Part 2: Managing Fibroids in Perimenopausal Women: Challenges and Best Practices

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Uterine fibroids are common, impacting anywhere between 20% to 70% of women.1

They’re almost always harmless—in other words, they rarely develop into cancer—and sometimes women don’t even realize they have them.

That’s not always the case.

Other women have severe symptoms:1

  • very heavy menstrual cycles
  • so much bleeding that they become anemic
  • very large fibroids that cause the uterus to be up to 10 times its normal size
  • related symptoms like constipation or increased urination

As we explored in Part 1 of this series, there are unique considerations when managing fibroids in perimenopausal women. Among the biggest concerns are continued or new fibroid growth and abnormal uterine bleeding. We also looked at the challenges of diagnosing fibroids in perimenopause, and the hormonal management of fibroids. 

Here’s Part 2 of our look at managing fibroids in perimenopausal women, including the challenges faced by obstetricians and gynecologists in fibroid management during this stage.

Surgical Intervention: Myomectomy vs. Hysterectomy

Hormone treatment is one way to treat fibroids, temporarily relieving heavy menstrual bleeding and period pain, as well as shrinking fibroids. But hormone therapy has benefits and risks, and can’t make fibroids disappear completely.2

Surgery is another possible treatment, and there are different choices among surgical options as well.

Myomectomy: This surgical procedure removes only the uterine fibroids and leaves the uterus. Reasons to choose a myomectomy include a desire to bear children; perhaps the fibroids are interfering with fertility. That’s not a common consideration for perimenopausal women, who are typically past the age of having children.3

However, there are some women who may still want to keep that option available to them. Some women also want to keep their uterus. Myomectomy patients typically see an improvement in fibroid symptoms, including decreased heavy menstrual bleeding and pelvic pressure.3

Hysterectomy: This is a major surgical procedure that removes the uterus, meaning a woman will no longer menstruate and can no longer get pregnant. It will also definitively resolve fibroid symptoms: menstrual bleeding stops, pelvic pressure is relieved, frequent urination improves and new fibroids cannot grow.4

The ovaries are not necessarily removed during a hysterectomy, and if they are, that can cause hot flashes, vaginal dryness and other menopause symptoms in premenopausal women. There are also different types of hysterectomy approaches: a vaginal hysterectomy, an abdominal hysterectomy and a laparoscopic hysterectomy.4

Myomectomy has a low complication rate, but there are possible risks, such as excessive blood loss, development of scar tissue, pregnancy or childbirth complications, and the rare chance that the surgeon has to perform a hysterectomy, removing the uterus if bleeding is uncontrollable or other abnormalities are found in addition to fibroids.3

Hysterectomy complications can vary depending on the type of surgery, but include bleeding, infections and injury to the intestines or bladder.5

As for the outcomes, one study found that long-term health-related quality of life improved in all women one year after hysterectomy or myomectomy.6 Another study found that hysterectomy was the most effective treatment, and more cost-effective—but among patients who were not concerned about preserving their uterus.7

The decision about which treatment to choose is dependent on the patient’s preference, as well as the size and location of the fibroids. Treatments also include innovative and minimally invasive surgical techniques.4 As a result, important considerations in choosing less invasive techniques include how much trauma is involved in the procedure, the length of hospital stay and the recovery time.8

A myomectomy is an option for removal of fibroids that is less invasive. It can be performed as a robotic myomectomy or a laparoscopic myomectomy. These techniques remove fibroids with less blood loss, fewer complications, a shorter hospital stay and a quicker return to activities than with open surgery.9

With either laparoscopic or robotic-assisted technology, small incisions are made in the abdomen. Myomectomy is an effective procedure for improving painful symptoms caused by fibroids, with the added benefit of protecting healthy tissue, including the uterus and ovaries. Multiple fibroids, including large fibroids, can be removed during either procedure.10 

Myomectomy is often chosen to remove certain types of fibroids, such as those within the uterine wall, or those that project to the outside of the uterus. It’s also a good option for smaller fibroids or a limited number of fibroids, as well as uterine fibroids that cause chronic pain or heavy bleeding.9

While there are physical effects that follow fibroid removal, in many cases they are outweighed by the relief from physical symptoms. However, a hysterectomy marks the end of the menstrual cycle, meaning a woman can no longer become pregnant. This is a permanent and life-altering change. It could trigger the symptoms of menopause, for instance, which could bring on low sex drive, vaginal dryness and other side effects.11

There are psychological and emotional consequences as well. While removal of the symptoms of fibroids is positive, some women may struggle emotionally. It’s normal to feel a sense of grief over losing the ability to bear children. The onset of menopause caused by surgery can create immediate symptoms brought on by a drop in hormone levels. That can lead to increased irritability, anxiety, and sadness.11

These are all considerations to discuss with patients prior to determining the best treatment option.

Uterine Artery Embolization (UAE) as a Non-Surgical Option

For perimenopausal women, the general approach to fibroids is to “hold off” and wait for menopause, particularly if women are asymptomatic or have mild symptoms. Although menopause is thought to relieve the symptoms of fibroids, that isn’t always the case.12

For instance, one study found that African American and white women have similar fibroid growth rates until the age of 35. After age 35, growth rates decline in white women but not in African American women.12

Menopause may help to relieve symptoms, but it does not prevent the occurrence of fibroids. And for many perimenopausal women, the side effects of fibroids affect their quality of life. Hysterectomy is not the only option. There are other medical solutions that can relieve symptoms and reduce the size of fibroids.12

One of those treatments is uterine artery embolization or UAE. This procedure is an alternative to open surgery for fibroids. Embolization blocks the blood flow to the fibroid or fibroids, causing them to shrink and die. It can also help relieve symptoms, reducing menstrual bleeding pain, pressure, urinary frequency or constipation.4

UAE is  performed by an interventional radiologist in a radiology suite rather than an operating room. A needle is placed in an artery in the patient’s leg, and a small catheter is inserted. X-rays are taken of the arteries that supply the fibroids, and then particles are injected that block the flow of blood. Women sometimes stay overnight to be monitored and most women can return to full activity in a week.

The fibroid, meanwhile, is receiving no oxygen so it will shrink and die over the next number of days and months. Some literature suggests that symptoms will improve in 80 to 90 percent of patients.4

Another study found that while fibroids are thought to regress after menopause, some postmenopausal women continue to have symptoms. UAE for the treatment of symptoms in these postmenopausal women was safe and effective, resulting in an 88% to 92% symptom improvement.13

Yet another study of women older than 50 years found that UAE was an effective alternative to surgery, with reduction in fibroid size and improvement of symptoms.14

Fibroid embolization is also unlikely to bring on early menopause. There is an age-based difference, however. Some research has shown that women older than 40 are at increased risk.15

Otherwise, the choice to treat fibroids with an embolization procedure should allow perimenopausal women to continue with a natural, age-appropriate onset of menopause, and even a chance of fertility. The other benefits to this minimally invasive approach include a short time to perform the procedure, often the chance to go home the day of the procedure, less pain and risk than a full surgery such as a hysterectomy, and a shorter recovery period.15

Collaborative Care and Patient Education

When it comes to determining a treatment plan, there is no “one size fits all” approach, and that’s true for perimenopausal women too. The best treatment choice for each woman depends on personal preference, the symptoms impacting her daily life, and the size and location of her fibroids.4

The healing process begins with diagnosis and treatment, and includes:

  • encouraging effective communication and shared decision-making with perimenopausal patients
  • providing educational resources for patients to make informed choices about their treatment
  • addressing the psychological impact of fibroids and their side effects on perimenopausal women 
  • empowering women with knowledge4
  • encouraging each patient to participate in choosing the best treatment option for her4
  • offering support throughout the process

There are many effective ways to treat uterine fibroids, including innovative and minimally invasive surgical techniques.4 Fibroid management may involve a multidisciplinary approach, including the patient’s family doctor as well as gynecologists, obstetricians and fertility doctors, depending on the patient and the chosen treatment plan.

Follow-up and Long-term Management

Removal of the fibroids does not always mean the end of the treatment journey.  There is a risk of fibroid recurrence or return. Hysterectomy will “cure” fibroids and eliminate any chance of recurrence. If the uterus is not removed—if UAE or myomectomy is the chosen treatment—then fibroids can regrow or entirely new fibroids can develop in new locations.8

One clinical study found that women have about a 10% chance of dealing with recurrent fibroids within 2 years of their first treatment. It appears that both UAE and myomectomy procedures have an equal chance of fibroid recurrence.8

Another possibility is reintervention, which is when a follow-up procedure is required to address recurrence or correct for a previously failed procedure. A small percentage of women that undergo fibroid treatment will later require a reintervention, and the treatment chosen then is again dependent on the patient’s condition and preference.8

Here are some statistics:8

  • After myomectomy: women have about a 7% to 8% chance of undergoing a follow-up procedure within 2 years; estimates place the risk of reintervention after myomectomy at 19% after 5 years. 
  • After UAE: reintervention rates are about 12% at 2 years and 24% at 5 years.
  • After hysterectomy: some patients may have a follow-up to the procedure to correct persistent abdominal pain, hernia, or prolapse. About 7% of hysterectomy patients will have a follow-up procedure within 2 years, with as many as 16% at 10 years. But overall, hysterectomy has lower reintervention rates than myomectomy and UFE.

This simply highlights the need for regular monitoring and follow-up after fibroid treatment. 

For instance, fibroids don’t always stop growing or shrink down through menopause. But some postmenopausal women with fibroids have significant symptoms like postmenopausal bleeding or pain. If a fibroid grows during menopause, it should undergo testing to determine the cause of the growth, as it may indicate an unexpected cancer.16

In general, women in perimenopause should focus on maintaining their overall health.

Here’s why.

Menopause itself may contribute to structural and functional changes in blood vessels. One study stated that within one year of the final menstrual period, arterial stiffness significantly increased. There’s also the possibility of menopause-related changes in brain health. Researchers continue to study the menopause associations of cognitive, brain, and cardiovascular health in women at midlife and beyond.17

Perimenopausal women should talk to their doctor about symptoms like hot flashes. Regular screening is important to check on bone health and osteoporosis; and a regular mammogram is suggested every two years typically beginning at age 50. It’s also a good idea to watch the diet and be physically active to mitigate increased risk of cardiovascular disease after menopause.17

Conclusion of Part 2

Uterine fibroids are a common condition, but that doesn’t mean treatment is straightforward. For women in perimenopause, the similarity of symptoms can make management and treatment different than at other times of life. Some women with fibroids have no symptoms, while others find their quality of life impacted enough that they want to seek treatment.

In this two-part series, we have examined the challenges of diagnosing fibroids in perimenopausal women, hormonal treatment, surgical and non-surgical treatment options, collaborative care and patient education, and follow up and long term management of fibroids. We continue to emphasize the importance of individualized treatment plans and patient-centered care.

Women’s Pelvic Health issues are often not talked about due to embarrassment or lack of knowledge, leading women to believe they are alone on this journey. Whether you’re a woman suffering with fibroids or you’re treating someone with this condition, it’s important to remember that you’re not the only one. Don’t go through this journey alone. 

There’s plenty of support, guidance and treatment options, including minimally invasive treatments offered by Caldera Medical, to help women regain confidence and live life to the fullest.

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