Non Hysterectomy Fibroid Treatments Including Embolization
Frederick R. Jelovsek MD
Questions About Fibroid Treatments
"I have heard that there is a new technique for removing uterine fibroids by injecting something into the blood. Can you tell me something about this? I'm not interested in a hysterectomy ". anonymous
There are several treatments for fibroids (myomas, leiomyomas) of the uterus that do not rely on hysterectomy. Some of these are fairly recent techniques and are not performed everywhere.
Hysterectomy is the most common treatment if a woman has completed childbearing because over a third of women have recurrences of fibroids whether they are removed by myomectomy, laparoscopic myomectomy or hysteroscopic resection of submucous or intramural fibroids. The high recurrence rate and the reason for removing the fibroids in the first place - bleeding, pain, pressure symptoms, or infertility - will play a role in selecting a non hysterectomy treatment. Most of the non hysterectomy techniques still involve being put to sleep under anesthesia or, in the case of embolization, conscious sedation. Thus fear of anesthesia is not necessarily the reason to seek out an alternative other than hysterectomy.
What are the non-hysterectomy options for fibroids?
- Myomectomy - Surgical removal of fibroids performed through a standard abdominal incision is called a myomectomy and is the oldest non hysterectomy treatment for fibroids. A standard (about 6 inches/15 cm) abdominal incision is made and recovery is about 6 weeks with a 2-3 day hospital stay. This surgery is appropriate for large fibroids causing pain or pressure symptoms, or for intramural myomas which may be affecting fertility or recurrent miscarriage. It is not used for bleeding problems due to fibroids.
- Laparoscopic myomectomy - Same as above only there are multiple, but very small incisions. Recovery is about 1-2 weeks. Large fibroids may not be able to be removed with this technique and deep intramural fibroids may be missed. This surgery is appropriate for fibroids causing pain or pelvic pressure, pedunculated fibroids presenting as unknown (but suspected) pelvic masses, or multiple myomas in a young woman who has several years to go before trying to conceive and the myomectomy is an effort to prevent destruction of the future ability to have children.
- Laparoscopic fibroid myolysis (coagulation) of fibroids - This is the same as laparoscopic removal of fibroids only an electrical current is used to coagulate the fibroids making them lose their blood supply and eventually dissolve and scar over.
- Hysteroscopic myoma removal - Using instruments through the vagina in the outpatient surgery setting, submucous fibroids and intramural fibroids impinging upon the uterine cavity are removed or shaved away using electrocautery or laser. Recovery is less than a week although sometimes a repeat procedure is needed if the fibroid is at all very large. It is used for bleeding problems due to fibroids.
- Uterine fibroid embolization - Under conscious sedation, catheters are placed in the femoral arteries (groin) and small alcohol containing microspheres are injected into the uterine vessels and they cut off the blood supply to the fibroids, causing them to die and then slowly scar over in time. This is mainly useful for fibroids causing pain and pressure. Submucous fibroids causing bleeding may take too long to slough off.
What is involved in the embolization technique for treating uterine fibroids?
Interventional radiologists have worked with injecting various substances into the uterine vessels in an attempt to cut off the blood supply to the fibroids. Since the vessels come in from all around the periphery of the myoma, cutting off the blood supply and causing the center of to myoma to necrose. It becomes gangrenous but not infected because there are no bacteria there.
The procedure takes about 1-1.5 hours and usually requires an overnight stay. Most patients experience moderate to severe pain afterwards for several hours. They may also have nausea, and possibly fever. The pain and nausea is controlled with intravenous medications, usually with a pump that allows self-administration of the medications. This is about the same degree of recovery as from an operative laparoscopy and almost as much as with a regular abdominal surgery. There may be severe cramping over several days and it may take 4 to 7 days for the pain to go away after the procedure. This is because the procedure basically induces degeneration of the fibroids, a condition that in itself, if it occurs naturally, causes about a week of severe pain.
Since the embolization technique is not yet widely used, we do not know the exact complication rate. Sepsis and death has been reported but there is no way of knowing if that is more or less than the rate of serious complications that would be expected with a major surgical procedure.
Is there a hormonal treatment that can treat fibroids?
Lupron® and other luteinizing hormone releasing factor medications are frequently used to decrease the size of the uterus and fibroids by about 50% over 3 months of use. If it is used longer than 6 months, most doctors feel that estrogens should be "added back" since a hypoestrogenic state is induced. Lupron® is quite expensive and does not seem suitable for long term suppression of fibroids. It is commonly used to reduce the size and decrease blood flow to the fibroids prior to surgery.
Both estrogen AND progestin/progesterone seem to increase the size of fibroids. There may be a future for anti-estrogen and anti-progesterone medications as treatment but these are still investigational.
If I choose one of the newer fibroid removal treatments such as embolization, what should I expect?
A woman needs to carefully examine her goals in having any treatment for fibroids whether it is hysterectomy or any of the non hysterectomy alternatives. For example, fear of anesthesia will play a role in all of the procedural myomectomies. Fear of complications from surgery will not disappear with the choice of an embolization procedure. If the ability to have children needs to be preserved, any of the non hysterectomy techniques should help with that. If bleeding is the main symptom, a hysteroscopic resection is the procedure to be most strongly considered.
The embolization procedure is not totally benign nor necessarily safer than one of the surgical treatments. It has a significant amount of pain associated with it but it does seem to be about 65-89% effective in reducing pain and some bleeding. If it is considered, it should be done at a center that has a moderate amount of experience in performing the procedure.
If symptoms are not too severe and a woman is close to menopause, Consideration of hormonal therapy with 6 months of Lupron® followed by raloxifene and even possibly some low dose estrogen add back might be discussed with your doctor. If bleeding is a symptom, be sure to have a hysteroscopy because the fibroids may not be the cause of the bleeding and removal of a polyp at D&C may totally resolve any bleeding problem.