Alternatives to Hysterectomy for Women Suffering with Fibroids
with John Lipman, MD
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Every very working day in this country over 3,000 women undergo hysterectomy. The most common reason is uterine fibroids. Fibroids are benign (non-cancerous) tumors that grow in the uterus. Over 1/3 of all women over 35 years of age have fibroids, and over ½ of all African-American women of child bearing age have fibroids. Fibroids cause symptoms based on where they are located in the uterus. If they are present centrally (near the uterine lining), they will cause heavy prolonged menstrual periods (often with blood "flooding" or "gushing" out and passage of clots). This abnormal bleeding is called menorrhagia. While this is often not life threatening, it can be severely debilitating to women, resulting in pain, fatigue, emotional stress/embarrassment, and anemia. |
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Fibroids are hard and firm tumors. They can be detected on physical exam by a healthcare professional. A woman’s abdomen may enlarge from the fibroids. This enlargement can be estimated and compared to a pregnant woman’s uterus (ex. 12-16 week size etc.). The toll from this bleeding can have a significant impact on a woman’s quality of life, including symptoms of depression, and days lost from work and social activities. If the fibroids are located near the bladder, they can act like a paperweight and cause a woman to urinate more frequently; often multiple times in the middle of the night. Fibroids can cause pelvic pain or pressure by pressing on pelvic nerves. This pain can radiate into the lower back or thighs. Fibroids are hard and firm tumors. They can be detected on physical exam by a healthcare professional. A woman’s abdomen may enlarge from the fibroids. This enlargement can be estimated and compared to a pregnant woman’s uterus (ex. 12-16 week size etc.).
Millions of women in the United States suffer silently with fibroids, due to their desire to avoid hysterectomy. Fortunately, there are several other choices available for the treatment of uterine fibroids. If a woman does not have significant symptoms, no treatment is necessary. Fibroids grow with estrogen stimulation which explains why they can grow during pregnancy, and why they will rarely be a problem after a woman reaches menopause. If the symptoms are mild, there are natural remedies and medications that can treat this. While birth control pills can be tried to help lighten the heavy bleeding, it can also cause the fibroids to grow (from the additional estrogen). When the symptoms are significant, there are several different treatment alternatives to hysterectomy available:
1. Uterine fibroid embolization/UFE (or Uterine artery embolization). This procedure is performed by Interventional Radiologists
. These are physicians who specialize in minimally invasive targeted treatments using imaging (ex. x-ray) guidance. The UFE procedure treats every fibroid in the uterus (i.e. global therapy). UFE can be an outpatient procedure. The typical recovery at home is 4 days, and patients often returns to work after one week. 88-92% of patients find significant or complete relief of all symptoms. Patients can get pregnant after UFE, although the impact on a woman’s fertility after this procedure is still unknown. Less risk, less invasive, and less recovery than surgery.2. Endometrial ablation: There is confusion as this procedure sounds like fibroid embolization. This procedure is best performed for women who do not have fibroids, but are suffering with heavy bleeding and are not interested in fertility.
3. MRI-guided focused Ultrasound: This treatment option is performed by Interventional Radiologists and Gynecologists. It is the most recent option of those listed. It received FDA-approval for fibroid treatment in October 2004. It is a local therapy (treats 1 or 2 fibroids). Patient lies prone (face down) on a special table that is connected to a MRI machine. Within the table, there is a built-in device that delivers a targeted beam of ultrasonic energy into the fibroid. This outpatient treatment typically takes 3-4 hours. Recently published data showed promising short-term results, but this treatment doesn’t completely destroy the fibroid. This might lead to a high recurrence rate, and there is no long-term data available. A potentially exciting application of this technology would be in a fertility patient who miscarries due to one fibroid that is distorting the uterus.
4. Surgical Myomectomy: This procedure is performed by Gynecologists. It removes fibroids through surgical incisions. If the fibroids are on a stalk or outside the uterus, they can be removed with laparoscopy (using several small incisions). If they are on the inside of the uterus or in the uterine cavity, they can be removed without an incision through a lighted instrument called a hysteroscope. Most fibroids are deep in the uterus and require open surgical myomectomy with a traditional open incision. This is a local therapy, and often leaves smaller (or inaccessible) fibroids behind which can lead to recurrence of symptoms. Usually inpatient (several days) hospital procedure under general anesthesia. Recovery is typically 4-6 weeks with open myomectomy; less for laparoscopic and hysteroscopic myomectomy. Risks include surgical and anesthetic risks, along with a small percentage requiring hysterectomy. Usually reserved for patient interested in fertility. Has a negative impact on fertility due to scarring from uterine incision(s).
Always discuss treatment options with your physician to decide what course of treatment, if any, is best for you.
