Treating Fibroids Without Surgery: Medicine and Embolisation

Fibroids can be treated without surgery, but only in the right woman and usually only for a limited time. Dr. Suman Lal, Senior Director & Unit Head - Obstetrics And Gynaecology, Robotic Surgery, Gynaecologic Laparoscopy, Pregnancy Management at Max Hospital, Gurugram, India, at the time of this masterclass, uses medicines to control bleeding and shrink fibroids for one or two years, and uterine artery embolisation for small fibroids in women who have completed their family.

The distinction she draws is between controlling symptoms and solving the problem. Most medicines do the first. Few do the second, and none permanently. This article sets out what each non-surgical option achieves, by how much, and where Dr. Lal draws the line and recommends surgery instead. How the right option is chosen in the first place, from a fibroid's size, location and number and the woman's age and fertility plans, is covered in the complete guide to uterine fibroid treatment options.

When medical treatment for fibroids makes sense

Dr. Lal reserves medicines for a defined group: women with heavy bleeding whose fibroid is not inside the cavity of the uterus, and women with small fibroids. In that group she offers painkillers, oral contraceptive pills and GnRH injections, with tranexamic acid and a hormonal coil as further options for bleeding.

The limit is time. Medical management of fibroids is advised for perhaps one or two years, to see a woman through her symptoms. Over the long run, she does not advise it. The reason is the behaviour of the strongest drugs: GnRH injections shrink a fibroid, but once they are stopped, the fibroid grows again.

Three situations where medicine has a strong role

Within those limits, Dr. Lal identifies three situations in which medicine is the right first answer:

1. A woman close to menopause. A woman of around 50 with heavy bleeding and a fibroid will probably reach menopause within one or two years. Medicine can be tried to stop the bleeding until then, because fibroids usually shrink after menopause.
2. A woman who plans to try for pregnancy soon. Where a woman with a fibroid and bleeding plans to conceive in the near future and an operation is best avoided, medicine can shrink the fibroid so that she can try for pregnancy with a smaller fibroid. If she does not conceive, Dr. Lal operates.
3. Before an operation, or where surgery is not possible. Medicine can be used preoperatively, in women who cannot have surgery, and where a very small fibroid is causing heavy bleeding.

Treating heavy bleeding from fibroids

Heavy bleeding is the most common reason a woman with a fibroid seeks help, and the first-line treatments target the bleeding rather than the fibroid. For a symptomatic fibroid that mainly bleeds, Dr. Lal's options are tranexamic acid, a hormone-releasing intrauterine system (Mirena), and hormonal treatment. A woman who does not respond moves on to surgery.

Tranexamic acid: less bleeding, same fibroid

A question from the discussion asked whether tranexamic acid can reduce the size of a fibroid. It cannot. Tranexamic acid helps the blood to clot, so a woman bleeding heavily because of a fibroid bleeds less when she takes it, because the small vessels clot. The fibroid stays the same size. Tranexamic acid is an antifibrinolytic: it slows the breakdown of blood clots, and it is taken only on the days of heavy bleeding, which makes it a non-hormonal option.

The hormonal coil

Dr. Lal uses a Mirena, a hormone-releasing intrauterine device, among her options for heavy bleeding. The shape of the cavity matters. A levonorgestrel intrauterine system releases a progestogen directly into the lining of the uterus and is highly effective against heavy menstrual bleeding, but a fibroid that distorts the cavity makes the device more likely to be expelled and less effective.

Oral contraceptive pills and painkillers

Combined oral contraceptive pills regulate the cycle and lighten periods, and painkillers relieve the cramps that accompany them. Anti-inflammatory painkillers such as mefenamic acid also reduce menstrual blood loss modestly. Neither changes the size of a fibroid.

Can progesterone shrink fibroids?

Progesterone is sometimes given for fibroids, but its ceiling is low: progestogen tablets control bleeding, and there is no reliable evidence that they shrink fibroids. She uses it in two settings: a woman with heavy bleeding who is waiting for surgery, and a woman with heavy bleeding who cannot have surgery. She does not advise progesterone for a woman who has a fibroid and no symptoms. It is given for heavy bleeding only, and in her words, surgery is the better answer than progesterone.

Progestogen tablets are used mainly to control bleeding, and the evidence that they shrink fibroids is limited, which is consistent with Dr. Lal's preference for surgery when a fibroid itself needs treating.

GnRH agonists: shrinking fibroids with injections

GnRH agonists (gonadotropin-releasing hormone agonists) are among the most effective medicines for shrinking fibroids. Given as injections, they switch off the ovaries' production of oestrogen and create a temporary, reversible menopause. Because fibroids depend on oestrogen, they shrink.

Dr. Lal puts the effect at a 40 to 50% reduction in fibroid size. That is enough to relieve pressure symptoms, and she uses GnRH agonists for women whose main complaints are pain and pressure rather than bleeding alone.

Leuprolide or goserelin?

Asked about the two GnRH agonists commonly used, leuprolide and goserelin, Dr. Lal's answer is practical: both genuinely reduce the size of a fibroid, and different centres use different ones. Either can be used.

Why the effect does not last

The shrinkage is temporary. Once the injections stop, oestrogen returns and so does the fibroid. GnRH agonists also produce menopausal side effects, including hot flushes and loss of bone density, which is why guidelines limit their use to short courses unless low-dose hormone "add-back" therapy is given alongside them. Short courses are commonly used before surgery, to shrink a fibroid and allow a woman's haemoglobin to recover from heavy bleeding.

A window for conception

The temporary effect can be turned into an opportunity. For a woman with fibroids who wants to conceive without surgery, Dr. Lal uses a GnRH agonist to shrink the fibroid. The shrinking effect lasts six to nine months, and within that window, once the fibroid is smaller, she can be given fertility medication and try to conceive. How this fits a wider fertility assessment is covered in the article on myomectomy, fertility and pregnancy.

The medicines compared

Uterine artery embolisation

Uterine artery embolisation (UAE), also called uterine fibroid embolisation, treats a fibroid without surgery and without medicine. Dr. Lal describes the procedure simply: a jelly-like material is placed into the artery that supplies the uterus, plugging it, so that the fibroid dies over time and stops growing. The procedure is performed by an interventional radiologist through a fine catheter passed into the arteries from the groin or wrist, under X-ray guidance, and the woman keeps her uterus. The facility is available at her hospital. Approximate costs for embolisation procedures are on Jivo Healthcare's embolisation cost page.

Who is a good candidate for embolisation

Dr. Lal regards embolisation as a very good technique in the right woman. She offers it when:

• the fibroid is small;
• there are few fibroids;
• the fibroid is not calcified;
• the woman has completed her family and does not want another baby.

Why embolisation is not advised before pregnancy

Embolisation works by cutting off blood supply, and that is exactly why Dr. Lal does not advise it for a woman who wants to conceive later. Blocking the artery reduces blood flow to the uterus as well as to the fibroid. If that woman becomes pregnant, the baby may not receive enough nutrition and its growth can be hampered. For a woman who wishes to conceive, the fibroids should be removed surgically (myomectomy) instead. Specialist guidelines take the same position: myomectomy is generally preferred to embolisation for women who want a future pregnancy.

When embolisation will not work

A calcified fibroid is another exclusion. Calcification means that no blood vessels run into the fibroid, so blocking the arteries has nothing to act on. Dr. Lal also does not advise embolisation for large fibroids.

When fibroid treatment without surgery stops working

Dr. Lal's thresholds for leaving medical treatment behind are consistent. Surgery is next when a woman does not respond to medicines for bleeding, when a fibroid grows into the cavity and causes heavy bleeding or obstruction, and when a fibroid in the muscle wall stands between a woman and a pregnancy. The surgical routes, from hysteroscopic removal as a daycare procedure to robotic myomectomy, are described in the article on myomectomy, fertility and pregnancy. Dr. Lal's answers to doctors' questions on tranexamic acid, progesterone and GnRH agonists are on the Live Discussion page. For a broader survey of the same treatments, Dr. Supriya Malhotra covers the medical management of uterine fibroids and embolisation and other minimally invasive options.