Uterine Fibroids (Leiomyomas) Treatment Program

Uterine fibroids, clinically referred to as leiomyomas or myomas, are benign smooth muscle neoplasms that originate within the myometrium—the muscular layer of the uterus. These growths are composed of interlacing bundles of smooth muscle cells interspersed with varying amounts of fibrous connective tissue, and they are hormonally responsive, particularly to estrogen and progesterone. Although benign in nature, fibroids are biologically active and may undergo changes in size and composition throughout a woman’s reproductive life cycle.

Fibroids are among the most prevalent gynecological pathologies, affecting a significant proportion of women by midlife. They are often discovered incidentally during routine pelvic examinations or imaging studies, but their clinical significance varies widely. Fibroids differ substantially in terms of volume, anatomical distribution, vascular supply, and growth dynamics, which may impact surrounding pelvic structures and influence clinical decision-making.

The management of uterine fibroids is highly individualized and influenced by several factors including the patient’s age, hormonal profile, parity status, fertility goals, symptom severity, comorbid conditions, and the fibroid’s anatomical relationship to the uterine cavity or adjacent organs. A multidisciplinary approach may be required to optimize care, incorporating the expertise of gynecologic surgeons, reproductive endocrinologists, and radiologists.

Given their chronic and often progressive nature, uterine fibroids are addressed through structured treatment programs that balance symptom control, preservation of reproductive function, and prevention of complications. These programs may involve longitudinal monitoring or active intervention through a range of medical and surgical modalities, depending on the patient’s clinical profile and therapeutic objectives.

Why Cuba

In Cuba, the management of uterine fibroids – particularly in cases where surgical intervention is warranted—is guided by a patient-centered philosophy that emphasizes symptom relief, preservation of reproductive function, and the prevention of long-term complications such as anemia, infertility, or uterine distortion. Elective procedures are offered as part of a structured and evidence-based treatment program, wherein each patient undergoes a comprehensive evaluation that considers fibroid size, number, anatomical location, prior response to conservative therapy, fertility goals, and overall health status.

Causes of Uterine Fibroids

The exact cause of uterine fibroid development remains unclear, but several contributing factors have been identified:

• Hormonal Influences: Estrogen and progesterone promote the growth of fibroids. They often shrink after menopause due to a drop in hormone levels.
• Genetic Predisposition: Family history increases the likelihood of developing fibroids.
• Growth Factors: Certain proteins involved in tissue growth and repair may contribute to fibroid development.
• Lifestyle and Environmental Factors: Obesity, high blood pressure, diet, and early onset of menstruation are associated with increased risk.

Types and Classification

Fibroids are classified based on their location in relation to the uterine wall:

• Intramural Fibroids: This is the most common type of fibroid and is located within the muscular wall of the uterus. Most common type.
• Submucosal Fibroids: Grow beneath the inner lining of the uterus and can protrude into the uterine cavity, often associated with heavy bleeding.
• Subserosal Fibroids: Extend beyond the outer uterine wall into the pelvic cavity.
• Pedunculated Fibroids: Attached to the uterus by a stalk and may be subserosal or submucosal.
• Cervical Fibroids: Arise in the cervix, though these are less common.

This classification helps guide diagnosis and treatment decisions, particularly when considering fertility preservation or surgical removal.

Symptoms of Uterine Fibroids

While many fibroids are asymptomatic, symptomatic fibroids can cause:

• Heavy or prolonged menstrual bleeding
• Pelvic pain or pressure
• Frequent urination or difficulty emptying the bladder
• Constipation
• Pain during intercourse
• Lower back or leg pain
• Reproductive issues (infertility, miscarriage, or complications during pregnancy)

Severity of symptoms often correlates with the size, number, and location of the fibroids.

Pre-Treatment Diagnosis

Accurate diagnosis of uterine fibroids is essential for guiding treatment decisions, determining the appropriate surgical or non-surgical approach, and assessing their impact on reproductive function and overall health. A combination of clinical evaluation and advanced imaging techniques is used to confirm the presence, size, location, and characteristics of the fibroids.

Pelvic Examination

• A bimanual pelvic examination is often the initial step in identifying uterine enlargement, irregular contours, or palpable masses suggestive of fibroids.

Transvaginal and Transabdominal Ultrasound

• Transvaginal ultrasound offers high-resolution imaging of the uterus and adnexa, making it ideal for evaluating smaller fibroids and assessing their relationship to the endometrial cavity.
• Transabdominal ultrasound is particularly useful for visualizing large fibroids or those that extend beyond the pelvis. When used together, these modalities provide a comprehensive view of fibroid size, number, and location.

Magnetic Resonance Imaging (MRI)

• MRI delivers detailed, multiplanar images that allow precise characterization of fibroids, including their vascularity, composition (e.g., degeneration), and proximity to adjacent structures.
• It is particularly valuable in pre-surgical planning, especially for patients considering uterine-sparing procedures such as myomectomy or uterine artery embolization, and when differentiating fibroids from other pelvic masses.

Hysteroscopy or Sonohysterography (for submucosal fibroids)

• Hysteroscopy involves direct visualization of the uterine cavity using a small camera inserted through the cervix, allowing for both diagnosis and potential resection of submucosal fibroids during the same procedure.
• Sonohysterography (saline infusion sonography) enhances standard ultrasound by distending the uterine cavity with saline, offering better delineation of intracavitary lesions such as submucosal fibroids or polyps.

Laboratory Tests to Assess Anemia or Hormonal Status

• Complete blood count (CBC) is essential to evaluate for anemia, which is a common complication of fibroid-related heavy menstrual bleeding and may impact surgical readiness.
• Hormonal panels, including thyroid function tests and reproductive hormones (FSH, LH, estradiol), help rule out other causes of abnormal bleeding and guide perioperative management, especially in perimenopausal patients.

Conservative (Non-Surgical) Treatment

Conservative management may be suitable for women with mild or manageable symptoms, or those wishing to delay or avoid surgery.

Common non-surgical treatment options include:

• Hormonal Therapies: Such as GnRH agonists, progestins, and oral contraceptives to regulate bleeding and shrink fibroids.
• Non-Hormonal Medications: NSAIDs for pain management, and tranexamic acid to reduce bleeding.
• Uterine Artery Embolization (UAE): A minimally invasive radiological procedure that reduces blood flow to fibroids, causing them to shrink.
• MRI-Guided Focused Ultrasound (MRgFUS): A non-invasive treatment that uses high-intensity ultrasound waves to destroy fibroid tissue.
• Watchful Waiting: For asymptomatic or postmenopausal patients, observation may be all that is needed.

Surgical Treatment Options

Surgical intervention for uterine fibroids may become necessary when symptoms are severe or unmanageable, when infertility is linked to fibroid presence, when fibroids show rapid or abnormal growth, or when conservative treatments have proven ineffective.

Minimally invasive techniques are preferred whenever clinically appropriate, due to their shorter recovery time and lower risk of complications. However, open surgical procedures remain necessary in more complex cases involving large, multiple, or deeply embedded fibroids. The choice of surgery depends on the patient’s symptoms, reproductive plans, overall health, and fibroid characteristics, such as size, location, and number.

Myomectomy

A myomectomy is a uterus-sparing procedure that involves the surgical removal of fibroids while leaving the uterus intact. It is the preferred option for women wishing to preserve fertility or avoid hysterectomy.

• Hysteroscopic Myomectomy (Minimally Invasive)
  • Best suited for submucosal fibroids that protrude into the uterine cavity.
  • Performed through the vaginal canal using a hysteroscope, with no incisions on the abdomen.
  • Offers a short recovery time and minimal blood loss, but is limited to specific fibroid types and sizes.

• Laparoscopic Myomectomy (Minimally Invasive)
  • Appropriate for intramural or subserosal fibroids that are accessible through laparoscopy.
  • Small abdominal incisions are made, and a camera-guided instrument is used for fibroid removal.
  • Associated with shorter hospital stays, faster recovery, and reduced postoperative pain.

• Abdominal (Open) Myomectomy (Open Surgery)
  • Recommended for large, multiple, or deeply embedded fibroids not suitable for minimally invasive techniques.
  • Involves a larger incision in the lower abdomen and longer recovery (typically 4–6 weeks).
  • Offers full access to the uterus and may be preferred in complex or recurrent fibroid cases.

Hysterectomy

A hysterectomy is the complete removal of the uterus, resulting in a permanent resolution of fibroids. It is the only definitive cure, as fibroids cannot recur after the uterus is removed.

• May be performed via laparoscopy (minimally invasive), vaginal route (minimally invasive), or abdominally (open surgery) depending on the size and position of the uterus and fibroids.
• Indicated for women with severe symptoms, no future fertility plans, or in cases of coexisting conditions such as endometrial hyperplasia or recurrent bleeding.
• Eliminates the need for future fibroid treatment.
• Resolves associated symptoms definitively.
• Longer recovery if performed through open surgery; minimally invasive approaches are preferred when feasible.

Endometrial Ablation (Minimally Invasive)

Endometrial ablation is a procedure that destroys the inner lining of the uterus (endometrium) to reduce or stop heavy menstrual bleeding.

• Suitable for women with heavy or prolonged periods caused by fibroids that distort the endometrial cavity.
• Not effective for large, intramural, or deeply embedded fibroids.
• Not recommended for women who desire future pregnancies, as it significantly reduces or eliminates fertility.