Dear Doc | Concerned about fibroid treatment and getting pregnant

Q Dear Doc, I have a concern. I am a woman in my mid-30s and I was having heavy periods, so I went to see my doctor. He told me I have fibroids and have to do surgery to take them out. The thing is, I don't have children and I don't know if I should be doing surgery on my womb, because it might affect my chances in the future. Do I really have to do surgery?

A This is a very common concern for women in your situation; and there are many women who are. This is because fibroids are very common, affecting approximately 80 per cent of women in their lifetime. They are also more common, more severe, and occur at an earlier age for women of African descent.

Not all women who have fibroids have symptoms. Treatment is available for women who have fibroid-related problems, such as heavy menstrual bleeding, pain or pressure in the pelvis, or problems with pregnancy or infertility.

Women who have no symptoms from their fibroids do not need treatment.

The best treatment option depends on the symptoms that are affecting the patient. The size, number and locations of fibroids, and your desire for future pregnancy, also play a role in selecting the best treatment option.

Easier said, the treatment is specifically tailored to each patient and not a one-treatment-fits-all situation.

Treatment can be classified as medical, surgical, or interventional.

 

Medical treatment

 

Most medical treatments use a medicine to reduce the heavy menstrual bleeding, which is the most common complaint of women with fibroids. Some medical treatments can shrink the fibroids, and others are focused on reducing pain or correcting anemia (low blood count) caused from the heavy menstrual bleeding.

Medical treatments are often recommended before surgical treatments.

Common options include:

- Iron and vitamins - For women who are anemic, it is an effective option to correct the low blood count.

- Non-steroidal anti-inflammatory drugs (NSAIDs) - These can help to reduce menstrual cramps as well as menstrual flow in some women; however, NSAID's do not reduce bleeding as well as other medical treatments do.

- Hormonal birth control - These methods of birth control can help to reduce bleeding, cramps, and pain during your menstrual period. It might take three months for bleeding to improve after you start taking hormonal birth control.

- Anti-fibrinolytic medicines - They medicines help to slow menstrual bleeding quickly. They work by helping blood to clot. Anti-fibrinolytic medicines do not shrink fibroids. Tranexamic acid, a type of anti-fibrinolytic medication, is used worldwide and is also approved by the US Food and Drug Administration for the indication of heavy menstrual bleeding.

Anti-fibrinolytic medicines slow bleeding quickly, only needs to be taken during your period or during the times of heavy menstrual bleeding. They do not affect your chances of becoming pregnant

- Progesterone receptor modulators - These medications modify the way the hormone progesterone acts. They rapidly stop heavy menstrual bleeding and cause some fibroid shrinkage.

- Gonadotropin-releasing hormone (GnRH) agonists - GnRH agonists are given by injection once a month or every three months. They are used to temporarily shrink fibroids as well as stop menstrual bleeding. It is often used in conjunction with surgical treatment, and your doctor might recommend that you first use GnRH agonists for three to six months to shrink the fibroids before your surgery, which can make the surgical procedure easier and reduce complications.

 

Surgical and interventional treatment

 

Your doctor might recommend a surgical or interventional treatment for your fibroids if you have heavy menstrual bleeding, pain, or pressure caused by your fibroids, and not improved with medical treatments. It may also be offered if you are trying to get pregnant and fibroids appear to be interfering.

Surgical options include:

- Myomectomy - This is a surgery done to remove the fibroids from the uterus (womb). Most women who have a myomectomy are able to have children afterwards; however, there is a chance that the fibroids will come back after the myomectomy.

There are several ways to perform a myomectomy; for example, by 'keyhole surgery' (laparoscopy). The best method depends on where your fibroids are located and their size and number.

- Endometrial ablation - This destroys the lining of the uterus. The treatment doesn't affect the fibroid(s) at all, but instead, helps to reduce the heavy menstrual bleeding caused by fibroids. In fact, some women who have endometrial ablation stop having menstrual periods.

Pregnancy is often not possible after ablation.

- Uterine artery embolisation - Also called UAE or uterine fibroid embolisation (UFE) is a treatment that blocks the blood supply to fibroids. This causes the fibroid to shrink within weeks to several months after the treatment and decreases other fibroid symptoms including heavy menstrual bleeding.

Pregnancy is not usually recommended after uterine artery embolisation, although it is possible to become pregnant.

- Hysterectomy - This surgery removes the uterus. It is a permanent treatment that cures heavy menstrual bleeding and the bulk of related symptoms of fibroids. However, it is a major surgery, and you will need up to six weeks to fully recover.

With all the various options, you will need to have the discussion with your gynaecologist as to which treatment, or combination of treatments, is best for you.

deardoc@gleanerjm.com