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Submucosal fibroids arise close to the uterine cavity and cause abnormal bleeding at smaller sizes than fibroids that occur further from the cavity.
A pencil sized(5mm) scope placed through the base of umbilicus(belly button) sends a video image
to the monitoring screen while the myomectomy is completed using 3 small access ports(trocars)
just above the pubic bone. The 2 side ports are for pencil size instruments. The 12 mm trocar site
is for suturing the uterus closed and fibroid morcellation. This form of myomectomy is outpatient
instead of 2-4 days in hospital. We have reported return to work is possible in 10 days for our
average patient, not 6 weeks. The average woman who has laparoscopic myomectomy states she feels
fully recovered in 3 weeks. This is 3 weeks before the open woman returns to work.
Laparoscopic myomectomy with endometrial ablation
For the woman who does not accept hysterectomy, but would like to terminate menstrual flow, the uterine lining can be removed at the same time as laparoscopic myomectomy.
Uterine artery embolization(UAE)
This procedure was first described in the mid 1990’s. A catheter is inserted into the femoral artery at the top of the leg and guided to the uterine arteries with fluoroscopy(live X-ray). Polyvinyl chloride particles are infused until blood flow no longer can be detected. The ischemic insult causes fibroids to shrink. Collateral blood supply saves the uterus from complete necrosis. The majority of women are satisfied with their outcome.
A comparative study of UAE and open abdominal myomectomy has been published. In the three years after UAE 35% of patients underwent a second surgical procedure, as opposed to 3% in the open myomectomy patients. A case series with 5 year follow up reported a 25% second intervention rate. One UAE expert has indicated 60% of woman seeking the procedure had no problem with hysterectomy they were just trying to avoid open abdominal surgery.
There are now studies in the medical literature that have compared Laparoscopic Supracervical Hysterectomy and Laparoscopic Myomectomy to UAE. Patients had similar recovery times. More importantly, patients were more satisfied with laparoscopic surgery than UAE.
MRI-guided high intensity focused ultrasound
This has been approved by the FDA. The procedure cannot treat more than 1-2 fibroids at a time in a 2-3 hour procedure. This is cost ineffective and typically is not covered by insurance. The patient with the larger uterus and multiple fibroids would require 2 or more procedures.
Uterine artery occlusion
This is described as a laparoscopic procedure to accomplish the same end result as UAE,
This was described around 1990 as a laparoscopic procedure to shrink fibroids tumors. It was the first laparoscopic alternative to hysterectomy. To shrink the fibroid, either a laser fiber or a bipolar cautery needle was inserted many times into different locations throughout the tumor. The fibroid got smaller over the next several weeks. Patients wanted laparoscopic myomectomy once we were able to offer it. They wanted the fibroids out and gone.
Laparoscopic radio frequency alblation(LRFA)
This is a new, FDA approved, laparoscopic procedure to accomplish the same end result as myolysis, LFRA may result in better outcomes than myolysis because only one insertion is made. More studies are needed to understand its benefit. It may be difficult to get covered by insurance since it is new. It is an alternative to hysterectomy if laparoscopic myomectomy is not an available option.
When medical therapy fails or is not an option and hysteroscopic surgery is not feasible some women choose hysterectomy. For the woman who feels comfortable with hysterectomy is it a good procedure. No woman should be told hysterectomy is her only option.
There are several forms of hysterectomy:
What is a uterus?
The uterus is a muscle with a cavity inside where the fetus grows until the muscle contractions of labor force the cervix to dilate for delivery. The cervix is a fibrous tissue attached to the muscle of the uterus. It is the same kind of tissue as tendons, which attach the other muscles of our body to our bones. It is very tough and is attached to the rest of your fibrous tissue pelvic supports. The cervix is as much a part of the vagina and pelvic supports as it is the uterus. The cervical canal is a glandular lined connection to help sperm move from the vagina into the uterine cavity and up through the tubes to fertilize the egg. The area where the glands of the cervical canal meet the squamous cells of the vagina is the location for the HPV virus infection that causes cervical cancer.
The abdominal hysterectomy is the most common approach to hysterectomy in the United States. About 60-70% of hysterectomies are abdominal. Hospital stay is 2-4 days, and patients typically take 6 weeks off work. Full recovery may take up to a year.
Vaginal hysterectomy is an alternative to abdominal hysterectomy when a woman has a normal-sized or only slightly enlarged uterus. Because no abdominal incisions are made, the patients tend to leave the hospital in 1-2 days. Women typically take 4 weeks off work.
Laparoscopically Assisted Vaginal Hysterectomy
This procedure was introduced in the late 1980s so a woman with a larger uterus could avoid an open hysterectomy. The uterine vascular supply can be secured laparoscopically, thus avoiding the large abdominal incision. The uterus is then removed vaginally along with the cervix. The recovery is more rapid than TAH and similar to vaginal hysterectomy.
Total Laparoscopic Hysterectomy
This procedure was developed to allow the woman with an enlarged uterus to avoid an open hysterectomy. The uterine vascular supply can be secured laparoscopically, thus avoiding the large abdominal incision. The vagina is entered from above instead of through the vagina. The uterus is then removed vaginally along with the cervix. The recovery is more rapid than TAH and similar to vaginal hysterectomy.
Laparoscopic Supracervical Hysterectomy (LSH)
LSH is the least painful form of hysterectomy, with the fastest recovery, ever described. Women who have LSH can go home the day of the surgery up to 90% of the time. Office workers are back to work in as few as 4 days, typically 4-6 hours. Most take 1-2 weeks off. Full recovery and return to exercise takes about 3-5 weeks. Women in physical jobs that require heavy lifting(more than 50 pounds) mostly need 6 weeks.
Since the cervix is left the vaginal and pelvic floor anatomy is not altered.
Whether LSH is less likely to create sexual and bladder dysfunction compared to traditional forms of hysterectomy is controversial. A randomized controlled trial did not show a difference in sexual and bladder function 12-18 months after open total abdominal hysterectomy compared to LSH. No study has 15-20 year outcome data which might be when differences show up.
A study about pelvic prolapse repair reported fewer complications when the LSH was performed compared to Total laparoscopic hysterectomy.
Laparoscopic Intrafascial Hysterectomy (LIH)
LIH is similar to LSH for post op recovery. The difference is how the cervical canal is treated.
Critics of LSH focus on continued risk of cervical cancer and post operative cervical bleeding, either cyclic or random. The pap smear has virtually eliminated cervical cancer but dealing with an abnormal PAP is stressful and costly. Cervical bleeding problems also make for an unhappy patient.
During the LIH procedure a donut hole like incision is made to remove the cervical canal. The cervical tissue is closed with suture. Reducing the risk of cervical cancer along with bleeding while still leaving the pelvic floor anatomy, nerve supply and blood flow as close to normal as possible is the purpose of LIH.
Uterine polyps – They are tumors of the uterine lining tissue origin, as they grow into the uterine cavity they can create abnormal bleeding.
Cervical polyps – Like uterine polyps they can cause abnormal bleeding.
Adenomyosis – When tissue that looks like the lining of the uterine cavity is found in the muscle wall of the uterus, outside the cavity, it is called adenomyosis. It occurs in approximately 25% of women during their lifetime. Adenomyosis can cause heavier flow and worsening cramps.
Cancer – This is more of a concern when abnormal bleeding occurs after the age of 50.
Other - Less common causes of abnormal bleeding include endometritis(low grade chronic infection) and adhesions(scar tissue from a previous uterine surgery),
The major reason for abnormal bleeding is ovarian dysfunction. In young women the ovaries are just getting started and in older women the ovaries are winding down. The perimenopausal transition usually begins in the 40s but can start in the 30s. Menopause before age 30 is premature. The uterine lining is stimulated by ovarian estrogen and progesterone. Fluctuations of these hormones will disrupt the normal process and can cause prolonged, irregular, or heavy bleeding.
Some bleeding problems are due to blood and vascular abnormalities. Young women with heavy periods may have a problem with her clotting factors or platelets. If the internal vascular regulatory mechanisms of the uterus do not function properly then the small arteries that supply the uterine lining may not properly constrict at the time of the menstrual flow and lead to heavier periods.
What are the symptoms?
Could it be cancer?
Usually when a woman presents with abnormal bleeding it is due to benign (not cancer) causes. In cases where the woman is around or beyond menopause, abnormal bleeding may be an early indication of uterine cancer. This should be evaluated with hysteroscopy and directed biopsy. In some cases, pre-cancerous conditions are found. Precancerous findings can be treated medically and hysterectomy may not be required.
What is the best way to diagnose abnormal uterine bleeding?
The first step in diagnosing abnormal bleeding is to take a thorough menstrual history. When a woman has recent changes in menstrual flow, this may indicate a fibroid or a polyp. A woman with longstanding heavy flow all of her life may have hormonal or blood clotting problems. Irregular menstrual periods may be caused by ovarian dysfunction, especially in younger or older women.
The next step involves a physical examination. An enlarged uterus may indicate fibroid tumors, but a normal uterus does not rule out small fibroids inside the uterine cavity.
Transvaginal ultrasound is a cost effective diagnostic technology used to evaluate the uterus. It uses sound waves to image the pelvic structures rather than X-ray. Ultrasound is like a visual pelvic examination and should be performed when a woman complains of abnormal bleeding. A simple pelvic exam is not sufficient.
The American College of Obstetrics and Gynecology states that ultrasound is the preferred technology for imaging the uterus and should be performed instead of CT or MRI for the initial evaluation of abnormal bleeding.
Diagnostic hysteroscopy(using a small narrow scope that goes through the cervix) is the procedure we use to evaluate the uterine cavity and cervical canal for fibroids, polyps, and other pathologies that are too subtle for transvaginal ultrasound to detect. When there is a concern that cancer may be present diagnostic hysteroscopy is more accurate than a D&C.
Women can successful get pregnant after myomectomy. The procedure has been described in the medical literature for over 100 years. Myomectomy is safe when performed by an appropriately trained physician. Return to work is usually 6 weeks. Complete recovery can take longer.
A complete and thorough evaluation is important to the success of any surgery. Women who have multiple fibroids or other pathology may want to consider other minimally invasive approaches.
Adenocarcinoma of the uterus is more of a concern when abnormal bleeding occurs after the age of 50. The cancer occurs because estrogen continues to be produced without progesterone being secreted by the ovaries. Hysteroscopy directed biopsy can more effectively diagnose adenocarcinoma and hyperplasia(precancer). Hyperplasia in many cases can be treated medically, as an alternative to hysterectomy
Laboratory tests may be required. A blood count is important, especially when the patient is suspected as having anemia. Abnormal thyroid function may cause abnormal bleeding and can be corrected medically. Small pituitary tumors called prolactinomas may also cause abnormal bleeding. These tumors are sometimes associated with breast milk secretion, so when a woman complains of both irregular bleeding and secretions from the breast, a prolactin test becomes important. FSH(follicle stimulating hormone) is the pituitary hormone that regulates the ovary. If FSH is elevated it indicates the abnormal bleeding is due to ovarian failure and impending menopause.
What are the treatment options?
There are several options depending on your circumstances.
When the evaluation is completed and no structural cause (fibroids, polyps, etc) is found, the cause of the abnormal bleeding is considered medical. If tests show a woman is hypothyroid, she will need thyroid medication. Pituitary prolactinomas can also be treated medically with Bromocriptine. Elevated follicle stimulating hormone suggests approaching menopause and management should be individualized. Hormonal therapy is recommended when no other cause is found.
Oral contraceptives(OC’s), as well as newer transdermal contraceptives, are the first line of therapy unless there is a contraindication. Approximately half of women who use OC”s for abnormal bleeding do fine, and the other half stop for several reasons including high blood pressure, affect on mood, break through bleeding, my partner had a vasectomy and I don’t want to take the risk anymore, and other side effects or circumstances.
There is an intrauterine hormonal delivery system that is very effective at controlling heavy flow and appears to have a low rate of systemic hormonal side effects. The device can potentially reduce the chances of needing a surgery for heavy periods by 50%.
High dose oral or intramuscular Depoprovera may be used to control heavy bleeding and correct anemia. GnRH agonists are a class of medication that temporarily inhibit the pituitary gland from stimulating the ovary. They are for short term use to correct anemia or shrink fibroids while implementing medical therapy or preparing for surgical intervention.
When abnormal bleeding is caused by fibroids or polyps growing into the uterine cavity they can be removed with minimal discomfort. Women are back to work in 2-3 days and all normal activities in one week on average. Hysteroscopic surgery will correct the bleeding problem with less pain and risk than hysterectomy. This is especially important for the woman who wants to maintain fertility.
Centers that specialize in laparoscopic surgery have reported that more than 95% of hysterectomies for benign disease could be done laparoscopically instead of open.
What is abnormal bleeding?
The typical menstrual period lasts 7 days or less. The average menstrual cycle is 28 days from the start of one period to the start of the next period. However, cycles can vary in length from 22-35 days. Some women have very regular cycles and others have variations. There are apps that assist in tracking cycles.
The average blood loss during a menstrual period has been precisely studied. Generally, a woman changes a regular pad or tampon 4-6 times a day during the heaviest parts of her menstrual period.
Abnormal bleeding means different things to different women. If you use 6 tampons a day when you are used to only 3 a day that seems heavy and it could mean something is wrong. Bleeding or spotting before, after or between periods is not normal. When abnormal changes persist then something is probably wrong. Our goal is to provide you with an accurate diagnosis and then discuss options.
What causes abnormal uterine bleeding?
Most of the time abnormal bleeding is caused by ovarian dysfunction, especially in adolescents and women as they approach menopause. However, approximately one third of women over 35 years of age with abnormal bleeding have uterine pathology such as:
Fibroids - Fibroids are tumors of the uterine muscle wall. They are almost always benign (not cancer), but as they enlarge they can distort the uterine cavity and interfere with the normal function of the uterus, causing the menstrual periods to become heavy, prolonged and more painful.
ERA is a sub-specialty procedure. It is the most effective alternative to hysterectomy to stop bleeding.
In the last several years devices have been developed to make endometrial ablation easier so general OB/GYN’s can offer this less invasive, less painful treatment for abnormal bleeding to their patients. These devices use various forms of energy to destroy the uterine lining.
Global ablation is a less invasive, less painful alternative to hysterectomy.
If you want the “State of the Art” for ablation you should contact us.
Fibroids that are too large for hysteroscopic myomectomy can be removed without the need for hysterectomy. Myomectomy should be discussed with each patient. Not all women want or are ready for a hysterectomy.
Surgical alternatives to hysterectomy for fibroids include:
Open abdominal myomectomy
Through a 4-8 inch abdominal incision fibroids are removed and the uterus is closed with suture.
First described in 1972, endometrial ablation is an alternative to hysterectomy for abnormal uterine bleeding.
Endometrial Resection Ablation (ERA)
The same scope used for hysteroscopic myomectomy and polypectomy is used to remove the uterine lining, thus eliminating menstrual flow. Return to work is also 2-3 days and complete recovery is one week on average. The average woman waits 4 weeks to return to work after a vaginal hysterectomy. Three randomized controlled trials comparing ERA to vaginal hysterectomy concluded, overall, patients were equally satisfied with their surgery after one year or more
ERA is considered the gold standard of endometrial ablation.