Fibroids, which are common in women of reproductive age, may cause heavy menstrual bleeding and symptoms related to leiomyoma bulk. Hysterectomy is an effective treatment, but many uterus-sparing options are available and should be discussed with patients. The latest Clinical Practice review is on this topic, and comes from Elizabeth A. Stewart, M.D., at the Mayo Clinic.
The lifetime prevalence of fibroids exceeds 80% among black women and approaches 70% among white women. Despite the high prevalence of fibroids and related annual U.S. health care costs exceeding $34 billion, there are few randomized trials to guide treatment.
- What are some of the risk factors for uterine fibroids?
Increasing age up to menopause and black race are the major risk factors for fibroids. Increasing parity is associated with a decreased risk, possibly through elimination of incipient fibroids as the uterus involutes post partum. Early menarche and the use of oral contraceptives before 16 years of age are associated with an increased risk, whereas the use of progestin-only injectable contraceptives is associated with a reduced risk.
- What is the role of uterine artery embolization?
Uterine-artery embolization is a minimally invasive interventional radiologic technique that has been shown in randomized trials to result in quality of life that is similar to that after surgery, with shorter hospital stays and less time to resumption of usual activities. The rates of major complications after embolization are similar to those after surgery, but embolization is associated with a higher risk of minor complications and of the need for additional surgical intervention (typically hysterectomy). In large case series and multisite registries, common complications include mild fever and pain (a constellation of symptoms called the postembolization syndrome) and vaginal expulsion of fibroids. Concerns about the safety of future pregnancies and impaired ovarian function currently limit wider use of embolization.
Figure 4. Uterine-Artery Embolization.
Morning Report Questions
Q: What medical therapies are available for women with heavy menstrual bleeding from fibroids?
A: Tranexamic acid, an oral antifibrinolytic agent that is taken only during heavy menstrual bleeding, results in decreased bleeding and improved quality of life with minimal side effects. Although its mechanism of action raises concern about thrombotic risk, this association has not been seen in clinical studies. The levonorgestrel-releasing intrauterine device (IUD) effectively decreases menstrual bleeding and provides contraception; however, the rate of expulsion of the IUD among women with submucosal fibroids may be high (12% in one case series). Observational data support the use of oral contraceptives to reduce menstrual bleeding in women with fibroids. A meta-analysis of randomized trials concluded that nonsteroidal antiinflammatory drugs, as compared with placebo, decreased menstrual pain and heavy menstrual bleeding, but they were less effective in reducing bleeding than tranexamic acid or the levonorgestrel-releasing IUD.
Q: When is surgical myomectomy recommended?
A: For most women in whom submucosal fibroids with a large intracavitary component (FIGO types 0 and 1) are found to be the cause of bleeding, hysteroscopic myomectomy is the best therapeutic option. Most guidelines support surgical myomectomy as the preferred option for treatment of symptomatic intramural and subserosal fibroids in women who wish to have a subsequent pregnancy. Nonetheless, abdominal myomectomy confers substantial risks with respect to fertility, including a 3 to 4% risk of intraoperative conversion to hysterectomy and frequent development of postoperative adhesions. Data are lacking from comparative-effectiveness research regarding fertility in women who have received various therapies for fibroids. Since intramural fibroids are themselves associated with an increased risk of infertility and pregnancy complications, and myomectomy does not reduce that risk, treatment of asymptomatic intramural fibroids is not recommended. Recurrence of fibroids is also common; at least 25% of women who have undergone myomectomy require additional treatment.