Overview

Uterine fibroids, also known as leiomyomas, are common non-cancerous growths seen in and around the womb (uterus). Every one in three individuals assigned female at birth experience heavy periods, tummy pain, bloating, frequent constipation, urge to urinate, or pain while having sex.¹ It is more prevalent in those of 35–39 years of age and older. 77% of individuals assigned female at birth develop fibroids sometime during their childbearing years. Latin America, Eastern Europe, India and Brazil experience the greatest uterine fibroid burden.²

Fibroids can be as small as a grain or as big as a football. They are diagnosed through a pelvic examination or using imaging techniques.

Conventional treatments

The treatment of fibroids depends on symptoms, location and size of the fibroids, age, medical history and desire for future pregnancy.

If the symptoms are tolerable, the doctor may suggest ‘watchful waiting’ till menopause, monitoring the symptoms and significant changes in the condition during follow-up visits. Otherwise, the doctor may recommend medicines or surgery.³

Medicinal treatment 

• Anti-inflammatory agents: E.g., ibuprofen and naproxen are given to reduce pelvic pain and menstrual bleeding in individuals with fibroids
• Hormones: Oral contraceptives, progesterone-containing pills, injections and intrauterine devices are used to control bleeding associated with fibroids. Mifepristone and ulipristal acetate are progesterone receptor modulators used to reduce the size of fibroids⁴
• Gonadotropin-releasing hormone agonists: can be given for short periods to shrink the fibroids and temporarily pause bleeding⁵

Surgical treatment 

To minimise the long-term side effects of medicines, and when medicines do not seem to be working, a surgical approach is considered.

Myomectomy

It is a surgical procedure to remove fibroids from the lining of the uterus, without damaging it.⁶

1. Abdominal myomectomy- where a horizontal cut is made in the abdomen to remove the fibroid from the uterus
   • Disadvantages: longer recovery, scarring, pain and chances of uterine rupture
2. Robotic or laparoscopic myomectomy - where small cuts are made in the abdomen and a laparoscopic or robotic arm is used as a guide to remove multiple fibroids⁶
   • Advantages: less invasive, less bleeding and faster recovery
   • Disadvantages: the chances of uterine rupture during pregnancy
3. Hysteroscopic myomectomy- a tube inserted through the vagina into the uterus, which has an operative arm that removes the fibroid tissues
   • Advantages: no cuts or incisions, least invasive and recovery in 2-3 days
   • Disadvantages: can be used to remove small fibroids, but not deep in the uterine wall⁶
4. Uterine artery embolisation is a newer, minimally invasive procedure that shrinks the fibroids by cutting off the blood supply
   • Disadvantages: long-term studies are required to know its effects on fertility and regrowth
5. Magnetic resonance-guided focused ultrasound is a newer technique where high-intensity ultrasound energy is used on the uterus to destroy the fibroids
   • Disadvantages: less data is available on the long-term effects of this treatment
6. Radiofrequency ablation is a newer technique where heat is applied using ultrasound and laparoscopic guidance, making the fibroids smaller and softer
   • Disadvantages: The effects on fertility are not yet well understood
7. Hysterectomy is a surgical procedure where the entire uterus is removed by placing a large cut in the abdomen or vagina⁶
   • Advantages - no chances or recurrence, the most effective method for fibroid treatment
   • Disadvantages - invasive, slow recovery, chances of infection and damage to other organs, loss of fertility and early menopause

Rise of complementary and alternative treatments 

Due to the side effects, fear and cost associated with surgery, and cultural variations in treatment approach, many people opt for natural and alternative sources of treatment. The system of medicine that falls out of mainstream care is called complementary and alternative medicine(CAM). 

Herbal remedies

There has been a rise in research on botanical drugs for treating uterine fibroids as they offer lower risk and greater benefits. The table below shows various botanical drugs and polyherbal formulations.^7,8,9

Polyherbal formulation

Other herbal remedies

• Black cohosh is used to treat gynaecological disorders due to its effect on regulating estrogen levels.¹⁰ However, its effectiveness in treating fibroids is debatable, with mixed results
• Chasteberry has been used to treat hormonal imbalances and menstrual problems, but there is no direct evidence on its fibroid-shrinking ability
• Randomised controlled studies on 2 Ayurvedic regimens demonstrated effectiveness in fibroid shrinking and reducing fibroid-related symptoms¹¹
• Some studies have also proved that Chinese herbal prescriptions containing Ejiao or Velvet antlers are better than surgery and Western medicines in shrinking the volume of fibroids¹²

Benefits of herbal treatments for fibroids

• Inhibit inflammation-causing enzymes and factors
• Inhibit expression of genes that cause cell growth, multiplication and formation of new blood vessels supporting fibroids¹³
• Control the size, volume and growth of fibroid^12,13
• Promote the death of multiplying fibroid cells
• Reduce estrogen and progesterone, which directly affect the growth of fibroids

Limitations

• Poor absorption, fast metabolism and excretion from the body, e.g Curcuma longa⁸
• Lack of human studies, many studies have been done in vitro or on animals⁸
• Lack of robust, well-designed and long-term studies on the safety and efficacy of botanicals, e.g green tea⁹
• Many herbs have lower potency when used alone than in combination with Western medicine, meaning, Chinese medicines combined with Western medicines have shown better results in treating fibroids^12,14
• Anecdotal evidence and conflicting results^7,9
• Liver toxicity with black cohosh
• Interaction with fertility drugs, oral contraceptives and anticoagulants causes side effects

Alternative treatment

Studies have shown that obesity, stress and high blood pressure increase the chances of having fibroids. Thus, treatment targeting these parameters also needs to be considered.

Limitations

• Lack of standardisation in studies. ⁷
• No direct effects on fibroid shrinkage. 
• Insufficient data on long-term effects. 

Empowering strategies for prevention

Innovative strategies for uterine fibroid management have been designed by Vafaei et al¹⁸ and are named LIFE UP awareness, standing for Lifestyle Interventions, Food Modifications, and Environmental Practices for Uterine Fibroid Prevention. These are non-invasive, cost-effective, safe, and accessible measures which can prevent fibroids and improve overall reproductive health. A balanced diet, regulating hormonal profiles, and regular medical checkups can mitigate the risk and severity of fibroids.

Summary 

Fibroids are a global health concern affecting a majority of individuals assigned female at birth in their reproductive years. The dependency on pharmaceutical drugs is slowly diminishing, with a growing demand for complementary and alternative treatment options. Although herbal agents offer promising results, maintaining caution with unverified treatments is necessary. A clear understanding of underlying symptoms is crucial in planning individualised therapies. An integrated evidence-based approach is required, which is cost-effective and beneficial in treating fibroids.