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Uterine fibroids are almost always benign, but the debilitating symptoms experienced by an estimated 30% of women with fibroids can feel far from it. The nature and severity of fibroid symptoms depends on the size, and/or classification (submucosal, subserosal, intramural, or pedunculated) of the fibroids: common symptoms include abnormally heavy uterine bleeding, pelvic pain and bloating, abdominal pressure, urinary frequency, and constipation. A variety of surgical options are available to eliminate the tumors; for many women, however, the first step in addressing their condition is to seek relief of the symptoms through pharmacological treatments.

How Hormone Therapies Work

The majority of pharmacological products used to treat uterine fibroids do so by acting on the body’s hormonal balance. Research has shown that fibroid growth is fueled by hormones, specifically the hormones estrogen and progesterone. By directly or indirectly altering the levels of these hormones in the body, hormonal therapies can reduce the severity of fibroid symptoms like heavy bleeding and potentially shrink or inhibit the growth of fibroids. Approved hormonal therapies include GnRH agonists, oral contraceptives, progestins, aromatase inhibitors (AI), and other hormone-suppressing drugs like mifepristone.

Gonadotripin-releasing hormone agonists (GnRH-a) suppresses the body’s production of estrogen, creating a post-menopausal degree of estrogen deficiency. GnRH-a therapy has proven effective in both shrinking fibroids and managing symptoms like heavy bleeding. However, these effects are not sustained after discontinuing treatment. Use of GnRH agonists carries certain serious long-term health risks, including bone loss. Furthermore, because GnRH-a therapy essentially pushes the body into a menopausal state, women undergoing the treatment experience menopausal symptoms like hot flushes, vaginal dryness, weakness and fatigue, mood swings, and lowered libido. The negative effects of GnRH-a therapy can be countered by supplemental hormone treatments, but its associated health risks make GnRH agonists appropriate only for short term use, typically no longer than 6 months. Perhaps its most useful clinical application is rapidly shrinking large fibroids in preparation for surgical removal.

Oral contraceptives and progestins can be used for symptom relief, but their ability to reduce fibroid size is still uncertain. Studies have shown improvement in abnormal uterine bleeding with oral contraceptives. Drugs in this category, including lynestrenol, dienogest, and norethisterone, are considered relatively safe, and their low cost combined with potential benefit make them a promising choice for some women. However, women with pressure symptoms may not experience relief with oral contraceptives and progestins since they do little to shrink the fibroids or provide relief of bulk symptoms.

Aromatase inhibitors (AIs), part of a class of drugs known as anti-oestrogens, suppress the activity of the enzyme aromatase, which is responsible for the conversion of androgens into estrogens. Studies have suggested that use of AIs could inhibit fibroid growth and eliminate the need for surgery; however, further research has failed to provide sufficient evidence of this effect. Research surrounding the usefulness of AI’s in treating uterine fibroids continues, but in the meantime, the treatment is still considered experimental.

Mifepristone, a drug formerly known as RU486, belongs to a class of drugs known as progesterone receptor antagonists. As the category name implies, the drug acts on progesterone receptors. Mifepristone has proven effective in reducing uterine volume, thereby reducing blood loss and relieving related “bulk symptoms” like pelvic and lower back pain, abdominal pressure, and urinary frequency. The side effects of mifepristone are similar to GnRH-a therapy’s menopausal symptoms: hot flushes, mood swings, fatigue, and decreased libido are common, as well as headache, nausea, and diarrhea. In clinical trials, endometrial hyperplasia, a thickening of the uterine lining that creates a potential cancer risk, frequently resulted from mifepristone use. Due to a lack of data related to the safety outcomes of mifepristone use, the drug is not indicated for long-term use.

Comparing Pharmacological Treatment Options

How do these various hormonal therapies compare in terms of effectiveness? Comparative study data is still somewhat limited. One study compared the oral progestin lynestrenol with leuprolide, a GnRH agonist, and found no significant difference in their effectiveness for relieving pelvic pain and heavy bleeding. A separate, randomized clinical trial compared the GnRH agonist triptorelin with an aromatase inhibitor called letrozole, and revealed similarly significant decreases in fibroid volume (33% and 45%, respectively) with both therapies. In the latter study, however, none of the women treated with the aromatase inhibitor reported experiencing hot flushes, whereas 96% of the women taking a GnRH-a did. All of the approved hormonal therapies have shown some degree of effectiveness in treating fibroid-related symptoms; what determines their relative usefulness is predominantly the patient’s unique health history, as well as the nature and severity of each drug’s known side effects.

Limitations

While the available treatments vary in their mechanism for altering hormone levels, the hormonal therapies have a common limitation: they are not meant for long-term use. Clinical studies have consistently associated safety concerns with continued use of hormonal therapies in the treatment of fibroids. For many women, however, pharmacological treatments are an appropriate first step in addressing symptomatic fibroids. When symptoms persist and fibroids continue to impact a woman’s quality of life after trying a pharmacological treatment, a surgical approach would be an appropriate next step. For women concerned about the invasiveness of surgery, or the potential harm to the uterus that a procedure like hysterectomy entails, less invasive surgical options are worth consideration. Minimally invasive, uterine-sparing fibroid treatments like the Acessa Procedure offer a quicker recovery then major surgeries like hysterectomy, while providing the longstanding results that pharmacological therapies cannot.

 

SOURCES:
Levy, B. S. “Modern Management of Uterine Fibroids”, ACTA Obstetricia et Gynecologica, 2008, pp. 812-823

Song, H. et al. “Aromatase inhibitors for uterine fibroids”, Cochrane Database for Systematic Reviews/Cochrane Library, Oct 23, 2013. Web: http://onlinelibrary.wiley.com/enhanced/doi/10.1002/14651858.CD009505.pub2. Retr: Aug 1,2015

 

 

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Fibroids, also known as leiomyomas, are estrogen-dependent. As a result, they typically grow and present symptoms during a woman’s reproductive years, when the ovaries are active. Once the ovaries stop naturally producing estradiol (estrogen)—usually in her mid-50’s— a woman is said to have entered menopause. Logically, the drop in estrogen production that occurs in menopause would cause any uterine fibroids to gradually shrink, and this is typically the case. Fibroids and their accompanying symptoms often diminish after menopause. But what if they don’t?

There are a number of reasons why a woman would continue to have difficulty with a fibroid tumor during this stage of her life: stimulation from exogenous estrogen production (i.e. hormone replacement therapy), cancerous tumors, or malignant uterine/fibroid changes are a few possible causes.

Hormone replacement is commonly prescribed for menopausal women to reduce the uncomfortable symptoms that result from estrogen-deficiency, including hot flushes, vaginal dryness, mood fluctuations, and reduced desire for sex. Estrogen deficiency can also compromise bone health, increasing the risk of fractures; adding supplemental estrogens back into the body can help maintain a woman’s bone strength after menopause.

Replacing estrogen with hormone therapy can drastically increase the quality of life for many women in menopause. However, the risks of hormone replacement can sometimes outweigh the benefits, the recurrence or worsening of fibroid symptoms being one example. Dr. Donald Galen, OB-GYN and former Surgical Director at the Reproductive Science Center of the San Francisco Bay Area explains, “if fibroids are present, the addition of estrogens will generally stimulate fibroid growth, or minimize fibroid regression which otherwise would occur during natural menopause.” A study by Lamminen et al. that compared the activity of fibroids in pre- and post-menopausal women found just that: proliferative activity was low in the post-menopausal subjects who weren’t receiving hormone replacement, whereas those women who were receiving hormones had “fibroid proliferative activity equal to premenopausal women”. Dr. Galen also advises patients of other risks related to hormone therapy, as well. He explains, “estrogen can increase health risks, such as an increased risk of blood clots, increased risk of breast hyperplasia/cancer, and increased risk of endometrial hyperplasia and/or endometrial cancer.”

Hormone replacement therapy isn’t the only reason women see a persistence in fibroid symptoms after menopause. Malignant changes in existing fibroids or the emergence of new, cancerous tumors (“neoplasia”) on the uterus or reproductive organs can produce symptoms like those of benign leiomyomas.  Dr. Galen advises, “as a precaution, any woman with an increase in uterine growth/size and/or post-menopausal uterine bleeding should be evaluated to rule-out malignant uterine/fibroid changes.”

 

 

SOURCES:

Burbank, Fred. Fibroids, Menstruation, Childbirth and Evolution: The Fascinating Story of Uterine Blood Vessels. Tucson, AZ: Wheatmark, 2009. 93. Print.

Lamminen, S. et al.”Proliferative activity of human uterine leiomyomacells as measured by automatic image analysis”,Gynecologic and Obstetetric Investigation. 1992; 34:111-114

 

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shutterstock_325530068Fibroids are the most common type of pelvic tumor among women of reproductive age. Despite their prevalence, however, fibroids are widely misunderstood. A number of popular misconceptions, in particular, create confusion for women with fibroids who are trying to understand their condition and treatment options. To clear up some of this confusion, we’re breaking down five of the most common myths surrounding fibroids.

 

MYTH: If you have fibroids, you will experience symptoms like heavy menstrual bleeding and pain.
As common as the condition is, researchers estimate that between 50-80% of women with fibroids will experience no fibroid symptoms at all. Many women with asymptomatic fibroids never even know that they have the condition. And, because fibroid tumors are almost always benign, women who aren’t experiencing symptoms may opt to forgo treating their fibroids.

MYTH: A routine ultrasound will detect any uterine fibroids that are present.
If fibroids are suspected, the first diagnostic tool gynecologists employ to confirm the suspicion is transvaginal ultrasound. However, this imaging method doesn’t always reveal all existing fibroids. The size and location of uterine fibroids varies greatly, and extremely small fibroids, submucosal fibroids, and small fibroids that are hidden behind larger tumors, aren’t always detectable through a routine pelvic ultrasound. For clearer visualization of the tumors, physicians frequently rely on laparoscopic ultrasound, which requires inserting a scope through the vagina and into the abdominal cavity provides. Research has shown that laparoscopic ultrasound can detect up to twice as many fibroids as transvaginal ultrasound.

MYTH: Fibroid tumors will become cancerous.
Uterine fibroids, also known as leiomyomas, are almost always benign: in women of reproductive age, less than 0.01% of (removed) fibroids become cancerous. While fibroids typically shrink after menopause, those that do appear in post-menopausal women may be the cancerous type, called leiosarcomas. It’s important to note, however, that – regardless of age – simply having fibroids does not increase a woman’s chances of developing cancer in her reproductive organs.

MYTH: Endometrial ablation is a method of treating fibroids
Endometrial ablation (EA) is a commonly used to treat abnormal uterine bleeding. The technique entails destroying the layer of tissue that lines the uterus known as the endometrium, preventing new tissue from growing and thereby reducing or eliminating menstrual bleeding. While you may have heard EA discussed in the context of fibroids, it is not, in fact a fibroid treatment. The destruction of fibroids that can occur with EA is incidental, and is not likely complete. In such cases, the ablated fibroids will often regrow, since subserosal fibroids – the type that grow inside the uterus and are therefore subject to destruction during EA – often originate below the endometrium layer.

MYTH: If left untreated, fibroids will continue to grow throughout a woman’s lifetime.
Fibroid growth is fueled by estrogen. Accordingly, fibroids will grow and shrink in response to the body’s hormone fluctuations. Pregnant women often experience rapid growth in existing fibroids and may develop new fibroids during pregnancy, due to the heightened levels of estrogen that their bodies are producing. Conversely, fibroids typically shrink after menopause, because the ovaries have stopped producing estrogen. (Post-menopausal women undergoing hormone replacement therapy can expect the opposite to occur, however, since they are artificially replacing the missing estrogen.) Although fibroids do tend to disappear naturally after menopause, pre-menopausal women who are suffering with symptoms of uterine fibroids may not want to wait.

When fibroids are interfering with the quality of life, it’s advisable to discuss treatment options with a gynecologist. With a plethora of treatments available to women with fibroids, including uterine conserving methods like Acessa Procedure, it’s not necessary to endure long-term suffering!

 

SOURCES:

American Society for Reproductive Medicine, “What Are Fibroids? Fact Sheet”, Resources, ReproductiveFacts.org: rev. 2012. Retrieved Aug 26, 2015, from http://www.reproductivefacts.org/FACTSHEET_What_are_Fibroids/

Levine, D.J. et al. “Sensitivity of Myoma Imaging Using Laparoscopic Ultrasound Compared With Magnetic Resonance Imaging and Transvaginal Ultrasound”, Journal of Minimally Invasive Gynecology. Nov/Dec 2013; Vol 20(6): 770-4

Burbank, Fred. Fibroids, Menstruation, Childbirth and Evolution: The Fascinating Story of Uterine Blood Vessels. Tucson, AZ: Wheatmark, 2009. 135. Print.

 

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