Do you know what the most common noncancerous tumour in women is? The answer is #fibroids – growths that arise from the smooth muscle of the uterus. Many women are likely to experience them at some point during their reproductive lives; they are the most common pelvic tumour in women. Fortunately for some, fibroids come with only a few minor, if any, symptoms. But for others, they can cause an array of troubling problems from pressure and pain to heavy menstrual bleeding and even difficulties getting pregnant or miscarriage.
At one time, there were not a lot of options to treat symptomatic fibroids. A hysterectomy, or complete removal of the uterus, was the mainstay of fibroid management, and while it does ensure that fibroid symptoms will be resolved and won’t return, it is invasive surgery and prevents the possibility of any future pregnancies. As health technologies have advanced, the number of treatment options has increased, potentially allowing women to avoid surgery and preserve their fertility. But having so many options can make choosing a treatment difficult for both patients and their doctors.
If symptoms are absent or mild, a woman and her doctor might choose no treatment. Some women may choose drug treatment options, which often help with symptoms such as heavy bleeding but don’t directly treat the fibroids themselves. There is one medication available in Canada that specifically targets fibroids, called ulipristal acetate. It helps to improve fibroid-related symptoms such as heavy bleeding but is only used in women of reproductive age who are eligible for surgery, and the treatment is limited to three months. For many women with fibroids, a procedure that more directly addresses their fibroids as well as their symptoms will be needed. A hysterectomy is only one option; there are also a number of procedures now available that preserve the uterus. These include myomectomy (surgical removal of the fibroid but not the uterus), uterine artery embolization or occlusion (procedures that cut off the blood supply to the fibroid so that it shrinks and dies), myolysis (destruction of the fibroid and its blood supply with an electric current, laser, or radiofrequency), magnetic resonance-guided focused ultrasound (destruction of the fibroid with high-energy ultrasound, performed inside an MRI machine to precisely locate the fibroid), and endometrial ablation (destruction of the uterine lining using energy from an instrument inserted into the uterus, which reduces or eliminates menstrual bleeding). Each procedure has its own advantages and drawbacks. And many factors will need to be considered when choosing a treatment option, including the type, number and location of the fibroids; the desire for future pregnancies; the availability of the procedures; physician experience; the age of the patient; and which procedure is preferred by the patient.
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To help guide decisions about the procedures to treat fibroids, the health care community turned to #CADTH — an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures — to find out what the evidence says. CADTH gathered the evidence from medical research and compared the different procedures for symptomatic fibroid treatment with hysterectomy and with each other. They looked for evidence on how well the procedures worked, their safety, and whether they offered good value for their cost.
Evidence was found on myomectomy, uterine artery embolization, uterine artery occlusion, magnetic resonance-guided focused ultrasound, and radiofrequency volumetric thermal ablation (a type of myolysis). In general, when compared with each other, all of the procedures for fibroids that preserved the uterus were successful in reducing fibroid symptoms and improving the women’s quality of life. However there were some differences among the procedures — for example, uterine artery embolization reduces abnormal uterine bleeding better than myomectomy, but myomectomy improves “bulk” symptoms such as pain and pressure better than uterine artery embolization. When it comes to future fertility, the limited evidence shows that patients treated with myomectomy have better reproductive outcomes than uterine artery embolization, but more research on this is needed. Some other differences between the procedures in complication rates, length of hospital stay, and the need for future procedures for fibroids were also found.
When compared with conventional hysterectomy, the procedures to treat fibroids that preserve the uterus are associated with fewer complications, shorter hospital stay, and higher patient satisfaction. However, patients treated with hysterectomy report better quality of life related to their health. In the long term, procedures that preserve the uterus are linked to the possible need for future procedures or interventions to treat fibroids. This makes sense since women who have had a hysterectomy cannot develop another fibroid. But in women who still have their uterus, future problems with fibroids are still possible.
Overall, the evidence suggests that there is no one best procedure for the treatment of fibroids – one size does not fit all. However, the evidence taken together with the many other important considerations that go into making the treatment decision can help women and their doctors choose the procedure that is best for them.
If you’d like to learn more about CADTH’s project on the treatment of fibroids, visit www.cadth.ca/fibroids. And if you would like to learn more about CADTH and the evidence it has to offer to help guide health care decisions in Canada, please visit www.cadth.ca, follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: www.cadth.ca/contact-us/liaison-officers.