Uterine Fibroids Treatments : Part 2

by Food and Drug Administration (FDA)

(Page 2 of 3)

Side effects of GnRH analogs include many of the symptoms experienced by women during menopause: "hot flashes," vaginal dryness, and bone loss. Because of these side effects, the drugs are not approved for use for longer than six months. And once the medication is stopped, the fibroid usually starts to grow again.

Some gynecologists are now experimenting with combining GnRH analogs with hormone replacement therapy to "add back" lost estrogen. "This is not generally accepted clinical use as yet," says Barad. "We don't know that simply adding back estrogen will address all the safety considerations of long-term use of GnRH analogs."

Barad and others have found a useful role for GnRH analogs as preoperative therapy to shrink fibroids and stop heavy bleeding. "Both anesthesia and surgery are easier and safer if you can first make the fibroid smaller and stop the heavy bleeding so the patient isn't anemic," says Barad.

The drug danazol (Danocrine), which is chemically similar to the male sex hormone testosterone, may also be prescribed to stem heavy menstrual bleeding caused by a fibroid. Like the GnRH analogs, danazol is approved for treatment of endometriosis but not for treatment of fibroids. Its main side effect is to increase male characteristics, such as facial hair and deepening of the voice; however, not all patients experience this side effect.

New Surgical Techniques

The development of endoscopes, lasers, and electrosurgical devices has led to new, less-invasive surgical techniques to remove fibroids. An endoscope is a thin fiberoptic tube that surgeons insert into the body. It can transmit an image to a television-like screen. Specialized endoscopes for viewing the abdominal cavity are called laparoscopes. Endoscopes designed to view the inside of the uterus are known as hysteroscopes. A laser is a device that uses a thin, intense light beam to "cut" or vaporize tissue, while electrosurgery or electrocautery devices use electricity to destroy tissue by applying heat.

These devices can be combined in several ways to perform a variety of procedures. Some devices combine the visualization and surgical functions in one instrument, such as the hysteroscopic resectoscope, which consists of a hysteroscope with an electrosurgery device built into it. This device is often used to remove submucous fibroids, the type most likely to cause symptoms of heavy menstrual bleeding (see "Fibroid Types").

The most appropriate procedure for each patient will depend on factors such as the size and position of the fibroid, the severity of symptoms, and future childbearing plans. Hysterectomy, by removing the uterus, makes it impossible to become pregnant or carry a baby.

Endometrial ablation, in which an electrosurgical device is used to remove the lining of the womb, may be recommended if a woman's major fibroid-related symptom is heavy, debilitating menstrual bleeding. This procedure also makes pregnancy impossible.

Myomectomy, or surgical removal of a fibroid leaving the uterus in place, may be an alternative to hysterectomy, particularly for women who still want to have children. In determining whether to recommend a myomectomy, a doctor will take into consideration the woman's overall health as well as the number and location of the fibroids, says Grant Bagley, M.D., of FDA's Office of Health Affairs.

"A myomectomy can be a very simple procedure or it can be very complicated," says Bagley. "A thorough discussion is needed with each patient as to whether their particular case will be difficult."

According to Barad of Montefiore, myomectomies can result in higher than average blood loss and scarring of the uterus that can adversely affect a woman's chances of becoming pregnant. "The operation you are performing to preserve reproductive potential may actually have the opposite effect." However, Bagley says newer techniques can be used to limit blood loss and preserve fertility.

If the fibroid is approachable from inside the uterus, a myomectomy may be performed using a hysteroscope. This procedure may be done in a physician's office if the fibroids are small. In some cases, patients can resume normal work and leisure activities within about a week.

A woman who has discomfort and heavy menstrual bleeding caused by a large fibroid, and who does not want to become pregnant, may opt to have a hysterectomy. A traditional abdominal hysterectomy is major surgery, requiring a four- to five-day hospital stay and a recuperation period of about six weeks.

Women with relatively smaller fibroids may be able to have a vaginal hysterectomy instead. In this procedure, the uterus is removed through the vagina, thereby avoiding a large abdominal incision. Some doctors will prescribe GnRH analogs for several months before surgery to try to shrink the woman's uterus so that a vaginal hysterectomy can be performed instead of an abdominal one. In some cases, a vaginal hysterectomy is done with the assistance of a laparoscope. Most patients will have a shorter hospital stay and recovery period for a vaginal hysterectomy than for an abdominal procedure.

Physicians differ in their approach to the treatment of fibroids, Rarick points out. "Some will only do hysterectomies. Others will do everything they can to preserve the uterus."

And Williams advises: "Patients need to ask questions and be aware of all their options."

About the Author

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