FIBROID  FACTS - II . . . indications and treatment options available Indications | Hysterectomy | Medications | Myomectomy | Uterine Artery Embolization

INDICATIONS FOR TREATMENT Thirty years ago, the indications for surgery on fibroids were far more liberal than they are today. The accepted treatment then was also far more extreme, i.e., HYSTERECTOMY which was done almost automatically in the face of fibroids, once childbearing was no longer an issue. Over the years, studies have shown that fibroids are - in many cases - a much less threatening condition than once believed. With this newer understanding, gynecologists can - in good conscience that they are still doing the best for their patients - offer options more tailored to their patients' needs. Yet there are still times when observation - nevertheless - is no longer the right or even the safest way. The patient then must listen to the reasons her gynecologist offers - to understand why "waiting" is no longer a good plan. What then are the current reasons for being more aggressive in the treatment of fibroids, and when this occurs - what are the points to consider for the various options we have? A PARTIAL LIST OF INDICATIONS (For a more extensive discussion, the proper thing to do is to discuss it with your gynecologist - as there may be some things unique to you which bear on the recommendation.) Size: The uterus has reached the size of a 5 month pregnancy - some physicians feel that a 3 1/2 month to 4 month pregnancy size (approximately the size of a cantalope) is their preference. This is all based on the fact that if the uterus becomes any larger, blood loss at surgery and other complications are significantly higher. Has grown quickly and suddenly Is causing the patient considerable pressure discomfort while performing usual tasks Has become large enough to start putting pressure on the tube (ureter) draining urine from the kidneys. Bleeding Abnormalities: (Once more serious causes have been ruled out, it often suggests the presence of Sub-Mucous fibroids within the uterine cavity.) Extreme or prolonged bleeding at the time of the period which sharply decreases the patient's blood count Gradually increasing bleeding correlated with an increase in fibroid size. Hemorrhage with each period, not responding to D&C or medical treatment. Infertility: Sub-Mucous Fibroids have been discovered at the time of an Infertility workup, or when recurrent spontaneous miscarriage is being evaluated. (Many Infertility Experts believe that a sub-mucous fibroid should be removed before the patient attempts a pregnancy again.) Pain: Fibroids have been known to cause pain and pelvic discomfort. However, there are many causes of pelvic pain NOT related to fibroids, so CAUTION is advised. For example we often see patients with a moderately enlarged fibroid uterus, who are virtually symptom free. Thus pain, which appears to be related to fibroids, must be carefully evaluated before embarking on any treatment. We never want to overlook a Non-Fibroid related cause for the pain.

HYSTERECTOMY (Still a useful technique in special circumstances) Large Uterus: Removing individual fibroids in a very large uterus, can cause heavy blood loss and expose the patient to blood transfusion or a higher incidence of post-operative infection. Straightforward Hysterectomy, in the event the childbearing is not an issue, and the patient prefers a definitive cure - may be the best choice. Also the increased operating time required to do the more conservative procedures may not be in the patient's best interest. Patient's Choice: The one negative of conservative surgery is that there can be no guarantee that fibroids will not reoccur. Though our experience suggests that many do not reoccur (or do so in minimum ways), yet it is impossible to predict accurately the probability of reoccurrence. Under these circumstances, and after hearing all her different options, the patient herself may elect Hysterectomy as a final treatment. Rapid Uterine Growth: It is difficult to be certain when rapid growth may be an indication of the presence of malignant change. There are no accurate tests prior to hysterectomy to determine presence of absence of a Sarcoma. Hence in this special subset of patients, hysterectomy may be the safest plan. Note: If the fibroids are not too large, your gynecologist may recommend a "Laparoscopically Assisted Vaginal Hysterectomy." This is especially useful it the patient's pelvic organs are very well supported. Approximately 2/3rds of the procedure is done through the laparoscope, while the other 1/3 is done vaginally. If technically appropriate, this procedure can drastically decrease the post-operative discomfort, and hasten recovery greatly. But remember - this procedure becomes technically impossible if the uterine size is too large. Your gynecologist just has to be the judge of whether or not this is a safe approach for you. .

MEDICATIONS The most commonly used drug to treat fibroids is LUPRON. The effect of a Lupron injection is to suppress the ovaries, drop the patient's estrogen putting her into a temporary menopause, which then shrinks the fibroids as much as 50%. It is not useful as a permanent solution. The reason is that it has two problems: The shrinkage is not permanent. Once the monthly injections are stopped, in 85% or more of cases - the fibroids return to pre-treatment sizes in 6 months. The medication is not advised for use over 6 months as a menopausal induced bone loss occurs. There has been some work done in which a small amount of Estrogen is added to the regimen. This issue has not been resolved by the researchers looking at this possibility. The most common usage of the drug - then - is to shrink the fibroids as a pre-operative measure. The logic is that if the fibroid is smaller, there will be less blood loss and the surgery will be less traumatic. However, in Fibroid Embolization techniques, it is better to leave the fibroid full size so as to preserve the size of its blood supply. (As you will see, it is the large caliber of the vessels which make the procedure successful.) Hence Lupron is not used in the pre-treatment for this procedure.

MYOMECTOMY PROCEDURES. "Myomectomy" simply means the removal of a fibroid(s) with the uterus remaining in place. Because over 60-80% of fibroids are multiple, "Multiple Myomectomies" is what usually takes place. All the different techniques come down to four methods: Excise the fibroid by making an incision Pare a Sub-Mucous fibroid down and remove it a piece at a time Vaporize the fibroid and suction it away, Interrupt its blood supply so that it breaks down and is "suctioned away" by the body itself. Let's say that your Gynecologist recommends "Myomectomy." There are a few decisions to make, and treatments to plan which will be discussed with you in detail. First: What is the location of the fibroid(s) to be removed, i.e., serosal, intra-mural, etc? This is important because the techniques for removal vary. Second: What techniques are available at the medical center where your surgery will be done? Remember too, that different physicians will have their preferred technique(s) for "Myomectomy". Be advised that there is no one single "Gold Standard" treatment at this time agreed upon by all gynecologists. Third: You may well be interested in a specific technique that - after discussion with an expert - "makes sense to you." Fourth: Expect some delay in scheduling the case, because almost all gynecologists "Pre-Treat" with medication to shrink fibroids first.

Summary of techniques for use in Serosal and Intra-Mural Fibroids Laparoscopic (A telescope is introduced into the abdomen through an incision approximately 1/2" or less, followed by appropriate other instruments through other tiny incisions to accomodate the surgical tools required.) Harmonic Scapel - using ultra-sound as the cutting tool. Laser Vaporization of fibroids - in the event of large fibroids, the operative time may be excessive. Your gynecologist must be the judge of what is "too long." Surgical This - the most traditional approach - requires an incision in the abdomen after which each individual fibroid is removed from the uterus. A classic case from the annals of Gynecology reports removal by one surgeon (Dr. V. Bonney in 1931) of over 225 fibroids! The Gynecologist carefully notes whether or not the surgery requires entry into the cavity of the uterus. At this time, if the cavity is entered, any subsequent pregnancy should be delivered by Cesarean Section. The reason is that the scar could become weak during labor and rupture, causing potential major problems for both you and your baby. Uterine Artery Embolization (go to other pages of this WebSite to read about this technique which is performed by an Interventional Radiologist.) Summary of techniques for use in Sub-Mucous Fibroids Myomectomy - this technique (done abdominally) always requires entry into the endometrial cavity, and hence later C-Section in pregnancy. As a result, it has been mainly replaced by Hysteroscopic methods which neither require abdominal entry or later C-Section. Hysteroscopy (a procedure done through the vagina during which the inside of the uterus can be vizualized.) Hysteroscopic Resection of a Sub-Mucous Fibroid: In this procedure, the fibroid is slowly pared down until the level of the uterine wall is reached. Versipoint Vaporization of a Sub-Mucous Fibroid: In this procedure (pictured below) the fibroid is slowly vaporized, and the tissue suctioned from inside of the uterus. (Hysteroscopic pictures courtesy of Christina Veit, MD)                   At the start of the procedure                               After the fibroid has been resected Uterine Artery Embolization (go to other pages of this WebSite to read about this technique which is performed by an Interventional Radiologist.)

© 1998 Carlos Forcade, MD (888) 666-2002

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