Uterine Fibroids and Hysterectomy
DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of uterine fibroids
Alternative NamesEndometrial Ablation; Hysterectomy; Laparoscopy; Myomectomy; Uterine Fibroids
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.
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).
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:
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:
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.
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.
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.