Treatment of Fibroids

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The most important question to ask is whether or not the fibroids need to be treated at all. The vast majority of fibroids grow as a woman gets older, and tend to shrink after menopause. Obviously, fibroids that are causing significant symptoms need treatment. While it is often easier to treat smaller fibroids than larger ones, many of the small fibroids never will need to be treated. So just because we can treat fibroids while they are small, it doesn't follow that we should treat them. The location of the fibroids plays a strong influence on how to approach them. A gynecologist experienced in the treatment of fibroids can help you determine if they need to be treated.

Treatment with medicines:
There are not any currently available medicines that will permanently shrink fibroids. Often heavy bleeding can be decreased with birth control pills. There are a number of medications in the family of GnRH agonists, such as Depo-Lupron, which induce a temporary chemical menopause. In the absence of estrogen myomas usually decrease in size. Unfortunately, the effect is temporary, and the fibroids rapidly go back to their pre-treatment size when the medication is discontinued. Mifepristone, better know as the 'French abortion pill or RU-486, may decrease the size of myomas, and abnormal uterine bleeding. It's use is promising, but it is not currently available in the United States.

Surgical treatment of fibroids:
There have been a number of procedures recently promoted for treatment of fibroids. Some are truly new. Others are being marketed as new in order to promote the sale of expensive instruments, without offering any real advantages. Many new procedures prove over time to be major advances; we may look back on others as not so wonderful. With any new procedure, it is important to look at studies published in peer-reviewed medical journals as well as promotional materials by a physician, clinic, or instrument manufacturer. In deciding whether any procedure is for you, you should look at advantages and disadvantages of all available options. Seek out centers where all options are available. If there is only one treatment on the "menu" you can be sure that will be the only option offered.

Treatment of Myomas may depend on where in the uterus the fibroids are located:

Intracavitary Myomas
When a myoma is inside the uterine cavity, it will frequently cause abnormal bleeding and cramping. If it is not currently causing problems, the odds are very high that it will. For this reason, we usually recommend that they be removed. These can usually be removed by using a special kind of hysteroscope, or resectoscope. The resectoscope is a telescope with a built-in loop that can cut through tissue. It has been used for years to treat enlargement of the male prostate gland, and has more recently been used inside the uterus. This is called hysteroscopic resection of myomas. In skilled hands most myomas inside the uterus can be removed in an outpatient setting.

Submucous Myomas
Unlike intracavitary myomas, some of the fibroid is also in the wall of the uterus. Submucous myomas often cause abnormal bleeding. Many of these can also be treated by hysteroscopic resection. During the process of removing submucous myomas by this method the uterus contracts, and tends to push the portion of the myoma that is in the wall into the cavity of the uterus. The decision on which myomas should be treated by this method should be made by an experienced hysteroscopic surgeon. If heavy bleeding is the main reason for desiring treatment, and fertility is no longer desired, an endometrial ablation may also be done at the same time.


Intramural and Pedunculated Myomas
Myomas that are in the wall of the uterus or on the outside of the uterus are not accessible to hysteroscopic treatment through the cervix. If these need to be treated, there are essentially three types of procedures: remove the fibroid(s), destroy the fibroid(s), or remove the uterus. All of the surgical options available are variations on one of these "themes".


Hysterectomy:
Hysterectomy is the only procedure that comes with a guarantee: no more bleeding and no regrowth of fibroids. Like any alternative, there are advantages and disadvantages of having a hysterectomy.


Myomectomy: Removal of the fibroid(s):
Myomectomy, with one exception, involves making an incision into the uterus and removing one or more fibroids. If the fibroid is on a stalk (pedunculated) it is not necessary to cut into the uterus to remove the fibroid. Unless the myoma is on the outside surface of the uterus, the uterus is repaired with sutures. One of the major differences in how a myomectomy is done involves the surgical approach to the uterus. In a laparotomy an incision is made in the abdomen to reach the uterus. The advantage of this is that large myomas can be quickly removed. The surgeon is able to feel the uterus, which is helpful in locating myomas that may be deep in the uterine wall. The ability to touch the uterus facilitates repairing the uterus. The disadvantage of a laparotomy is that it requires an abdominal incision. Most of my patients who have this procedure spend two nights in the hospital, and return to work in about four weeks.


Some myomas can also be removed by laparoscopy. The laparoscope is a telescope placed in the abdomen through the belly button. Other instruments are inserted through small individual incisions in the abdominal wall. Many myomas can be removed by laparoscopy; this is easier to do when the myomas are on a stalk or close to the surface. Once the fibroids are removed they are cut into pieces by one of several instruments designed for this purpose, and removed. The advantage of laparoscopic myomectomy is that it is usually done as an outpatient, and allows faster recovery than a laparotomy. One of the disadvantages is the extended time needed to remove large fibroids from the abdomen, although newer instruments are improving this. Since the surgeon cannot actually touch the uterus, it may be more difficult to detect and remove smaller myomas. In addition, if a woman plans pregnancy after her myomectomy, there is a question of whether the uterus can be repaired through the laparoscope as well as it can be by laparotomy.


Although many myomas can be removed through the laparoscope, the decision of which myomas should be removed laparoscopically and which by laparotomy depends on many factors. A woman should discuss the advantages, disadvantages, and risks of each type of surgery with a surgeon who is experienced in all treatment methods.


Destruction of the myomas:
Several procedures have been designed to treat the myomas by destroying their blood supply instead of removing them. The first procedure, called myolysis, is done through a laparoscope. In this procedure an electrical device, is placed into the fibroid through the laparoscope, and used to coagulate the myoma or the blood vessels feeding the myoma. The dead tissue is then gradually replaced with scar tissue.


There are several disadvantages to the procedure. Since no sample of the fibroid is sent to the lab, for a biopsy, in the rare case of malignancy may not be diagnosed. Frequently the procedure causes adhesions (organs such as intestines stick to the uterus), which could cause problems later on. As with any new procedure, there is no long term information on what will happen over time.
 

Uterine artery embolization, which is described below, seems to offer many advantages over myolysis.

Uterine artery embolization (UAE):
This is the newest treatment for fibroids. This procedure involves placing a small catheter into an artery in the groin and directing it to the blood supply of the fibroids. Little plugs are injected through the catheter to block these arteries. This causes the fibroids to shrink, although there may be pain for a short time afterwards requiring the use of narcotics. Uterine artery embolization is usually successful in treating heavy bleeding caused by fibroids.


Uterine artery embolization may eliminate the need for surgical treatment of myomas. As in myolysis, no samples are sent for biopsy, although the chance of malignancy in fibroids are low. It is important to seek evaluation from physicians knowledgeable in both embolization and traditional methods of treatment before deciding on treatment.