Uterine Fibroid Treatment Options

Choosing between uterine fibroid treatment options comes down to five facts: the fibroid's size, its location in the uterus, how many fibroids there are, the woman's age, and whether she wants a baby. 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 those five facts to decide between medicines, embolisation and surgery.

Her starting point is reassurance. A fibroid is not cancer. It is a rounded growth on or inside the uterus, and it is the most common gynaecological problem in young women. Medically it is called a leiomyoma or myoma: a benign tumour of the smooth muscle that forms the wall of the uterus. Most fibroids never need treatment. The question that matters is which ones do, and with what.

This guide sets out how Dr. Lal answers that question. The two deeper articles cover treating fibroids without surgery, with medicines and embolisation, and myomectomy, fertility and pregnancy with fibroids.

Who develops uterine fibroids

Dr. Lal groups the risk factors into a short list:

• High hormone levels, above all oestrogen.
• Age between 30 and 40 years.
• Obesity.
• High blood pressure.
• A family history of fibroids.

Genetics carries real weight in her assessment. Diet and lifestyle can shift the odds, but a woman whose mother or sister had fibroids starts from a higher baseline. Dr. Lal's advice to women at high risk is an ultrasound check-up, and a visit to the doctor as soon as any symptoms appear.

Why fibroids grow

After decades as the most common benign growth of the uterus, the exact reason fibroids form is still unknown. What is understood, in Dr. Lal's account, is the role of oestrogen: the more unopposed oestrogen the uterus is exposed to, the more fibroids form, and any state that raises oestrogen in the body makes fibroids more likely. "Unopposed" means oestrogen acting without the balancing effect of progesterone. She recalled that older gynaecology textbooks put it more bluntly, holding that a uterus that does not carry a baby produces fibroids instead. The modern reading is the hormonal one: fibroids are oestrogen-sensitive, which is also why they usually shrink after menopause.

Symptoms of uterine fibroids

Many women with fibroids have no symptoms at all. When symptoms appear, Dr. Lal sees six recurring presentations:

1. Heavy periods and anaemia. Blood loss is the most common complaint, and repeated heavy bleeding leaves many women anaemic.
2. Pain, including pelvic pain and menstrual cramps.
3. Urinary problems, such as difficulty passing urine and pain when passing it.
4. Bowel problems, including constipation and difficulty passing stool.
5. A growing abdomen, where a large fibroid is felt as a mass over the uterus.
6. Burning and throbbing pain during intercourse.

Fibroids also surface in fertility clinics, where they are found in women being assessed for IVF. Their effect on fertility and pregnancy is covered in the article on myomectomy, fertility and pregnancy.

How location shapes the symptoms

The pelvis is arranged front to back: bladder, then uterus, then rectum. A fibroid on the front (anterior) surface of the uterus pushes against the bladder and separates it from the uterus, which is why such women struggle to pass urine and feel pain when they do. A fibroid on the back (posterior) surface presses towards the rectum and causes rectal pressure, pelvic pain and constipation.

Why fibroids make periods painful

Dr. Lal explains menstrual pain through two mechanisms, depending on where the fibroid sits:

• A fibroid inside the cavity behaves like a foreign body. When a period starts, the muscle of the uterus contracts, and with each contraction the uterus tries to expel the fibroid, much as it expels a baby in labour. The result is cramping pain.
• A fibroid within the muscle wall enlarges the uterus and increases its surface area, which causes more pain and more bleeding, both of which accompany the cramps.

How fibroids are diagnosed

Two imaging tests do the work. Ultrasound is the first test and shows the size, number and position of the fibroids. MRI gives the exact location, which matters most when surgery is being planned. Pelvic ultrasound is the standard first-line investigation worldwide; MRI is reserved for mapping complex cases, such as a uterus with many fibroids, before an operation.

The three locations that drive treatment

Before planning any surgery, Dr. Lal establishes where each fibroid lies, because the location determines the route of treatment:

Any of the three can cause trouble. A fibroid growing into the cavity is the one most likely to cause heavy periods and pain, and a large fibroid growing inwards is, in Dr. Lal's words, a case that needs an expert surgeon, new technology and a good team.

Five factors that decide fibroid treatment

Dr. Lal does not treat a fibroid on its measurement alone. Treatment depends on:

1. Size of the fibroid.
2. Location: intramural, subserosal or submucosal.
3. Number of fibroids.
4. Age of the woman.
5. Fertility plans: whether she wants a baby.

Does a 5 cm fibroid need surgery?

The question came up directly in the discussion, and Dr. Lal's answer shows the framework at work. A 5 cm fibroid that grows into the cavity and causes heavy bleeding or obstruction needs to come out. A 5 cm fibroid on the outside of the uterus that causes no problem needs no operation. A 5 cm fibroid in the muscle wall that is causing problems, in a woman who wants a baby or is heading for IVF, often has to be removed. The same size leads to three different answers. Symptoms, need, location and size are weighed together before a plan is made.

Uterine fibroid treatment options at a glance

Dr. Lal works through a ladder of options, from the least invasive to the most:

Two principles run through her choices. Medicines control symptoms but rarely solve the problem in the long run: GnRH injections, which create a temporary menopause, shrink a fibroid by 40 to 50%, but the fibroid grows back once they stop. And a woman who wants future pregnancy should have her fibroids removed (myomectomy), not embolised, because embolisation reduces the blood supply that a pregnancy depends on. The reasoning behind each medicine and the limits of embolisation are set out in the guide to treating fibroids without surgery. The surgical routes, and what each means for a later pregnancy, are in the article on myomectomy and fertility. Approximate costs are on Jivo Healthcare's myomectomy cost page.

Diet, folic acid and fibroid risk

Patients often ask whether diet causes or cures fibroids. Dr. Lal's position is measured. Fibroids, endometriosis (tissue similar to the lining of the uterus growing outside it) and adenomyosis (the same tissue growing into the muscle wall) share, in her view, a background of stress and rising hormone levels, so she advises women to reduce stress, stop smoking, avoid excessive alcohol, and take enough folic acid and vitamins, especially vitamins A and C, which help repair cells. Women who do so, she observes, have fewer of these hormone-driven growths.

Folic acid is the most common question. Evidence that folic acid lowers fibroid risk is limited; diets rich in fruit and vegetables, and adequate vitamin D, are the dietary factors more consistently associated with fewer fibroids. That does not make folic acid a treatment: a woman who already has a fibroid will not see it disappear by taking folic acid. Dr. Lal uses it as a preventive measure in high-risk women, not as a cure.

Diet matters, but in her view genetics is also very important. Her practical advice is twofold: modify the diet, and if the risk is high, have an ultrasound check-up and see a doctor as soon as symptoms appear.

A single vulval wart: what it signals

One question in the discussion moved beyond the uterus: does a single wart on the vulva matter? Dr. Lal's answer is that vulval warts are caused by low-risk types of human papillomavirus (HPV), but one wart can be followed by more. Her approach has four parts:

• Treat the wart, and any further warts that appear.
• Examine the partner and refer him for treatment if he has warts.
• Counsel the woman that this is a low-risk virus.
• Make sure her cervical screening is up to date, because the high-risk HPV types cause cervical cancer; HPV DNA testing of the wart itself is not recommended, and a biopsy is reserved for a wart that looks atypical or does not respond to treatment.

The low-risk HPV types behind genital warts are distinct from the high-risk types that cause most cervical cancers, which is why a wart calls for screening rather than alarm.

Where to read next

The full exchange with the attending doctors, including questions on tranexamic acid, GnRH agonists and menstrual pain, is on the Live Discussion page. Related specialist perspectives on the same condition are in Dr. Deepika Aggarwal's guide to robotic surgery for fibroids, Dr. Shelly Singh's article on fibroids and surgery before IVF, and Dr. Supriya Malhotra's complete guide to uterine fibroids. The wider specialty is covered on the obstetrics and gynaecology hub.