What is the treatment for uterine fibroids?

Dear Dr Mitchell,

I am a 25-year-old woman with a very large intramural fibroid in the cervix. I have some seedlings also. They tend to cause a lot of pain and recently I had a ruptured ovarian cyst. I would like to know if there is any other treatment in Jamaica for uterine fibroids apart from myomectomy and hysterectomy?

Uterine fibroids or leiomyoma are the most common solid pelvic tumours in women and are the most common indication for hysterectomy (removal of the uterus). Fibroids are common in women of the reproductive age group and tend to reduce in size after the onset of the menopause. They are particularly common in black women and grow to an extremely large size when compared with women who are of a Caucasian background.

Fibroids may be located within the wall of the uterus (Intramural), inside the endometrial cavity (submucosal) or outside of the wall of the uterus (subserosal). Some fibroids are small and do not cause any symptoms and need no surgical intervention.

Symptoms of uterine fibroids include heavy menstrual periods, severe period pains, chronic pelvic pain or dyspareunia (painful sexual intercourse). Some symptoms are due to compression from the large pelvic mass and sometimes infertility. Compressive symptoms include frequent urination, constipation and swelling of the feet, which may be associated with changes in the colour of the skin due to altered blood flow. Infertility may be associated with fibroids in up to 15 per cent of patients and this is especially seen in patients with submucosal fibroids.

The presence of the large intramural fibroid in the cervix definitely needs intervention. This may cause problems later on especially if you become pregnant. This can cause obstruction to the birth canal and result in the need for a caesarean section. It may also be associated with abnormal presentation and abnormal lie of the foetus in pregnancy. This may result in complications in the pregnancy such as premature labour, cord prolapse or cord presentation and the associated increased risk of death of the baby.

The surgical treatment that is available locally for the uterine fibroids includes myomectomy and the hysterectomy.

Myomectomy is removal of the fibroids with preservation of the uterus while hysterectomy is the removal of the uterus. Myomectomy may be done by the usual method of

laparatomy, laparoscopy or hysteroscopy. The laparascopic method is only appropriate for small fibroids but has the cosmetic advantage of reducing the size of the abdominal incision. It is not appropriate for large fibroids. Hysteroscopic removal of fibroids is appropriate for fibroids located in the cavity of the uterus. This involves the removal of fibroids through the vagina.

Uterine artery embolisation is a radiologic alternative to the surgery that involves partial blockage of the uterine arteries and decreases the blood flow to the uterus and fibroids. Most patients have a significant decrease in bleeding symptoms in addition to a reduction in uterine size. However, uterine artery embolisation may have serious consequences including infection, massive uterine bleeding and necrosis or sloughing of the uterus, which requires emergency surgery. This is still regarded as investigational and is not an appropriate form of treatment for young women who desire future fertility. Uterine artery embolisation is not currently available in Jamaica.

Medical treatment of uterine fibroids using the progesterone antagonist mifepristone (RU486) and gonadotrophin releasing hormone antagonist (GNRH) have been shown to produce shrinkage of uterine fibroids, however, fibroids tend to grow back to the original size after the discontinuation of the treatment. This form of the treatment using GNRH is only appropriate for short-term relief of symptoms since it is expensive and has significant side effects due to low oestrogen levels. This includes osteoporosis and increased risk of heart disease. Your best option would be to remove the fibroids by myomectomy if they are symptomatic and large or leave them alone and deal with them after childbearing if they still pose a problem.

Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions and comments via e-mail to allwoman@jamaicaobserver.com or fax to 968-2025. We regret that we cannot supply personal answers.