves greater blood loss during surgery than hysterectomy and also has a higher risk for hemorrhage after surgery. On the plus side it carries less chance of infection and of damage to the urinary tract compared with hysterectomy.

Fibroids can regrow after a myomectomy and about 20 percent of women who have the procedure need further treatment, often a hysterectomy.

Hysteroscopic resection doesn't require an incision. It involves inserting an instrument known as a hysteroscope into the uterus via the vagina. The surgeon can view the uterus and use a laser or electric knife to remove the fibroids and cauterize the endometrium. The procedure requires either an outpatient or overnight stay.

Although hysteroscopic resection reduces or eliminates irregular and heavy bleeding in women with submucous fibroids, additional treatment may be needed later.

Angiographic embolization works by cutting off blood supply to fibroids. A small incision is made in the groin, and a catheter is threaded to the site of the blood vessels that supply the tumor. Tiny plastic particles are injected into the vessels to block them, thus shrinking the fibroid. This is still considered an experimental procedure. Only some hospitals offer it, and it may not be paid for by all insurance plans.

As physicians work to develop new techniques for treating fibroids, women have more alternatives to hysterectomy. Taking the time to discuss treatment options and to seek second or even third opinions will help women identify the best treatment to fit their individual physical and psychological needs.

REFERENCES:
Celso-Ramon Garcia, "Uterine Fibroids-Treat or Ignore?" Patient Care, January 15, 1997.
A.M. Kaunitz, "Primary Care of Uterine Fibroids: an Update," Journal Watch Women's Health, November 1997.
P.W. Law et al, "Magnetic-Resonance-Guided Percutaneous Laser Ablation of Uterine Fibroids," The Lancet, December 11, 1999.
Gail McBride, "Gone But No Longer Forgotten-Fibroids Get Their Own Conference," The Lancet, October 23, 1999.
Maryann Napoli, "Uterine Fibroids May Have a Dietary Link," HealthFacts, November 1999.
"Oral Contraceptives and Uterine Fibroids," American Family Physician, September 1992.
"Treating Fibroids," Harvard Women's Health Watch, April 1998.