Although the number of hysterectomies has been declining since 1987, this operation remains the second most frequently performed surgery in the U.S.; only cesarean section is performed more frequently. Fibroids remain the number-one reason for hysterectomy with 150,000 to 175,000 operations carried out each year because of fibroids.
Hysterectomy for uterine fibroids historically has been based on uterine size. Once the uterus reached the size that it would be in the 12th week of pregnancy it was considered time to perform a hysterectomy. The decision was based mainly on the fact that fibroids of such volume could shield the presence of uterine cancer. Without effective diagnostic procedures the medical community considered it safer to remove the uterus than to possibly harbor a growing malignancy. Now, however, improved imaging procedures such as ultrasound and magnetic resonance imaging (MRI) can effectively determine whether or not a rapidly growing tumor is present, reducing the number of hysterectomies performed. Therapy for uterine fibroids should be based on symptoms and not the idea that uterine fibroids will continue to grow until it becomes necessary to perform a hysterectomy.
If a fibroid is particularly troublesome, the surgeon often can remove only the tumor. leaving the uterus intact (leiomyomectomy).
This may leave the wall of the uterus weakened, in which case any pregnancy that occurs later most likely will be delivered by caesarean section. Many women with fibroids have successful outcomes of pregnancy with no undue incidence of miscarriage or other unfavorable outcome.
More and more, physicians are beginning to realize that uterine fibroids may not require any intervention or, at most, limited treatment. For a woman with uterine fibroids that are not symptomatic the best therapy may be watchful waiting. Some women never exhibit any symptoms or have any problems associated with fibroids, in which case no treatment is necessary. For women who experience occasional pelvic pain or discomfort, a mild, over-the counter anti-inflammatory or painkilling drug often will be effective. More bothersome cases may require stronger drugs available by prescription.
The fact that fibroids seemingly are estrogen-dependent has led to attempts to control them by reduction in available estrogen. Hormone-like agents that counter the action of gonadotropin-releasing hormone (GnRH) are being investigated as one such agent. The use of a GnRH agonist lowers blood levels of estrogen and reduces uterine volume by as much as 60 percent.
Of primary concern in the use of such agents is the possibility of increasing blood cholesterol levels and reducing bone density, which may lead to osteoporosis. Although only modest increases in blood cholesterol have been noted in women undergoing this treatment, the therapy itself was of short duration. Unfortunately, the uterus returned to its pre-treatment size within 3 to 6 months after GnRH agonists were stopped.
It would seem from these observations that the use of GnRH agonists is of limited application. But, in fact, defined protocols have been worked out for administration of these agents for use in women who have symptoms, are poor candidates for surgery, and are nearing menopause. Also, for patients needing a hysterectomy, the use of GnRH agonists can reduce uterine size considerably, making abdominal hysterectomy easier or even allowing a vaginal hysterectomy rather than an abdominal one.
Three GnRH agonists are currently available. Two must be given by injection and the third is administered by an inhaler. Side effects that have been found include hot flushes, depression, insomnia, decreased libido, and joint pain. Maximum uterine shrinkage is achieved after 3 months of therapy.
Studies have only just begun on the newest class of antihormonal agents, the antiprogestins, the best known of which is RU 486.* Even though fibroids appear primarily stimulated by estrogens, drugs in this class which oppose the other major female hormone, progesterone, also seem to be effective for treatment of uterine fibroids. Studies using these drugs are still in the early stages.**
* *Supported by San Diego Reproductive Medicine Educational and Research Foundation, and NIH Grant RR-00827
***Murphy, AA et al. Journal of Clinical Endocrinology and Metabolism Reproduced from the Natinal Institute of Child Health & Human Developement
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