Uterine fibroids are the most common benign tumors in the female reproductive system, which are formed by the abnormal proliferation of uterine smooth muscle cells. Clinically, common symptoms include uterine bleeding, breast distension and pain, dull pain in the lower abdomen, compression symptoms of adjacent organs, increased leucorrhea, infertility, and anal distension. The treatment of uterine fibroids depends on various factors, such as the patient's age, presence or absence of symptoms, location, size, growth rate and number of fibroids, the degree of uterine deformation caused, whether to retain fertility, and the patient's willingness. There are several treatment methods as follows.
Expectant Management for Uterine Fibroids
If the fibroids are small, asymptomatic, free of complications and degeneration, and have no impact on health, expectant management can be adopted. For perimenopausal patients without clinical symptoms, it is considered that the fibroids may shrink or regress after the decline of ovarian function. In the above cases, expectant management can be taken, that is, regular follow-up and observation (once every 3 to 6 months) in terms of clinical and imaging aspects. The treatment plan will be determined according to the re-examination results.
Usually, fibroids will shrink naturally after menopause, so no surgical treatment is needed. However, if a fibroid patient is over 40 years old and may be several years away from menopause, surgical treatment can also be considered. But before surgery, drug conservative treatment can be carried out first; if the drug is effective, surgery can be temporarily avoided. It should also be noted that in a few postmenopausal women with fibroids, the fibroids do not shrink but increase instead, so follow-up should be strengthened. Dr. Emma Wilson, a gynecologist specializing in reproductive diseases, reminds that regular re-examination is crucial for patients receiving expectant management to timely detect changes in fibroids.
Drug Treatment for Uterine Fibroids
There have been many new advances in drug treatment for uterine fibroids, which mainly aim to shrink fibroids, relieve symptoms, and avoid or delay surgical intervention.
Indications for Drug Treatment
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Young patients who wish to retain fertility. For infertility or abortion caused by fibroids during childbearing age, drug treatment can shrink fibroids to promote conception and ensure the survival of the fetus.
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Pre-menopausal women with small fibroids and mild symptoms. After drug application, the uterus will shrink and menopause will occur, and the fibroids will shrink accordingly, thus avoiding surgical treatment of uterine fibroids.
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Patients with surgical indications but with contraindications that need to be treated before surgery.
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Patients with internal or surgical diseases who cannot tolerate surgery or are unwilling to undergo surgery.
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Before choosing drug treatment for uterine fibroids, diagnostic curettage and endometrial biopsy should be performed to rule out malignant changes, especially for patients with irregular menstruation or increased menstrual volume. Curettage has both diagnostic and hemostatic effects.
Surgical Treatment for Uterine Fibroids
In the past, the age for hysterectomy and adnexectomy in fibroid patients was set at over 45 years old. Now, it is necessary to proceed from reality, especially according to the progress of gynecological endocrinology. The age for retaining ovaries is generally set at 50 years old (the average age of menopause is 49.5 years old), that is, for patients under 50 years old, ovaries should be retained if possible. Or normal ovaries of patients over 50 years old who have not yet menopause should also be retained, not based on age. Because normal ovaries still have certain endocrine functions after menopause and will work for another 5 to 10 years. Retaining ovaries helps stabilize the autonomic nervous system, regulate metabolism, and facilitate the transition to old age. The uterus also has its endocrine function; it is a target organ of the ovaries and should not be removed casually. Usually, the age for hysterectomy is set at over 45 years old; for patients under 45 years old, especially under 40 years old, myomectomy is preferred. For those who retain adnexa, if both sides can be retained, retaining both sides is better than retaining only one side. The incidence of ovarian cancer in patients with retained ovaries is 0.15%, which is not higher than that in patients without hysterectomy.
Myomectomy
Myomectomy is an operation to remove fibroids from the uterus while retaining the uterus. It is mainly used for patients under 45 years old, especially under 40 years old. This operation is not only performed for infertile women without children, but also for those who already have children but have large fibroids (diameter greater than 6cm), excessive menstrual volume ineffective to conservative drug treatment, compression symptoms, submucosal fibroids, or rapidly growing fibroids. Myomectomy should also be performed for physical and mental health. As for the number of fibroids, it is usually limited to less than 15. For those who are eager to have children, even if the number of fibroids is more, even more than 100, there are cases of successful pregnancy after myomectomy. The maximum number of myomas removed in a single operation by Dr. Michael Brown, a well-known gynecological surgeon, is 116.
Myomectomy is contraindicated if the fibroids are malignant, accompanied by severe pelvic adhesions (such as tuberculosis or endometriosis), or if the cervical cytology is highly suspected of malignancy.
For patients undergoing myomectomy, it is best to have a pathological examination of the endometrium before surgery to rule out precancerous lesions or cancer of the endometrium. During the operation, attention should be paid to whether the fibroids have malignant changes; if suspected, rapid section examination should be performed.
For abdominal myomectomy, to prevent abdominal adhesions after surgery, the incision on the uterus should be on the anterior wall, and as few incisions as possible should be made to remove as many fibroids as possible from one incision. Penetration of the endometrium should also be avoided as much as possible. The incision should be thoroughly hemostatic, and no dead space should be left when suturing the incision. At the end of the operation, the uterine incision should be peritonealized as much as possible. For submucosal fibroids that have protruded into the cervix, the fibroids can be removed transvaginally; excessive traction should be avoided during removal to prevent damage to the uterine wall. For those not protruded, they can also be taken out by opening the uterus abdominally. Postoperative treatment should include hemostatic drugs and antibiotics; unpregnant patients should use contraception for 1 to 2 years; future pregnancy should be alert to uterine rupture and placenta accreta, and selective cesarean section should be performed at full term. There is a possibility of recurrence after myomectomy, so regular examination is necessary.
Hysterectomy
If expectant management and drug therapy cannot improve the patient's symptoms, and the patient who needs surgery does not meet the criteria for myomectomy, hysterectomy should be performed. Hysterectomy can be total hysterectomy or supravaginal hysterectomy. Hysterectomy is mainly performed abdominally; in individual cases where the tumor is small, there is no inflammatory adhesion of the adnexa, the abdomen is too obese, or there is eczema on the abdominal wall, transvaginal hysterectomy can be considered.
The advantages of abdominal hysterectomy are: simpler technical operation than transvaginal hysterectomy, less bleeding; it is easier to handle large fibroids and adnexal adhesions. The disadvantage is that if there is rectocele or vaginal wall relaxation, additional vaginal surgery is often needed.
Complex cases such as cervical and broad ligament fibroids lead to anatomical variations and severe adhesions of pelvic organs (ureter, bladder, rectum, large blood vessels, etc.), and difficult exposure during surgery, which bring great difficulties to the operation. These problems can be referred to gynecological surgery monographs.
Severe anemia secondary to bleeding caused by large submucosal fibroids is generally treated with surgery (simple myomectomy or hysterectomy) after blood transfusion to improve the patient's condition. However, in remote rural areas, blood sources are sometimes lacking, bleeding does not stop, and the patient is not suitable for moving. If the cervix is dilated and the fibroids have protruded outside the cervix or near the vaginal opening, the fibroids should be removed transvaginally, which is often more helpful for hemostasis and improving the general condition.
Total hysterectomy is generally advocated, especially for patients with severe cervical hypertrophy, laceration or erosion. However, if the patient's general condition is poor and technical conditions are limited, subtotal hysterectomy can also be performed, and the incidence of stump cancer is only about 1% to 4%. But regular examination should still be performed after surgery.
Focused Ultrasound Ablation for Uterine Fibroids (Key Introduction)
Focused Ultrasound Ablation (FUA) is a minimally invasive, non-surgical treatment technology that has developed rapidly in recent years and has become an important alternative to traditional surgery and drug treatment for uterine fibroids. It uses high-intensity focused ultrasound waves to converge on the fibroid tissue through the skin and abdominal wall without damaging the surrounding normal tissues, generating high temperature (60-100℃) in the target area to ablate and necrose the fibroid cells, so as to achieve the purpose of reducing or eliminating fibroids.
Compared with traditional treatment methods, FUA has obvious advantages: first, it is non-invasive, leaving no surgical incisions on the body, avoiding the risks of infection, bleeding and adhesion caused by surgery, and the patient's recovery speed is significantly faster, usually able to be discharged from the hospital 1-3 days after treatment. Second, it can effectively retain the uterus and ovarian function, which is especially suitable for young patients who wish to retain fertility. Third, the treatment process is relatively comfortable, and most patients can complete the treatment under local anesthesia or mild sedation without severe pain. Fourth, it has good curative effect; after treatment, the volume of fibroids can be significantly reduced, and clinical symptoms such as menstrual abnormalities and abdominal pain can be effectively relieved. According to clinical data, the effective rate of FUA in treating uterine fibroids is over 90%.
Indications for FUA include: patients with uterine fibroids with diameters of 2-10cm; patients who wish to retain fertility; patients who cannot tolerate or are unwilling to accept traditional surgery; patients with recurrent fibroids after myomectomy. Contraindications include: patients with malignant tumors of the uterus or ovaries; patients with severe heart, liver, kidney and other organ diseases; patients with coagulation dysfunction; pregnant or lactating women; patients with metal implants in the pelvic cavity.
Dr. Sophia Carter, an expert in minimally invasive gynecology, points out that FUA has become a preferred minimally invasive treatment for many patients with uterine fibroids due to its advantages of non-invasiveness, quick recovery and preservation of fertility. However, patients need to undergo a comprehensive examination before treatment to evaluate the size, location and nature of fibroids, so as to determine whether they are suitable for FUA treatment. Regular re-examination is also required after treatment to monitor the shrinkage of fibroids and the recovery of the uterus.