I am 40 years old with a large uterine fibroid. About six months ago, my doctor prescribed the pill, and that cleared up my anemia, heavy bleeding and bad cramps. I don't have any children and don't plan to. My doctor has offered me several options: a drug to shrink the fibroid, a wait-and-see approach, or a hysterectomy without removing the ovaries. What are the pros and cons of these options at my age?

-- Lisa

It is difficult to answer this question completely because I do not know your complete medical history. For example, if you are a nonsmoker and do not have high blood pressure, diabetes or other major medical problems, staying on the pill is certainly an option. However, if you smoke, using the pill is not such a good idea.

Lupron is a commonly used GnRH-agonist that is FDA-approved to shrink fibroids. It is given by injection. Other similar medications are available as well. GnRH-agonists work by shutting down the normal hormonal pathways that lead to ovulation and menstruation; they suppress estrogen levels as well. The general action is that of a false menopause. Because the fibroid is no longer being stimulated by the hormones, it may shrink. Lupron can be very effective, but once it is stopped (usually after six months), the fibroid(s) may begin to grow again. Lupron is frequently used before surgery to make the surgery easier; for instance, a uterus that was initially too large for a vaginal hysterectomy may shrink enough to allow this approach. It may also be very effective in women who are close to menopause, allowing adequate shrinkage of the fibroids and relief of symptoms -- and once natural menopause occurs, fibroids do not usually cause any further problems. Side effects include all the usual menopausal symptoms -- hot flashes, night sweats, vaginal dryness, etc. In addition, use of Lupron or any other GnRH-agonist may produce osteoporosis, which is why use is generally limited to six months or less.

Myomectomy is another option for fibroids that are causing problems. This is a surgical procedure to just remove the fibroid(s). Sometimes a myomectomy may be done through a minimally invasive approach such as hysteroscopy or laparoscopy, depending on the size, number, and location of the fibroids. Often, however, an open abdominal approach is necessary. Myomectomy is the procedure of choice for women who have not completed their families or who wish to preserve the uterus. As long as any uterus remains, however, new fibroids may eventually appear. Similar uterus-sparing options that are generally reserved for women who do not wish to become pregnant (because we do not know the effects of these procedures on the subsequent strength of the uterine wall) are myolysis ("cooking" the fibroid with electrical energy via laparoscopy or hysteroscopy), cryomyolysis (similar to the above, but the fibroid is frozen) and selective embolization (a catheter is fed into the blood supply to the fibroid and tiny particles are released, blocking blood flow and causing the fibroid to shrink).

Hysterectomy is the most definitive treatment for fibroids, as the entire uterus is removed; once the uterus is gone, there is no chance that fibroids may recur. Ovaries may be removed as well or spared, depending on age, other gynecologic conditions and individual preference. Hysterectomy may be done through an abdominal incision, through the vagina, through the laparoscope or through a combination of laparoscope and vaginal approaches. The route of hysterectomy depends on the size of the uterus, the skill of the surgeon and the presence of significant scar tissue. Hysterectomy is major surgery and has the same risks as any other surgery -- anesthetic complications, bleeding, infection, damage to adjacent structures and organs. It also, obviously, means future childbearing is out of the question. Recovery time varies depending on the approach used, but in general four to six weeks is average.

The choice of which treatment to select depends on many factors. Each woman must discuss all the options with her own doctor, and the doctor should discuss the risks as well as the potential benefits of every option, not just the one she or he prefers.