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Treatment Options
There are a variety of treatment options for uterine fibroids. These include:
Medical Therapy
Medical therapy is usually the first line of therapy in patients with
symptomatic uterine fibroids. Hormonal therapy with oral contraceptives can sometimes improve symptoms. Many women are given anti-inflammatory agents such as Motrin to treat fibroid symptoms. Some are prescribed GnRH therapy (Lupron) which lowers estrogen levels, causing the fibroids to shrink. Unfortunately, Lupron is associated with many side-effects similar to those experienced with menopause. Additionally, the fibroids will grow back when Lupron is halted and symptoms usually return. Fibroids often shrink in size and become asymptomatic as a woman goes through menopause which usually occurs around age 50. Some women near the age of 50 elect to treat the symptoms with medical therapy and wait for menopause.Myomectomy
Myomectomy is the surgical removal of a fibroid leaving the uterus in place. Myomectomy is less invasive than a hysterectomy with much shorter recovery periods. Unfortunately, as many as 35% of women will have a recurrence of their fibroids and up to 25% will require further surgery.
There are numerous ways that doctors perform a myomectomy. The type, size and location of your fibroids determine which of the following myomectomies might be recommended:
- Laparoscopic Myomectomy
- Hysteroscopic Myomectomy
- Laparotomy (Abdominal Myomectomy)
Laparoscopic Myomectomy involves removing subserosal fibroids visible on the surface of the uterus. Small incisicions are made in the navel and abdomen and long, slender instruments known as a laparoscopes are inserted to perform the surgery.
Hysteroscopic Myomectomy is an outpatient, office procedure where submucosal fibroids are removed with a small instrument called a hysteroscope that is inserted through the cervix into the uterus.
Abdominal Myomectomy via Laparotomy involves a traditional abdominal incision much like in a hysterectomy where multiple fibroids can be removed.
Uterine Fibroid Embolization (UFE)
Uterine fibroid embolization is a minimally-invasive, non-surgical procedure performed by an interventional radiologist (IR). This procedure involves placing a catheter into the artery in the groin and directing it into the arteries supplying the uterus under x-ray guidance. Small particles are then injected into the artery, blocking the blood supply to the fibroids. When deprived of their blood supply, the fibroids die and shrink significantly. The procedure takes between one and two hours and usually requires an overnight stay in the hospital for pain control. Most women experience pelvic cramping and pain which is controlled through the use of narcotics in the form of a patient controlled analgesia (PCA) pump. Because this is a non-surgical procedure, recovery is extremely fast and most women return to work within one week.UFE works to stop the blood flow to all types of fibroids in the uterus. However, it is generally recommended that submucosal or subserosal fibroids which protrude from the uterus on a thin stalk (pedunculated) be removed through hysteroscopy or laparoscopy first. Pedunculated submucosal fibroids that die and detach from the uterus as a result of UFE may be expelled from your body vaginally. If, however, you have detached submucosal fibroid material that is too large for your body to expel, it is extremely important that it be removed as quickly as possible through hysteroscopic resection to avoid serious infection potentially requiring hysterectomy.
Myolysis
Myolysis involves inserting surgical instrument laparascopically which send high frequency electrical current into the fibroid. The electrical current obliterates the blood vessels that supply blood flow to the fibroids. The fibroids die and eventually shrink. Myolysis is only performed on subserosal fibroids that fit a certain size range.
Hysterectomy
There are three primary forms of hysterectomy.
Abdominal Hysterectomy involves the removal of the uterus through an incision in the abdomen. This may be a horizontally oriented Pfannenstiel incision (bikini-cut) or a longitudinal incision down the midline if the uterus is too large for the bikini style incision. In a Total Hysterectomy and Salpingo-oophorectomy, the ovaries and fallopian tubes are removed, along with the uterus and cervix. A variation of this procedure is a Subtotal (Supra-cervical) Hysterectomy in which the pelvic structural ligaments and cervix is left in place. The fallopian tubes and ovaries may or may not be removed. This a major surgical procedure which requires a 2-3 day hospital stay and a 6 week recovery period.
Vaginal Hysterectomy involves removing both the body of the uterus and the cervix, through the vagina. Many women are not a candidate for vaginal hysterectomy. If uterus is moderately enlarged, it may not be possible to remove the uterus through the vagina. If vaginal hysterectomy can be performed, it is usually associated with fewer complications, a shorter recovery period and no visible scar.
Laparascopically Assisted Vaginal Hysterectomy is a less invasive option where a surgeon places long slender scopes through small incisions in the abdomen. These laparascopes have tiny cameras which allow a surgeon to see the structures within the pelvis. Small surgical instruments are inserted to aid in the removal of the uterus through the vagina. There are size requirements of the uterus in order to perform laparoscopically-assisted vaginal hysterectomy. If the uterus is smaller than the size limit and can be performed, it is usually associated with a shorter recovery period and very small scars where the laparoscopes are inserted.
In making a decision, you should consider that a hysterectomy is not reversible. After a hysterectomy, you will no longer be able to bear children and you will no longer menstruate.
Surgical Risks
The surgical risks of hysterectomy and myomectomy include the risks of any major operation. You may have an infection in your bladder, incision, or pelvis that could require treatment with antibiotics during recovery. Occasionally an infected fluid collection called an abscess may occur which may require surgical drainage. Surgery may lead to significant blood loss which occasionally requires a blood transfusion. Complications related to anesthesia may occur. Blood clots in leg and pelvic veins may occur which could lead to a pulmonary embolism (blood clots traveling to the lung). Adhesions leading to bowel obstruction is a risk of any abdominal or pelvic surgery. Injuries to the bladder or ureters (tubes that drain the kidneys into the bladder) can occur which may require further surgery. Rarely, even death can occur. Eleven women die for every 10,000 hysterectomies performed.
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