Future Treatment of Myomectomy

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Dr. Togas Tulandi: “I’m Togas Tulandi, and I’m Professor of Obstetrics and Gynecology and Milton Leong Chair in Reproductive Medicine at McGill University. I have with me Dr. Alan DeCherney who is Professor and Chair of Obstetrics and Gynecology at UCLA. Dr. Cherney is the keynote speaker of the ISGE meeting this morning. Alan, could you describe your thoughts about the future treatment of myomectomy?”

Dr. Alan DeCherney: “Myolysis, of course, is the last thing we did discuss as a controversial area. I think that the only thing that’s on the horizon is treating these with high intensity ultrasound with a transabdominal approach.”

Dr. Togas Tulandi: “I have done myolysis in two or three patients, and I also did second look laparoscopy. They were full of adhesions so I stopped doing it. Tell me about this ultrasound treatment of myomas, Alan.”

Dr. Alan DeCherney: “I don’t really know about it. I think at the American Colleague meeting people are going to be talking about it. I think that’s where the concept will be released and they’ll be encounter groups talk about it but, basically, I know very little about it at this point.”

Dr. Togas Tulandi: “How about uterine artery embolization and the risk of premature menopause?”

Dr. Alan DeCherney: “Of course, that’s been described because of the occasional breaking off of some of the embolizing material into the ovary so I think that’s a risk that has to be explained to the patient. I think it’s a small risk but it definitely is there and of course there have been embolization material that’s been broken off and gone to the kidney as well.”

Dr. Togas Tulandi: “So what you’re saying is the best treatment is still laparotomy-myomectomy?”

Dr. Alan DeCherney: “I think for abdominal myomas the best treatment is abdominal myomectomy. I think in certain cases in certain surgeon’s hands a laparoscopic myomectomy is a good technique. The one technique that has made the most impact and I think is most important is the treatment of intracavitary myomas with a hysteroscopic approach.”

Dr. Togas Tulandi: “What’s your cut off point in terms of the size?”

Dr. Alan DeCherney: “If you mean for intracavitary - I don’t have a cut off. If I put them on Depo Lupron and shrink them down so that they’re not at the internal os so that I have a decent operative field, I’ll do them. If it’s into the internal os, of course, I can’t do them because I can’t get a good visualization of the fibroids.”

Dr. Togas Tulandi: “I don’t think there is any point anyway. How about the submucous myoma with a large intramural component?”

Dr. Alan DeCherney: “I think that probably those don’t represent a problem and should be left alone unless you can document that that’s the cause of that patient’s bleeding. If it’s just kind of slightly bulging into the endometrium, I usually don’t think that that’s a problem but they’re easy to treat and they’re easy to shave down because you only have to shave down a small portion to get below the level of the endometrium so normal endometrium can grow over them.”

Dr. Togas Tulandi: “So you shave it until it is level with the rest of the endometrium?”

Dr. Alan DeCherney: “Or a little less.”

Dr. Togas Tulandi: “How often does it come back?”

Dr. Alan DeCherney: “I don’t think that fibroids grow to recreate a sphere. I think if you truncate them they stay truncated. I think what happens in those when they recur is that the muscle squeezes the fibroid, the intramural part, back into the uterus over time so it’s not really a recurrence, it’s just that the muscle kind of works it in, it’s not really growing.”

Dr. Togas Tulandi: “Often when we are doing the procedure, when we pull out the scope and put it back in, the fibroid is extending more into the cavity because of uterine contraction. Do you find that?”

Dr. Alan DeCherney: “Yes, I think that’s true and that’s really the same phenomena.”

Dr. Togas Tulandi: “Dr. DeCherney, is there anything else you want to add for the future of treatment of myomas? Do you think there is anything else on the horizon?”

Dr. Alan DeCherney: “No, except the use of hormonal treatment in order to shrink them other than Depo Lupron, and utilizing serums or some other hormonal treatment to shrink them but, of course, that will only be temporary as long as the patient is on them.”

Dr. Togas Tulandi: “There is a new treatment - progesterone receptor modulator, I think it’s still on an investigational basis at the moment. Have you tried that?”

Dr. Alan DeCherney: “No, actually I haven’t used the selective progesterone receptor modulators; I’ve been to a conference on them. As I said today, fibroids are responsive to both estrogen and progesterone so I think that blocking one receptor is not going to be particularly helpful.”

Dr. Togas Tulandi: “Thank you very much, Dr. DeCherney.”