Medical Management of Uterine Fibroids: Drugs and Diet

Medical management of uterine fibroids controls symptoms rather than removing the fibroid. Pain relief and tranexamic acid reduce pain and blood loss, the combined pill, progestogens and the hormonal coil make periods lighter and less painful, and gonadotrophin-releasing hormone (GnRH) analogues shrink fibroids temporarily before surgery or near menopause. Diet, weight control and stress management help where symptoms are mild.

Dr. Supriya Malhotra, Senior Consultant Obstetrics & Gynaecology, Fortis La Femme, Greater Kailash II, New Delhi, India, was precise about the limits of each drug. Of the drugs she described, only the GnRH analogues reliably reduce fibroid size, and even that effect is temporary. The others control bleeding and pain while the fibroid itself stays where it is. This article sets out each option, the regimens she described and the questions doctors raised about them; uterine fibroid symptoms and diagnosis are covered in the series guide.

Watchful waiting: when fibroids need no treatment

The first line of management is often no treatment at all. A woman whose fibroids cause no symptoms needs no medicine and no procedure. Dr. Malhotra was clear, however, that watchful waiting is active follow-up, not neglect: once fibroids are known to be present, she follows the patient to see whether they are growing or static.

The biology supports patience in the right patient. Fibroids depend on oestrogen and progesterone, so as menopause approaches and those hormones fall, fibroids smaller than about 5 cm very often shrink and stop causing problems.

Medical management of uterine fibroids: what each treatment does

NSAIDs and tranexamic acid for fibroid bleeding

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are available over the counter and reduce both period pain and the volume of bleeding. Tranexamic acid, a drug that slows the breakdown of blood clots, is taken for 3 to 4 days during the period to reduce bleeding. Neither changes the fibroid, but together they can make heavy, painful periods manageable.

The combined pill and norethisterone

The combined oral contraceptive pill contains an oestrogen and a progestogen. Dr. Malhotra explained that it suppresses the body's own production of oestrogen and progesterone, which reduces the bleeding a fibroid causes and makes cycles painless. She was explicit that the pill does not remove fibroids or reduce their size; its value lies in symptom control.

Where a woman cannot tolerate the oestrogen in the combined pill, a progestogen alone is an alternative. Dr. Malhotra's regimen with norethisterone, a commonly used oral progestogen, is twice daily, given in one of two ways:

1. Cyclically, from day 5 to day 25 of the cycle, then stopped. The withdrawal bleed that follows is lighter and much less painful than a normal period. This suits a woman who wants a monthly bleed.
2. Continuously, without a break, for a woman who would rather not have periods at all.

She still regards the combined pill as the better choice where it is tolerated.

Does Mirena treat fibroids?

The levonorgestrel intrauterine system, known by the brand name Mirena, controls the symptoms of fibroids but does not remove them. It is a contraceptive device placed inside the uterus that releases a very small amount of progestogen every day. Progestogen counters the effect of oestrogen, the hormone most implicated in fibroid growth. The result is less pain and bleeding that becomes scanty or stops altogether.

Asked directly whether Mirena treats fibroids, Dr. Malhotra answered no. Definitive treatment remains removal by myomectomy or hysterectomy, or one of the minimally invasive procedures.

GnRH analogues: the drugs that shrink fibroids

GnRH analogues are the one class among these medicines that shrinks fibroids, and the effect lasts only while hormones stay suppressed. Oral GnRH antagonists and ulipristal acetate can also reduce fibroid volume; the use of ulipristal is restricted because of rare serious liver injury. Gonadotrophin-releasing hormone analogues, such as leuprolide and goserelin, mimic the natural releasing hormone that controls the ovaries. They bind its receptors in the pituitary gland, producing a brief initial surge of hormone release followed by a sustained fall, because the occupied receptors stop responding. Oestrogen and progesterone drop, the patient enters a temporary menopause-like state (a "pseudomenopause", in Dr. Malhotra's term), and the fibroids shrink.

They are not a long-term treatment. Oestrogen and progesterone protect the heart and bones in a woman of reproductive age, and removing them brings menopausal side effects such as hot flushes, vaginal dryness and bone loss. Dr. Malhotra therefore uses GnRH analogues for a short time and for two specific purposes.

Before a myomectomy for a large fibroid. The larger the fibroid, the more bleeding to expect during surgery. Giving a GnRH analogue for one to about three months beforehand, as a monthly or a three-monthly injection, shrinks the fibroid so that it is easier to remove.

In a woman approaching menopause. Her fibroids will shrink once menopause arrives, and her hormones are already falling. A few months of treatment hastens the shrinkage and can bridge her to menopause.

Is long-term hormone suppression safe?

A doctor in Tanzania asked how Dr. Malhotra views the future of blocking the hormones that drive fibroid growth. Her answer was that this already happens every day: the oral contraceptive pill suppresses the body's own hormones, and young women commonly take it from about 17 to 35. As long as there are no contraindications, she considers it quite safe. The conditions that matter are those in the WHO eligibility criteria: the combined pill should be avoided in women aged 35 or over who smoke, and in women with high blood pressure, migraine with aura, or a history of blood clots or stroke.

The same doctor asked whether targeted gene therapy might one day treat fibroids. There is a genetic predisposition, Dr. Malhotra explained, but no definitive targeted gene therapy exists yet, partly because the definitive cause of fibroids is still not known. Oestrogen and progesterone are assumed to be responsible because fibroids shrink after menopause. Gene therapy may come in future, but it is not available now.

Lifestyle and diet for fibroids

Dr. Malhotra recommends lifestyle changes for three purposes: to control symptoms, to reduce the chance of developing fibroids and to stop existing fibroids from worsening. She was realistic about their reach: they help manage symptoms to some extent when those symptoms are not severe.

Weight and exercise

Staying within a healthy body weight is the foundation. Fat tissue produces oestrogen, which acts on the uterus and drives fibroid growth, so obesity raises both the incidence and the size of fibroids. Dr. Malhotra stresses weight control most of all in women who are obese, through a regular exercise regime combined with diet control.

An anti-inflammatory diet

The diet she recommends is anti-inflammatory and broadly Mediterranean:

• Plenty of fibre, cereals, fruit and green leafy vegetables.
• Sources of omega-3 fatty acids such as walnuts and flax seeds, along with olives and olive oil.
• Less red meat, which she regards as inflammatory, with white meat such as fish, turkey and chicken in its place.
• No caffeine and no alcohol.

Asked by a doctor in Ghana about meat consumption against a planetary health diet, she gave the same answer: weight control first, an anti-inflammatory Mediterranean pattern, and less red meat.

No smoking

Dr. Malhotra was emphatic that women with fibroids should not smoke. Evidence does not show that smoking makes fibroids grow; the reasons not to smoke are general and cardiovascular health and the safety of hormonal treatment, since the combined pill should be avoided in smokers aged 35 or over.

Stress management and practical measures

Stress raises cortisol, which Dr. Malhotra described as playing havoc with the body's hormones. She recommends yoga, deep breathing and meditation. Two practical measures complete the list: tracking the menstrual cycle, and heating pads for cramps.

Period pain in young women: rule out the cause first

A doctor from the Democratic Republic of Congo asked how to treat dysmenorrhoea, painful periods, in a young unmarried woman. Dr. Malhotra's first step is diagnostic: rule out a fibroid, adenomyosis (endometrial tissue growing into the uterine muscle), endometriosis (endometrial tissue growing outside the uterus) and pelvic inflammatory disease, because a known cause can be treated far more effectively.

For the pain itself, she uses NSAIDs such as ibuprofen and naproxen. Where the pain is severe and the patient has no contraindication, a trial of the oral contraceptive pill reduces both pain and flow, making periods regular, lighter and pain-free. Dr. Tripti Sharan's article on endometriosis treatment with medicines, Mirena and surgery covers that diagnosis in depth.

What medicine cannot do

Every medical option shares one limit: it does not remove the fibroid. The pill, progestogens and the hormonal coil control bleeding and pain for as long as they are taken. GnRH analogues shrink fibroids, but only for as long as the hormones stay suppressed, and their side effects rule out long-term use. A woman with large fibroids, a submucosal fibroid blocking conception, or symptoms that persist despite treatment needs a procedure. Uterine artery embolisation, myomectomy and hysterectomy are compared in myomectomy vs hysterectomy: fibroid procedures compared.

For a second specialist's view of non-surgical options, including how much GnRH injections and progesterone shrink fibroids, see Dr. Suman Lal's article on treating fibroids without surgery. The full set of questions doctors put to Dr. Malhotra, including those on norethisterone and Mirena, is in the Live Discussion.