Fibroids: your options before a hysterectomy

Key takeaways

• Fibroids are very common non-cancerous growths. Cleveland Clinic notes that up to 80% of women develop them by age 50.
• Fibroids that cause no symptoms usually do not need treatment.
• The position of a fibroid often matters more than its size. One inside the cavity can cause heavy bleeding even when small.
• Fibroids often shrink after menopause as hormone levels fall, which matters if you are already in your mid to late 40s.
• Hysterectomy is one valid option among several. Removing healthy ovaries at the same time should only happen if you clearly choose it.

First, what kind of fibroid is it?

The first thing I tell women is: the word "fibroid" on your sonography report is not a sentence. It is the start of a conversation. Fibroids are growths of the womb muscle, and where they sit decides what they do. Think of the womb as a room. A fibroid can sit inside the room, inside the wall, or on the outside of the wall, and each one causes a different kind of trouble.

The NHS lists symptoms of fibroids as heavy or painful periods, stomach or lower back pain, needing to pass urine more often, bowel problems such as bloating, discomfort during intimacy, and difficulty getting pregnant. Many women have no symptoms at all and only find out on a routine sonography.

Do I actually need treatment?

Not always. The NHS states that treatment is not always needed if fibroids are not causing symptoms. Reasons to consider treatment include: - Heavy bleeding, especially if it is causing anaemia - Pain or pressure that affects daily life - Bladder or bowel symptoms - Fertility concerns - A fibroid that is growing quickly, which needs specialist review

If yours are small and silent, a sonography at agreed intervals and a yearly blood count may be all you need.

Will my fibroids shrink after menopause?

Often, yes. Fibroids feed on estrogen and progesterone. As the ovaries slow down, fibroids commonly shrink, and many women's symptoms settle. A Cleveland Clinic gynaecologist puts it beautifully: "When you stop your periods, the fibroids go to sleep."

This matters for timing. Indian women reach menopause at about 46 on average. A woman of 47 with manageable symptoms may reasonably choose medicines to bridge the gap rather than surgery. A woman of 38 with large fibroids faces a very different calculation. Same word on the report, completely different decision.

One important caution: if you have bleeding after menopause, please don't assume it is your fibroids. Any bleeding after menopause needs prompt assessment of the womb lining.

What are the options before a hysterectomy?

1. Medicines to control bleeding and pain. NICE lists tranexamic acid, anti-inflammatory painkillers, the hormonal coil (levonorgestrel intrauterine system), combined hormonal contraception and cyclical progestogens. The hormonal coil is best suited to fibroids under 3 cm that do not distort the cavity. NICE notes that medicines may be less effective for fibroids substantially larger than 3 cm. These reduce symptoms rather than remove fibroids.

2. Medicines to shrink fibroids for a time. GnRH analogues cause a temporary menopause-like state that shrinks fibroids. NICE suggests considering them before surgery when fibroids enlarge or distort the womb, to make the operation easier. They are short-term treatments because they cause menopause-like side effects. Ulipristal acetate is now restricted by NICE to intermittent use in premenopausal women when surgery and embolisation are unsuitable, have failed or are declined, with liver monitoring, because of rare liver injury.

3. Hysteroscopic removal. Fibroids inside the cavity can often be removed with a camera passed through the cervix, with no cut on the abdomen. NICE recommends considering this for submucosal fibroids. It is often a day procedure.

4. Myomectomy. Surgical removal of the fibroids while keeping the womb, by laparoscopy (keyhole) or open surgery depending on size and number. It is the usual choice for women who may want a pregnancy. New fibroids can form afterwards, so follow-up is sensible.

5. Uterine artery embolisation (UAE). An interventional radiologist passes a fine catheter through an artery from a small cut in the groin and blocks the blood supply to the fibroids, which then shrink. There is no abdominal cut. The NIH's women's health institute notes that about one-third of women need retreatment within 5 years, and that most providers do not recommend it for women planning pregnancy.

6. Other procedures. Endometrial ablation, which destroys the womb lining, can help bleeding with small fibroids. MRI-guided focused ultrasound uses sound waves to destroy fibroids but is not widely available and may need repeating. Availability of these varies in Mumbai.

How do the main options compare?

When is a hysterectomy the right choice?

For some women, especially those with large or many fibroids, severe symptoms, no wish for pregnancy, and other options that have failed, hysterectomy is a reasonable and definitive choice. I am not against it. NICE advises a full discussion beforehand: effects on intimate and bladder function, recovery, psychological impact and alternatives. It also advises that healthy ovaries should only be removed with your express wish and informed consent, because removing them causes immediate menopause. If you are considering this, see Menopause after a hysterectomy.

See, I'll tell you what I say to every woman who walks in with a surgery date already fixed: please understand all your options first. Then decide. It is your body and your decision, and you will live with it for the next forty years.

How I approach this at Dr Tvacha

At Cocoon × Dr Tvacha in Thane West, I review your sonography and symptoms, check your blood count, and explain each option for your fibroid type, your age and your plans, including when watching and waiting is reasonable. If a procedure is needed, the options and costs are explained before you decide anything. Read about the Right Stop Programme on our women's health page, and see Heavy periods in your 40s.

Written by

Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187

Leads midlife women's health at Cocoon × Dr Tvacha, Thane.