Providing Fertility-Sparing Treatment Options for Fibroid Uterus

Discussion

Fibroids, also known as leiomyomas, are the most common pelvic tumors among women. These non-cancerous, vascular tumors are made of smooth muscle and connective tissue, developing in or around the uterus.

Associated symptoms involve bleeding, abdominal bloating and fullness, changes in bowel or bladder function, and back and pelvic pain; these may impact quality of life. Specifically, large pedunculated exophytic fibroids have the potential for red or carneous degeneration due to interruption of their blood supply, which can cause acute pain. ¹

Medical options currently available in the United States for heavy menstrual bleeding secondary to uterine fibroids may include nonsteroidal anti-inflammatory drugs for pain management, estrogen/progestin medications, levonorgestrel intrauterine device, antifibrinolytics, and gonadotropin-releasing hormone agonists and antagonists. Surveillance alone may be offered for asymptomatic or mildly symptomatic women who do not desire treatment. ^2,3

Current data suggest there are several related modifiable risk factors: diets high in fat, refined carbohydrates, and processed foods; high blood pressure; time since last birth; lack of physical activity; psychosocial stressors; and endocrine-disrupting chemicals such as phthalates and dichlorodiphenyldichloroethylene (DDE) as environmental exposures. ^{4 –9}

Hysterectomy is an evidence-based treatment option for fibroids associated with severe symptoms, including iron-deficiency anemia and mass effect. ^1,3,6

The roles of the uterus are well known, for housing the zygote and fostering the fetus. Furthermore, preclinical and observational studies have demonstrated a possible association between hysterectomy (without oophorectomy) and risk of cognitive impairment. ¹⁰ This suggests that the uterus may be responsible for more than reproduction. At the same time, removal of this dynamic organ bears additional patient risk. In review of mortality data, compared with no surgery, hysterectomy without oophorectomy before 35 years was associated with an “increase in all-cause mortality (hazard ratio, 1.29; 95% confidence interval, 1.19–1.40); for surgery after 35 years of age, there was an inverse association (35–44 years: hazard ratio, 0.93; 95% confidence interval, 0.89–0.97).” ¹¹

Thus, clinical teams must have detailed discussions about the risks and benefits of hysterectomy with priority review of reproductive goals for the best outcome of the patient. Disproportionately, Black women have the highest prevalence of fibroids and are affected two- to threefold more frequently than White women. ¹² In addition, studies demonstrate that fibroids have an earlier age of onset, greater number and size at diagnosis, faster growth rate, and symptom severity in Black women. ^{13 –15} Of significant concern, Black women are two to three times more likely to have a hysterectomy for fibroids compared with other racial groups, even after adjusting for fibroid characteristics and socioeconomic status. ^{7,10 –12} Critically, patients, who are at highest risk for hysterectomy, may benefit from a second opinion with an experienced specialist to explore all options. The decision for hysterectomy must be an evidence-based and shared decision between the physician(s) and patient. ^{2,6 –8}

The Comparing Options for Management: PAtient-centered REsults for Uterine Fibroids (COMPARE-UF) registry was designed to provide comparative data on different procedural options using patient-centered outcomes and featuring a geographically, racially, and ethnically diverse population of women. ^14,16 Using emerging data from this study, both patients and clinical teams can make informed decisions about equitable care options based on preferences and needs.

Team-based approaches may include primary care, gynecology, reproductive endocrinology and infertility, and lifestyle medicine to prioritize patient goals holistically. In alignment, care plans ideally address modifiable risk factors and lifestyle changes longitudinally. Related data about explicit lifestyle strategies are limited, but future in vivo studies may inform more specific recommendations, including physical activity, sleep and stress management, and consumption of plant-based diets for fibroid management. ^1,4,16,17

In review of this case, this young Black patient is presenting with acute pain likely from red or carneous degeneration of a chronic fibroid. Acute devascularization and degeneration of a fibroid can cause infarction or ischemia-related abdominal pain, consistent with our patient's symptoms. ¹ As pain can impact decision-making, women with symptomatic fibroids should be advised of available treatment options through a shared decision-making model and only after pain is controlled. Considerations include patient age, reproductive goals, anatomy, number and size of fibroids, anticipated pathological findings, physician training and experience, as well as referral for additional expert opinion. When used, referral must include an experienced gynecological specialist skilled in medical and surgical management of fibroids with priority discussions about fertility goals.

Myomectomy is generally supported as the preferred surgical treatment option for symptomatic fibroids in women of child-bearing age, who elect for uterine-sparing options to preserve fertility. ^2,3 Although there are other interventional procedures that accommodate uterine preservation, there are limited available data on reproductive outcomes following those treatments at this time. ³ Patients who are contemplating pregnancy or desire nonsurgical options may consider a second opinion with a skilled gynecologist with extensive experience in treating complex fibroids. This includes specialists, who perform myomectomies predominantly or exclusively.

As concluded by Stewart et al., “Despite the clinical importance of uterine fibroids tumors, there is little comparative efficacy research to guide treatment decisions.” ¹⁶ This case spotlights the disparity of hysterectomies performed for Black women and aims to promote safe accessible options for effective uterine fibroid treatment. Also, this highlights the utility of a dynamic centralized database of national fibroid experts with regular oversight for equitable patient access and best clinical outcomes.

Answer: The correct answer is (B)

Option A: Hysterectomy can be discussed through shared decision-making after pain is well controlled and patient values are identified. However, this patient is nulligravid and of reproductive age; she benefits from a discussion about fertility-sparing options.

Options C and D: These are uterine-sparing interventions, but there are limited data on successful reproductive outcomes following these procedures. In addition, these options may be less suitable because of the size, number, and location of fibroids as well as large uterine volume. ³