DIAGNOSIS AND WATCHFUL WAITING
If your fibroids do not cause symptoms, there may be no need to treat them. Your doctor will likely want to watch them and monitor for any fibroid growth at each of your annual gynecological (OB-GYN) examinations. Some women may have fibroids but not experience symptoms that affect their daily life.
Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids but may shrink them. The side effects of using these medications are similar to the symptoms experienced as a result of hormonal changes during and after menopause. These include weight gain, hot flashes, vaginal dryness, mood swings, changes in metabolism, and infertility. In almost all cases, once hormone therapy has been stopped, fibroids tend to grow back, possibly reaching their original size again. This often occurs if the use of hormone therapy is not accompanied by another treatment.
MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND SURGERY (MRgFUS)
High-intensity focused ultrasound waves are used to heat an area of the fibroid, causing cell death. Pulses of ultrasound energy are repeatedly applied to treat the fibroid. During treatment, magnetic resonance images are used to enable the doctor to see the fibroid and surrounding organs in 3-D, pinpoint, guide, and continuously monitor the treatment in a non-invasive manner. The procedure can take 3-4 hours and requires you to lie on your stomach. Sedation and pain-relieving medication will be given to help you relax. You will most likely be conscious throughout the procedure and will probably feel some warm sensation over the abdomen during the treatment. Patients may experience some abdominal pain, cramping, or nausea. You may experience some cramps, shoulder or back pain that may last a few days after the procedure. Most women are able to return to work within 1-2 days.
Less Invasive Treatment Options
UTERINE FIBROID EMBOLIZATION (UFE)
The uterine fibroid embolization procedure begins with a tiny incision in the groin or wrist. This incision provides the interventional radiologist (IR) with access to the artery. Using specialized X-ray equipment, the IR passes a catheter (small tube) into this artery, to access the uterine artery, and guides it near the location of the fibroid tumor. When the IR has reached the location of the fibroids, embolic material is injected through the catheter and into the blood flow leading to the uterine fibroid tumors. The embolic material blocks the vessels around the fibroid, depriving it of oxygenated blood. The oxygen deprivation results in fibroids shrinking. The embolic material remains permanently in the blood vessels at the fibroid site. The catheter is then moved to the other side of the uterus, usually using the same incision. Once the IR has completed embolization of the uterine artery on both sides, the catheter is gently removed and the IR places finger pressure or vascular closure device over the small incision for a few minutes to stop bleeding at this location. The entire fibroid treatment typically lasts less than one hour and patients may go home the same day or stay overnight.
A procedure called endometrial ablation destroys the endometrium – the lining of your uterus – with the goal of reducing your menstrual flow. In some women, menstrual flow may stop completely. No incisions are needed for endometrial ablation. Your doctor inserts slender tools through your cervix — the passageway between your vagina and your uterus. The tools vary, depending on the method used to destroy the endometrium. Some types of endometrial ablation use extreme cold, whereas other methods depend on heated fluids, microwave energy, or high-energy radio frequencies. Endometrial ablation can only be used to treat submucosal fibroids that are less than one inch in diameter.
In this procedure a long, thin scope with a light is passed through the vagina and cervix into the uterus. No incision is needed. A camera also can be used with the scope. Submucosal or intracavitary fibroids are easily visualized and can be resected or removed using a wire loop or similar device. Patients usually are sent home after the procedure. The hospital stay can last from 30 minutes to 2 hours and recovery time is generally 1-2 days. Generally only fibroids that are small and accessible through the cavity can be treated this way.
The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Two or three small, half-inch incisions are made below the pubic hairline, and instruments are passed through these small incisions to perform the surgery. Next, a small scissors-like instrument is used to open the thin covering of the uterus. The fibroid is found underneath this covering, grasped, and freed from its attachments to the normal uterine muscle. After the fibroid is removed from the uterus, it must be brought out of the abdominal cavity. The fibroid is cut into small pieces with a special instrument called a morcellator, and the pieces are removed through one of the small incisions. Most women are able to leave the hospital the same day as surgery. For more extensive surgery, a 1-day stay may be required. Patients can usually walk on the day of surgery, drive in about a week and return to normal activity, work, and exercise within 2 weeks.
In this procedure, four standard, small incisions are made and ports are inserted for the robot’s camera and instrument arms. The surgeon first injects medication into the fibroids to decrease overall bleeding, and then makes an incision in the uterus. The surgeon then removes the fibroid(s) from the surrounding uterine tissue. Once the fibroid has been removed, the surgeon uses a special device called a morcellator to cut the fibroid into smaller pieces inside the patient’s abdomen. These pieces are then removed through one of the incision ports. Patients typically go home the same day of the procedure, and most patients are able to resume normal activities within 2 weeks.
In this operation, your surgeon enters the pelvic cavity through one or two incisions, depending on the size of the fibroid(s). A vertical incision is made from the middle of your abdomen and extends from just below your navel to just above your pubic bone. A vertical incision is usually recommended if your uterus has reached or exceeded the size comparable to if it were carrying a 16-week pregnancy. This incision might also be used if a fibroid is in a ligament between your uterus and pelvic wall. In other cases, a horizontal bikini-line incision is made that runs about an inch (about 2.5 centimeters) above your pubic bone. This incision follows your natural skin lines, so it usually results in a thinner scar and causes less pain than a vertical incision. Because it limits the surgeon’s access to your pelvic cavity, a bikini-line incision may not be appropriate if you have a large fibroid. Abdominal myomectomy usually requires a hospital stay of 2-3 days. Recovery takes 4-6 weeks.
The uterus is removed through the vaginal opening. This procedure is most often used in cases of uterine prolapse or when vaginal repairs are necessary for related conditions. During a vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes, and upper vagina as well as from the blood vessels and connective tissue that support it. The uterus is then removed through the vagina. However, if your uterus is enlarged, vaginal hysterectomy may not be possible.
LAPAROSCOPE-ASSISTED VAGINAL HYSTERECTOMY (LAVH)
Laparoscopically assisted vaginal hysterectomy (LAVH) is a surgical procedure using a laparoscope (a thin, flexible tube containing a video camera) to guide the removal of the uterus and/or fallopian tubes and ovaries through the vagina (birth canal). During LAVH, several small incisions are made in the abdominal wall through which slender metal tubes known as “trocars” are inserted to provide passage for a laparoscope and other microsurgical tools. Next, the uterus is detached from the ligaments that attach it to other structures in the pelvis using the laparoscopic tools. The fallopian tubes and ovaries are also detached from their ligaments and blood supply. The organs and tissue are then removed through an incision made in the vagina. LAVH typically requires a 1-3 day hospital stay. Complete recovery time is usually 4 weeks.
ROBOTIC-ASSISTED LAPAROSCOPIC HYSTERECTOMY
A robotic-assisted laparoscopic hysterectomy uses a computer to control the surgical instruments during the surgery. The surgeon controls the movements of the computer from a computer station in the operating room. At this point, three or four small incisions will be made near your belly button. Gas may be pumped into your belly to distend it to give your surgeon a better view and more room to work. The laparoscope is inserted into your abdomen, whereas other surgical instruments will be inserted through the other incisions. The surgeon will attach the laparoscope and the instruments to the robotic arms of the computer and then move to the control area to remotely control the surgery. Your uterus will be cut into small pieces that can be removed through the small incisions. Depending on the reasons for your hysterectomy, the whole uterus may be removed or just the part above the cervix. The fallopian tubes and ovaries attached to the uterus may also be removed. Most people stay in the hospital for a few days. Complete recovery may take anywhere from a few weeks to a few months.
The uterus is removed through the abdomen via a surgical incision about six to eight inches long. The main surgical incision can be made either vertically, from the navel down to the pubic bone, or horizontally, along the top of the pubic hairline. After the incision has been made through the layers of skin, muscle, and other tissue, the physician will inspect the organs and other structures in the abdomen and pelvis. The tissues connecting the uterus to blood vessels and other structures in the pelvis will be carefully cut away. The uterus will be removed, along with any other structures, such as the ovaries, fallopian tubes, and cervix, as required by your situation. Abdominal hysterectomy usually requires a hospital stay of 1-2 days, but it could be longer. The recovery period is usually 6-8 weeks.