Factors that determine the types of treatment offered
There a variety of medical and surgical treatments for fibroids. The treatments offered depend on a variety of factors that include but are not limited to:
OVERALL MEDICAL HEALTH
- Heart disease
- Pulmonary disease
- Coexisting cancer
SYMPTOMS (BLEEDING, INFERTILITY, MASS EFFECT)
DESIRE TO MAINTAIN FERTILITY
- The existence of severe pelvic adhesions
- Anatomic issues (size, number, type and grade)
- Coexisting issues: Endometriosis, urinary incontinence and other urinary tract issues
MOTIVATION FOR A PARTICULAR PROCEDURE OR TO AVOID A PARTICULAR APPROACH
AVAILABILITY OF SURGICAL EXPERIENCE IN YOUR REGION
AVAILABILITY OF IMAGING TECHNIQUES IN YOUR REGION
- Cost of the procedure (co-pays, deductibles)
- Cost of repeat procedures or additional procedures
When you begin to examine all that goes into making a medical decision that both the woman and the physician agree upon you can understand why some cases are quite complex. For this reason it is not unusual for women with fibroids to ask for second opinions.
Different types of Treatment
The treatment of fibroids can be divided into medical, surgical and radiological. The vast majority of women who have symptomatic fibroids are treated medically or surgically. However, we will discuss the radiological treatment at the end of this section as there are clearly cases that may benefit from this form of management.
MEDICAL TREATMENT OF FIBROIDS
In general, we employ the medical treatment of fibroids when the symptoms produced by them are mild, when surgery needs to be delayed or the radiological treatment is clearly not indicated. Medical treatment is also used when the uterus is being “prepared” for surgery or as emergency treatment for uncontrollable bleeding until definitive surgery can be arranged.
Medications used to treat symptoms produced by fibroids
There are several scenarios in which the use of medication is clearly preferable to surgery. This includes the presence of small fibroids that are causing minimal to moderate symptoms and fibroids in women that are poor candidates for surgery because of their overall health. Medications are useful in extremely anxious women who wish to avoid any type of surgery or radiologic intervention. These medications are generally hormonal and consist of birth control pills, progestin-containing intrauterine devices (Mirena IUD), Depo Provera or other progestin-only pills such as norethindrone. Rarely androgen (weak male hormones) can be given to shrink fibroids and reduce their blood loss. The most common androgen used for such purposes is Danazol—a synthetic drug similar to testosterone. However, the unpleasant side effects (weight gain, acne, deepening of the voice) often limit the usefulness of this medication.
Medications have one clear distinct advantage—if they don’t work or if they produce side-effects one can simply discontinue them.
Medical treatment of Fibroids to “prepare” the uterus
There are instances when it is preferable to “shrink” fibroids prior to surgery. As we learned earlier in this chapter fibroids respond to a variety of hormones including estrogen and progesterone. During menopause, when these hormones are less plentiful the natural course of fibroids is to shrink—though they never disappear. Often the shrinking of fibroids is desirable since smaller ones can removed more easily—whether laparoscopically or hysteroscopically (see below).
One such popular drug for reducing the size of fibroids is Lupron Depot® (leuprolide acetate). Lupron is not a hormone. It actually falls under a class of compounds called polypeptides (complex sugar) which is in a family of drugs called gonadotropin-releasing hormone (GnRH) agonists. Lupron causes a temporary menopause (generally lasting one month). The most bothersome side effect of Lupron is – not surprisingly—hot flashes. The vast majority of women tolerate Lupron quite well though some have troublesome hot flashes or headaches.
Medical treatment of hemorrhage
The Food and Drug Administration (FDA) approved Lysteda (tranexamic acid) in 2009 and it has been available to the U.S. market since 2010 as the first non-hormonal product cleared to treat heavy menstrual bleeding. Lysteda works by stabilizing a protein that helps blood to clot and is a very important drug inasmuch as it can be given in the presence of acute hemorrhage which might otherwise require hospitalization and blood transfusions. It is non-hormonal and unlike the hormonal treatment of heavy vaginal bleeding it works relatively quickly—within hours of administration. The most common side effects include headaches, sinus and nasal symptoms, back pain, abdominal pain, muscle and joint pain and fatigue.
SURGICAL TREATMENT OF FIBROIDS
The surgical treatment of fibroids is an ever growing and changing field. The very nature of fibroids requires different surgical approaches.
In some instances, the best way to deal with multiple fibroids may be the removal of the uterus (hysterectomy). Although many women fear hysterectomy two facts should be understood about hysterectomy.
- Hysterectomy means removal of the body of the uterus. It does not mean removal of the ovaries (where hormones are produced). Removal of the ovaries is generally not necessary for the treatment of fibroids.
- Although hysterectomy may not be less invasive than other forms of treatment it is often the best. Physicians do not knowingly suggest multiple “less invasive” procedures if they feel that hysterectomy will still be required. Unfortunately, some women take the position that they will do anything to avoid hysterectomy. Often, this leads them to making good, sound and well-informed decisions. Occasionally, such decisions only lead them to additional suffering before they require a hysterectomy.
The other surgical strategies for removal of fibroids aim to preserve the uterus. These procedures have a great deal to offer women provided the physician is well-experienced and the patient understands what these procedures can and cannot promise.
In general, submucous fibroids (those residing primarily inside the uterus) are removed hysteroscopically. Hysteroscopic methods should not be confused with hysteroscopic tools. Subserous fibroids are exclusively removed through abdominal incisions—either by laparotomy or laparoscopy. Intramural fibroids are quite variable with some lending themselves better to an abdominal approach while others are better approached hysteroscopically.
A WORD ABOUT “MINIMALLY INVASIVE SURGERY”
Minimally Invasive Surgery (MIS) has unfortunately become somewhat of a marketing device among health care providers and hospitals. Of course women want minimally invasive surgery! Who wouldn’t?
There are several important questions you should ask about minimally invasive surgery—or any surgery
- If this surgery is “less invasive” what is it less invasive than?
- Will this surgery “fix” the problem?
- Is the “fix” permanent?
- Is the “fix” temporary? If it’s a temporary fix how long can I expect it to last?
- Are there other “less invasive” methods available to choose from?
- Are you (the surgeon) able to provide me with those other options?
- Is there someone better qualified to provide me with those options?
- If I was a member of your family would you still suggest this surgery for me in my particular situation?
As you might expect there are women, particularly younger women who seek to improve their fertility, that require both a hysteroscopic and a laparoscopic approach. This makes sense given that many women have multiple fibroids some of which may be submucous while others are intramural or subserous. We will now explore the hysteroscopic approach as well as the abdominal approach –laparoscopic or with laparotomy.
Types of Surgical Treatment
ULTRASOUND-GUIDED HYSTEROSCOPIC MYOMECTOMY (UGHM)
Ultrasound-Guided Hysteroscopic Myomectomy was described by our team in 1995 (Wortman M, Daggett A. Hysteroscopic Myomectomy. Journal of the American Association of Gynecologic Laparsocopists 1995. November; 3(1):39-46.). This technique involves a surgical instrument placed inside the uterus called a resectoscope or an operative hysteroscope. Under direct vision the fibroid can be seen and sliced into smaller, removal bits of tissue. We did not invent the technique of using a resectoscope to remove fibroids—we were, however, among the first in the world to perform this under ultrasound guidance.
The use of ultrasound in conjunction with operative hysteroscopy—known as UGHM—dramatically reduces complication rates from hysteroscopic myomectomy while improving the likelihood of removing the entire fibroid or group of fibroids.
The resectoscope consists of a lit telescope and an electrically charged electrode (note: not a laser). The charged electrode can cut and cauterize tissue more effectively than any instrument to date. Even though there are newer devices—called mechanical morcellators—they are simply incapable of removing fibroids as efficiently as the traditional resectoscope. The electrical loop can be easily seen on ultrasound and allows one to monitor the surgery in three dimensions.
Hysteroscopic Morcellation — MyoSure® and TRUCLEAR®
For the sake of completeness it’s important to mention both the MyoSure ™ and the TRUCLEAR System ™. These are both hysteroscopic devices that are placed into the uterine cavity and through a small mechanical attachment grind up or “morcellate” the fibroid. The devices are both mechanically and medically sound. However, their limitation is three-fold: one cannot remove fibroids larger than 5 centimeters with them very reliably; they will not remove fibroids that are attached to certain portions of the uterus, and; they are unable to remove any intramural fibroids. However, they have an excellent safety profile and are quite popular among certain physicians. The major risk of hysteroscopic morcellation is that they often fail in completing the removal of larger fibroids.
In the mid- to late-1980s a laparoscopic revolution occurred in this country. Surgery which had previously been performed through large abdominal incisions—called laparotomy incisions—could now be performed through a series of smaller incisions.Visualization was supplied by the development of small color television cameras mounted on a telescope and a new generation of long and narrow surgical instruments was invented to allow the surgeon to operate with small incisions. This became known as laparoscopic or “key-hole” surgery.
Today, laparoscopic surgery has become the mainstay of all kinds of surgery. Many gynecologists perform laparoscopic surgery though not all are trained or experienced in laparoscopic myomectomy. It’s extremely important, when choosing a physician, to have some idea regarding their experience and whether or not they feel capable of managing your particular issue. Occasionally, the removal of fibroids cannot be accomplished laparoscopically and a larger laparotomy incision must be made. There is nothing wrong with this approach if it provides the best possible surgical outcome for you.
Robotic myomectomy is often been touted as “minimally invasive” surgery. It is minimally invasive compared to laparotomy but not compared to laparoscopy. Today’s graduating physicians are simply not trained in laparoscopic myomectomy and have come to depend on very expensive robots to help them accomplish what was once accomplished through fewer and often smaller incisions.
Robotic myomectomy may be the best choice for the removal of your particular fibroids but you should not have the impression that it is less “modern” or “effective” than laparoscopic surgery—it is certain not less invasive.
In order to remove fibroids through small incisions the physician utilizes laparoscopic morcellators. The safety of morcellation has been questioned these past few years as some are concerned that they have the potential to spread certain rare cancers within the abdominal cavity. Please make sure you discuss this issue with your surgeon before undergoing a laparoscopic or a robotic myomectomy. As far as we know there are not the same risks associated with hysteroscopic myomectomy
HYSTERECTOMY AND SUBTOTAL HYSTERECTOMY
Oftentimes the best treatment for fibroids remains hysterectomy!
I am a specialist in hysteroscopic surgery and have several highly skilled and world-class laparoscopic surgeons available to me—we all perform “minimally invasive surgery.” However, there are clearly times when the “least invasive” option for a woman is to have a hysterectomy. Hysterectomies can be performed by a variety of routes including through small abdominal incisions (laparoscopic or robotic), a large abdominal incision (laparotomy) or through the vagina.
Women may be better served with hysterectomy if they have met many of the following criteria.
- They have completed their family
- They are under the age of 35 and having significant symptoms
- They have multiple moderate and large fibroids whose removal would pose greater risk than a hysterectomy
- There is a high risk that the fibroids will return and cause symptoms.
- They are healthy enough to undergo hysterectomy
- They do not have a history of severe pelvic adhesive disease
- They are motivated to undergo hysterectomy
Keep in mind that a hysterectomy means just removing the uterus. It does not mean that the ovaries need to be removed.
Additionally, when a hysterectomy is performed for fibroids it is often possible to save the cervix. This is called a subtotal hysterectomy or a supra-cervical hysterectomy.
Before agreeing to a hysterectomy you should understand the answers to these questions?
- What will be the short term and long term consequences of hysterectomy?
- Is it possible to do something less invasive?
- Is it reasonable to do nothing for now?
- Will doing nothing have long-term consequences?
Radiological Treatments of Fibroids
We will discuss 2 types of treatments of fibroids that are typically performed by radiologists—uterine fibroid embolization (UFE) and Focused Ultrasound.
UTERINE FIBROID EMBOLIZATION (UFE)
Uterine Fibroid Embolization (UFE) is a non-surgical technique that shrinks fibroids without removing them. The procedure is performed by an interventional radiologist and is generally achieved with the use of intravenous sedation. In a UFE procedure, the radiologist uses an x-ray camera called a fluoroscope to guide the delivery of a catheter through which small particles are injected into the artery or arteries that nourish the uterus or a particular fibroid. This causes the fibroid to necrose (die) and shrink. Since the effect of UFE on fertility is generally unknown it is typically offered to women who no longer wish to become pregnant and would like to avoid a hysterectomy.
What happens during UFE?
The procedure is generally performed in a “suite” used by interventional radiologists. You will be positioned on an examination table and connected to monitors that keep track of your blood pressure, pulse and oxygenation. A technologist then inserts an intravenous line into a vein so that sedation can be safely delivered during the procedure. The area of your body—the groin region–where the catheter is to be inserted will be shaved, washed with an antiseptic agent and covered with a surgical drape. After a local anesthetic is injected into the skin an incisions is made just above the femoral artery. Following this a catheter is inserted. A small amount of contrast is injected and provides a road map for the catheter as it is maneuvered into your uterine arteries. The embolic agent (small plastic beads) are then released at the targeted fibroid. After the procedure the catheter is removed and pressure is applied to the incision. You will mostly likely be admitted to the hospital overnight so that you can be observed and receive pain medication. The procedure typically takes about 90 minutes.
What happens after UFE?
Immediately after the embolization (the process of pushing small beads into the arteries that supply the fibroid) most women will experience moderate to severe pain. Women are typically hospitalized for a short period of time in order to manage the pain.
It generally takes 6 weeks to determine the outcome for UFE. In 3-6 months the uterus and fibroids decrease about 40% in size. This procedure is typically best suited for women who have very large fibroids and whose symptoms are related primarily to the bulk of the uterus and fibroids. A significant number of women –you’ll have to ask your radiologist for her data—will continue to have troublesome symptoms and will require surgery nonetheless.
Keep in mind that UFE is still a relatively new procedure and that in many instances long-term data on its usefulness is still unavailable. If you are interested in UFE you should discuss this procedure with both your gynecologist and your radiologist.
The decision of who is or is not a good candidate for UFE is a complex one. Gynecologists –who are trained as surgeons—don’t typically think of UFE as a first line method to manage the symptoms of an enlarged fibroid uterus. They are more likely to consider surgical approaches including the removal of fibroids or hysterectomy. Radiologists, on the other hand, are quite skilled with embolization and other interventional techniques but are not trained as surgeons. The patient can easily get caught in the middle of this information gap.
It may be best to consult with interventional radiologists and gynecologists that have formed a team as they are better equipped to reach a decision on the best approach for you. Fortunately, there are such teams beginning to emerge and we recommend them to selected women.
MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND
This is a very new and experimental method of treating some fibroids. Basically MRI is used to focus ultrasound waves onto a fibroid. This is a non-invasive alternative to treat some women with fibroids who meet strict criteria. Presently, this technique is only available at certain centers that are using the technique under careful protocols. It is not recommended for women wishing future fertility.