ObGyn Matters Fibroid Fibroid Clinic aims to operate an outpatient clinic with a comprehensive patient centered approach to the care of women with fibroids. As in all areas of medicine the key to successful treatment of fibroids is in the careful selection of the right treatment for each individual patient. Patients have different needs and it is important that these are acknowledged and that treatment is centered round them.
The treatment that is offered is primarily to control symptoms and depends on the symptoms with which the woman presents.
If women are diagnosed with a fibroid by chance, perhaps on a routine ultrasound scan, then it may not be necessary to have any treatment. Medical treatments have not been shown to decrease the chance of the fibroid growing in the future. In these women regular monitoring is sufficient. This should involve a 6 monthly to yearly pelvic ultrasound scan.
For most women heavy periods are a significant feature. It is difficult for women to know how heavy their periods should be. But, if you are having to wear tampons and towels, bleed into your sheets at night, cannot go to work for 2 days a month or are becoming anaemic then you clearly have a problem.
With fibroids the bleeding is usually regular, may only be excessively heavy for one or two days a month and may also be painful. This bleeding is usually associated with bloating.
There are two approaches to controlling this problem.
Non-hormonal treatments include Tranexamic and Mefenamic acid. These two drugs sound very similar but are in fact quite different and work in completely different ways. They are normally taken together.
Tranexamic acid is an Antifibrinolytic. It reduces the amount of blood loss by making the blood in the womb clot better. It does not cause blood clots elsewhere. Mefenamic acid is a Non Steroidal Anti-inflammatory, which reduces the amount of blood flow during your period and also reduces inflammation and pain by affecting Prostaglandins.
These drugs may be sufficient to control periods and make them manageable. They have the advantage of only needing to be taken during the period and cause minimal side effects. They may be taken in combination with Hormones.
Hormonal treatments change the hormonal environment and can reduce the flow and limit how frequently the periods come.
The combined oral contraceptive pill may be used in younger women and can be used continuously, without a break, for three months at a time thereby reducing the number of priods to 4 a year. I also reduces blood flow but is only helpful in women with small fibroids.
Progesterones stop the menstrual blood flow altogether. When taken orally they need to be taken up to three times a day, everyday. As soon as the medications stops the bleeding resumes. Progesterones all cause side effects, which can include, mood changes, weight gain and greasy skin and acne. They are not a long-term solution but may be used temporarily whilst iron is given to treat anaemia. In Europe and North-America, Dinogest is commonly used. This is a powerful progesterone that is not yet licensed in the UK. It can only be sourced on-line.
Progesterone delivered using the Mirena coil may be used long term but is less effective with big fibroids and where the cavity is enlarged. Side effects may still occur but are less common. One draw back is that women with intra-cavity fibroids may experience, unacceptable,continuous spotting.
Hormonal treatments may also be used in preparation for surgery. Stopping the period allows the blood count to recover and treatments may also help to shrink the fibroids and reduce vascularity prior to surgery.
The most commonly used therapy is to make women Menopausal using GnRH analogues. These switch off your ovaries, stop ovulation and periods. The treatment effect is to shrink the fibroids. This treatment can only be given for short periods and the fibroids grow back with a vengeance once it is stopped. Alone, it is not a long-term solution to fibroids.
Ulipristal acetate (Esmya) is a different type of hormonal treatment. It works by modulating the progesterone receptors in the fibroid. This has been shown to permanently reduce the size of fibroids. We had hoped that this would be a ‘game changer’ in the medical treatment of fibroids. Unfortunately important side effects have become apparent with more widespread use. A rare complication of liver failure can occur, women have needed liver transplantation and some women have died. This had seriously limited our use of this drug and all women taking it must have regular blood tests to check liver function.
Relugolix is a new combination drug that has undergone recent long term trials for the treatment of fibroids. It consists of a GnRH antagonist combined with oestrogen and progesterone to mitigate side effects. this comes a s a single tablet that is taken daily. It normal takes a few weeks for bleeding to stop but then there is no further bleeding. the treatment allows women to recuperate their iron stores and also shrinks the fibroids by up to 70%. the treatment has few side effects and has been shown to be effective at 2 years. We do not have data beyond this. It is certainly a useful treatment in stabilising and shrinking the fibroids prior to surgical intervention and gives women a choice as to when they want to plan surgery.
Medical treatments may be effective in controlling symptoms. They have not yet been shown to reduce the size of fibroids in the long term, nor to limit their long-term growth potential. They are really effective in women with smaller and less troublesome fibroids.