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What are the treatment options?
There are several options depending on your circumstances. |
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MEDICAL:
When the evaluation is completed and no structural cause
(fibroids, polyps, etc) are 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 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 hysterectomy for
heavy periods by 50%.
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Hormonal therapy is utilized when no other cause is found. Typically, oral contraceptives
are the first line of therapy unless there is a contraindication, such as high blood pressure,
a smoking history, woman over 35 or any of the other contrindications to taking oral
contraceptives. Low-dose estrogen or progesterone may also be used. There are also intrauterine
hormonal delivery systems which may be effective within the uterus, but not have the systemic side
effects of other hormonal treatment. This has been used with success in Europe and is now available
in the United States. |
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SURGICAL:
Hysteroscopic Myomectomy/Polypectomy
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.
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Endometrial Ablation
First described in 1972, endometrial ablation is an alternative
to hysterectomy for abnormal uterine bleeding.
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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.
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.
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Global Ablation
ERA is a sub-specialty procedure. 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.
- Balloon Therapy
- Hot saline infusion
- Cryoablation
- Microwave Ablation
- Electrocautery
Global ablation helps many women with a less invasive, less painful
treatment for abnormal bleeding. The failure rate for global ablation
is higher than for ERA. Sub-specialty evaluation for abnormal bleeding
is more accurate.
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Myomectomy
Fibroids that are too large for hysteroscopic myomectomy causing abnormal
bleeding 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 incude:
Open abdominal myomectomy
Laparoscopic myomectomy
Laparoscopic myomectomy with endometrial ablation
Uterine artery embolization
MRI-guided high intensity focused ultrasound
Uterine artery occlusion
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Open abdominal myomectomy
Through a 4-8 inch incision fibroids are removed and
the uterine incision(s) closed with suture.
Women can successful reproduce 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.
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Laparoscopic myomectomy
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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.
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The morcellator is a hollow tube for inserting a grasper. The tissue
is pulled into the morcellator and removed.
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 before the open woman returns to work.
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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
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Uterine artery embolization(UAE)
This minimally invasive surgery 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 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. No laparoscopic comparison studies are
available. Small case series of patients having laparoscopic
surgery for failed UAE suggest pain and recovery may be equal
to or less.
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MRI-guided high intensity focused ultrasound
This has been recently approved by the FDA. The procedure cannot treat
more than 1-2 fibroids at a time in a 2-3 hour procedure. This could
be cost ineffective. The patient with the larger uterus and multiple
fibroids would require 2 or more procedures.
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Uterine artery occlusion
First described as a laparoscopic procedure to accomplish the
same end result as UAE, research has changed what could be.
There is a procedure in European research trials that may
occlude the uterine arteries using a transvaginal, temporary,
clamp. Doppler ultrasound identifies the artery and when no
flow is present. The clamp can be removed after a few hours
with the outcome likely similar to UAE.
Laparoscopic treatment of fibroids has been shown to be
less painful than open surgery, as has UAE. Radiology procedures
need to be compared to laparoscopic surgery to truly answer the
question of which is the best approach.
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Hysterectomy
When medical therapy fails or is not an option and hysteroscopic
surgery is not feasible then hysterectomy may be reasonable.
Again, a thorough evaluation and discussion of choice is important.
There are 4 ways to perform hysterectomy:
Abdominal hysterectomy
Vaginal hysterectomy
Laparoscopic-assisted vaginal hysterectomy
Laparoscopic supracervical hysterectomy
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Abdominal Hysterectomy
The abdominal hysterectomy is the most common approach to
hysterectomy in the United States. About 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.
4-8 Inch Incison
It is the opinion of the Advanced Women's Health Institute
that more than 95% of abdominal hysterectomies performed
for benign disease could be done laparoscopically if referred
to an appropriately trained minimally invasive surgeon.
All too often the woman discusses this with her general
OB/GYN who is usually aware of laparoscopic procedures but
has an economic conflict of interest and therefore does not
offer referral. The average OB/GYN in America performs 1-2
hysterectomies a month. This is not enough to adopt the more
complex laparoscopic hysterectomy technique and barely enough
to stay proficient
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Vaginal Hysterectomy
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.
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Laparoscopically Assisted Vaginal 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 uterus is then removed vaginally along with the cervix.
The recovery is more rapid than TAH, but is no faster on average than
vaginal hysterectomy.
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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. The average patient is back to work in 2 weeks, and
reports full recovery and return to exercise in 3 weeks.
Since the cervix is left the vaginal and pelvic floor anatomy is
not permanently altered, thus leading to the belief that LSH is
less likely to create sexual and bladder dysfunction compared to
traditional forms of hysterectomy. This is controversial,
randomized controlled trials have not shown a difference in
sexual and bladder function 12-18 months after open total or
supracervical hysterectomy. However, a student t-test, a time
honored statistical comparison, identified a statistically
significant difference in the incidence of deep pain with
intercourse at one year in one study. No study has 15-20 year
outcome data which might be when differences show up.
Critics of the technique focus on the need for cervical cancer
screening following an LSH and extended post operative vaginal
bleeding, either cyclic or following intercourse. The pap smear
has virtually eliminated cervical cancer and is only needed every
three years in women over 30 who have had several years of normal
findings. Bleeding post LSH can be addressed with an in office
procedure. Women who have had the cervix removed still need
regular exams, so the is not much difference in post operative
medical needs.
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