Several non-surgical treatments have emerged in recent years to manage the symptoms of uterine fibroids, particularly heavy menstrual bleeding. These advancements offer promising alternatives to traditional surgery.

1. Hormonal medications

   Injectable medications known as Gonadotropin-Releasing Hormone (GnRH) agonists, such as leuprolide (Lupron), goserelin (Zoladex), and triptorelin (Trelstar) are used to reduce fibroid size and control heavy bleeding. These medications are generally used as a temporary solution, typically for up to six months. However, fibroids often regrow after treatment is stopped. GnRH agonists are commonly administered before surgery to shrink fibroids, optimise pre-surgical conditions, and alleviate symptoms.

   More recently, GnRH antagonists such as elagolix, relugolix, and linzagolix have emerged as oral treatment options. These medications effectively manage heavy bleeding and can be used safely for up to two years, offering a longer-term solution with fewer side effects.

2. Uterine Artery Embolisation (UAE)

   Uterine Artery Embolisation (UAE) is a minimally invasive procedure that blocks the blood supply to fibroids, causing them to shrink. Studies have shown that UAE can significantly reduce heavy menstrual bleeding and pelvic pain. However, in some cases, symptoms may return over time, and additional treatments, such as myomectomy or even hysterectomy (removal of the uterus) may be required within two to five years following the procedure.

3. Microwave ablation

   Microwave ablation is a newer non-surgical treatment that uses microwave energy to destroy fibroid tissue. Early studies suggest it is both safe and effective in improving symptoms and quality of life. This treatment offers a promising alternative for women seeking options other than surgery. However, larger and longer-term studies are still necessary to fully assess its effectiveness and safety over time.

Dr Najwa, an Obstetrician and Gynaecologist, highlights that these non-surgical treatments have provided significant benefits for many women dealing with fibroids. "While each treatment has its limitations, these advancements offer alternatives that can help manage symptoms effectively and reduce the need for surgery," she explains.

Dr Najwa explains that there is a recognised association between uterine fibroids and infertility, although the exact mechanisms remain incompletely understood. Fibroids can alter the endometrial environment (the inner lining of the uterus), distort the shape of the uterine cavity, and impact uterine contractility, all of which can interfere with embryo implantation. Depending on their size and location, fibroids may also obstruct the fallopian tubes, which can disrupt the transport of sperm.

"Submucosal fibroids, which extend into the uterine cavity, are particularly known to reduce pregnancy rates and increase the risk of miscarriage," she adds. "In contrast, subserous fibroids, which grow on the outer surface of the uterus, typically do not affect fertility."

Treatment for fibroids in the context of infertility depends on their size, number, and location, with options ranging from surgical procedures, like myomectomy, to non-surgical treatments such as uterine artery embolisation (UAE) or high-intensity focused ultrasound (HIFU).

1. Surgery (Myomectomy)

   Myomectomy is a surgical procedure aimed at removing fibroids while preserving the uterus, making it a common option for women wishing to maintain fertility. The procedure can be performed via:

   • Hysteroscopy: For fibroids located inside the uterine cavity. It is particularly considered for women with submucosal fibroids who are facing infertility or heavy menstrual bleed.
   • Laparoscopy and robotic-assisted surgery: Minimally invasive surgery using small abdominal incisions. Recovery is generally faster and less painful compared to traditional open surgery.
   • Laparotomy (open surgery): For larger or more complex fibroids.

   Myomectomy is typically recommended for women with large fibroids or those experiencing significant symptoms that could interfere with pregnancy.

2. Uterine Artery Embolisation (UAE)

   UAE is a non-surgical procedure that blocks the blood supply to the fibroids, causing them to shrink. Although pregnancies have been reported following UAE, its effect on fertility remains uncertain. UAE also carries a risk of reduced ovarian function or early menopause, which makes it generally unsuitable for women planning future pregnancies.

3. High-intensity Focused Ultrasound (HIFU)

   HIFU is a non-invasive treatment that uses focused ultrasound waves to heat and destroy fibroid tissue without affecting surrounding structures. While pregnancies have been reported following HIFU, the long-term effects on fertility and pregnancy outcomes are not yet well-established, and availability is still limited to clinical research settings in some areas.

Some studies suggest a possible link between uterine fibroids and hypertension (high blood pressure), as well as other cardiovascular risk factors. Although the exact mechanism is not yet fully understood, fibroids and hypertension appear to be more prevalent among women from certain ethnic backgrounds, particularly those of African descent.

Research also indicates that women with untreated hypertension may be at a higher risk of developing fibroids compared to those whose blood pressure is well-managed through medication. However, these studies have limitations, and further research is necessary to better understand the connection between these conditions and how to manage them effectively.

Dr Najwa emphasises the importance of women diagnosed with uterine fibroids having regular medical check-ups, including blood pressure monitoring. "Managing both conditions is crucial to reducing the risk of cardiovascular complications and maintaining overall health," she advises.

Uterine fibroids are hormone-sensitive and typically shrink after a woman reaches menopause due to the natural decline in oestrogen levels. As a result, most women experience a reduction in symptoms such as heavy bleeding and pelvic pressure during this stage of life.

However, women who are living with obesity may continue to have persistent fibroids even after menopause. This is because fat tissue produces oestrogen, which can create a higher oestrogenic environment that may support fibroid growth even after natural hormone levels have declined.

It’s also important to note that other conditions, such as endometrial polyps and leiomyosarcoma (a rare form of uterine cancer), can resemble fibroids on an ultrasound. Differentiating between uterine fibroids and leiomyosarcoma is challenging before surgery, as a definitive diagnosis is often made based on histopathology of the surgical specimen. Therefore, it is crucial to monitor any fibroid that increases in size after menopause, particularly if the woman experiences postmenopausal bleeding. This may warrant further investigation to rule out other conditions.

When selecting the most appropriate treatment for uterine fibroids, especially in women with additional health concerns like heavy menstrual bleeding or hypertension, Dr Najwa, highlights several key factors:

Key factors to consider:

• Fertility goals: If a woman wishes to preserve fertility, myomectomy (removal of fibroids) is often preferred. A hysterectomy (removal of the uterus) is a permanent solution that ends fertility.
• Type of surgery: The choice of procedure, whether open surgery, laparoscopic (keyhole), or robotic-assisted surgery, depends on fibroid size, location, and number.
• Underlying health conditions: Conditions like hypertension, obesity, or heart disease may increase surgical risks and influence treatment options.
• Patient preferences: A patient's comfort and personal preferences should guide the treatment plan.
• Costs and accessibility: Not all treatments are equally accessible or affordable, so these factors should be considered.
• Risk of recurrence: Fibroids can return after some treatments, and patients should be aware of the potential for future procedures.
• Hypertension management: For women with high blood pressure, effective hypertension management and screening for cardiovascular risk factors are crucial before considering surgery.

More research is needed to develop tailored treatment strategies for women with complex presentations, such as those with both fibroids and cardiovascular risk factors. Customised approaches will help ensure better outcomes and quality of life for individuals affected by these conditions.