Articles
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From the 35th Annual
Meeting - Las Vegas, Nevada- November 2006
Minimally Invasive and Non-invasive Treatment for Fibroids
Paul Indman, MD, OBGYN.net Editorial Advisor
Tom Lyons, MD, EndometriosisZone.org Editorial Advisor
watch the video interview in Windows Media
Dr. Indman: Hello, I am Dr. Paul Indman, at the Global Congress of Minimally Invasive Gynecology and we are extremely fortunate to have with us today Dr. Tom Lyons of Atlanta, Georgia. Now Tom, you are known nationally, internationally, for hysteroscopic supracervical hysterectomies, but also you do myomectomies, you take out fibroids and what I would like to talk about today is how do we counsel women who are trying to decide between a hysterectomy and myomectomy? Certainly, if someone wants children, that is fine, but let’s say you have a 42-year-old woman with fibroids and she says, doctor, what should I do, be thinking about?
Dr. Lyons: That is an excellent question and I see patients very frequently who come in and they usually fall into one of several categories. The first category of woman I see is the patient who comes in who perhaps has fibroids, has been told by her physician, say they are a younger woman, let’s just say under 40, and has been told by her physician that she needs to have her fibroids removed before she has her babies. That is an easy one because, in general, if that patient is not bleeding abnormally and does not have other severe symptoms, I tell them you do not need surgery at all, go have your babies, you will do fine, it will be okay. The other group which, in my case, I find the more interesting group, this is the patients who come in pretty much at any age who have symptomatic fibroids, certainly patients who have completed their families and patients who have not completed their childbearing, and those patients, again, if someone wants to have more babies and they are having abnormal bleeding, they are symptomatic fibroids, then that patient probably is best served with a myomectomy procedure; removal of those fibroids.
There are other alternatives, including uterine artery embolization, MRI-guided ultrasound, ablation of fibroids, things of this nature. We discuss all of those things. In my opinion, most of those patients are better off with a myomectomy if they desire future childbearing. We talk about the risks, etc. with myomectomy and childbearing, etc. I tell those people flat out that I am not going to make them more fertile by taking out their fibroids and I am not going to increase their chances of having term pregnancies by taking out their fibroids; in fact, I am going to do the opposite. But it may the only thing or the right thing to do in some of those patients. Now, then you get this group of patients who are potentially older, maybe over, we will just say over 40. I am not going to say people over 40 are older.
Dr. Indman: Thank you.
Dr. Lyons: Not even over 50, is my guess. But who have completed their family but have symptomatic fibroids. In that situation where there is either abnormal bleeding or whatever else, once again, we have discussed the alternatives of the uterine artery embolization, we discuss the MRI-guided ultrasound and those types of things but, in reality, probably that patient is better off with some sort of surgical procedure to either remove their fibroids or to remove the uterus which is the source of the fibroids. What we try to do is offer that patient choices and I think that is what we are all about. What we want to do is offer them minimally invasive choices. I will do a laparoscopic procedure with myomectomy or supracervical hysterectomy or whatever the patient wants to do. Again, it depends on what that patient wants and what their desires are and how they feel about it, but I think the key is I can take away these big laparotomy incisions or whatever else for the patient and allow them to make a decision based on what they want in their future instead of how badly the surgery is going to affect them over the next several weeks.
Dr. Indman: Well, let’s say we have a 45-year-old woman. Her uterus is about up to her belly button. She has been walking around. She has a few big fibroids, maybe the size of a grapefruit and an orange and a dozen or two little ones the size of walnuts and she has been bleeding and she finally got her blood count up and she is looking for advice. What do you really think is the best operation for her?
Dr. Lyons: In my opinion, in that particular case, that operation is supracervical hysterectomy, a laparoscopic supracervical hysterectomy, mainly because I want to take away the recurrence risk of her fibroids, which is a 10% per year recurrence risk no matter what her age is in essence, I am going to take away the bleeding as an issue, I can leave her ovaries in place so hormonally she will remain intact, and the only thing she is going to lose is the fundus of the top of the uterus and with that, she is not going to have potential for myomal recurrence or fibroid recurrence, she is not going to have recurrent bleeding, she is not going to have any of those things, she will maintain her hormonal environment. There are some people for whom that is not sufficient and they want to hang on to that uterus. In that situation, if that patient wants it, desires it and understands the ups and downs of a myomectomy, a laparoscopic myomectomy in that case, I will do it. At the same time, any time I discuss myomectomy with any patient, I also discuss hysterectomy because it is not a common occurrence, by any means, but there is always a risk of the need to do a hysterectomy in a myomectomy procedure if bleeding were to be severe, etc., something of that nature.
Dr. Indman: How often, what percentage of the cases have you had to do a hysterectomy because of bleeding during a planned myomectomy?
Dr. Lyons:: Less than 1%.
Dr. Indman: Yes, I have never had to do that. We hear that a lot. That is just to scare women.
Dr. Lyons: I am sure there is a patient I may have done at some point in years past, but I still feel obligated to tell them about it.
Dr. Indman: Definitely. Well, I think you gave us a lot of very good points. Dr. Lyons from Atlanta, Georgia, thank you.
Dr. Lyons: Thanks, Paul.
