I CAN’T TAKE IT ANYMORE (MANAGING WOMEN WITH SYMPTOMS)
If you’ve had to run out of a room with your sweater around your waist to hide your blood-stained pants, or if you have to miss a day of work each month because of painful menstrual cramps, you don’t have to take it anymore. Depending on the severity of your fibroid symptoms and whether or not you have completed childbearing, you will want to look into these treatment options.
Drug Therapy - Synthetic hormones are prescribed which can decrease the size of the uterus and the fibroid. The drugs can be prescribed alone or in conjunction with a surgical procedure to shrink fibroids prior to surgery.
Myomectomy - This is a surgical procedure, but it is a less "radical" approach to treating fibroids, than a hysterectomy. Fibroids are cut away, but the uterus is preserved meaning you can still have children. Traditionally, this procedure involved an abdominal incision and several days in the hospital. Today, depending on the size and location of the fibroid, your doctor can also remove the fibroid using less invasive procedures like hysteroscopy and laparoscopy. In most cases, these can be done on an outpatient basis or overnight stay, but there are still some risks involved. Generally, the risks are lower and the recovery is easier than traditional surgery. During a hysteroscopic myomectomy a thin telescope-like instrument is inserted through your vagina and cervix into the uterus. Special surgical tools are fitted to the hysteroscope to remove the fibroids. During a laparoscopic myomectomy a thin telescope-like instrument is inserted through a small cut just below or through the navel that enables your physician to see inside your abdomen. Very thin surgical tools are are used in conjunction with the laparoscope to remove the fibroids.
Myolysis - This is typically used for fibroids near the uterine surface. Using medications to shrink the fibroids first, your doctor performs this laparoscopic procedure which involves using an electrical needle to destroy the blood vessels feeding the fibroids. Eventually, the fibroids shrink and occasionally may even disappear.
Endometrial Ablation - This is helpful for excessive bleeding. In this procedure, the endometrial lining (the tissue that makes up the inner lining of the uterine wall) of the uterus is destroyed and it is generally no longer possible to have children. Originally, surgeons used a YAG laser to destroy the lining, but that technique has been replaced in most centers in favor of a safer one done through an operating hysteroscope (resectoscope) fitted with a special tools known as rollerballs, rollerbarrels, resecting loops and vaportrodes that allows your doctor to destroy the lining. There is also a fairly new, experimental type of ablation technique known as uterine balloon therapy. A balloon catheter is inserted into the uterus, where the balloon is filled with a sterilized liquid. Then, a heating element raises the liquid temperature and the lining of the uterus is destroyed or ablated. Considered safer than previous methods that use lasers or electrocautery to ablate the endometrium, this procedure is still being tested. There is also no guarantee that bleeding will not recur.
Uterine artery embolization - Used to treat excessive bleeding due to fibroids. Blood flow to the fibroid is blocked, causing the fibroid to shrink and die. During this low-risk procedure, an interventional radiologist (a specialized physician who uses x-rays or other imaging techniques to place needles or catheters in different areas of the body, to evaluate and/or treat a variety of conditions in a minimally invasive fashion) inserts a catheter through a small incision in the groin, threading it into the femoral artery (major artery supplying blood to the leg) and then up to the uterine artery (main artery supplying the uterus). Plastic sand-sized particles are injected into the catheter. These fine particles lodge in tiny blood vessels, cutting off blood flow to the fibroids.
Hysterectomy - A surgical procedure to remove the entire uterus. Although there is a move away from hysterectomy to treat fibroids, for a small percentage of women it may be the best choice. You need to be certain that your doctor is recommending this procedure for the right reasons and not because he/she is unfamiliar with the newer, less invasive techniques that are now available.
Surgery is not always necessary to alleviate fibroid symptoms. There are different types of drugs that can control your symptoms. Basically, these drugs are designed to shrink your fibroid and reduce bleeding. However, these drugs will not get rid of your fibroid. Fibroids can re-grow after you stop taking these medications. There are also side effects associated with the drugs that you will want to discuss with your doctor.
Progestins
Progestins are female hormones. Excessive bleeding , known as menorrhagia (pronounced men-o-raj-ia) can be controlled with this class of medications. Medroxy-progesterone acetate and Megestrol are commonly prescribed Progestins.
GnRH Analogues
One of the newer and most promising group of drugs being used are synthetic hormones known as gonadotropin-releasing analogues (GnRH Analogues). Acting like hormones which occur naturally in our bodies, these "look-alikes" reduce blood flow to the uterus and in turn to individual tumors. The end result is a decrease in the overall size of both the uterus and the tumor. Lupron Depo is a commonly prescribed drug.
Some physicians are prescribing GnRH agonists prior to surgery to shrink large fibroids, making it easier to remove them. In some cases, where a small fibroid is thought to be interfering with fertility, physicians will suggest a course of GnRH to shrink the fibroid in order to increase the chances of conception.
There is a down side to GnRH agonists: the results achieved with GnRH agonists are temporary. Current studies show that within four to six months following the drug therapy, tumors will regrow to their original size. Also, because the GnRH agonist is suppressing estrogen, women will experience side effects similar to those associated with menopause, such as mild hot flashes, vaginal dryness, mood swings and increased risk for osteoporosis (weakening of the bone). GnRH agonists are generally used for 6 months are less to minimize the risk of osteoporosis.
During this procedure your doctor will remove your fibroid(s), leaving the uterus intact. This approach preserves the possibility of continued childbearing and is typically easier to recover from than a traditional hysterectomy.
There are several ways that a fibroid can be removed during a myomectomy. Depending on the location and size of your fibroid, you doctor will recommend either an abdominal (traditional) myomectomy, hysteroscopic myomectomy or laparoscopic myomectomy.
Abdominal or Traditional Myomectomy
During an abdominal myomectomy, your doctor removes only the fibroid(s), leaving the uterus intact. An incision is made through the abdominal wall that is similar to one made with a hysterectomy.
In the past, myomectomy was considered to be a more difficult procedure than a hysterectomy. It took longer and there was a greater risk of blood loss associated with the procedure. A growing number of researchers today believe that it is for this reason that so many unnecessary hysterectomies are still being performed; doctors who have not trained to perform myomectomies simply find it easier to do a hysterectomy. However, myomectomies are now considered just as safe, or safer than a hysterectomy in the hands of an experienced surgeon.
Before committing to any surgery, ask your doctor about his/her training and the number and type of procedures they do each month.
Will my fibroids return after a myomectomy?
Having a myomectomy does not guarantee that your fibroid problems are over for good. Fibroids reappear in about 30% of women. There’s also a small chance that the procedure will cause internal scarring that can interfere with your ability to become pregnant, but this is generally not the case.
Ask your doctor how you should expect to feel after the procedure. Keep in mind that an abdominal myomectomy is still major surgery and it will take some time to recover.
Hysteroscopic Myomectomy
If your fibroid(s) protrudes into the cavity of the uterus, this variation of a traditional myomectomy may be a good option for you. In this outpatient procedure, an abdominal incision is avoided making the recovery easier. The surgeon inserts a hysteroscope - a thin telescope-like instrument that can be fitted with special surgical tools - through the vagina and into the uterine cavity to remove the fibroid.
Laparoscopic Myomectomy
If your fibroid is located on the outside of the uterus, your surgeon may also be able to get to the fibroid without making a large incision in the abdomen. During this outpatient, or overnight stay procedure, the surgeon will insert a thin tube through a small incision just below or through the navel. The laparoscope - a thin-telescope like instrument - is place through this tube to look at the contents of the abdomen and pelvis, in this case specifically looking for the fibroid(s). While the surgeon views the inside of the abdomen, he/she guides other tubes into the sides of the lower abdomen. The lower abdominal tubes are fitted with long and thin specialized surgical instruments that are used to remove the fibroid(s).
Adjuncts to Myomectomy
Myomectomy via the hysteroscope (through the vagina) or the laparoscope (through the navel) are associated with a faster recovery than with a traditional myomectomy that involves an abdominal incision. There are also several techniques that have been developed to make it easier to perform the less invasive hysteroscopic and laparoscopic myomectomies.
Gonadotropin Releasing Hormone Analogues (GnRH Analogues) are synthetic hormones that can be taken prior to surgery to reduce the size of the fibroids and make them easier to remove.
A small amount of a substance known as Vasopressin (an agent that constricts vessels) can be injected into the uterus during surgery, shrinking the blood vessels and thereby reducing the amount of bleeding.
Devices such as electrosurgical instruments (tools that can cut and coagulate with the aid of electricity), lasers, and others can be used as cutting tools instead of a scalpel or scissors. They decrease the amount of bleeding while cutting into the uterus or around the fibroids.
The Dreaded Hysterectomy (It’s Not Your Destiny)
Ten years ago, chances are your doctor would recommend treating your symptomatic fibroids with major surgery - the dreaded hysterectomy - to remove the entire uterus. It was almost like a right of passage into the Golden Years. This is no longer the case. Don’t let anyone tell you that you have no choice but to face a hysterectomy as part of being a woman or a woman with fibroids (you’d be surprised how many women are made to feel foolish for trying to avoid a hysterectomy even today).
As the number of safer, less invasive treatments continues to grow, hysterectomy should be at the bottom of your list. Unfortunately, because there have been so many advances in a short period of time, not every doctor is knowledgeable about or qualified to perform these newer techniques. You really have to do your homework and learn what your options are. Then, find a doctor who feels comfortable with and does a lot of the newer techniques.
How do I know if I really need a hysterectomy?
If you are considering a hysterectomy to treat fibroids, you probably don't need to have a hysterectomy at all. Talk to your doctor about trying drug therapy or other less invasive surgical procedures first. Get a second and even a third opinion. You need to be convinced that a hysterectomy is absolutely the best solution for you.
Supracervical Hysterectomy Through the Laparoscope
You may be surprised to learn that not every hysterectomy requires an abdominal incision. In some cases, it is possible for your doctor to do what is known as a supracervical hysterectomy through the laparoscope (a thin telescope-like instrument inserted through a small cut just below or through the navel). In this procedure, the surgeon removes only the top part of the uterus, leaving the cervix intact. The recovery is shorter than one with an abdominal incision and there is less risk of complications. This type of hysterectomy is extremely popular in Europe and will probably become more popular in the United States as well. A recent study in Scandinavia compared women who had supracervical hysterectomies with those who had a total (the cervix is removed) hysterectomies in terms of sexual dysfunction after the procedure. They found that there were less complaints when the cervix was not disturbed.
A Mini-History of Hysterectomies
The original hysterectomy involved an abdominal incision (there were no laparoscopes at the time) but it was a supracervical hysterectomy - doctors only removed the top of the uterus and left the fallopian tubes, ovaries and the cervix intact. Then, in the 1930s, doctors became concerned when they noticed there were large numbers of women, some who had hysterectomies, who were dying of cervical cancer. The response: surgeons started doing what is known as a total hysterectomy to remove the cervix as well. This is a longer operation, associated with more blood loss and more complications to the urinary tract and the intestines. Today, we understand that every woman, whether she has had a hysterectomy or not, has a very low risk of developing invasive cancer of the cervix as long as she has a routine pap smear. With the advent of the pap smear and the laparoscope, supracervical hysterectomies may have a resurgence.
In the simplest terms, fibroids grow old and then they die (as the estrogen in a woman’s body decreases with age). This latest treatment option just speeds up the process of degeneration. (To find an Interventional Radiologist near you, or more about UAE visit http://www.SCVIR.org/) Doctors cut off blood flow to the fibroids using angiography -- a low-risk radiologic procedure which does not require major surgery or anesthesia. To date, this procedure is only recommended for women with heavy bleeding due to fibroids and the results are overwhelmingly successful.
Your gynecologist is not trained to do this procedure. You will be referred to a specially trained radiologist known as an interventional radiologist. During the procedure, the doctor inserts a catheter through a small incision in the groin, into the femoral artery (major artery supplying blood to the leg) and up to the uterine artery (artery supplying the major blood supply to the uterus). Plastic sand-sized particles are injected into the catheter. These fine particles lodge in tiny blood vessels, cutting off blood flow to the fibroids.
Actually, this new technique is just a new twist on a proven procedure for treating life threatening pelvic hemorrhage related to childbirth or pelvic cancer. Historically, surgeons would block the blood flow into the uterus, but they had to make a major abdominal incision first. In many cases, this is no longer necessary. With the advances in angiography (visualizing vessels with the aid of x-ray, after the injection of a special dye), doctors can thread a thin catheter through a blood vessel to the precise site of bleeding. By injecting sand-sized plastic particles into the vessel, the bleeding can be controlled.
Can I get pregnant after undergoing uterine artery embolization?
Yes. There is no indication at the present time that a uterine artery embolization will prevent women from becoming pregnant. It is not clear, however, whether or not this procedure can actually improve a woman’s chances of fertility if she has fibroids and has been having difficulty getting pregnant.
Who should have this procedure?
This procedure is for the woman who is having problems with excessive bleeding due to fibroids. It avoids major surgery, and leaves open the option for pregnancy at a later time.
This article courtesy of EmpowerMed, an Internet-based service that empowers individuals and their families to become more active participants in the decisions that affect their health and well-being. This free service will be available in April, 1998 at www.empowermed.com. Copyright 1998 EmpowerMed, all rights reserved.