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Uterine Fibroids and Hysterectomy

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of uterine fibroids

Alternative Names

Endometrial Ablation; Hysterectomy; Laparoscopy; Myomectomy; Uterine Fibroids

Other Procedures

In order to operate on the uterus, the surgeon may choose to reach the area through a wide abdominal incision (laparotomy) or using less invasive measures with the use of endoscopy. The decision usually is based on the severity of the case. It should be noted that research on treatments for uterine fibroids is very scanty and even physicians may not have the best data needed to make an optimal decision for their patient. Women should discuss all options very carefully and be sure that their surgeons have had experience with any procedure they choose.

Laparotomy. Laparotomy is the standard abdominal surgical procedure. It is invasive and usually requires a wide abdominal horizontal incision right above the pubic bone, the so-called bikini incision.

Endoscopy. Endoscopic techniques used for uterine disorders are hysteroscopy and laparoscopy. Endoscopic techniques are used increasingly to replace conventional surgical techniques for many disorders. A common factor in all endoscopic procedures is the use of a fiberoptic scope and tubes, tiny camera lenses, and minuscule surgical instruments. Any incisions used are very small, Band-Aid size.

  • Operative Hysteroscopy. In this procedure, the cervix is dilated, which requires either a local or general anesthetic. A device called a hysteroscopy is inserted up through the vagina and cervix into the uterine cavity. It contains tiny surgical instruments as well as a mini-camera and light source to view images of the uterus, which are transmitted to a video monitor. This approach is becoming increasingly common. Complication rates include excessive fluid absorption, infection, and uterine perforation.
  • Laparoscopy. This procedure employs two or more small incisions, one at the navel, and one or more in the lower abdomen. Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away. A laparoscope is inserted through the navel incision and a probe is inserted through a second incision above the pubic hairline. The probe allows the physician to directly view the abdominal cavity, including the outer walls of the uterus, fallopian tubes, and ovaries. The physician manipulates surgical instruments that are passed through additional small abdominal incisions, using the image of the uterus on the video monitor as the guide.

Preoperative Hormone Treatment

GnRH agonists, usually depo-Lupron or Synarel, are often used for about two to three months before many uterine surgical procedures.

There are a number of benefits:

  • May reduce the volume of fibroids by 40% to 60%, in some cases to the extent that a less invasive procedure may be performed.
  • May reduce the risk of bleeding.
  • May shorten operating time.
  • May reduce postoperative symptoms for many patients.

Treatments may not be useful, however, for small fibroids, which may shrink to the point that they are no longer visible at the time of surgery. Since fibroids regrow after treatment, the problem would recur.

There has also been some question whether these drugs provide any additional advantages for myomectomies that use conventional surgical techniques. Ultrasound may be useful in helping to detect fibroids most likely to benefit from GnRH agonists before such a procedure.

Myomectomy

A myomectomy surgically removes only the fibroids and leaves the uterus intact, often preserving fertility. Myomectomy may also help regulate abnormal uterine bleeding caused by fibroids. Not all women are candidates for myomectomy. If the fibroids are numerous or large, myomectomy can become complicated, resulting in increased blood loss. If cancer is found, conversion to a full hysterectomy may be necessary. To perform a myomectomy, the surgeon may use standard surgical approaches (laparotomy) or less invasive ones (hysteroscopy or laparoscopy).

  • Laparotomy. Laparotomy employs a wide abdominal incision and conventional surgery. It is used for subserosal or intramural fibroids that are very large (usually more than four inches), that are numerous, or when cancer is suspected. Using this approach, the physician may be able to feel the fibroids, particularly intramural types, which can be missed during laparoscopy or hysteroscopy. (The physician can only view the uterine cavity or outside surface with these latter procedures.) After the fibroids are removed, careful reconstruction of the uterine wall is critical in both laparotomy and laparoscopy, so that bleeding and infection do not occur. While complete recovery takes less than a week with laparoscopy and hysteroscopy, recovery from a standard abdominal myomectomy takes as long as six to eight weeks. It also poses a higher risk for scarring and blood loss than with the less invasive procedures, which is a concern for women who want to retain fertility.
  • Hysteroscopy. A hysteroscopic myomectomy may be used for submucous fibroids found in the uterine cavity. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed up into the uterine cavity through the vagina and cervical canal. A wire loop carrying electrical current is then used to shave off the fibroid. In one study, nearly 60% of patients conceived after this procedure. However, it is not appropriate for many women.
  • Laparoscopy. Women whose uterus is no larger than it would be at a six-weeks pregnancy and who have a small number of subserous fibroids may be eligible for treatment with laparoscopy. Laparoscopy requires incisions, but they are much smaller than with laparotomy. As with hysteroscopy, a thin scope is employed that contains surgical and viewing instruments. In centers with extensive experience, laparoscopy has fewer complications, and also shorter recovery time and lower costs than laparotomy. On the other hand, compared to the invasive surgery, laparoscopy has a greater chance for fibroid recurrence (over 16% at five years in one study), and a greater danger for a weakened uterine wall, which could threaten pregnancies.

Complications and Postoperative Factors. Any procedure for myomectomy is very complex. To reduce the risk for complication, patients should seek a surgeon experienced in myomectomies. Complications that occur during a myomectomy from any procedure include the following:

  • Excessive blood loss (higher incidence in laparotomy).
  • Uterine weakening and rupture during pregnancy. (This has been more of a concern with laparoscopy.)
  • Subsequent development of scar tissue (called adhesions). There is a higher incidence of adhesions in laparotomy. Lubricating gels (Intergel) or patches made of animal tissue sewn over the uterus are under investigation to reduce this risk. More studies are needed.
  • Infection.
  • Damage to the bowel or bladder (higher incidence in laparotomy).

Pregnancies After Myomectomy. Studies are finding that pregnancy can be restored in more than half of women after the procedure. In appropriate candidates, there appear to be no differences in fertility rates and pregnancy complications between laparotomy or laparoscopy. The best candidates for retaining fertility include women with pedunculated and superficial serosal fibroids (stalk-like fibroids that grow out from the uterine surface). Women with deep intramural fibroids, for example, are at higher risk for infertility after myomectomy.

It should be noted that although studies indicate that between 40% and 58% of women become pregnant after myomectomy, only about a quarter of the women carry their babies to term. Women who become pregnant subsequently face a higher risk for cesarean section or miscarriage. It is still unresolved whether laparoscopic myomectomy weakens the uterine walls and poses a higher risk for rupture during pregnancy than laparotomy.

Recurrence of Fibroids and Recurrent Surgeries. The recurrence rate for fibroid growth after myomectomy is high. Between 11% and 26% of patients will have recurring fibroids that are severe enough to need additional treatment. One study suggested that women who had uteruses that were less than the equivalent size of 12 weeks of pregnancy and women who were overweight had a higher risk for needing repeat surgery.

Uterine Artery Embolization

Uterine Artery Embolization (UAE), also called uterine fibroid embolization, is a very promising nonsurgical therapy. It destroys fibroids by depriving them of their blood supply. It is less invasive than hysterectomy and myomectomy, and involves a shorter recovery time than the other procedures.

The procedure is typically performed in the following manner:

  • Specialists insert a catheter (a thin tube) into a uterine artery.
  • Small particles are injected at the point where the artery feeds the blood vessels leading to the uterine fibroid. They can be made of organic compounds (e.g., polyvinyl alcohol particles) or acrylic materials (e.g., Embosphere microspheres). The particles block the blood supply to the tiny arteries that feed abnormal fibroid cells and the tissue eventually dies. Circulation to normal uterine tissue, however, is usually restored.
  • Patients can expect to stay in the hospital overnight after UAE, but studies are underway to see if the procedure can be done on an outpatient basis.

Effect on Fertility. In general, UAE is an option only for those who have completed childbearing. Although UAE may protect fertility in many women, the procedure does pose some risk for ovarian failure and infertility. Experts recommend that women who still hope to have children after the procedures should wait one or two years afterward before trying to conceive. One study reported some ovarian damage in more than half of women with this procedure. In one study, menstruation stopped in 1% to 7% of women under 40. In some women, so far only those over 40 years old, normal menstrual bleeding stopped altogether after therapy.

Complications and Postoperative Effects. Serious complications occur in less than 0.5% of cases, and no deaths have been associated with the procedure.

  • Pain. Abdominal cramps and pain after the procedure are nearly universal and may be intense. It usually begins soon after the procedure and typically plateaus by six hours. On-demand painkillers may be required. The pain usually improves each day over the next several days, but some patients may experience pain for as long as two weeks after treatment.
  • Ovarian Failure.
  • Fibroid Slough. A few patients experience fibroid slough, in which fibroid material becomes trapped in another area (like the cervix) as it is being expelled. This can cause intense labor-like pain and also increase the risk for infection.

Success Rates. Studies on uterine artery embolization are showing high patient satisfaction (over 90%) and low complication rates. In 2003, a study of eight Canadian medical centers reported 83% improvement in heavy bleeding, 77% reduction in menstrual cramps, and 85% improvement in urinary symptoms. Symptom improvement was unrelated to the reduction in fibroid size (which averaged 42%). Such results are similar to findings from other centers. Patients are also reporting an improvement in their sex life following the procedure, including increased frequency of sex, increased desire, and less pain during intercourse. Any long-term complications, however, are still unknown. At least 10% to 15% of patients will require further treatment. However, a less invasive approach may be needed in these cases.

Endometrial Ablation or Resection

In either endometrial ablation or endometrial resection, the entire lining of the uterus (the endometrium) is removed or destroyed. These procedures are useful for women with severe heavy menstrual bleeding, including some with fibroids. They are generally not useful for large fibroids. Standard resection uses an electrosurgical wire loop to surgically remove the lining. With ablation, uterine tissue is usually vaporized using a thin powerful laser beam or high electric voltage. Newer ablation procedures including balloon ablation (ThermaChoice) and techniques that use electric wands, freezing, hot saline, lasers, microwaves, and radiofrequency.

Myolysis (Laparoscopic Leiomyoma Coagulation)

Myolysis, or laparoscopic leiomyoma coagulation, uses either lasers or electrosurgery to heat and coagulate and destroy the fibroid tissue. This approach may prove to be beneficial for women with fibroids that measure a diameter of 10 cm (about 4 in.) or less and that respond to hormone treatments with GnRH agonists.

Myolysis employs a needle or a Nd:YAG laser that rapidly punctures a number of holes in the fibroid, heating and destroying the tissue in various locations. This widespread destruction cuts off the blood supply and shrinks the fibroid over ensuing months. The uterus is left intact, but tissue destruction makes childbearing unlikely.

In one study, myolysis performed either alone or with endometrial resection was successful in avoiding the need for major surgery in 97% of women. Advanced techniques that are performed by surgeons who are highly skilled in the procedure may make it possible to destroy even large intramural fibroids, but further study is required.

In most cases, patients return home the same day and can return to normal activities within a week. There are few side effects. However, as the fibroids degenerate over time, many women report considerable pain.

Investigative Approaches

Some researchers are studying high-intensity focused ultrasound guided by magnetic resonance imaging (MRI) to heat and destroy uterine fibroids. Encouraging trials using this procedure have been conducted, but more research is necessary to demonstrate the safety and efficacy of the technique.

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