Fast Forward: Fibroid Management in 2042

It is January 5, 2042 at 7:00AM. I do not have surgeries this week, only office visits, teaching and research. The first patient scheduled in clinic today is 42-year-old lady, has a Body Mass Index (BMI) of 34 and is hypertensive. She initially presented for heavy periods and pelvic pain. Imaging revealed several small fibroids, and her labs showed elevated cholesterol and triglycerides. Her fibroid biomarkers suggested that her metabolic disorders are contributing to the development of her fibroids. I discussed the findings with her, recommended lifestyle changes and started her on simvastatin. I also started her on an angiotensin-converting enzyme (ACE) inhibitor for her elevated blood pressure.

My second patient today is a 29-year-old lady presenting for a uterine fibroid screening consultation. Her demographic, family history and clinical findings alerted her primary care providers to a high risk for developing fibroids and referred her to me. The routine fibroid panel was already completed prior to her visit. Her lab results showed a low vitamin D level and elevated uterine fibroid predicting biomarkers. I entered her BMI, blood lab results, and her family’s history of uterine fibroids in the uterine fibroid risk calculator. Her risk of developing uterine fibroids over the next five years is elevated. I counseled, recommended lifestyle modification, including a healthier diet and more exercise to lose weight, and started her on vitamin D.

Reflecting back on our management of uterine fibroids, we have come a long way. In the past, effective medications to treat this condition were limited, and we performed surgeries on many of our patients as we did not have other successful options. We also had limited understanding of the pathogenesis, and we were more interested in treating than preventing fibroids. Shifting our focus to prevent uterine fibroid development through lifestyle changes and medications was groundbreaking and improved the lives of millions of women in our country and worldwide.

Fibroid markers were proposed a while ago before being further developed and incorporated into practice (1). The benefits of vitamin D in uterine fibroid management were known for some time before it was widely implemented (2, 3). Similarly, the association of fibroids with cardiometabolic risk factors was known for years before it was implemented in fibroid prevention programs (4). The association of obesity, hypertension, and metabolic syndrome offered the potential for clinical intervention through lifestyle changes and medications. Also, the possible beneficial effects of simvastatin, an anti-hyperlipidemic drug, on uterine fibroids were demonstrated (5–10). Similarly, studies suggested that angiotensin-converting enzyme inhibitors reduce uterine fibroid incidence in hypertensive patients (11). The clinical trials for vitamin D, simvastatin, ACE inhibitors, and their combinations showed remarkable therapeutic and preventive benefits. The establishment of uterine fibroid predictive biomarkers served as a catalyst to develop a risk score calculator that predicts with considerable accuracy the rate of development of this tumor. This changed the paradigm in uterine fibroid management.

I cannot believe how many hysterectomies and myomectomies used to be done the past or that small asymptomatic fibroids were left untreated until they become symptomatic. Available medical therapies were expensive, difficult to access, and could not be taken for an extended periods of time. The previously available therapies could not be given to women attempting to get pregnant, who often needed the treatment if the fibroids were affecting their fertility. Fibroids were treated the way infections were treated in the pre-antibiotic era. This improvement in the management of uterine fibroids could not have been possible without the collaborative effort of scientists, physicians, academic institutions, funding agencies, and, above all, our patients.