A smaller dose of the "morning after" birth control pill may help to control fibroids in the uterus as well. That's the conclusion of two new studies. They were done in Europe, where the pill is awaiting approval. Fibroids are growths that can cause heavy bleeding and pain. Fibroids are not cancerous, but treatments often don't work well. Esmya is a lower dose of the drugs in Ella, an emergency birth control pill. The new studies included a total of 550 women with fibroids. All had such severe symptoms that they were planning surgery. In one study, women were randomly assigned to take Esmya or placebo (fake) pills for 3 months. The other study compared Esmya with a monthly hormone-blocking shot. It controls fibroids, but can thin bones after long use. Women received either Esmya and a fake shot, or a real shot and a fake pill. Esmya stopped bleeding and shrank fibroids in most women. The second study showed it worked as well as the shot, but with fewer side effects. The New England Journal of Medicine published the studies. The Associated Press wrote about them February 2.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

When a medical condition has several treatment options, with none being the best, it's welcome news to hear about a treatment with fewer side effects. That may be the case for a drug called ulipristal acetate. It's a new treatment for fibroid symptoms.

Fibroids in the uterus are very common. They occur in up to 75% of women. They are rubbery growths in the wall of the uterus. Fibroids are not cancerous.

The hormones estrogen and progesterone stimulate the growth of fibroids. Therefore, they tend to enlarge during a woman's child-bearing years, when the ovaries are still producing female hormones. When hormone levels fall after menopause, fibroids shrink.

Most women have no symptoms from fibroids. They might never know that they had them if they are small. Or a doctor could feel them during a pelvic exam or see them on an ultrasound done for some other reason.

About 25% of women have symptoms. The most common symptoms are discomfort in the pelvic area and irregular or heavy menstrual bleeding. The pain sometimes can be quite severe. And the heavy periods can lead to iron-deficiency anemia (a low red blood cell count).

Large fibroids can push on the bladder, causing a frequent urge to urinate. During pregnancy, very high levels of estrogen and progesterone can stimulate quicker growth of fibroids. This is linked with a greater than average risk of miscarriage.

African-American women are three times more likely to develop symptom-causing fibroids than women of other ethnic groups. Also, they typically do so at an earlier age.

No one knows exactly why fibroids form. Genes that speed up the growth of muscle cells in the uterus may play a role. Abnormal blood vessels in the uterus may also be involved. Clearly estrogen and progesterone play a major role in their growth, but that doesn't mean they cause fibroids to form.

What Changes Can I Make Now?

If you have fibroids and no symptoms, no treatment is needed. If you do have symptoms, your doctor will consider your age and how severe your symptoms are. He or she will also want to know if you are planning future pregnancies. Fibroids can grow rapidly during pregnancy.

There are many ways to treat fibroids. You and your doctor will make the choice between medical and surgical options or one of the newer approaches.

If you're in your 40s and symptoms aren't severe, you may simply wait out your fibroids. They will likely shrink after menopause, and symptoms should go away.

Meanwhile, you can use over-the-counter painkillers. These include:

• Acetaminophen (such as Tylenol)
• Nonsteroidal anti-inflammatory drugs
  
  • Ibuprofen (such as Motrin, Advil)
  • Naproxen (such as Aleve)

To treat the anemia caused by heavy bleeding, increase your iron intake through diet and an iron supplement.

No medicine can prevent fibroids or guarantee that they won't return. Right now, the primary medical option is injection with gonadotropin-releasing hormone (GnRH) agonists. An example is leuprolide (Lupron), which was used in one of the new studies. These drugs are given as a monthly shot. They suppress estrogen production by the ovaries.

Without estrogen, fibroids shrink. But they usually grow back once the drug is stopped. Side effects, similar to those of menopause, are common.

Surgery to remove the uterus (hysterectomy) is the ultimate cure for fibroid symptoms. Your decision will depend largely on whether you might want more children or you are willing to wait for menopause.

Other options include:

• Myomectomy -- This operation removes only the fibroids. It preserves the uterus.



• Uterine artery embolization (also known as uterine fibroid embolization) -- A radiologist inserts a thin tube called a catheter through the skin into an artery in the groin. The catheter is pushed into the artery that feeds blood to the uterus. Sand-sized particles are injected into the uterine artery. The particles come together and cut off blood supply to the fibroids.



• Magnetic resonance-guided intensity ultrasound -- This treatment works by heating and shrinking the fibroid with high-intensity ultrasound waves. MRI is used to see the fibroid and keep track of temperature changes in the uterus during the procedure. This is not widely available. It may not be covered by insurance.

What Can I Expect Looking to the Future?

This new drug ulipristal acetate sounds very promising as an alternative to hormone-blocking shots. It appears to work at least as well at shrinking fibroids and perhaps better. We don't know yet whether ulipristal can be used long-term as an alternative to surgery or other procedures. It is not approved by the U.S. Food and Drug Administration. It probably won't be approved for at least two more years.