The most common symptom of fibroids is heavy menstrual bleeding (HMB). There is a wide spectrum of troublesome bleeding that fibroids can cause, from slightly heavier or longer periods, to extremely heavy periods which require hospital admission for a blood transfusion every month. This blog post will outline the management options for fibroid-related heavy bleeding, from simple over-the-counter medications, through to definitive surgical management (e.g. hysterectomy).
What types of fibroids cause heavy menstrual bleeding (HMB)?
As described in a previous blog post, broadly speaking there are three types of fibroids, which are categorised based on their location in relation to the uterine cavity and muscle:
– Subserosal fibroids are on the outer surface of the uterus
– Intramural fibroids are contained within the muscular layer of the uterus (which is called the ‘myometrium’)
– Submucosal fibroids protrude into the inside of the uterine cavity, often distorting its shape
Only the latter two types of fibroids cause HMB. Intramural and submucosal fibroids that impinge on and distort the uterine cavity increase the surface area of the uterine lining (the ‘endometrium’). Hence, there is more tissue to shed every month during a period, so period bleeding is heavier than it would otherwise be.
Medical options for managing fibroid-related heavy menstrual bleeding (HMB)
There is a wide spectrum of management options for fibroid-related HMB, which can be thought of as a ladder. If you are standing on the ground (yet to start climbing the ladder), you are not doing anything to manage your fibroid-related heavy periods. The first rung of the ladder is non-hormonal, over-the-counter medicines. As you climb higher and higher on the ladder, each rung is a more aggressive management option: it is more likely to successfully manage your fibroid-related HMB, but may have a higher risk of side-effects (or complications). The top rung of the ladder is hysterectomy (surgical removal of the uterus). As outlined below, there are many rungs in-between the two extremes…
Iron tablets help to top up your iron stores, which can be depleted by heavy periods.
If you have significant side-effects from taking iron tablets, or if oral medicines aren’t sufficient, your GP may suggest an intravenous iron infusion: a liquid form of iron, that is given to you through a ‘drip’ into your vein. This is much more effective than iron tablets, but comes with some disadvantages: it takes time to attend a centre to receive an infusion; it necessitates the insertion of a ‘drip’ to access your vein; and may (very rarely) cause an allergic reaction.
There is a non-hormonal medicine called ‘tranexamic acid’, which may be prescribed by your GP. It is only taken during your period, and has been shown to reduce the heaviness of periods by 40%.
Continuing with the ladder analogy, you have now climbed onto the bottom rungs of the ladder of management: you are taking iron tablets regularly, and tranexamic acid during your periods. Despite this, your heavy periods are still problematic. It’s time to consider the next rungs of the ladder: hormonal medications.
The combined oral contraceptive pill lightens periods by about 50%. So, you may consider trialling The Pill to manage your fibroid-related HMB.
Whether or not you are trying to conceive, another option is to trial ‘norethisterone’ tablets in the second half of your menstrual cycle (i.e. start the tablet two weeks after your period starts, and continue it for two weeks). ‘Norethisterone’ is a progesterone-type medicine; we would expect that your period will start when you stop the two week course of tablets. Progesterone stabilises the lining of the uterus (the ‘endometrium’), which helps to thin the uterine lining, thereby lightening the ensuing period.
The above hormonal options (The Pill, and progesterone tablets in the second half of your menstrual cycle) can be prescribed by your GP. The next rung of the ladder (so-called ‘GnRH agonists’) are really only prescribed by gynaecologists. This family of medicines are quite strong drugs, in that they turn off your ovaries (temporarily), and put you into a temporary menopause. They are very successful in managing fibroid-related HMB, in that 95% of women will stop having periods all-together within six months of starting this medicine. They also shrink fibroids by about 40%, which helps to relieve pressure-related symptoms (as outlined in a previous blog post). However, GnRH agonist medicines have their down-sides, principally: significant side-effects (such as menopausal ‘hot flushes’, and irreversible osteoporosis if taken for more than six months); and unusual administration routes (e.g. a twice-daily nasal spray for ‘Synarel’, or a monthly injection into your tummy for ‘Zoladex’). Given the above, these medicines are only prescribed by gynaecologists in very particular situations (e.g. prior to a planned operation).
A relatively new medicine that has come onto the Australian market recently is called ‘Ryeqo’ (pronounced REE-ECHO). This is a combination of three different medicines, in one tablet: ‘relugolix’ (which acts to turn the ovaries off temporarily, creating a temporary menopause), ‘estradiol’ (which minimises the side-effects of relugolix, such as hot flushes) and norethisterone (to prevent the uterine lining from becoming cancerous). For women who have fibroid-related HMB, ‘Ryeqo’ has been shown to lighten periods by 85%. Advantages over the GnRH agonists mentioned above are that ‘Ryeqo’: is a single daily tablet; doesn’t cause osteoporosis; and can be taken indefinitely until menopause. The main drawback is that it is not (yet) covered by the Australian government’s pharmaceutical benefits scheme, so costs approximately $130 every month. Should you want to avoid surgical management, it may be worth discussing the pros and cons of ‘Ryeqo’ with your gynaecologist.
Procedural options for managing fibroid-related HMB
The next rungs of the ladder are procedures, which: may or may not require general anaesthetic; and do not leave you with any visible scars or require any stitches. These include: a ‘Mirena’ intra-uterine device; endometrial ablation; and uterine artery embolisation (UAE), as outlined below.
‘Mirena’ intra-uterine device (IUD)
‘Mirena’ is a small white plastic rod, which can be inserted through the vagina and cervix, into the uterine cavity. It is 3.2cm long; the insertion tube is 4.4mm wide. It contains progesterone hormone, which is absorbed locally in the lining of the uterus, thereby lightening periods by 80%. Sometimes a ‘Mirena’ can be inserted in our clinic rooms, using only local anaesthetic. In other situations, a general anaesthetic is needed.
One notable caveat regarding the use of ‘Mirena’ to manage fibroid-related HMB is that the shape of the uterine cavity needs to be normalised before a ‘Mirena’ can be inserted. Hence, if you have intramural and / or submucosal fibroids that are distorting the uterine cavity, your gynaecologist will need to perform a hysteroscopic myomectomy (see below) in order to normalise the uterine cavity, before a ‘Mirena’ can be inserted.
Endometrial ablation is a procedure that is performed under a general anaesthetic, in which the lining of the uterus (the ‘endometrium’) is burnt. The aim is to make the endometrium non-functional, in order to lighten periods thereafter. ‘Novasure’ is the brand name for one type of endometrial ablation, which is commonly employed by Australian gynaecologists.
As for ‘Mirena’, the shape of the uterine cavity needs to be normalised before ‘Novasure’ endometrial ablation can be completed. So your gynaecologist may need to perform a hysteroscopic myomectomy (see below) before endometrial ablation can be done.
Uterine artery embolisation (UAE)
Uterine artery embolisation is a procedure performed by interventional radiologists. A small tube is inserted into a blood vessel in your groin, then tiny particles (about the size of grains of sand) are then injected into the blood vessels of the problematic fibroid. The aim is to stop the blood supply to the fibroid, thereby causing it to slowly die, and shrink.
UAE is not appropriate for all women with fibroids. There are several advantages and disadvantages of UAE. Approximately 50% of patients notice a good symptomatic relief after having UAE; 50% do not. However, approximately 20% of patients who undergo UAE will need to undergo myomectomy or hysterectomy down the track. If you want to know more, please discuss UAE with your gynaecologist.
Surgical options for managing fibroid-related HMB
By now, you’ve climbed up many rungs of the ladder, and have reached the rungs of surgical management. These include operations to remove your fibroids (a ‘myomectomy’) while preserving the uterus, and an operation to remove the uterus and the fibroids (a ‘hysterectomy’), as outlined below. These operations require a general anaesthetic.
‘-ectomy’ means ‘removal of’, and ‘myoma’ is the technical name for fibroids. Hence, ‘myomectomy’ is the surgical removal of fibroids. For submucosal fibroids, the best approach is hysteroscopic: i.e. through the vagina and cervix. A small video camera is introduced through the vagina and cervix, then the fibroid(s) can be ‘shaved’ under direct vision, thereby normalising the shape of the uterine cavity. This decreases the surface area of the lining of the uterine cavity, thereby decreasing the heaviness of periods thereafter.
Intramural fibroids often need to be approached from outside the uterus, using keyhole (or ‘laparoscopic’) surgery. This involves: a general anaesthetic; making four small incisions in your tummy (one for the video camera, and three for our surgical instruments); making a cut on the outside of the intramural fibroid, in order to remove it; stitching up the hole in the uterine muscle where the fibroid was; and removing the fibroid from your abdominal cavity. Myomectomy allows patients to conceive and bear children in future.
Very occasionally, your fibroids may be so large and / or so numerous, that keyhole surgery is not feasible. In that case, the most appropriate option may be open (or ‘abdominal’) surgery, through one large incision. Post-operative recovery and pain are noticeably worse (compared to keyhole surgery), so an open approach is avoided whenever possible.
As noted above, ‘-ectomy’ means ‘removal of’; ‘hyste-’ refers to the uterus. Hence, hysterectomy is the surgical removal of the uterus. Given this, hysterectomy is the most definitive management option for fibroid-related HMB, in that you will not have any periods at all after having both your uterus and fibroids removed. Obviously, you will not be able to bear children after having your uterus removed, so hysterectomy is only appropriate if you do not want to bear children in future.
Frequently asked questions (FAQs)
How do I know that fibroids are the cause of my heavy periods?
As discussed in a previous blog post, fibroids are only one of several possible causes of heavy periods. If the heaviness of your periods is troubling you, please see your GP and ask to be referred for a pelvic ultrasound. A high quality transvaginal ultrasound will help to elucidate the presence of several possible causes, such as adenomyosis and fibroids. Ideally, such a scan will also clarify the number, size and location of your fibroids: information that will guide your gynaecologist as to which management option is most appropriate for you.
Are iron tablets all the same? Or are some better than others?
There is a wide variety of iron supplements available over-the-counter in Australia. They vary in terms of: form (i.e. liquid versus tablets versus capsules); dose (i.e. the amount of ‘elemental iron’ in each dose); and side-effects. The table below allows for easy comparison of various available options:
Different formulations have different side-effects, most notably constipation and black poo. You may need to try a few different formulations before you find one that works for you.
How do I decide between the different management options?
Your GP is able to provide advice about the lower few rungs of the management ladder: i.e. iron supplements, tranexamic acid, and the contraceptive Pill. The higher rungs require a nuanced discussion with a gynaecologist, about the advantages and disadvantages of each option.