Managing and treating uterine fibroids

The American Hospital of Paris is one of the only private hospitals in France to offer multidisciplinary care adapted to each patient. Specialists from our gynecology, radiology and interventional radiology units, and from our assisted reproduction technology unit where appropriate, meet to analyze each case and give a collective opinion.

The American Hospital of Paris offers the full range of treatments for uterine fibroids, including uterine fibroid embolization. Recent fertility-preserving techniques are combined with effective pain management thanks to the presence of an anesthesiologist dedicated to the patient. 

Uterine fibroids, also called myomas, leiomyomas or uterine myomas, are noncancerous tumors that grow in and around the uterus. They develop in one in four women, and their frequency increases with age. Black women are twice as affected as white women.

Despite its frequency, many women are unaware of this recurring hormone-dependent disorder, which can cause acute pelvic pain and impact quality of life, sexuality and fertility.

The exact causes of uterine fibroids remain unknown, although experts appear to agree that a hormone imbalance is a frequent contributing factor. Fibroids are roundish in shape and vary in size, with some growing as large as a melon.

There are three types of fibroid:

• Subserosal fibroids grow outside the uterus. Some, known as pedunculated subserosal fibroids, are attached to the uterine wall by a peduncle (a bundle of nerves and blood and lymphatic vessels that form a “stem”).
• Intramural fibroids grow within the muscular wall of the uterus (the myometrium). This is the most common type of fibroid.
• Submucosal fibroids grow inside the uterine cavity. This rarer type of fibroid can cause heavy bleeding, fertility issues and complications during pregnancy.

Only symptomatic fibroids should be treated. Despite their frequency, fibroids only cause symptoms in fewer than one-third of cases. Treatment is therefore not systematic.  Furthermore, fibroids go away on their own with the arrival of menopause.

Fibroids cause symptoms that vary based on fibroid location and size, but generally include pelvic pain, prolonged heavy periods or abdominal bloating.

Fibroids can also press on other organs, resulting in frequent urination, hemorrhoids or pain during intercourse. When fibroids are located in the uterine cavity, they can also cause infertility.

On average, two-and-a-half years go by between the onset of symptoms and the medical diagnosis. That is why it is important for women to be informed, in order to prevent symptoms from worsening and ensure prompt treatment.

A fibroid can be detected by a gynecologist during a clinical exam, but a transvaginal or transabdominal pelvic ultrasound is always necessary to confirm the diagnosis.

The ultrasound will determine the number of fibroids, their size and their location. The treatment will be determined based on the patient’s age, whether or not she would like to get pregnant, and the severity of her symptoms.

• In asymptomatic patients, medical surveillance is sufficient and no treatments are prescribed. In general, asymptomatic fibroids shrink after menopause.
   
• In symptomatic patients, medication may be prescribed to relieve symptoms or reduce the size of the fibroid. France’s national drug safety agency has nevertheless issued a warning about certain hormone therapies that have been linked to significant side effects and an increased risk of developing a meningioma. Medication can nevertheless be helpful before a surgical procedure, to reduce the size of the fibroids.
   
• When fibroids cause significant pain, bleeding or infertility, or when they are very large, a medical procedure is necessary. Several procedures are available; the most appropriate one will be determined based on the number and size of the fibroids and whether or not the patient wants to get pregnant. 
  • Surgical techniques: 
    • Myomectomy: This technique consists in removing the fibroids while sparing the uterus. It is used when subserosal or intramural fibroids are present in small numbers. Depending on fibroid size, the surgeon may perform a laparotomy (by opening the abdominal wall), laparoscopy (the fibroid is broken down into fragments which are then removed through small abdominal incisions) or a transvaginal procedure. A future pregnancy remains possible once the uterus has healed, but there is a 20 to 30 percent risk of fibroid recurrence. This risk is mainly associated with the presence of subserosal or intramural fibroids that are left in place.
    • Hysterectomy: This is the partial or total removal of the uterus. It is often indicated in the case of recurrent fibroids or submucosal fibroids. Pregnancy is no longer possible following a partial or total hysterectomy.
  • Uterine artery embolization: This procedure consists in blocking the uterine arteries that supply the fibroids by injecting microparticles under X-ray guidance. Blood no longer flows to the fibroids, which gradually shrink after the procedure, thereby alleviating symptoms. This minimally invasive procedure can be used on practically all types of fibroids, and the recurrence rate is lower than 10 percent.

The question of fertility plays a central role in the diagnosis and treatment of fibroids.
In fact, it is often during an infertility consultation that women discover the presence of one or more fibroids, which prevent the fertilized egg from implanting in the uterus. Fibroids can also complicate pregnancy and are a risk factor during childbirth. Pregnant women with a fibroid have a higher risk of miscarriage or premature delivery.

Whether or not a woman wants to become pregnant in the future therefore significantly influences her treatment pathway, which can directly impact a future pregnancy and childbirth. If a myomectomy is chosen for patients who wish to preserve their fertility, it is preferable to wait until the uterus has fully healed from the procedure (6 to 12 months) before trying to conceive. Depending on the size and position of the scar, a cesarean section may be recommended.

Based on current literature, uterine artery embolization can be neither recommended nor proscribed for patients who wish to become pregnant. Although reducing blood circulation in the endometrium, uterine wall and ovaries can lead to risks in terms of fertility, recent studies show that this risk is low, and many patients have carried their pregnancy to term after a fibroid embolization procedure.