There are four main treatments for uterine fibroids: expectant therapy, drug therapy, surgery and radiation therapy. The specific treatment depends on the patient’s age, symptoms, location, size, growth rate, number of fibroids, deformation of the uterus, whether to preserve fertility and the patient’s wishes.
I. Expectant therapy
It is suitable for those who have small fibroids, no symptoms, no complications and no degeneration, and no impact on health. For perimenopausal patients without clinical symptoms, considering the possibility of myoma regression or shrinkage after ovarian dysfunction. All of the above cases can be treated expectantly, i.e., regular follow-up observation (once every 3-6 months) in clinical and imaging terms. Their management will be decided based on the review.
Usually, leiomyomas regress naturally after menopause and therefore do not require surgical management. However, patients with leiomyosarcoma who are over 40 years old and may still have a few years before menopause can be considered for surgery. However, conservative medication can be used before surgery, and those with effective medication can also be treated without surgery. It should also be noted that in postmenopausal women with leiomyoma, there are a few patients whose leiomyoma does not shrink but increases in size, so follow-up should be strengthened.
Drug treatment
The basis of drug treatment is that uterine fibroids are sex hormone-dependent tumors, so drugs that antagonize sex hormones are used to treat them. The newly applied drugs are those that temporarily suppress the ovaries.
Danazol and cotton wool are commonly used drugs in China. Other androgens, progestins and vitamin drugs are also used. Studies since 1983 have reported the successful reduction of uterine smooth muscle tumors with the application of gonadotropin-releasing hormone analogs (GnRHa). Studies have shown that GnRHa indirectly reduces gonadotropin secretion at the pituitary level, thereby effectively suppressing ovarian function, a phenomenon known as “downregulation”.
(I) Indications for drug therapy
1. Young people who want to preserve their reproductive function. In case of infertility or miscarriage due to fibroids at the reproductive age, drug therapy can make the fibroids shrink and promote conception and fetal survival.
2.Uterine fibroids less than 2-2.5 months pregnant uterus, light symptoms, near menopausal age, after the application of drugs to make the uterus atrophy menopause, fibroids then shrink and avoid surgery.
3.Large fibroids and the requirement of preserving the reproductive function, avoiding the uterus too large, too many incisions.
4.Women aged 45 to 50 years old with fibroids causing excessive menstruation and anemia can be considered for surgery, but are unwilling to have surgery.
5.Larger fibroids are prepared to be removed by cathodic or laparoscopic or hysteroscopic surgery.
6, before surgical removal of the uterus to correct anemia, to avoid intraoperative blood transfusion and the resulting complications.
7.Patients who have indications for surgery, but currently have contraindications that require treatment before surgery.
8.Patients with combined medical or surgical diseases who are not capable of surgery or unwilling to operate.
Before choosing drug treatment, it is advisable to do diagnostic scraping for endometrial biopsy to exclude malignant changes, especially for menstrual disorders or increased menstrual flow. Scraping has both diagnostic and hemostatic effects.
(B) Contraindications to drug treatment
1.Fast growth of fibroids, malignant changes cannot be excluded.
2.Myoma degeneration and malignant change cannot be ruled out.
3.Submucosal fibroids have obvious symptoms and affect conception.
4.When the subplasmalemma myoma is twisted.
5.Myoma has caused obvious compression symptoms, or myoma occurred pelvic entrapment can not be reset, etc.
If drug treatment fails, if the symptoms cannot be reduced but worsened, or if malignant change is suspected, surgery should be performed.
Third, surgical treatment
The age of hysterectomy for patients with myoma was set at 45 years old or above. Now, it seems to be practical, especially according to the progress of gynecological endocrinology, the age of ovarian preservation is generally defined as 50 years old (the average age of menopause is 49.5 years old), that is, those who are within 50 years old and can preserve their ovaries should be preserved. Alternatively, normal ovaries of those who are not menopausal after the age of 50 should also be preserved, without drawing a line by age.
The reason is that normal postmenopausal ovaries still have some endocrine function and will work for another 5 to 10 years. Preserving the ovaries helps to stabilize the vegetative nerves, regulate metabolism, and facilitate the transition to old age. The uterus also has an endocrine role and is a target organ for the ovaries, which should not be removed casually. Usually, the age of hysterectomy is set at 45 years or older, and myomectomy is recommended for those under 45 years of age, especially those under 40 years of age. If the adnexa can be preserved bilaterally, it is better to preserve both sides than only one side. The incidence of ovarian cancer is 0.15% if the ovaries are preserved, which is not higher than that of those without hysterectomy.
1. Myomectomy
The uterus is incised, the fibroid is removed from the pseudo-envelope, and then the uterus is sutured. The uterus is preserved, so that the patient still has menstrual flow after surgery and the conception function of the uterus is preserved; the female internal reproductive organs and their blood supply and function are preserved. However, there is a recurrence of postoperative fibroids. For some patients, laparoscopic myomectomy can be performed as an option on a case-by-case basis.
Indications.
(1) Single or multiple uterine fibroids that affect fertility.
(2) Patients with uterine fibroids causing menstrual disorders, excessive menstrual flow, combined with anemia, large tumors, and need to preserve the reproductive function.
2.Total hysterectomy
It is the most traditional and classical surgical route for uterine fibroids. It is suitable for patients with any disease requiring uterine resection, especially those with cervical lesions, and can reduce the occurrence of cervical stump cancer. However, postoperative shortening of the vagina and relaxation of the pelvic floor ligaments may occur, such as painful intercourse.
Indications.
(1) Multiple uterine fibroids with uterus larger than 2.5 months gestation size and obvious symptoms.
(2) Older patients with uterine fibroids who do not require fertility.
(3) Combined cervical lesions requiring cervical resection.
(4) Patients with cervical fibroids.
(5) Patients with suspected malignant possibility.
Interventional treatment (uterine artery embolization)
Embolization of uterine fibroids is one of the vascular interventional techniques. Under the guidance of medical imaging equipment, the catheter is inserted into the anterior stem of internal iliac artery or uterine artery through percutaneous puncture and embolization for the purpose of treating uterine fibroids.
Indications: The key to interposition therapy for uterine fibroids lies in the abundance of blood supply within the fibroids, so the indications for UAE therapy should be determined through arterial OSA imaging, based on the blood flow typing within the fibroids. The degree of blood flow within the myoma can be initially assessed preoperatively by ultrasound or MRI.
Contraindications.
(1) The presence or absence of interstitial degeneration, calcification, or necrosis of the leiomyosarcoma; interventional treatment is not recommended in such cases.
(2) Myxoma sarcoma, clinical examination suggests the possibility of malignant transformation, surgical excision is the better choice, arterial intervention first and surgery later is appropriate.
(3) Interventional treatment is not recommended for subplasmatic leiomyosarcomas with tissues, broad ligament leiomyosarcomas, and leiomyosarcomas without abundant blood flow.
Side effects and complications.
(1) Common side effects after embolization: regurgitation of embolic agent, catheter displacement, misembolization, appendage thrombosis and pulmonary embolism, which may cause death in severe cases.
(2) Pelvic pain: due to severe degeneration and necrosis of uterine fibroids, post-embolization pain usually appears within 6-8 hours after surgery and can last for several days, and about 5%-10% of women have pelvic pain lasting up to more than 2 weeks. If there is no evidence of infection and the pain persists for more than 2-3 months, surgical treatment is required.
(3) Embolism syndrome: the incidence can be up to 40%, including lower abdominal pain, fever, irregular vaginal bleeding or increased vaginal discharge and nausea and vomiting, which is self-limiting and usually resolves on its own within 48 hours to 2 weeks with conservative and supportive treatment and often does not require antibiotics.
(4) Soreness and weakness of the lower extremities.
(5) Retention and drainage of necrotic tissue.
(6) Endometritis: rarely occurs and may be related to the presence of foci of infection in the endometrium of the patient before surgery. Intraoperative intra-arterial application of broad-spectrum antibiotics can effectively prevent it, but one should be alert to the possibility of septic death due to infection after embolization.
The most important causes of hysterectomy after uterine artery embolization are: infection, post-embolization pain, vaginal bleeding, and myoma prolapse. In addition to these common complications, some rare complications have been reported recently, such as permanent amenorrhea with endometrial atrophy after embolization therapy or incomplete bowel obstruction.
Interventional treatment of uterine fibroids is still in the exploratory stage, and its long-term efficacy and impact on ovarian function need to be observed in a large number of clinical follow-ups. Therefore, interventional treatment for uterine fibroids should be chosen with caution, especially for those with uncontrolled pelvic inflammation, those who wish to preserve their reproductive function, patients with arteriosclerosis and those who have their own contraindications to angiography, which should be listed as contraindications to this treatment.