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Uterine Fibroids Treatment and Care

Urology: Urinary & Reproductive Disease Diagnosis & Treatment

Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.

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Therapeutic Strategy: The Ladder of Intervention

Therapeutic Strategy: The Ladder of Intervention

The management of uterine fibroids at Liv Hospital is highly personalized. We adhere to a “patient-centered” philosophy in which treatment choice is guided by the severity of symptoms, the patient’s age, the size/location of the tumors, and, most importantly, her reproductive goals. The treatment spectrum ranges from expectant management to definitive surgery.

1. Watchful Waiting (Expectant Management)

For asymptomatic women or those with mild symptoms and small fibroids, active surveillance is the standard of care. Fibroids are benign, and treatment is not mandatory solely due to their presence. This involves annual pelvic exams and ultrasounds to monitor growth rates. Since fibroids naturally regress after menopause, many peri-menopausal women can be managed expectantly until their symptoms resolve naturally.

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2. Pharmacological Management

2. Pharmacological Management

Medications cannot “cure” fibroids (remove them), but they can manage symptoms, correct anemia, and temporarily reduce tumor volume.

  • Non-Hormonal Treatments:
    • Tranexamic Acid: An antifibrinolytic agent taken only during the days of heavy bleeding. It stabilizes the blood clots in the uterine vessels, reducing menstrual blood loss by up to 50%.
    • NSAIDs (Ibuprofen, Naproxen): These inhibit prostaglandin synthesis, reducing dysmenorrhea (cramps) and blood loss.
  • Hormonal Treatments:
    • Combined Oral Contraceptives (OCPs): They help regulate the cycle and reduce bleeding, but do not shrink fibroids.
    • Levonorgestrel-Releasing IUS (Mirena): An intrauterine device that thins the endometrium. It is highly effective for reducing bleeding in patients with small intramural or subserosal fibroids, but may be expelled if submucosal fibroids distort the cavity.
    • GnRH Agonists (Leuprolide/Lupron): These drugs induce a temporary, reversible “medical menopause” by suppressing the pituitary-ovarian axis. This halts estrogen production, causing amenorrhea (no periods) and shrinking fibroids by 30-50%. They are primarily used as a preoperative adjunct for 3-6 months to correct anemia and shrink the uterus before surgery. Long-term use is limited by side effects (hot flashes, bone density loss).
    • GnRH Antagonists (Relugolix, Elagolix): A newer class of oral medications that rapidly suppress hormones to manage heavy bleeding. They are often combined with “add-back” therapy (low-dose hormones) to minimize menopausal side effects, allowing for longer-term use.

3. Surgical Management: The Gold Standard

For symptomatic fibroids unresponsive to medication, or where fertility is compromised, surgery remains the definitive treatment.

Myomectomy (Uterine Preservation)

This is the surgical removal of fibroids (enucleation) while reconstructing and preserving the uterus. It is the procedure of choice for women who wish to conceive or preserve their uterus for personal reasons.

  • Robotic Myomectomy (da Vinci): Liv Hospital specializes in this advanced minimally invasive technique. The surgeon sits at a console controlling robotic arms.
    • Advantages: The system provides 3D high-definition visualization and wristed instruments with 7 degrees of freedom (greater than the human hand). This allows for precise dissection of complex, deep intramural fibroids and meticulous multi-layered suturing of the uterine defect. Strong suturing is critical to prevent uterine rupture in future pregnancies.
    • Outcome: Significantly less blood loss, reduced pain, and faster recovery compared to open surgery.
  • Laparoscopic Myomectomy: A standard minimally invasive “keyhole” surgery suitable for subserosal and accessible intramural fibroids.
  • Hysteroscopic Myomectomy: An incision-less procedure performed through the vagina. A resectoscope (a wire loop with electrical current) is used to shave submucosal fibroids (Types 0, 1, 2) from inside the cavity. It is the gold standard for treating fibroid-related infertility and bleeding.
  • Abdominal (Open) Myomectomy (Laparotomy): Reserved for cases with extensive disease (e.g., >20 fibroids), giant fibroids extending above the umbilicus, or when minimally invasive techniques are not feasible. It allows for tactile palpation to remove even the smallest nodules.

Hysterectomy (Definitive Cure)

The surgical removal of the uterus. It is the only treatment that guarantees 100% cure with zero risk of recurrence. It is an option for women who have completed their family and desire a permanent solution to bleeding and bulk symptoms.

  • Types: Can be Total (removing cervix) or Supracervical (keeping cervix). It can be performed Vaginally, Laparoscopically, Robotically, or Abdominally.
  • Ovarian Preservation: In premenopausal women, the ovaries are typically preserved to maintain hormonal function and prevent surgical menopause.

4. Minimally Invasive Interventional Radiology

  • Uterine Artery Embolization (UAE/UFE): A procedure performed by an interventional radiologist, not a surgeon. A catheter is threaded through the femoral or radial artery to the uterine arteries. Micro-particles (PVA or microspheres) are injected to block the blood flow specifically to the fibroids.
    • Mechanism: The fibroids, which are highly vascular, suffer ischemic infarction (death) and shrink by 40-60% over the following months. The normal myometrium recruits collateral blood supply and survives.
    • Indication: Excellent for women desiring uterine preservation who wish to avoid surgery and the recovery time of myomectomy.
  • Magnetic Resonance-guided Focused Ultrasound (MRgFUS): A non-invasive thermal ablation technique. High-intensity ultrasound waves are focused on the fibroid under MRI guidance, heating and destroying the tissue (coagulative necrosis) without incisions.
  • Radiofrequency Ablation (Acessa): A laparoscopic procedure where a needle electrode is inserted into the fibroid to destroy it with heat.

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FREQUENTLY ASKED QUESTIONS

Will fibroids grow back after a myomectomy?

Myomectomy removes clinically visible fibroids but does not alter the underlying genetic or hormonal drivers of the disease. Therefore, new fibroids can grow from microscopic seeds. The recurrence rate is approximately 15-30% over 5-10 years, with higher risks in younger women and those with multiple fibroids.

While pregnancy is biologically possible after UAE, data suggest it is associated with a higher risk of complications such as miscarriage, malpresentation, preterm birth, and postpartum hemorrhage compared to myomectomy. Therefore, surgical removal (myomectomy) is generally the preferred standard for women actively desiring future fertility.

The robotic system offers superior precision. In myomectomy, the most critical step is reconstructing the uterine wall. The robot allows the surgeon to suture with the same strength and precision as open surgery but through tiny incisions, combining the safety of a laparotomy with the recovery speed of laparoscopy.

 A hysterectomy removes the uterus, which stops menstruation and the ability to carry a child. However, if the ovaries are left in place (ovarian conservation), they continue to produce estrogen and progesterone, so the patient does not enter menopause until the natural age (around 51).

UAE is typically performed under local anesthesia and moderate sedation. The procedure itself takes about 60 to 90 minutes. However, patients usually require an overnight hospital stay for pain management, as the degeneration of the fibroids can cause significant cramping in the first 24 hours.

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