A 39-year-old woman has been found to have four 5 cm diameter fibroids when she had a scan after complaining of bladder irritation and heavier periods. They are mainly intramural but all have a significant subserosal component. She is nulliparous, has no partner and wants to avoid hysterectomy.
What are the medical options?
What are the surgical options?
What are the benefits and risks of uterine artery embolization?
Uterine leiomyomas (fibroids) are benign smooth muscle tumours and are the most common gynaecologic tumours in women of reproductive age.1,2 Uterine leiomyomas clinically affect 25%–30% of American women; however, an incidence of upwards of 77% has been reported.1,2 They are more common in African-American women, with some studies indicating they are diagnosed three times more frequently than in white women.1,2 They are often associated with reproductive and gynaecologic disorders ranging from infertility and pregnancy loss, to pelvic pain, and excessive uterine bleeding. They are steroid-dependent tumours that rarely progress to malignancy and regress at the menopause.
What are the medical options?
The aim of the medical options is to reduce her menstrual bleeding and to reduce fibroid size. With regard to the former, medical options will not improve her pressure symptoms. Options to reduce fibroid size tend to be of limited value and the fibroids will regrow when treatment is stopped.
Non-steroidal anti-inflammatory drugs and antifibrinolytic agents
Non-steroidal anti-inflammatory drugs (NSAIDs) and antifibrinolytic agents are used to reduce menstrual blood loss (see Case 1: Menorrhagia with Medical Management). However, they may be less effective in the presence of fibroids, especially if they are submucous fibroids.
Depot medroxyprogesterone acetate in case–controlled studies is associated with a protective effect on the development of fibroids. Clinical trial data in the management of fibroids are limited. A six-month clinical trial of 20 women found that 30% became amenorrhoeic and 70% noticed improvement in their bleeding pattern.3 Mean uterine and fibroid volume was also reduced by 48% and 33%, respectively.
Intrauterine levonorgestrel (levonorgestrel intrauterine system [LNG-IUS]) is a very effective treatment for menorrhagia but there are comparatively few studies in women with fibroids. Expulsion rate may be higher in women with a cavity distorted by fibroids. A systematic review found that all studies directly assessing LNG-IUS in women with fibroids reported decreased menstrual blood loss (84%–90%) and similar increases in haemoglobin of 2–3 g/dl.4 However, there was inconsistency on whether LNG-IUS is associated with decreased fibroid or no change in fibroid size.
Gonadotrophin-releasing hormone (GnRH) analogues
GnRH analogues produce amenorrhoea and fibroid shrinkage. Unfortunately, shrinkage is rarely complete and not sustained after cessation of therapy. Another concern is the bone ...