The GFT algorithm below was created to help women and their physicians chart the best course of treatment depending on their individual situation. The process begins with an assessment of two key questions: are symptoms present and is fertility (pregnancy) desired?
Most women may have several fibroid treatment options available, with their ultimate decision based upon the effect on their quality of life and their fertility desire. See below for more details on these options.
Women desiring fertility are not candidates for endometrial ablation, Mirena IUD, oral contraceptives, hysterectomy, or usually uterine fibroid embolization (UFE). Instead, myomectomy or no surgery are the most common courses of treatment.
Treatment options for uterine fibroids do not apply to all patients. Some symptoms may have a different cause unrelated to fibroids. Some patients may have contraindications to some treatments. Some patients may first need testing to rule out conditions such as cancer.
It is advised that you first discuss these options with your physician or schedule an initial fibroid consultation with Dr. Goldberg, Director of the Philadelphia Fibroid Center at Einstein.
Some patients with none to minimal symptoms (bleeding, pain, infertility) need no treatment for their fibroids. Fibroids very rarely are cancerous (leiomyosarcoma). In one study of patients suspected of having cancerous fibroids, only 1 in 400 women actually did. As the future is unpredictable, patients initially receiving no treatment may require it in the future if symptoms worsen. When the woman reaches menopause (average age 51), estrogen and progesterone levels will decrease, leading to shrinkage of fibroids and improvement or resolution of symptoms.
In patients mainly experiencing fibroid related painful menses, NSAIDs (ex. ibuprofen) taken at that time may be helpful in reducing menstrual pain and possibly decreasing menstrual bleeding.
In patients mainly experiencing fibroid related heavy menses or irregular bleeding, continuously taken (no placebo pills) combination oral contraceptives may stop bleeding. Depending upon the woman’s age, bleeding pattern, and other risk factors, she may require biopsy of the endometrial (inner uterine) lining to rule out endometrial cancer.
A GnRH (gonadotropin releasing hormone) agonist such as Lupron® acts upon the hypothalamus and pituitary gland in the brain to decrease levels of estrogen and progesterone. This then simulates a temporary menopausal state. The decrease in estrogen and progesterone will lead to shrinkage in fibroid volume up to 50 percent, cessation in uterine bleeding, and increase in hemoglobin level. Most commonly, an intramuscular injection lasting three months is given, which may be repeated. It is unusual that a patient receives this medication for longer than a year due to effects on bone, side effects, and cost. Some women will experience side effects such as hot flashes, vaginal dryness, and emotional disorders. Due to its cost, some insurances may refuse coverage or require significant co-pays for this expensive medication.
GnRH Agonist (Lupron®) is primarily used in two situations: pre-operatively or as a transition to menopause. Used pre-operatively, it will shrink fibroid / uterine volume. This may decrease surgical risk and allow other surgical options. In anemic patients, it will decrease the risk of blood transfusion. In patients believed to be close to menopause (average age 51), GnRH Agonist (Lupron®) may provide a short period of fibroid symptom relief allowing the woman to reach menopause before needing more invasive treatment.
Fibroid size and associated symptoms will decrease due to lower levels of progesterone, as well as estrogen, stimulation. SPRMs (selective progesterone receptor modulators) act by blocking the progesterone receptors on the fibroids. Multiple studies of different SPRMs have demonstrated significant fibroid volume reduction and improvement in symptoms. These drugs may potentially be used short term pre-operatively or long term in treating fibroids. Although some SPRMs are currently FDA approved, this drug class is not yet regularly used in clinical practice. Jay Goldberg, MD, MSCP, of the Philadelphia Fibroid Center at Einstein, has been involved in research studies on SPRMs.
In patients not desiring future fertility mainly experiencing heavy menses or irregular bleeding, endometrial ablation may help. The goal is to destroy the inner lining of the uterus to prevent future growth and shedding of the endometrium. For this reason, it cannot be considered in women possibly considering future pregnancy. There are several techniques used to accomplish this. Typically an instrument is inserted vaginally, through the cervix, and into the uterine cavity. Either heat or cold is applied to the inner portion of the uterus for a short time period. It is an outpatient procedure. Although cramping may persist for several days post-op, many women can return to work the next day. Up to 75 percent of women will have improvement in bleeding, with some becoming amenorrheic (no bleeding). Endometrial ablation is less effective in women with large uteri or large intra-cavitary fibroids.
In patients not desiring fertility soon, mainly experiencing heavy menses or irregular bleeding, a Mirena® IUD may help. It will also provide contraception. The small plastic T-shaped intra-uterine device (IUD) is inserted through the vagina and cervix into the uterus. It is effective for five years. Mirena® IUD does not shrink fibroids or improve bleeding or infertility symptoms. Women usually cannot become pregnant with an IUD. Some insurances may refuse coverage or require significant co-pays.
Uterine Fibroid Embolization (UFE) may be effective in treating fibroid related bleeding and bulk symptoms. UFE allows uterine preservation. It was first described as an effective fibroid therapy in the 1990s by Jacques Ravina, MD, from France. Approximately 40 percent shrinkage of fibroid volume occurs following UFE. Approximately 80 percent of patients will relieve symptomatic relief from UFE allowing them to avoid hysterectomy. Approximately, 500,000 women have undergone UFE. Jay Goldberg, MD, MSCP, of the Philadelphia Fibroid Center at Einstein has published much of the scientific literature on UFE, including the first series of pregnancies following UFE.
Myomectomy is the surgical removal of uterine fibroids. In addition to treating infertility, myomectomy can also improve bleeding and bulk symptoms. It is usually performed in patients desiring future fertility as the uterus is preserved. Some women not desiring fertility, but wishing to retain their uterus, elect to undergo myomectomy rather than hysterectomy. The failure rate for myomectomy, defined as needing to undergo another surgical procedure in the future for the occurrence of new fibroids, is reported as less than 10 percent.
Myomectomy can be performed hysteroscopically, to remove only submucosal (confined to the endometrial cavity) fibroids, or through abdominal incisions. Dr. Goldberg has performed over 1,000 myomectomies, as well as other fibroid-related surgeries, the majority of which were performed using his minimally invasive, mini-lap technique.
Hysterectomy is the surgical removal of the uterus. 60 percent of hysterectomies are performed to treat symptomatic fibroids. There are several surgical approaches to hysterectomy: vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, and abdominal hysterectomy. When the cervix is removed along with the uterine corpus (body), it is a total hysterectomy. When the cervix is not removed it is a supracervical hysterectomy. Depending upon the patient’s age and family history, the adnexa (fallopian tubes and ovaries) may be removed at the time of hysterectomy. If the ovaries are not removed, it will not affect hormone levels or put the woman into early menopause.
Hysterectomy is the only guaranteed cure for fibroids.While hysterectomy is an excellent treatment option for many women, a study published by Dr. Goldberg reported that 61 percent of patients with symptomatic fibroids not desiring fertility had an unfavorable perception of hysterectomy.
With HIFU (High Intensity Frequency Ultrasound), ultrasound waves are directed at fibroids while monitored by MRI. The procedure is extracorporeal, meaning no cutting occurs. Approximately 13 percent shrinkage has been reported following HIFU. Very few insurances cover HIFU, with it being performed rarely outside of the research setting.