What are the treatment options if I am diagnosed with fibroid tumors?
There are several options available depending upon your circumstances. We will discuss the most common options, then after each option discuss the procedure and recovery.
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Hysteroscopic Myomectomy – A slender scope known as a resectoscope is passed through the cervix to remove submucosal fibroids. In some instances, a laparoscope may be inserted to view the outside uterus wall to attempt to reduce the chances of complications or treat other fibroids. Hysteroscopic myomectomy can be performed with IV sedation, epidural, spinal, or general anesthesia, depending upon size and whether other fibroids are present elsewhere in the uterus. It is performed on an outpatient basis. Recovery is generally 2-4 days. The same scope is used to remove polyps from the uterine cavity. The procedure is called hysteroscopic polypectomy, and recovery is the same as hysteroscopic myomectomy.
Laparoscopic Myomectomy – Instead of making an open abdominal incision to remove large fibroids, a scope is inserted and instruments are introduced through other small access ports. The uterus is opened with laparoscopic scissors. The fibroid is removed, and the uterus is closed with standard suture material. The fibroid is then removed through a process called morcellation. The morcellator is a mechanical instrument that shaves off small strips of fibroid tissue until the entire tumor is removed. It Is possible to remove fibroids laparoscopically, even when the uterus is up to the umbilicus. The procedure is performed on an outpatient basis. Return to work is anticipated in 10-14 days and full recovery in 3 weeks.
Over 500 laparoscopic myomectomy procedures have been tracked by the AWHI database. The procedure was successful laparoscopically in 99% of causes. Only 1% of patients were opened for their myomectomy.
Abdominal Myomectomy – Abdominal myomectomy typically involves a 4-8 inch abdominal incision. The fibroids are removed and the uterus is sutured back together. The hospital stay is usually 2-4 days. The average time off work is 6 weeks, and full recovery takes much longer than the laparoscopic alternative.
Laparoscopic Supracervical Hysterectomy (LSH) – This hysterectomy is performed laparoscopically. It has the least pain and fastest recovery of any form of hysterectomy. The body of the uterus is removed, but not the cervix. The procedure is almost always performed on an outpatient basis. The average patient is able to return to work in 10 days and reports full recovery in 3 weeks.
Total(TAH) and Subtotal(SAH) Abdominal Hysterectomy – This procedure involves a 4-8 inch incision in the abdomen. The hospital stay is usually 2-4 days. Return to work is typically 6 weeks, and full recovery may take months. Fatigue is reported to last up to a year in some cases after TAH, in which the cervix is removed. SAH generally implies leaving the cervix. A woman should clarify the Doctor’s definition because it could pertain to the ovaries. A TAH to some Doctors means removal of ovaries and SAH means leaving the ovaries but still removing the cervix. Management of the ovaries should always be discussed clearly and separately.
Removal of the cervix was logical before the PAP smear, when cervical cancer was the leading cause of death in young women. The PAP smear was introduced into general gynecology in roughly 1960. A few years later researchers produced evidence that cervical cancer was a sexually transmitted disease(STD) and that led to the discovery of human papilloma virus(HPV). Because the HPV infection is asymptomatic, before the PAP it went undetected. Generally, it takes 20 years for HPV to mutate into cervical cancer.
Presently, ACOG recommends women over 30 who are HPV negative can have a PAP every three years. They still suggest a regular exam.
Leaving the cervix in place is less likely to alter vaginal anatomy or affect the nerve supply of the bladder. This is controversial. Short term follow up in randomized prospective trials conclude no difference, but long term outcome data is not known. An analysis of the reported incidence of deep pain with intercourse in one study showed a significant difference. The authors used other statistical analysis and reported no difference in sexual function. Because there is a study reporting more urge urinary incontinence in hysterectomy vs no hysterectomy older women the debate about the cervix will go on for many years to come.
Total (TVH) and Laparoscopically Assisted(LAVH) Vaginal Hysterectomy – TVH is removing the uterus and cervix. Although less painful than TAH, the procedure typically require 1-3 days in the hospital, 4 weeks away from work, and full recovery is longer than the recovery after LSH. LAVH was published in 1988 to help the patient avoid an open incision. LAVH is less painful than TAH. Postoperative pain and recovery is similar to TVH.
Uterine Artery Embolization(UAE) – The procedure is performed by an interventional radiologist. A catheter is inserted into the femoral artery at the groin and guided to the uterine arteries which are then completely blocked with plastic particles, thus cutting off the blood and oxygen supply to the fibroid and the uterus. The first 12-24 hours are reported to be extremely painful. It is like a heart attack in the uterus. Heart attacks occur because arteries become clogged off by a blood clot.
The appeal of UAE is avoiding open abdominal surgery and the long recovery. The majority of women who pursue UAE are not opposed to hysterectomy. Available data shows, in the 3-5 years following UAE 25-30% of women will undergo a second surgery. In a comparison study on fibroids, 3 years after open myomectomy 3% of patients required a second procedure vs 30% who had UAE. No studies have compared laparoscopic surgery and UAE, but published return to work data is similar to laparoscopic fibroid therapy. The woman accepting of the logic of hysterectomy may be better served by LSH. Management of the ovaries should always be discussed separately.
UAE can result in premature menopause and should not be offered to women who might have any desire for pregnancy or disruption of ovarian function.
Magnetic Resonance guided Focused Ultrasound (MRgFUS) – Ultrasound for pelvic imaging of fibroids uses very low energy. By increasing the energy and focusing the sound beam the inside of the fibroid it can be superheated. The internal tissue then undergoes necrosis (death) and the fibroid shrinks. The patient lies tummy down on a procedure table, under IV sedation. No incisions are required other than starting the IV. Return to work data is not yet available.
MRgFUS has certain limitations; it takes 2-3 hours to treat 1 or 2 fibroids, meaning multiple sessions could be required. The cost of MRgFUS may prohibit its usefulness for women with multiple fibroids. Patient movement will effect where the energy is delivered, Skin and sciatic nerve burns have been reported. Fibroids on the surface of the uterus, near the bowel, might be dangerous to treat. Shrinkage averages 15%, so women with larger fibroids will not be relieved of some bulk symptoms such as bladder pressure.
The technology has promise. Refinement of the use of high intensity focused ultrasound for smaller, newly discovered fibroids is the most interesting application.