Laparoscopy Hospital - Frequently asked questions about Treatment of Fibroids

It is important to find a surgeon who takes time to talk to you and after a thorough evaluation discusses all of your treatment options. It's difficult to evaluate surgical skills without talking to medical personnel who observe surgery, but you can get some idea of someone's comfort level with a procedure by talking to them. While it's important to understand that there are risks to any surgery, it’s not in reality or to believe blindly that myomectomy is too difficult to do, bleed too much, it differs from individuals, or does if they do not seem comfortable with the procedure. While there is no fixed number of cases required to gain the necessary skill, you want to be sure that you have someone who does more than an occasional myomectomy, and who has the expertise and determination to complete the procedure.

Depo-Lupron is a medication that induces temporary menopause. It causes modest and temporary shrinkage of fibroids. A short term solution, but is used at times prior to surgery. One can offer it for large fibroids if feeling it will allow a substantially smaller incision. Most women have annoying but tolerable side effects such as hot flashes. Disadvantages of Depo-Lupron include the possibility that it may make small fibroids more difficult to find so that they are more likely to be left behind, and that at times it can make it more difficult to separate the fibroids from the wall of the uterus.

Once fibroids are removed those particular fibroids cannot grow back. But fibroids are caused by genetic mutations within uterine muscle cells. This process can over time create new fibroids. In addition, there can be tiny fibroids that cannot be seen or felt, and therefore cannot be removed. Recurrence is least likely in women with one or few large fibroids than with multiple small ones. This is most likely to happen in someone who has many little fibroids.

Are fibroids cancerous?
Fibroids are benign tumors. There is no evidence that benign fibroids will become cancerous. This risk of cancer in a fibroid is estimated to be less than 1 in 500.

Whether the need for the treatment of fibroids is essential or not is the most important question to be asked. As a woman gets older the huge majority of fibroids grow, and tend to shrink after menopause. Obviously, treatment is required for fibroids that are causing significant symptoms. The treatment of smaller fibroids is much easier than larger fibroids, many of the small fibroids never will need to be treated. while they are small we can treat them, it doesn't follow that we should treat them. A strong influence played by the location of the fibroids on how to approach them. Experienced in the treatment of fibroids can help you determine by a gynecologist if they need to be treated.

Treatment with medicines

Till today, to shrink fibroids permanently, no medicines currently available. Often with birth control pills heavy bleeding can be decreased. There are a number of medications in the family of GnRH agonists, such as Depo-Lupron, which can induct a temporary chemical menopause. In the absence of estrogen myomas usually decrease in size. Unfortunately, the effect is temporary, and when the medication is discontinued the fibroids rapidly go back to their pre-treatment size. 'French abortion pill or RU-486, is also known as Mifepristone, may decrease the size of myomas, and abnormal uterine bleeding. It is not currently available in the United States but its use is promising.

Surgical treatment of fibroids

for treatment of fibroids, there have been a number of measures recently promoted. Some are truly new. In order to promote the sale of expensive instruments, many steps with new instruments being taken, 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.

Unlike intracavitary myomas, some of the fibroid is also found in the wall of the uterus. Symptoms of abnormal bleeding often cause in Submucous myomas. 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.

when a myoma is inside the uterine cavity, abnormal bleeding and cramping will frequently cause. If it is not currently causing problems, the chances are very high that it will. For this reason, removal of it is usually recommended. A special kind of hysteroscope, or resectoscope can usually be used to remove these. 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.

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 needed, for treating these, 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".

Myomectomy: Removal of the fibroids

Myomectomy, with one exception, begins with making an incision into the uterus and removing one or more fibroids. It is not necessary to cut into the uterus to remove the fibroid if the fibroid is on a tail (pedunculated). 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. To reach the uterus, in a laparotomy an incision is made in the abdomen. 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 drawback of a laparotomy is that it requires an abdominal incision. Most of the 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. It is usually done as an outpatient is the advantage of laparoscopic myomectomy, 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 laparoscopy as well as it can be by laparotomy.

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

Hysterectomy

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

Several procedures have been designed to treat the myomas instead of removing them, by destroying their blood supply. The first procedure, called myolysis, is done through a laparoscopy. 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.

Several disadvantages to the procedure have been seen. 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.

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

An abdominal myomectomy is the removal of fibroids through an incision in the abdomen. It is usually done through a horizontal ("bikini") incision, even for large fibroids. Abdominal myomectomy is done in a hospital, and women usually can go home within 48 hours of surgery. There is no limit to the size or number of fibroids that can be removed.

Being able to hold the uterus allows the doctor to accurately repair the area from which large fibroids have been removed.The ability to actually feel the uterus allows finding fibroids deep inside the uterus that may not be visible just by looking.
The disadvantage of an abdominal myomectomy is that it requires an incision, so recovery is somewhat longer than required if an incision is carried out. Fibroids that are on the inside of the uterus (submucous) can usually be removed with a resectoscope, without requiring any incision. Through a laparoscope, Fibroids on the outside of the uterus (subserous) can sometimes be removed through several small incisions. It often depends on the method of choice for subserous or pedunculatd (on a stalk) fibroids. If there are many fibroids or fibroids that are deep can be easily done by doing an abdominal myomectomy. Most women feel that in the long run doing the best possible procedure to restore the health of the uterus is more important than recovering several weeks sooner.

When a myomectomy is done by a surgeon with extensive experience in the procedure usually there is little loss of blood. There are a number of ways to reduce blood loss. By using a laser to make the incision into the uterus, which seals blood vessels and reduce bleeding. Before the incision, medicines are injected into the uterus to shrink blood vessels. As a result, it is often found unusual to lose an excess amount of blood during a myomectomy, even with large fibroids. To reduce blood loss, there are a number of surgical techniques, so it is important to find a surgeon who is experienced in myomectomy.

	As an assumption, the uterus is the size of a 5 month pregnancy. It can be seen to protrude up to the belly button.
	The uterus, which, is greatly enlarged by the fibroid, is lifted through the incision. A laser is being used to make an incision into the uterus so the fibroid can be removed.
	The fibroid is being separated from the wall of the uterus (myometrium). It is very important to do this in the exact location between the fibroid and the myometrium in order to prevent excess bleeding
	This shows the fibroid almost completely free from the uterus. It is attached only at the base. The blood vessels at the base are being sealed with an electrosurgical device.
	The uterus is being reconstructed by suturing the walls together with dissolving suture. This is being done in multiple layers to ensure a precise repair.
	The last layer of sutures is placed, and the uterus is completely restored. A barrier to prevent adhesions will be placed before the uterus is replaced into the abdomen and the abdomen closed.

Recovery varies tremendously from person to person. Most women can return to work that does not require heavy lifting in 4 weeks. Many women can return in 2 weeks, and some women take 6 weeks.

To preserve fertility, Myomectomy is the only surgical treatment of myomas. The establishment of safety of pregnancy after uterine artery embolization is not possible, and pregnancy is impossible after hysterectomy. After a UAE, The average reduction in volume of fibroids is 50%, where fibroids that have removed are completely gone. To restore the uterus to normal function is the purpose of myomectomy. Symptoms such as heavy bleeding and pressure usually decrease or are gone once the fibroids are removed.

Possibilities of recurrence of Fibroids are there. While fibroids that are removed cannot recur, fibroids that are left behind can form, and new ones can grow. Sometimes a uterus may have a single or a few large fibroids, and the recurrence risk would be expected to be low. On the other hand a uterus with multiple tiny fibroids would run a higher risk of recurrence since it may be impossible to find all extremely small fibroids.
In addition to the fibroids, another possible problem is that severe adenomyosis can occur. This could lead to pain and heavy bleeding. As adenomyosis is commonly mistaken for fibroids, it is essential to have proper diagnosis before surgery!

Hysterectomy - the removal of the uterus-is rarely required for the treatment of fibroids. Nonetheless, it can be a reasonable option for women who do not want to remain fertile. No further menstrual bleeding will be there after going through Hysterectomy surgery. It guarantees that there will be no recurrence of fibroids. The only sure treatment for adenomyosis is Hysterectomy. Some women who want to have these guarantees but wish to have as little removed as possible elect to have a supracervical hysterectomy — a procedure in which the body of the uterus with the fibroids is removed and the cervix is left.

UAE is a new procedure in which tiny particles are injected through blood vessels to block the arteries supplying fibroids. This causes degeneration of the fibroids and decrease in size and symptoms. It is very important to be evaluated by a gynecologist familiar with UAE as well as other options before choosing UAE, as often the specialists in UAE are not experts in the management of fibroids, for patient, it is also an important life saving decision as for future prospect as concerne