Therapy of fibroids

It is always advisable to consider pharmacological therapies before resorting to invasive methods such as surgery (especially uterine removal) or radiological procedures.

Medication treatment options are used to treat uterine fibroids.

1. Reduce bleeding,
2. Controlling pain,
3. stop the growth of the fibroids
4. and/or to reduce the size of the fibroids.

GnRH agonists (Gonadotropin Releasing Hormone agonists)

GnRH analogs are administered as an injection (e.g., leuprorelin, goserelin, or triptorelin) or as a nasal spray (buserelin), and they inhibit the overproduction of hormones in the pituitary gland. This leads to a hypoestrogenic situation and, clinically, to a reversible type of „transient menopause.“ The myocytes (muscle cells) shrink, the fibroids shrink, and the blood clotting strength rapidly decreases to the point of secondary amenorrhea (stop of bleeding). However, the estrogen deficiency also causes the corresponding vasomotor menopause symptoms such as hot flushes, sweats, and dry skin of the vagina, among others. The therapy is limited to 6 months without adding any additional medication.

Hormonal contraceptives and gestagens

Often, attempts are made to reduce symptoms such as bleeding intensity and menstrual pain with hormonal contraceptives (such as COC, hormonal spiral, 3-month injection) in the case of small myomas. These medications are not approved by the authorities for the treatment of myomas – therefore their use is considered an individual therapeutic attempt (also called off-label use) and is not usually reimbursed by health insurance companies. In cases of milder bleeding symptoms, the use as primary therapy can be attempted.

Experimental and complementary therapeutic approaches

In addition to the traditional methods of conventional medicine, acupuncture and homeopathy are also recommended. A study on the use of green tea extract was initiated at the Charité. The results are yet to be known.

Overview of the medication treatment options

Operative myom therapy

Generally, fibroids should only be treated if they cause symptoms. Asymptomatic fibroids are not treated unless there is a „cancer fear.“ They should be informed that different fibroid treatment options can affect fertility and the preservation of the uterus. In the past, the entire uterus was removed when diagnosing fibroids. Today, efforts are being made to preserve the uterus as much as possible. It may be helpful to treat the fibroids medicinally preoperatively. Nevertheless, fibroids are still one of the most common indications for a hysterectomy (uterine removal) today. Hysterectomy should only be performed on women with a securely completed family planning plan.

Removal of the myomas (myomucleation or myom resection)

In this surgical procedure, the polyps are removed individually; healthy tissue is avoided as much as possible. The uterus itself remains intact. One advantage is the continued fertility if there is still a desire for children. Myom enucleation can be performed in various ways:

• Laparoscopically (abdominal examination)
• Laparotomy (abdominal incision – possibly also mini-laparotomy) or
• As part of an operative hysteroscopy (without a cut in the uterus)

Whether a myomectomy can be performed must be assessed individually and depends on the location, size, and number of myomas.

Removal of the uterus (hysterectomy)

The removal of the uterus remains the most common surgical procedure for myom therapy. This operation is often performed from the vagina (vaginal) or via laparoscopy (laparoscopic). An open abdominal surgery (laparotomy), also called abdominal myomectomy, is nowadays rather rare, but may be necessary, for example, in the case of very large myomas.

The advantage of removing the uterus is that the patient is symptom-free afterwards, especially since the bleeding disorders have been eliminated, and no more fibroids can occur.

After the removal of the uterus, pregnancy can no longer occur. Therefore, this method is not suitable for women with current or future fertility issues. It is advisable to exhaust all other treatment options first.

Myomembolization or uterine artery embolization (UAE)

In uterine artery embolization (UAE), the blood vessels that supply the tumor are blocked. To do this, gelatin or plastic particles are injected into the uterine arteries through a catheter in the groin, thereby creating an artificial closure. This reduces or interrupts the blood supply to the tumors, and the tumors can no longer grow or shrink within a few weeks or months.

When can an UAE be indicated?

For female patients who are poorly suited for surgical procedures (including minimally invasive operations), e.g.:

1. High risk of surgery due to clotting problems or internal diseases
2. Significant obesity (BMI 40)
3. In the past, repeated surgical procedures have been performed in the lower and upper abdomen

When can NO UAE be administered (so-called contraindication)?

1. In case of fertility problems
2. During pregnancy

The procedure is generally performed by interventional radiologists. It is minimally invasive and effective in relieving symptoms. The fibroids can become smaller. The uterus is preserved.

Embolization can be associated with pain during and after the procedure, which is why good pain management is part of the treatment. Revascularization of the polyps is possible. In Germany, family planning should be completed, as ovarian function is affected and this can lead to infertility.

Magnetic resonance tomography-controlled focused ultrasound (MRgFUS)

By targeting ultrasound waves, the tumor can be heated to 55–90°C. Coagulation necrosis occurs. Subsequently, they are broken down by the body’s immune system within the following weeks and months. The duration of the treatment is approximately three to four hours. The therapy is performed on an outpatient or inpatient basis and is only applicable to selected tumor locations and tumors smaller than 10 cm in size. The costs are covered by only a few health insurance companies.

No data are available on the interaction between drug therapy and MRgFUS treatment.

When can no MRgFUS be performed (so-called contraindication)?

1. In case of fertility problems
2. During pregnancy
3. With more than 5 polyps
4. In the case of polyps with a diameter of over 10 cm
5. In case of contraindications to the contrast agent

Overview of other treatment options