Hysterectomy for Uterine Fibroids: Good and Bad

Hysterectomy (surgical removal of the uterus) has proven to be a reliable method of treating women with uterine fibroid tumors that cause bleeding or pain. The most important advantage of hysterectomy is the ability to completely cure the disease, with no chance of recurrence. Hysterectomy also removes any risk of uterine cancer in the future (less important because this only occurs in a small minority of patients) and can make it easier to give estrogen replacement to some women after menopause (to prevent osteoporosis and heart disease).

Many women seek alternative treatment methods that allow them to avoid the surgical risks, discomfort, and the inconvenience of a hysterectomy and its 4-6 week recovery period. Also, some women do not wish to lose the ability to bear children; others do not feel comfortable losing a part of themselves. For this reason, several newer methods have been used to treat fibroids while leaving the uterus in place.

Uterus-sparing Treatment Options for Uterine Fibroids

Hormonal Therapy
With this form of treatment, the patient is given medications and does not undergo any invasive procedure. Currently available hormone treatments are very effective in shrinking fibroid tumors but cannot be continued for long periods of time because women tend to develop osteoporosis (bone weakening) and irregular menstrual periods; some women may stop having periods completely. When treatments are stopped, the fibroid tumors almost always grow back to their original size within a few months. Newer forms of hormonal therapy currently are being investigated.

Myomectomy
Myomectomy is a surgical procedure performed by a gynecologist that involves the removal of individual fibroid tumors while leaving the uterus in place.

This procedure can be performed in several ways: 1) in standard surgical fashion through an incision in the abdomen; 2) laparoscopically, through a tiny incision. The gynecologist inserts a camera in the abdomen to see the uterus and uses special instruments to remove the fibroids; and 3) hysteroscopically. The gynecologist inserts a camera in the uterus from below and removes fibroids on the inner surface of the uterus. Myomectomy procedures require general anesthesia in most patients.

Myomectomy is very effective when one or a few fibroid tumors are removed and is considered the standard treatment for women who desire future childbearing. Women who have multiple fibroids are at somewhat higher risk for bleeding and other complications after myomectomy. Some women undergoing myomectomy will have return of their original symptoms of bleeding or pain, and about 1 in 5 eventually will require another surgical procedure to treat their fibroids, usually hysterectomy.

Uterine Fibroid Embolization (UFE)
Uterine fibroid embolization (sometimes referred to as uterine artery embolization or UAE) is a procedure performed by an interventional radiologist, a physician who specializes in using imaging guidance (X rays, ultrasound, CAT scans, MRI scanning) to perform minimally invasive procedures to treat various diseases.

In this procedure, the radiologist injects a material into the arteries feeding the uterus (and fibroid tumors), blocking the arteries and essentially "starving" the fibroid tumors of blood. The procedure takes about one hour to perform and does not require general anesthesia (although women are given sedative medications for their comfort during and after the procedure).

About 90 percent of women undergoing UAE experience significant improvement in their symptoms of bleeding or pain and have measurable shrinkage of their fibroid tumors. Because UAE has been successful in the short-term, does not involve surgery, and has a shorter recovery period than myomectomy and hysterectomy, many physicians believe that this procedure will replace myomectomy as the standard treatment for women who wish to keep their uterus.

Because this is a relatively new procedure (introduced in 1996), it is not yet known how long the improvement in symptoms will last.

Myolysis
Myolysis refers to a family of procedures that involve the use of extreme heat or extreme cold to destroy fibroid tumors while leaving the uterus in place.

These procedures are generally performed laparoscopically (inserting a camera through a tiny abdominal incision to see the uterus) and require the use of general anesthesia. Because these techniques are so new, the results of preliminary studies are not yet available.