Fibroids: What are my (surgical and non-surgical) treatment options?

Fibroids are benign (non-cancerous) growths, made of muscle and fibrous tissue, that develop in or outside the womb (uterus). These growths can vary in size, and one or more can develop at the same time.

Here to provide an expert insight into fibroids, including symptoms and surgical and non-surgical treatment options, is Mr Michael Magro, renowned consultant gynaecologist based in London.

What are the key factors to consider when determining the most appropriate management approach for fibroids?

For a patient with fibroids, there are a variety of different factors that need to be taken into account.

The location of the fibroids

In general, fibroids can be found in three places:

• Submucous: Poking inside the lining of the womb
• Intramural: Growing within the muscle of the womb
• Subserous: Growing outside of the womb

It’s important to determine the exact location of the fibroids, because the different types generally cause different symptoms. In addition, the main management approach for fibroids actually involves treating the symptoms, rather than treating the fibroids themselves.

Fibroids are also very common, occurring in up to 60 - 70 per cent of women throughout their lifetime. It’s important to know, however, that some fibroids don’t need to be treated at all. If fibroids aren’t causing symptoms, they can just be left alone, which is a very important option to offer to patients.

The patient’s symptoms

Fibroids that cause heavy bleeding can lead to a variety of other symptoms. Similarly, fibroids that cause pelvic pain can cause pelvic discomfort or bloating as well. Sometimes, fibroids are large enough that they actually become visible through the tummy, causing pressure effects on the bladder or bowel, in addition to back pain.

The patient’s fertility plans

If fertility is still needed or wanted, or the patient wants to preserve their uterus, then this limits some of the surgical treatment options available for fibroids, such as a hysterectomy.

Which treatment options are available for fibroids? How do you assess and monitor the growth and progression of fibroids over time?

In simple terms, the management approach for fibroids is by symptom control. This can be achieved with:

1. Medication

This may be medication or devices to stop bleeding, such as progesterone, the Mirena coil, or contraceptives.

2. More specific treatments

The first option is uterine artery embolisation (UAE), which is a non-surgical procedure carried out by my interventional radiology colleagues. During the procedure, a needle is passed through the groin into the blood vessels that supply the womb. The blood vessels are then blocked, causing the fibroids to shrink. With a uterine artery embolisation, patients can achieve a maximum of 30 - 50 per cent reduction in the size of the fibroids. This is usually very, very good for symptoms such as heavy bleeding, but it may not be enough to resolve cases where the size of the fibroids and the pressure effects of the fibroids are the main issue. It is also not suitable for all fibroid types, so a discussion with your Gyanecologist is required.

The second option is Esmya (Ulipristal acetate), which is a medication used to shrink fibroids. Esmya is extremely safe for most patients and there is good evidence detailing its capacity to reduce bleeding. Esmya, however, can only be used for pre-menopausal women when surgery or UAE has failed or is not suitable. It also requires periodic blood tests and close monitoring before and throughout the duration of treatment.

The third option is Ryeqo, a relatively new, once-a-day tablet used to treat moderate to severe symptoms of fibroids, but it is not suitable for women wishing to conceive.

3. Surgical options

The first option is a hysteroscopy, which is particularly effective for symptoms such as heavy bleeding. During the procedure, a camera is inserted inside the lining of the womb and the submucous fibroids (that are poking inside the lining of the womb) are then removed. No cuts are made.

The second option is a myomectomy, which is particularly effective for symptoms such as pain, bloating, or heavy bleeding. During the procedure, the fibroids are actually cut out from the womb via a cut in the tummy. Nowadays, many myomectomy procedures can be performed via keyhole surgery, which is one of the areas that I specialise in. Keyhole surgery allows patients to recover more quickly – often, going home the next day after surgery.

The final option is a hysterectomy, which can also be performed via keyhole surgery and sometimes, via a cut in the abdomen. This procedure is recommended if:

• A patient doesn’t want biological children
• A patient doesn’t want any more biological children
• A patient wants a total resolution of symptoms

What are the potential complications or risks associated with these treatments?

In terms of risks, it very much depends on the treatment option that is chosen.

Contraceptives like the contraceptive pill, the contraceptive implant, or the Mirena Coil for symptoms such as heavy bleeding, all have their own specific risks. These risks are very low for the majority of patients, but for patients who are overweight or who smoke for example, there can be additional risks such as the development of blood clots in the legs and lungs (called deep vein thrombosis).

There is an extremely rare complication with Esmya where it can affect the liver and cause liver disease. This is why there is very strict monitoring in place before and throughout the duration of treatment.

With surgery, the risks of major complications are generally very low – no more than 1 in 100, or 1 in 1,000 for some of the very serious complications.

In terms of a hysteroscopic resection, also known as a transcervical resection of fibroids, where the fibroids are removed through the vagina without making any cuts, the common side effects are infection and a bit of bleeding after the procedure. There is additionally a very rare risk of making a hole in the womb, but this is very unlikely if the hysteroscopic resection is performed under vision and by a qualified, experienced specialist.

In terms of a keyhole myomectomy, there is less risk of wound infection and/or pain after the operation, and overall quicker healing. There is, however, a small risk of damaging something inside of the tummy (be it a blood vessel, the bowel, the bladder, or the ureters).

Thus, one of the first things I do when I see a patient at my clinic is make an individualised assessment and provide a variety of treatment options, allowing my patient to choose which one they would like.

A patient who has had major abdominal surgery, for example, may opt not to have further surgery, because their risk of suffering complications will be higher. Instead, a non-surgical procedure like a uterine artery embolisation might a better option for them. On the other hand, an operation like a hysterectomy might be the first choice for a patient who has completed their family, who has never had surgery, who is physically slim, and who wants total resolution of their symptoms.

What recommendations would you give to a patient who is struggling with fibroids?

I would tell patients to:

1. Please don’t suffer with your symptoms. See your GP promptly if you have symptoms that you are worried about, so that you can start treatment or be referred to a specialist gynaecologist if required. There are many different treatment options available!
2. Determine the symptoms, and if these are related to the fibroids. A large proportion of women will have fibroids during their lifetime, but these may be asymptomatic, in which case other treatment options may be available instead.
3. Know that fibroids are common, and thus, can also be associated with other gynaecological conditions like endometriosis and adenomyosis. It’s important to be aware of any co-existing condition that may be present for the effective management of all symptoms.

Mr Michael Magro is a leading consultant gynaecologist with over a decade of experience who specialises in all aspects of gynaecology.

If you have or suspect fibroids, don’t hesitate to book an appointment with Mr Magro via his Top Doctors profile today to receive expert assessment, treatment, and advice.