Fibroids — Treatment

Treatment — Fibroids

Treatment may not be necessary if you have fibroids but don’t have any symptoms, or if you only have minor symptoms that aren’t significantly affecting your everyday activities.

Fibroids often shrink after the menopause, and your symptoms will usually either ease or disappear completely.

If you have fibroids that need treatment, your GP may recommend medication to help relieve your symptoms.

But you may need to see a gynaecologist (a specialist in the female reproductive system) for further medication or surgery if these are ineffective.

See your GP to discuss the best treatment plan for you.

The various treatments for fibroids include:

Medication for symptoms

Medicines are available that can be used to reduce heavy periods, but they can be less effective the larger your fibroids are.

These medications are described below.

Levonorgestrel intrauterine system (LNG-IUS)

The levonorgestrel intrauterine system (LNG-IUS) is a small, plastic T-shaped device placed in your womb that slowly releases the progestogen hormone levonorgestrel.

It stops your womb lining growing quickly, so it’s thinner and your bleeding becomes lighter.

Side effects associated with LNG-IUS include:

  • irregular bleeding that may last for more than 6 months
  • acne
  • headaches
  • breast tenderness
  • in some cases, no periods at all (absent periods)

LNG-IUS also acts as a contraceptive, but doesn’t affect your chances of getting pregnant after you stop using it.

Tranexamic acid

If LNG-IUS is unsuitable (for example, if contraception isn’t desired) tranexamic acid tablets may be considered.

They work by stopping the small blood vessels in the womb lining bleeding, reducing blood loss by about 50%.

Tranexamic acid tablets are taken 3 or 4 times a day during your period for up to 4 days. Treatment should be stopped if your symptoms haven’t improved within 3 months.

Tranexamic acid tablets aren’t a form of contraception and won’t affect your chances of becoming pregnant.

Indigestion and diarrhoea are possible side effects of tranexamic acid tablets.

Anti-inflammatory medicines

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and mefenamic acid, can be taken 3 times a day from the first day of your period until bleeding stops or reduces to manageable levels.

NSAIDs work by reducing your body’s production of a hormone-like substance called prostaglandin, which is linked to heavy periods.

Anti-inflammatory medicines are also painkillers, but they aren’t a form of contraception.

Indigestion and diarrhoea are common side effects of NSAIDs.

The contraceptive pill

The contraceptive pill is a popular method of contraception that stops an egg being released from the ovaries to prevent pregnancy.

As well as making bleeding lighter, some contraceptive pills can help reduce period pain.

Your GP can provide you with further advice about contraception and the contraceptive pill.

Oral progestogen

Oral progestogen is synthetic (man-made) progesterone (one of the female sex hormones) that can help reduce heavy periods.

It’s usually taken as a daily tablet from days 5 to 26 of your menstrual cycle, counting the first day of your period as day 1.

Oral progestogen works by preventing the womb lining growing quickly. It’s not a form of contraception, but can reduce your chances of conceiving while you’re taking it.

The side effects of oral progestogen can be unpleasant and include weight gain, breast tenderness and short-term acne.

Injected progestogen

Progestogen is also available as an injection to treat heavy periods. It works by preventing the lining of your womb growing quickly.

This form of progestogen can be injected once every 12 weeks for as long as treatment is required.

Common side effects of injected progestogen include:

  • weight gain
  • irregular bleeding
  • absent periods
  • premenstrual symptoms, such as bloating, fluid retention and breast tenderness

Injected progestogen also acts as a contraceptive. It doesn’t prevent you becoming pregnant after you stop using it, although there may be a significant delay (up to 12 months) after you stop taking it before you’re able to get pregnant.

Medication to shrink fibroids

Gonadotropin releasing hormone analogues (GnRHas)

If you’re still experiencing symptoms related to fibroids despite treatment with the above medications, your GP can refer you to a gynaecologist.

They may prescribe medication called gonadotropin releasing hormone analogues (GnRHas) to help shrink your fibroids.

GnRHas, such as goserelin acetate, are hormones given by injection. They work by affecting the pituitary gland, which stops the ovaries producing oestrogen.

The pituitary gland is a small, pea-sized gland located at the bottom of the brain. It controls a number of important hormone glands within the body.

GnRHas stop your menstrual cycle (period), but aren’t a form of contraception. They don’t affect your chances of becoming pregnant after you stop using them.

If you’re prescribed GnRHas, they can help ease heavy periods and any pressure you feel on your stomach. They also help improve symptoms of frequent urination and constipation.

GnRHas are sometimes also used to shrink fibroids prior to surgery to remove them.

GnRHas can cause a number of menopause-like side effects, including:

  • hot flushes
  • increased sweating
  • muscle stiffness
  • vaginal dryness

Sometimes a combination of GnRHas and low doses of hormone replacement therapy (HRT) may be recommended to prevent these side effects.

Osteoporosis (thinning of the bones) is an occasional side effect of taking GnRHas.

Your GP can give you more information about this, and may prescribe additional medication to minimise thinning of your bones.

GnRHas is only prescribed on a short-term basis (a maximum of 6 months at a time). Your fibroids may grow back to their original size after treatment is stopped.

Ulipristal acetate

Some women may be offered a medication called ulipristal acetate (Esmya) for fibroids.

Ulipristal acetate may be offered to women over 18 years old who have not yet experienced the menopause if they:

  • have moderate to severe symptoms and are waiting for surgery – only 1 course of medication would be prescribed
  • have moderate to severe symptoms but aren’t able to have surgery – more than 1 course of medication may be prescribed

In rare cases, ulipristal acetate can cause liver damage. Your doctor should explain this risk, but you’ll need several blood tests to monitor your liver before, during and after taking it.

Ulipristal acetate shouldn’t be prescribed to women with an underlying liver condition as there’s a higher risk of causing liver damage.

If you’re taking ulipristal acetate, stop taking the medicine and contact your doctor immediately if you have symptoms.

  • nausea or vomiting
  • severe tiredness
  • yellowing of the eyes or skin (jaundice)
  • dark urine
  • itchy skin
  • stomach ache on the upper right side of your body

These symptoms could be a sign of liver damage.

For further information about ulipristal acetate, speak to your doctor or read the patient information leaflet (PDF, 109kb) on the eMC website.

Surgery

Surgery to remove your fibroids may be considered if your symptoms are particularly severe and medication has been ineffective.

Several different procedures can be used to treat fibroids. Your GP will refer you to a specialist, who’ll discuss the options with you, including benefits and any associated risks.

The main surgical procedures used to treat fibroids are outlined below.

Hysterectomy

A hysterectomy is a surgical procedure to remove the womb. It’s the most effective way of preventing fibroids coming back.

A hysterectomy may be recommended if you have large fibroids or severe bleeding and don’t wish to have any more children.

There are a number of different ways a hysterectomy can be carried out, including through the vagina or through a number of small cuts (incisions) in your tummy (abdomen).

Depending on the technique used, a hysterectomy can be carried out using a spinal or epidural anaesthetic, where the lower parts of the body are numbed.

Sometimes a general anaesthetic may be used, where you’ll be asleep during the procedure.

You’ll usually need to stay in hospital for a few days after having a hysterectomy. It takes about 6 to 8 weeks to fully recover, during which time you should rest as much as possible.

Side effects of a hysterectomy can include early menopause and a loss of libido (sex drive). This usually only occurs if the ovaries have been removed.

Myomectomy

A myomectomy is surgery to remove the fibroids from the wall of your womb. It may be considered as an alternative to a hysterectomy if you’d still like to have children.

But a myomectomy isn’t suitable for all types of fibroid. Your gynaecologist can tell you whether the procedure is suitable for you based on factors such as the size, number and position of your fibroids.

Depending on the size and position of your fibroids, a myomectomy may involve making either a number of small incisions in your tummy (keyhole surgery) or a single larger incision (open surgery).

Myomectomies are carried out under general anaesthetic and you’ll usually need to stay in hospital for a few days afterwards. You’ll be advised to rest for several weeks while you recover.

Myomectomies are usually an effective treatment for fibroids, although there’s a chance the fibroids will grow back and further surgery will be needed.

Hysteroscopic resection of fibroids

A hysteroscopic resection of fibroids is a procedure where a thin telescope (hysteroscope) and small surgical instruments are used to remove fibroids.

The procedure can be used to remove fibroids from inside the womb (submucosal fibroids) and is suitable for women who want to have children in the future.

No incisions are needed because the hysteroscope is inserted through the vagina and into the womb through the entrance to the womb (cervix).

A number of insertions are needed to ensure as much fibroid tissue as possible is removed.

The procedure is often carried out under general anaesthetic, although local anaesthetic may be used instead. You can usually go home on the same day as the procedure.

After the procedure you may experience stomach cramps, but they should only last a few hours. There may also be a small amount of vaginal bleeding, which should stop within a few weeks.

Hysteroscopic morcellation of fibroids

Hysteroscopic morcellation of fibroids is a new procedure where a clinician who’s received specialist training uses a hysteroscope and small surgical instruments to remove fibroids.

The hysteroscope is inserted into the womb through the cervix and a specially designed instrument called a morcellator is used to cut away and remove the fibroid tissue.

The procedure is carried out under a general or spinal anaesthetic. You’ll usually be able to go home on the same day.

The main benefit of hysteroscopic morcellation compared with hysteroscopic resection is that the hysteroscope is only inserted once, rather than a number of times, reducing the risk of injury to the womb.

The procedure may be an option in cases where there are serious complications.

But because hysteroscopic morcellation is a new technique, evidence about its overall safety and long-term effectiveness is limited.

Read the National Institute for Health and Care Excellence (NICE) guidance about hysteroscopic morcellation of uterine fibroids.

Non-surgical procedures

As well as traditional surgical techniques to treat fibroids, non-surgical treatments are also available.

These are outlined below.

Uterine artery embolisation (UAE)

Uterine artery embolisation (UAE) is an alternative procedure to a hysterectomy or myomectomy for treating fibroids. It may be recommended for women with large fibroids.

UAE is carried out by a radiologist, a specialist doctor who interprets X-rays and scans. It involves blocking the blood vessels that supply the fibroids, causing them to shrink.

During the procedure, a special solution is injected through a small tube (catheter), which is guided by X-ray through a blood vessel in your leg.

It’s carried out under local anaesthetic, so you’ll be awake but the area being treated will be numbed.

You’ll usually need to stay in hospital a day or two after having UAE. When you leave hospital, you’ll be advised to rest for 1 to 2 weeks.

Although it’s possible to have a successful pregnancy after having UAE, the overall effects of the procedure on fertility and pregnancy are uncertain.

It should therefore only be carried out after you have discussed the potential risks, benefits and uncertainties with your doctor.

Endometrial ablation

Endometrial ablation is a relatively minor procedure that involves removing the lining of the womb.

It’s mainly used to reduce heavy bleeding in women without fibroids, but it can also be used to treat small fibroids in the womb lining.

The affected womb lining can be removed in a number of ways – for example, by using laser energy, a heated wire loop, or hot fluid in a balloon.

The procedure can be carried out either under local anaesthetic or general anaesthetic.

It’s fairly quick to perform, taking around 20 minutes, and you can usually go home the same day.

You may experience some vaginal bleeding and tummy cramps for a few days afterwards, although some women have bloody discharge for 3 or 4 weeks.

Some women have reported experiencing more severe or prolonged pain after having endometrial ablation.

In this case, you should speak to your GP or a member of your hospital care team, who may be able to prescribe a stronger painkiller.

It may still be possible to get pregnant after having endometrial ablation, but the procedure isn’t recommended for women who want to have more children because the risk of serious problems, such as miscarriage, is high.

The Royal College of Obstetricians and Gynaecologists (RCOG) have more information about endometrial ablation.

MRI-guided procedures

There are also 2 relatively new techniques for treating fibroids that use MRI.

  • MRI-guided percutaneous laser ablation
  • MRI-guided transcutaneous focused ultrasound

These techniques use MRI to guide small needles into the centre of the fibroid being targeted.

Laser energy or ultrasound energy is passed through the needles to destroy the fibroid.

These treatment methods can’t be used to treat all types of fibroids, and the long-term benefits and risks are unknown.

As these procedures are relatively new, they’re not yet widely available in the UK.

Research is still being carried out, but there’s some evidence to suggest that these non-invasive procedures have short- to medium-term benefits when performed by an experienced clinician.

But the effects on pregnancy and women who want to have a baby in the future aren’t fully known, so this should be taken into consideration.

For further information, read the NICE guidance about:

Page last reviewed: 17 September 2018
Next review due: 17 September 2021

www.nhs.uk

PART 20 — COUNTERCLAIMS AND OTHER ADDITIONAL CLAIMS

Contents of this Part

Title Number
Purpose of this Part Rule 20.1
Scope and interpretation Rule 20.2
Application of these Rules to additional claims Rule 20.3
Defendant’s counterclaim against the claimant Rule 20.4
Counterclaim against a person other than the claimant Rule 20.5
Defendant’s additional claim for contribution or indemnity from another party Rule 20.6
Procedure for making any other additional claim Rule 20.7
Service of claim form Rule 20.8
Matters relevant to question of whether an additional claim should be separate from the claim Rule 20.9
Effect of service of an additional claim Rule 20.10
Special provisions relating to default judgment on an additional claim other than a counterclaim or a contribution or indemnity notice Rule 20.11
Procedural steps on service of an additional claim form on a non-party Rule 20.12
Case management where a defence to an additional claim is filed Rule 20.13

Purpose of this Part

20.1 The purpose of this Part is to enable counterclaims and other additional claims to be managed in the most convenient and effective manner.

Scope and interpretation

20.2

(1) This Part applies to –

(a) a counterclaim by a defendant against the claimant or against the claimant and some other person;

(b) an additional claim by a defendant against any person (whether or not already a party) for contribution or indemnity or some other remedy; and

(c) where an additional claim has been made against a person who is not already a party, any additional claim made by that person against any other person (whether or not already a party).

(2) In these Rules –

(a) ‘additional claim’ means any claim other than the claim by the claimant against the defendant; and

(b) unless the context requires otherwise, references to a claimant or defendant include a party bringing or defending an additional claim.

Application of these Rules to additional claims

20.3

(1) An additional claim shall be treated as if it were a claim for the purposes of these Rules, except as provided by this Part.

(2) The following rules do not apply to additional claims –

(a) rules 7.5 and 7.6 (time within which a claim form may be served);

(b) rule 16.3(5) (statement of value where claim to be issued in the High Court); and

(c) Part 26 (case management – preliminary stage).

(3) Part 12 (default judgment) applies to a counterclaim but not to other additional claims.

(4) Part 14 (admissions) applies to a counterclaim, but only –

(a) rules 14.1(1) and 14.1(2) (which provide that a party may admit the truth of another party’s case in writing); and

(b) rule 14.3 (admission by notice in writing – application for judgment),

apply to other additional claims.

(Rule 12.3(2) sets out how to obtain judgment in default of defence for a counterclaim against the claimant, and rule 20.11 makes special provision for default judgment for some additional claims).

Defendant’s counterclaim against the claimant

20.4

(1) A defendant may make a counterclaim against a claimant by filing particulars of the counterclaim.

(2) A defendant may make a counterclaim against a claimant –

(a) without the court’s permission if he files it with his defence; or

(b) at any other time with the court’s permission.

(Part 15 makes provision for a defence to a claim and applies to a defence to a counterclaim by virtue of rule 20.3).

(3) Part 10 (acknowledgment of service) does not apply to a claimant who wishes to defend a counterclaim.

Counterclaim against a person other than the claimant

20.5

(1) A defendant who wishes to counterclaim against a person other than the claimant must apply to the court for an order that that person be added as an additional party.

(2) An application for an order under paragraph (1) may be made without notice unless the court directs otherwise.

(3) Where the court makes an order under paragraph (1), it will give directions as to the management of the case.

Defendant’s additional claim for contribution or indemnity from another party

20.6

(1) A defendant who has filed an acknowledgment of service or a defence may make an additional claim for contribution or indemnity against a person who is already a party to the proceedings by –

(a) filing a notice containing a statement of the nature and grounds of his additional claim; and

(b) serving the notice on that party.

(2) A defendant may file and serve a notice under this rule –

(a) without the court’s permission, if he files and serves it –

(i) with his defence; or

(ii) if his additional claim for contribution or indemnity is against a party added to the claim later, within 28 days after that party files his defence; or

(b) at any other time with the court’s permission.

Procedure for making any other additional claim

20.7

(1) This rule applies to any additional claim except –

(a) a counterclaim only against an existing party; and

(b) a claim for contribution or indemnity made in accordance with rule 20.6.

(2) An additional claim is made when the court issues the appropriate claim form.

(Rule 7.2(2) provides that a claim form is issued on the date entered on the form by the court)

(3) A defendant may make an additional claim –

(a) without the court’s permission if the additional claim is issued before or at the same time as he files his defence;

(b) at any other time with the court’s permission.

(Rule 15.4 sets out the period for filing a defence).

(4) Particulars of an additional claim must be contained in or served with the additional claim.

(5) An application for permission to make an additional claim may be made without notice, unless the court directs otherwise.

Service of claim form

20.8

(1) Where an additional claim may be made without the court’s permission, any claim form must –

(a) in the case of a counterclaim against an additional party only, be served on every other party when a copy of the defence is served;

(b) in the case of any other additional claim, be served on the person against whom it is made within 14 days after the date on which the additional claim is issued by the court.

(2) Paragraph (1) does not apply to a claim for contribution or indemnity made in accordance with rule 20.6.

(3) Where the court gives permission to make an additional claim it will at the same time give directions as to its service.

Matters relevant to question of whether an additional claim should be separate from the claim

20.9

(1) This rule applies where the court is considering whether to –

(a) permit an additional claim to be made;

(b) dismiss an additional claim; or

(c) require an additional claim to be dealt with separately from the claim by the claimant against the defendant.

(Rule 3.1(2)(e) and (j) deal respectively with the court’s power to order that part of proceedings be dealt with as separate proceedings and to decide the order in which issues are to be tried).

(2) The matters to which the court may have regard include –

(a) the connection between the additional claim and the claim made by the claimant against the defendant;

(b) whether the additional claimant is seeking substantially the same remedy which some other party is claiming from him; and

(c) whether the additional claimant wants the court to decide any question connected with the subject matter of the proceedings –

(i) not only between existing parties but also between existing parties and a person not already a party; or

(ii) against an existing party not only in a capacity in which he is already a party but also in some further capacity.

Effect of service of an additional claim

20.10

(1) A person on whom an additional claim is served becomes a party to the proceedings if he is not a party already.

(2) When an additional claim is served on an existing party for the purpose of requiring the court to decide a question against that party in a further capacity, that party also becomes a party in the further capacity specified in the additional claim.

Special provisions relating to default judgment on an additional claim other than a counterclaim or a contribution or indemnity notice

20.11

(1) This rule applies if –

(a) the additional claim is not –

(i) a counterclaim; or

(ii) a claim by a defendant for contribution or indemnity against another defendant under rule 20.6; and

(b) the party against whom an additional claim is made fails to file an acknowledgment of service or defence in respect of the additional claim.

(2) The party against whom the additional claim is made –

(a) is deemed to admit the additional claim, and is bound by any judgment or decision in the proceedings in so far as it is relevant to any matter arising in the additional claim;

(b) subject to paragraph (3), if default judgment under Part 12 is given against the additional claimant, the additional claimant may obtain judgment in respect of the additional claim by filing a request in the relevant practice form.

(3) An additional claimant may not enter judgment under paragraph (2)(b) without the court’s permission if –

(a) he has not satisfied the default judgment which has been given against him; or

(b) he wishes to obtain judgment for any remedy other than a contribution or indemnity.

(4) An application for the court’s permission under paragraph (3) may be made without notice unless the court directs otherwise.

(5) The court may at any time set aside or vary a judgment entered under paragraph (2)(b).

Procedural steps on service of an additional claim form on a non-party

20.12

(1) Where an additional claim form is served on a person who is not already a party it must be accompanied by –

(a) a form for defending the claim;

(b) a form for admitting the claim;

(c) a form for acknowledging service; and

(i) every statement of case which has already been served in the proceedings; and

(ii) such other documents as the court may direct.

(2) A copy of the additional claim form must be served on every existing party.

Case management where a defence to an additional claim is filed

20.13

(1) Where a defence is filed to an additional claim the court must consider the future conduct of the proceedings and give appropriate directions.

(2) In giving directions under paragraph (1) the court must ensure that, so far as practicable, the original claim and all additional claims are managed together.

(Part 66 contains provisions about counterclaims and other Part 20 claims in relation to proceedings by or against the Crown.)

www.justice.gov.uk

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