Treatment of Uterine Fibroids

Dr. YUEN Pong Mo

Director, Minimally Invasive Gynaecology

Honorary Consultant in Obstetrics & Gynaecology

Specialist in Obstetrics and Gynaecology

As a common gynecological condition, uterine fibroids are found in about 30% of women. While the cause is uncertain, the condition is usually associated with female sex hormones.

Risk Factors of Uterine Fibroids

Generally speaking, the risk of developing uterine fibroids increases with age. Other risk factors include family history, obesity, no childbirth experience, early menstruation and late menopause.

In recent years, uterine fibroids have become far more common in young women. The trend may have to do with late marriage, late childbirth and having few children. It is also suggested that the age trend might be associated with consumption of food with excessive hormones, but the link remains unproven due to the dearth of data.

Symptoms and Consequences

Uterine fibroids can appear in different parts of the uterus. The symptoms vary with location and size, and are not apparent in over 50% of cases. Most patients are diagnosed with uterine fibroids during physical examination or regular gynaecological check-up. Common symptoms include:  

• Abnormal uterine bleeding: heavy and prolonged periods due to impact on the uterine cavity; menstrual pain and anemia
• Pelvic pressure symptoms: discomfort due to pressure on pelvic organs
  • Pelvic heaviness/pressure or swelling pain
  • Frequent urination, difficulty emptying the bladder (pressure on the bladder)
  • Back pain and constipation (pressure on the rectum)
  • Urination difficulty, even inability to empty the bladder if located low and pressing on the urethral opening

Uterine fibroids are often -neglected for other conditions and left untreated. For example, patients with persistent abdominal swelling might only consider themselves as a bit chubby and fail to seek medical attention, when in fact the swelling may be caused by uterine fibroids. If the abdominal swelling feels hard and looks uneven, consult your doctor for examination as soon as possible.

Sometimes large uterine fibroids may press on the blood vessels in the pelvic cavity and impede blood circulation, causing leg swelling or deep vein thrombosis, even pulmonary thrombosis.

Uterine fibroids may also affect the chance of pregnancy especially when they attend to the uterine cavity, making it difficult for embryo implantation. Those women are more likely to have miscarriage, preterm delivery and pain, while the foetus may suffer from restricted growth or become mal-positioned. Caesarean section is frequently required, and excessive bleeding may occur due to poor uterine contraction.

Common Mistakes about Uterine Fibroids

Can I skip treatment if they are asymptomatic?

If the uterine fibroids are small and asymptomatic, no treatment is necessary. However, regular examination and monitoring is crucial because uterine fibroids generally increase in size and number, and they grow at a different rate. Most of them are benign. The latest published studies reported that the risk of finding occult malignancy after uterine fibroid surgery is within 1/1,500 to 1/2,000. The incidence is very low, but not rare.

In general, patients should undergo examination once a year or every 2 years if the fibroid is 2 to 3cm in size; or at least once a year if it is around 5 to 6 cm or there are multiple fibroids. Examination is especially important to women with sexual activity, and should be performed with cervical smear and ultrasound ovary examination.

Uterine fibroids are susceptible to hormonal influence. Despite the symptoms, will they resolve themselves once menopause kicks in?

It is a common thinking that problems associated with uterine fibroids will disappear when menopause occurs. The fact is, most fibroids will decrease in size and most of the period-related problems do resolve themselves at the time of menopause, the pressure symptoms and abdominal swelling may not necessarily disappear with the decrease in female hormones and cessation of menstrual flow. The extent of fibroid shrinkage also varies with patients and fibroid size. Some of them may remain unchanged in size, while others may continue to grow and need to be removed surgically.

Menopause occurs at a mean age of 51. If serious symptoms occur at an early age and cause severe discomfort and adverse impact on the quality of life, e.g. severe anemia, abdominal swelling and mental distress, you should receive treatment instead of “waiting out” the condition.

To sum up, there is no way to predict the actual age of menopause.  Uterine fibroids severally continue to grow before menopause and symptom likely to get worse if present, affecting the quality of life. They persist and occasionally continue to grow after menopause. Other condition related to uterus can still occur, then most serious is carcinoma of the endometrium, which is the third most common cancer of women in Hong Kong. Instead of waiting it out (which may be recommended only to women near the age of menopause or when surgery is considered too risky for them), early follow-up and treatment are advised to prevent any deterioration and adverse impact on life quality.

Surgery for Uterine Fibroids: Minimally Invasive? Open Surgery?

The complexity, risk and duration of surgery increase with the size of uterine fibroids. Even if asymptomatic, patients diagnosed with uterine fibroids should undergo regular ultrasound examination to monitor their growth. Removal of uterine fibroids should be considered if they reach a certain size or show symptoms.

The conventional approach to uterine fibroids is open surgery, which can cause larger wound, more complications and more severe post-surgical adhesion. With the introduction of minimally invasive surgery in the 1990s, uterine fibroids or the entire uterus can now be removed by way of laparoscopy. Those in the uterine cavity can be removed via hysteroscopy by placing an endoscope through the vagina and cervix without incision of the abdomen and uterus. 

Minimally invasive surgery results in less wound pain, faster recovery, and less severe uterine damage and post-surgical adhesion. Surgical complexity and duration and risk increase with fibroid size. When fibroids become too big, it may not be amendable with minimally invasive approach.  There is an increased risk of bleeding, intestinal and urinary tract damage and reversion to open surgery. This is especially so if the uterine fibroid is located in the low posterior part of uterus when it is in close vicinity to the rectum and urinary tract.

Generally speaking, removal of uterus does not necessarily lead to early menopause, premature aging, incontinence, organ prolapse or termination of sexual activity. Hysterectomy is a permanent solution for uterine fibroids, and hormone replacement is not required if ovaries are not removed. Factors like the size, number and location of uterine fibroids as well as the patient’s age and preference will be duly considered as to whether the uterus should be removed or not.

Non-surgical Treatment

For symptomatic uterine fibroids, non-surgical treatments include uterine artery embolization (UAE) and high-intensity focused ultrasound (HIFU). By focusing low-energy ultrasound on a small area, HIFU can ablate uterine fibroids gradually small volume by small volume, until most of the fibroid tissues are ablated. HIFU is considered less effective than surgery in terms of treatment outcome.

Uterine fibroids cannot be cured by pharmacological means alone. Medications, e.g. hormones, are mostly used to reduce menstrual bleeding or control abnormal uterine bleeding with only limited effect on pelvic pressure symptoms. They also cannot control or inhibit the growth of uterine fibroids permanently. Symptoms may recur and fibroids will regrow once the medications are stopped. 

In terms of quality of life, patient satisfaction, treatment outcome and rate of repeated treatment, surgery is still considered the best treatment option for uterine fibroids.