Uterine fibroids, also known as leiomyomas, are non-cancerous growths that develop from the muscle tissue of the uterus. They are common, affecting up to 77% of women during their childbearing years. When symptoms occur, they can significantly impact quality of life, often presenting as heavy or prolonged menstrual bleeding and pelvic pressure or pain. These symptoms can lead to anemia or frequent urination, prompting treatment discussions. While a hysterectomy—the surgical removal of the uterus—provides a definitive cure, it is not the mandatory first step for managing fibroids, as less invasive alternatives exist.
Managing Fibroid Symptoms Without Surgery
Treatment often begins with managing symptoms through medication. Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used to reduce menstrual pain and decrease blood flow by inhibiting the body’s production of prostaglandins. Hormonal therapies are also effective in controlling heavy bleeding by minimizing the growth of the uterine lining.
Combined oral contraceptives and progestin-only therapies, including the hormonal intrauterine device (IUD), are frequently prescribed to regulate the menstrual cycle and reduce blood loss. For temporary fibroid shrinkage, gonadotropin-releasing hormone (GnRH) agonists and antagonists can be used. These medications suppress estrogen production, inducing a temporary, reversible menopause-like state that reduces fibroid volume and can help improve anemia before a planned procedure.
For women seeking non-surgical, uterus-sparing procedures, Uterine Fibroid Embolization (UFE) is a common option performed by an interventional radiologist. This procedure involves injecting tiny particles into the uterine arteries that supply blood to the fibroids, effectively blocking the blood flow. This causes the fibroids to shrink and die, which reduces symptoms like heavy bleeding and bulk-related pressure.
Radiofrequency Ablation (RFA) is another minimally invasive technique that uses heat energy to destroy fibroid tissue. During RFA, a needle-like device is guided into the fibroid to deliver radiofrequency energy, either laparoscopically through the abdomen or transcervically through the vagina. The heat causes the tissue to coagulate and shrink over the following months. Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is a non-invasive variation that uses high-intensity sound waves to destroy the fibroid tissue from outside the body, preserving the uterus without incisions.
Uterus-Sparing Surgical Approaches
When non-surgical management is insufficient, a myomectomy—the surgical removal of fibroids while leaving the uterus intact—is the preferred option for patients who wish to retain their fertility. The surgical approach depends on the location, size, and number of the fibroids. The primary goal is the removal of symptomatic fibroids and the reconstruction of the uterine wall to maintain function.
Abdominal Myomectomy
An abdominal myomectomy, or open surgery, is typically performed for women with very large or numerous fibroids, especially those deep within the uterine wall (intramural). This approach requires a larger incision in the abdomen, allowing the surgeon to access and remove the fibroids. Although more invasive, it is often the most comprehensive method for complex cases.
Laparoscopic and Robotic Approaches
For smaller or fewer fibroids located on the outside of the uterus (subserosal), a laparoscopic or robotic-assisted approach is used. These minimally invasive techniques use small incisions and specialized instruments to remove the growths, resulting in less post-operative pain and a quicker recovery time compared to open surgery. Robotic assistance provides the surgeon with enhanced visualization and greater dexterity for suturing.
Hysteroscopic Myomectomy
Fibroids that project into the uterine cavity (submucosal) can often be removed using a hysteroscopic myomectomy. This technique involves inserting a slender instrument through the cervix and into the uterus, eliminating the need for abdominal incisions. Hysteroscopy is an excellent option for preserving fertility and has a very short recovery period.
Determining the Necessity of Hysterectomy
A hysterectomy remains the only permanent cure for fibroid symptoms. The necessity of this procedure arises when less invasive medical and surgical options have failed to provide adequate or lasting relief, especially if severe heavy bleeding or pressure significantly impairs a patient’s daily life.
Hysterectomy is often recommended when fibroids are extremely large, too numerous, or diffusely spread throughout the uterus, making a myomectomy complicated or unsafe. In these cases, the risk of excessive bleeding or scarring during a myomectomy can outweigh the benefits of preserving the uterus. It may also be the most appropriate choice if there is concern that the growth could be a leiomyosarcoma, a cancerous tumor.
The decision to proceed with a hysterectomy is a shared one between a patient and her healthcare provider. For women who have completed childbearing and desire a definitive end to their symptoms, a hysterectomy offers a final solution. The severity of symptoms, rather than the size of the uterus alone, should be the primary factor in determining the necessary course of action.