Alternative Treatments of Myomas

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Dr. Herbert Goldfarb: "Good afternoon, I'm Dr. Herbert Goldfarb and I'm here at the 10th Annual meeting of the International Society of Gynecological Endoscopy. My specialty is treating uterine fibroids and alternatives to hysterectomy. I'm Clinical Assistant Professor at New York University School of Medicine, and I have an office in Manhattan as well as Montclair, New Jersey. I'm also the author of a book called 'The No Hysterectomy Option' in which we help to counsel women about alternatives to hysterectomy. 

The parts of the program that I've been involved in this week include alternative treatments of myomas, and I have been involved with meetings concerning laparoscopic myomectomy and one of the specialties that I have is the procedure called myolysis. Now just as a little bit of an entre or introduction, the whole subject of uterine fibroids is one of significant controversy. Too many women who have uterine fibroids are told, especially if they're in their late thirties or early forties, that there is no other option but they need to have a hysterectomy. This could not be further from the truth and we have developed a whole spectrum of procedures and progressions of treatment to help women who are suffering from abnormal bleeding and uterine fibroids. 

First of all, I'd like to tell you that almost every woman in her late thirties and forties will have some abnormal menstrual bleeding. Most of that comes from a failure of hormonal function, which is not unusual to have when women reach sort of the ending of their reproductive years. If they happen to have a fibroid along with it, the physician might tell them that the fibroid is causing the bleeding without making certain of the diagnosis so we must differentiate between bleeding relating to function and bleeding relating to hormonal abnormalities. 

Secondly, if a woman is interested in conception and she has a fibroid tumor that's causing significant abnormality, pressure, or bleeding, it really should be removed prior to conception because often times these fibroid tumors can impact on the developing fetus if they're at a bad place near the cavity of the uterus. Certainly if it's a small fibroid sitting on top of the uterus - what we call a serosal fibroid - there's no reason to perform surgery. Now how this surgery is done is something that depends on the skill of the surgeon. Many of us can remove this laparoscopically. I have presented a technique at this meeting called the 'laparoscopic assisted vaginal myomectomy' where we actually remove and suture the uterus, remove the fibroid, and suture the uterus through the vagina. Certainly abdominal myomectomy is reserved for those patients who have very significant fibroids in which the fibroid is really, in my judgment, too large or too multiple in order to perform laparoscopically. Therefore, I feel very strongly that we have to be very conservative especially if a woman is interested in having a pregnancy and we have to treat them in a way as not to cause harm and, therefore, sometimes abdominal myomectomy is necessary. We do laparoscopic myomectomies if at all possible and we could also do the LAVM procedure, which is the laparoscopic assisted vaginal myomectomy. 

Each patient has to be studied in her own and the proper procedure has to be suggested. Now how about those women who are past the reproductive period of time who are developing uterine fibroids and who have significant bleeding? We have to investigate these patients; we actually do a procedure called a hysteroscopy where we look inside the hyster, which is the uterus. Just remember this, hyster is from the Greek word meaning uterus and that the term hysteria was coined in the Victorian era and certainly popularized by Freud in the nineteenth century to denote "abnormal female behavior." So hysterectomy is often times suggested for hysterical women and, therefore, I think when someone says you've had your children, you don't need your uterus, I would suggest that you beware and start looking for someone who is more interested in treating you as a person, the whole person, and not just removing your uterus. 

Now one of the alternatives that we have developed and I began performing in 1990 is a procedure called 'myolysis.' It's a procedure that I first did with a laser and then with bipolar electric needles where we actually destroy the blood supply to an individual fibroid. In that way we don't have to destroy the whole uterus, we just shrink the fibroid first with a medication called Lupron which is a GnRH analogue that will create a temporary lessening of estrogen in the system and causes the fibroid to shrink. Then we can destroy the blood supply with these electric needles. Concomitantly, we do intrauterine procedures - hysteroscopies with electro-dissection to remove fibroids and sometimes to destroy the lining so, therefore, a combination. We can perform a same day procedure in which the patient goes home that same day, is back to work within a week in women who have moderate size fibroid tumors, moderate meaning less than 7-8 cm, and who respond to this GnRH analogue which we use for three months prior to the surgery. It's given with monthly injections and they then undergo the myolysis and hysteroscopic procedures and these people have done very well. 

We've been doing this for almost eleven years now, and we've had very few failures. We have about a 5% hysterectomy rate which means that for every 100 patients that we've done the procedure on we have 5-6 patients who have then subsequently had a hysterectomy so we have almost a 95% success rate, therefore, there are multiple options. Now even embolization, which is not done by gynecologists but done by radiologists, is an alternative but I believe that because of time constraints for this talk I can't go into all the pros and cons of embolization. Embolization, in my hands, is reserved for those women who've had recurrent myomas, who've failed, who've had multiple surgical procedures, who were afraid to go back into the abdomen if we don't have to, or who have multiple fibroids - 8, 10, or 20 fibroids. These people have what I call fibromatosis and, therefore, prior to hysterectomy they would do better having embolization. So each procedure has its place and your physician should be versed and skilled in all the procedures or else find someone who specializes in fibroid treatment. Thank you very much. I wish you good luck, and thank you for having me."