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Health Protocols

Uterine Fibroids

Conventional Treatment

Many women do not need treatment for uterine fibroids because their fibroids do not cause any noticeable symptoms. For fibroids that require intervention, treatment can be approached medically or surgically (Mitwally 2013).

Medical Treatments

Gonadotropin-releasing hormone agonists. Gonadotropin-releasing hormone (GnRH) agonists such as leuprolide (Lupron) and nafarelin (Synarel) are non-surgical options to treat uterine fibroids (Doherty 2014). They inhibit the production of estrogen and progesterone, resulting in a decrease in fibroid size (Mayo Clinic 2014a). GnRH agonists may be prescribed to shrink fibroids before a hysterectomy or myomectomy, as they appear to improve outcomes and may allow more patients to undergo a less invasive vaginal hysterectomy instead of an abdominal procedure (Lethaby 2001).

Side effects of GnRH agonists are similar to symptoms and complications that can accompany menopause: hot flashes, vaginal dryness, and bone loss (Islam 2013; Magon 2011). Because of this effect on bone, the FDA recommends that GnRH agonists should only be used for the short-term treatment of fibroids – less than six months (Doherty 2014; Gargiulo 1997). The effects of GnRH agonists are reversible, and fibroids tend to return to their pretreatment size approximately six months after drug discontinuation (Golan 1996; Mayo Clinic 2014a). 

Estrogen and progestin therapy. Estrogens and progestins (synthetic, progesterone-like drugs) are commonly combined in oral contraceptive pills. They are often a first-line therapy for patients with excessive bleeding symptoms associated with uterine fibroids; however, they do not reduce fibroid size. In fact, estrogens and progestins may stimulate fibroid growth. Therefore, oral contraceptives should be used with caution in patients with symptoms caused by large fibroids (Doherty 2014).

Tranexamic acid. Tranexamic acid (Lysteda) stabilizes blood clots and is frequently prescribed to prevent excessive menstrual bleeding in women with uterine fibroids who want to maintain fertility and are unable to take oral contraceptives (Doherty 2014; Kumsar 2011; Sweet 2012). It is a well-tolerated drug that works by causing blood clots to form in fibroids, which results in fibroid cell death and eventual fibroid regression. This can cause symptoms of pelvic pain, nausea, fatigue, and low-grade fever (Doherty 2014). 

Non-steroidal anti-inflammatory drugs. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil) or naproxen (Aleve), are commonly prescribed to reduce pain associated with fibroids (UMMC 2014). NSAIDs are also able to reduce menstrual bleeding by approximately 30-40% (Livshits 2010). Women who have heavy menstrual bleeding may have abnormal levels of prostaglandin in their endometrial tissue, and NSAIDs may mitigate uterine bleeding by modulating these prostaglandin levels (Smith 2007; Livshits 2010).

A review of 17 randomized, controlled trials found that NSAIDs were more effective than placebo but less effective than tranexamic acid at reducing excessive menstrual bleeding (Lethaby 2007). NSAIDs reported to be effective for heavy menstrual bleeding include ibuprofen, mefenamic acid (Ponstel), and naproxen (ARHP 2008).

Surgical Procedures

Hysterectomy. Hysterectomy is the surgical removal of the uterus, which can be performed abdominally, vaginally, or laparoscopically (Elsevier BV 2011). Approximately 15% of women who have uterine fibroids undergo hysterectomies (Ferri 2014). One study found that women who underwent hysterectomy reported greater improvements in subjective measures compared to women treated pharmacologically (Kuppermann 2004). 

In abdominal hysterectomy, the uterus is removed through a large incision in the abdomen (Mitwally 2013). In a vaginal hysterectomy, an incision is made in the vagina in order to access and remove the uterus. Compared with abdominal hysterectomy, women report less pain and better physical capability after vaginal hysterectomy (Silva-Filho 2006).

In laparoscopic hysterectomy, small incisions are made in the abdomen, and the uterus can be shredded using a process called power morcellation to allow extraction through the incisions (Nevarez Bernal 2012; Serur 2011). However, the use of power morcellation increases the risk of disseminating undetected (occult) cancer (Mitwally 2013; FDA 2014a; FDA 2014b; Nappi 2014; Della Badia 2010). Given the risks associated with power morcellation, women should discuss other options with their healthcare providers.

Surgical procedures that are less invasive than traditional abdominal hysterectomy and that do not involve power morcellation include minilaparotomy, laparoendoscopic single-site manual morcellation, and vaginal manual morcellation via culdotomy or colpotomy. In these procedures, physicians gain access to the uterus through relatively small incisions in the vagina or abdominal wall. If the target tissue needs to be cut into smaller pieces to be extracted, this can be accomplished manually with a scalpel. However, there is no strong evidence that clearly indicates so-called manual morcellation confers less risk for disseminating hidden cancer than power morcellation, yet the current FDA position only advises against power morcellation (AAGL 2014; FDA 2014b).

Oophorectomy – removal of the ovaries – is sometimes performed at the time of hysterectomy, though controversy exists over whether or not this relatively aggressive treatment is warranted in this context. This procedure may be indicated when there is a high risk of ovarian cancer or of certain types of breast cancer, but bilateral oophorectomy is performed in over 55% of women who undergo hysterectomy for uterine fibroids; a growing concern is the appropriateness of such aggressive treatment in the context of uterine fibroids. Fewer than 5% of women undergoing oophorectomy and hysterectomy actually meet the high-risk criteria for ovarian or breast cancer (Larson 2011; Hickey 2010; Shoupe 2007).

Hysterectomy prevents future menstruation and any chance of recurrent uterine fibroids. However, it also poses potentially serious risks, including damage to the bowel, bladder, or ureter; hemorrhage; infection; wound rupture; blood clots; and pulmonary embolism, a blockage of lung arteries (Khan 2014).

Removal of the ovaries causes an abrupt decline in sex hormones and disrupts the hypothalamic-pituitary-ovarian axis (Rocca 2009). This results in premature menopause, potentially causing symptoms of hot flashes, vaginal dryness, depression, anxiety, and decreased sex drive, and increased risk of heart disease, osteoporosis, and memory loss. These complications are usually treated with hormone replacement therapy (Mayo Clinic 2014c). Some evidence suggests that oophorectomy may do more harm than good (Parker 2014; Parker 2010; Shuster 2008; Rivera 2009). A 24-year follow-up study of over 29 000 women compared the outcomes of women who had either hysterectomies that preserved their ovaries or complete hysterectomies with oophorectomy. While oophorectomy decreased the risk of developing cancer of any kind, including breast cancer and of course ovarian cancer, an increased risk of myocardial infarction (heart attack), stroke, lung cancer, and death from cancer or any cause was noted (Parker 2009). Other studies have confirmed these risks, with one analysis showing that obesity may mediate some of the negative risks of oophorectomy (Duan 2012; Orozco 2014; McCarthy 2012; Parker 2013).

The Dangers of Uterine Power Morcellation

About 500 000 women undergo hysterectomy each year in the United States, making it one of the most common gynecological surgical procedures (CDC 2002; Gaba 2014).

Historically, removal of the uterus through an incision in the abdomen was the standard method of performing a hysterectomy (Baggish 2005; Fram 2013). In recent decades, however, laparoscopic hysterectomy has become increasingly popular (Salama 2013). A laparoscopic operation involves making only a few small holes in the patient’s abdominal wall through which fine surgical instruments are inserted to perform the operation. This approach is more appealing from a cosmetic perspective because it causes considerably less scarring than a traditional abdominal hysterectomy (Reich 1994). However, laparoscopic hysterectomy poses an important obstacle: how to remove the excised uterus from the patient’s abdominal cavity (Kho 2014).

The medical community overcame this barrier by developing a procedure called uterine power morcellation. Power morcellation involves shaving or shredding uterine tissue into smaller pieces that can be extracted with laparoscopic instruments. This procedure uses an electrically powered device to shred the tissue. Although power morcellation offers an effective means of removing the uterus without leaving a large scar, there is a risk of spreading occult/undetected cancerous tissue throughout the abdominal cavity.

During the uterine power morcellation procedure, small pieces of tissue and cellular debris can be spread through the abdominal cavity. If any malignant cells are present in the morcellated uterine tissue, deposition of tissue debris in the abdominal cavity during power morcellation can give rise to disseminated cancer, which has a very poor prognosis (Kho 2014; Park 2011).

Uterine fibroids are benign, but unsuspected uterine sarcoma is present in about one in 350 women undergoing surgery for fibroids (FDA 2014a). In these cases, cancer that was contained within the uterus, and which could have been removed completely via a vaginal or abdominal hysterectomy, may be spread to other parts of the body during power morcellation (Kho 2014; FDA 2014a; Mitwally 2013; Mayo Clinic 2014a; Song 2013).

In light of these findings, on April 17th, 2014 the FDA issued a statement discouraging the use of power morcellation procedures for the removal of uterine fibroids and hysterectomy (FDA 2014a).

Power morcellation runs the risk of other complications as well, including injury to nearby organs and dissemination of fragments of uterine fibroid tissue, which, even if not malignant, can deposit elsewhere in the body and cause problems. For example, if noncancerous fibroid cells are dispersed into the abdominal cavity during power morcellation, they may attach to another abdominal structure, acquire a blood supply, and form a parasitic leiomyoma (Milad 2014; Kho 2014; Takeda 2007; Jebunnaher 2013; Yoshida 2014).

Myomectomy. Myomectomy is the surgical removal of fibroids without removal of the uterus. This procedure may preserve fertility and improve pregnancy outcomes (Mayo Clinic 2013). It can be performed with an abdominal incision; laparoscopically, often with the use of power morcellation; and hysteroscopically, in which the surgical instruments are introduced through the vagina and cervix. The success of myomectomy in treating symptoms associated with fibroids depends on the number and extent of the fibroids. Women who undergo myomectomy have a 10-30% chance of recurrent fibroids within 5 years (Evans 2007; Fauconnier 2000; Rossetti 2001; Desai 2011; Mayo Clinic 2013). 

In rare circumstances, surgical blood loss cannot be controlled or other uterine problems are discovered during a myomectomy procedure, and the surgeon must perform a hysterectomy. Cesarean section deliveries are often performed on women who have had a myomectomy due to risk of complications during vaginal birth (Mayo Clinic 2013).

In abdominal myomectomy, fibroids are removed by making a large incision in the abdomen. Compared with abdominal hysterectomy, abdominal myomectomy is a longer procedure; however, patients typically have significantly less blood loss and, on average, shorter hospital stays (Khan 2014).

Hysteroscopic myomectomy of submucosal fibroids significantly improves the chance of becoming pregnant and decreases the risk of miscarriage. Possible complications include hemorrhage, uterine perforation, cervical laceration, uterine scars, and infertility (Khan 2014; Pritts 2009). 

Laparoscopic myomectomy removes fibroids that deform the uterine cavity, fibroids larger than 3 cm, and multiple fibroids (Desai 2011). While some authors suggest that laparoscopic myomectomy improves a woman’s chance of conceiving and having a successful delivery (Tinelli 2012), it carries risks including blood loss, problems with childbirth, and complications from tissue power morcellation (if the procedure is used) (Mayo Clinic 2013; Buckley 2014).

All three types of myomectomy may cause adhesions (bands of scar tissue), which could block the digestive system, cause abdominal or pelvic pain, or fertility problems. A survey of 414 gynecological surgeons reported that, of surgeries performed for benign conditions, myomectomy posed the second highest risk of adhesion formation behind surgery to treat endometriosis (Wallwiener 2014).

Minimally-Invasive Procedures

Uterine artery embolization. During uterine artery embolization (UAE), a catheter is inserted through the large femoral arteries in the groin and guided into the arteries that supply blood to the fibroid tissue. Chemicals that block blood flow, called embolic agents, are injected into the catheter. The embolic agents cut off the blood supply to the fibroids, causing cells to die and the fibroids to shrink in size (Evans 2007).

Compared to hysterectomy or myomectomy, UAE involves a shorter procedure time, hospital stay, and quicker return to normal activities (Mara 2006; Mara 2008). Complications from UAE can include blood collection outside of vessels (hematoma), bleeding, and infection; further surgeries are required after UAE in approximately 30% of cases (Doherty 2014; Gupta 2012). Post-embolization syndrome, which is characterized by pelvic pain, cramping, nausea, vomiting, fatigue, and mild fever affects most UAE patients, but usually resolves within 48 hours (Mitwally 2013; Doherty 2014). Many authorities do not recommend UAE for women who want to maintain fertility (Doherty 2014; Pron 2005; Cook 2010).

Endometrial ablation and resection of submucosal fibroids. In endometrial ablation, instruments are inserted into the uterus through the vagina to destroy the uterine lining (endometrium). This procedure can remove submucosal fibroids, but not intramural or subserosal fibroids. It reduces menstruation and excessive bleeding, and may cause the complete cessation of menstruation in some women. However, it may contribute to high-risk pregnancies due to injury to the uterine lining, and may increase risk of perforation of the uterine wall, pain, bleeding, infection, or neighboring organ damage (Mayo Clinic 2012). 

Magnetic resonance-guided focused ultrasound surgery. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) (ExAblate 2000 system) is a non-invasive procedure that was approved by the FDA in 2004 for the treatment of uterine fibroids (Khan 2014). During the procedure, a patient is placed into an MRI machine to visualize fibroids and surrounding organs, while high-energy ultrasound waves are directed at the fibroid, causing an increase in temperature and tissue damage. Clinical studies show that 70-80% of women have improvements in clinical symptoms after MRgFUS (Roberts 2008; Abdullah 2010). However, these improvements may be temporary as one study found 71% of women experienced symptom reduction at six months, but the proportion declined to 51% at 12 months (Stewart 2006).

MRgFUS is an outpatient treatment that does not require general anesthesia, allowing patients to return to their normal routine in one or two days, compared to six weeks recovery or more for hysterectomy and 2-4 weeks for myomectomy. Side effects appear to be minimal, though damage to neighboring organs is possible but rare (Abdullah 2010). Only patients whose fibroids are located immediately beneath the frontal abdominal wall, and who have no bowel interference or prior scarring around the target area, are eligible for MRgFUS (Khan 2014). As of 2012, MRgFUS was not recommended for women who want to maintain their fertility (ASRM 2012b), though successful pregnancies have occurred following treatment (Rabinovici 2010).