Fibroid: What to Do When Fertility Is No Longer on Your Mind
If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some case) big uterine friend (s). They can be a big pain in the rear. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun.
Unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Simply stated, you are not the only person who RSVPed yes to the fibroid gala. While there are many ways to treat them, not everything works for everyone at every point in their life. Women at different stages of their lives (a.k.a. reproductive “stages”) and symptomology warrant different procedures. For those of you whose fertility ship has long since sailed and you are done and done, here’s what we recommend.
When babies are no longer on the brain, your options with regard to fibroid management (as well as where to go to dinner) are way more expansive. It no longer matters if they have crayons and serve you fast. You can do a lot with or to your uterus, if you don’t care if it functions for fertility purposes ever again. While you still have both medical and surgical options if you are totally fed up, going down the surgery path is a way to be totally done.
You still have medical options, and those include: oral contraceptive pills (a.k.a. “the pill”), the intra-uterine device (a.k.a. “the IUD”), Lupron (a.k.a. “I feel like I am in menopause with these hot flashes and vaginal dryness”), progesterone receptor modulators (mifepristone or ulipristal acetate), SERMs (raloxifene), aromatase inhibitors (letrozole), and anti-fibrinolytics. While some of the medical options are better at improving some of the symptoms (for example, OCPs will improve heavy bleeding but not the pressure symptoms), they very rarely fix it all.
Just like when selecting the OCP you want to “marry,” you may have to shop around the medical options before you land at your symptom-free spot. While Lupron (GnRH agonist) will do it all, it will cost you in the side effect department. Hot flashes, sleep problems, vaginal dryness, muscle and bone pains, and even changes in mood/thinking often come in conjunction with the reduction in fibroid bleeding, pain, and pressure. It’s because of the side effect profile that we don’t go with Lupron as our first medical treatment (and very rarely for women who are ready to wave goodbye to their fertility). It’s reserved for the fibroids that we don’t like in women who still want to give fertility a chance!
If having kids is no longer a consideration, surgically, you are no longer boxed into the myomectomy corner. While you can certainly elect to retain your uterus and just remove the fibroids (a.k.a. myomectomy), you can also go for broke and remove the whole uterus. By undergoing hysterectomy, you ensure that the symptoms are sayonara (even if you are not yet in menopause).
The approach for both a hysterectomy and a myomectomy can vary; the procedure can be performed abdominally through a bikini cut incision, laparoscopically through a camera, robotically through a robot (and small incisions), or vaginally (no explanation needed!). The approach depends on the size of the uterus and fibroid (s). If you are going for a myomectomy, the location and number of the fibroids also play a role. Lastly, your surgeon may have a bias and a preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.
Just as there are minor and major life decisions (dating vs. marriage, contraception vs. babies), there are minor and major surgeries. The majors, we described above; they require the big guns: anesthesia, intubation, hospital admission, and everything in between.
Minor procedures are still procedures but are much less involved. They can often be done in an office and under less paralyzing anesthesia, that is, no breathing tube. When it comes to fibroids, the minors we talk about in a major way include uterine-artery embolization (UAE) and endometrial ablation.
Our radiology friends perform UAE; they use some fancy catheters and particles (threaded from the groin to the uterus) to block off the uterine arteries (the blood supply to the uterus). By starving the uterus, they starve the fibroids. The fibroids shrink, and symptoms in most cases will resolve. While the uterus is not removed, we don’t recommend performing UAE in women who want to keep using their uterus. It can impact ovarian function and egg quantity. Endometrial ablation is also an option, particularly for women whose biggest gripe is bleeding. There are various devices and mechanisms to ablate the uterus (burn, freeze, microwaves, radio frequency), but essentially in all cases, the endometrium (uterine lining) is destroyed.
As with most things, there are pros and cons to all options. If you like lists (we love them!), here are the important points to note…For most women who have closed the kid chapter, the options are endless. You are not thinking with your fertility hat anymore! You can do whatever necessary to halt all symptoms. Based on your symptoms, the size of your fibroids/uterus, and your medical/surgical history, your OB/GYN will decide which route is the best to go.
Give their opinion a lot of thought, and seek out another one if you are on the fence so that you feel more than fine with your decision. News flash. If menopause is in the very near future, you may not need to do anything. Without postmenopausal hormone replacement therapy, fibroids will shrink, and symptoms will subside. Just make sure that your reproductive timeline matches up with your treatment timeline; in some cases, time will be on your side!
Fibroids are pretty pesky for most of us, but some women are completely unaware of their presence. They find out totally by accident during an ultrasound, a pelvic exam, or pregnancy. And just like if it isn’t broken don’t fix it, fibroids that are causing no symptoms are really no big deal. They can hang with you for as long as you both shall live. No divorce in sight. If they don’t bother you, don’t do anything with them until you have to. Prophylactic or preventative therapy to avoid future problems is not recommended (no pre-nup here!). Fibroids need to be fixed only if you can’t take them anymore. Otherwise, do your best to forget they even exist!
