It is important to note that although many patients have fibroids, not many patients need treatment for them. Only when symptoms occur do patients require treatment. In some cases of larger fibroids that have no symptoms, all that is required is close follow up by pelvic exam and pelvic ultrasound. Medical and surgical therapy are used for treatment of fibroids. Uterine artery embolization, a procedure performed by radiologists, can be used for some patients.
What medical treatments are available for fibroids?
Medical treatment for fibroids is based on drugs that will decrease the production of estrogen by the ovaries, resulting in shrinking the fibroids. Fibroids require estrogen for growth. Lupron is a drug that is given as an intramuscular injection that will stop estrogen production by the ovaries through blocking the production of FSH (follicle stimulating hormone) by the pituitary gland. If no FSH is produced, the ovaries will not produce estrogen. Use of drugs like Lupron will cause menopause and its symptoms such as hot flashes, night sweats, mood changes, anxiety, and also temporary bone loss through lack of estrogen. The use of “add back” therapy with low dose estrogen will help prevent these symptoms and usually will not affect the result. These medications can only be used for a limited time period, usually not more than 6 months, and then need to be stopped.
Lupron will only cause a temporary decrease in the size of fibroids, and is not permanent therapy. In some patients, Lupron will not decrease the fibroids to any great extent. Most physicians will use Lupron to shrink the fibroids down to a point so that a less invasive surgery can be performed to remove the fibroids.
What is Uterine Artery Embolization (UAE)?
UAE is a procedure performed by radiologists that blocks the blood supply to the fibroids, resulting in degeneration and shrinking of the fibroids. The uterine arteries on both sides of the uterus are block with synthetic particles, and the results followed over several months. Some patients may not be good candidates for this procedure, include those with rapidly growing fibroids, massively enlarged fibroids, or for those who desire to become pregnant. Note that UAE recently has been found to prevent successful pregnancy in patients who have undergone the procedure by decreasing blood flow to the uterus. The benefits of the procedure include eliminating surgical or medical therapy and the complications of both. In most cases, the procedure is successful if performed properly. Drawbacks of the procedure include pain associated with degeneration of the fibroids, which can be severe. In addition, some patients will not have a dramatic decrease in the size of the fibroids or in their symptoms due to collateral blood flow to the uterus. All patients have multiple blood supplies to the uterus, not only from the uterine arteries, but also from the ovarian artery, vaginal and cervical branches. Those patients that develop a collateral blood supply from these arteries will have continued fibroid growth or will maintain fibroid size and symptoms.
Laparoscopic Retroperitoneal Hysterectomy versus Uterine Artery Embolization and Open Hysterectomy
| Laparoscopic Retroperitoneal Hysterectomy | Uterine Artery Embolization | Open Hysterectomy | |
|---|---|---|---|
| Discharge Home | 24 hours or less, 80% discharged home day of surgery | Overnight admisstion for all patients due to pain | 2 to 4 days |
| Recovery Time | 2 weeks or less | Days to weeks, depending on pain level | 6 to 8 weeks |
| Incision Size | 4 – ¼ inch or 3 – ¼ inch and 1 – 1 to 2 inch for very large fibroids | 2 – ¼ inch for catheter | 6 to 12 inches |
| Pain Tolerance | Excellent to good, first 1 to 2 days mild to moderate only. Morphine pump not needed – pain controlled with motrin and percocet only. | Can range from excellent to poor with long term pain due to necrosis (death) of fibroids. All patients admitted after procedure for pain control with morphine pump | Poor due to large incision |
| Regrowth of Fibroids | None | Recurrence rates of 20 – 40+%, depending on size of uterus and fibroids | None |
| Symptomatic Relief Long Term | Excellent – fibroids cannot recur – uterus is removed | Fibroids can regrow leading to recurrence of bleeding, pain, pressure | Excellent – fibroids cannot recur – uterus is removed |
| Fibroid Size | Unlimited | Limited – single fibroids greater than 7 cm, pedunculated fibroids (on stalks), submucosal fibroids (in cavity), or larger uteri with less effective results | Unlimited |
| Blood Control | Very Good to Excellent | Excellent | Good |
| Procedure Time | 30 minutes to 1.5 hours | 1 hour in radiology suite | 1 to 2 hours |
Surgical Therapy
Surgery for fibroids consists of either myomectomy or hysterectomy.
What is myomectomy?
Myomectomy refers to removing only the fibroids and leaving the uterus and ovaries intact. This procedure is indicated for those patients who wish to preserve fertility, or for those that simply want to preserve the uterus. Laparoscopic Assisted Abdominal Myomectomy (LAAM), developed by the Women’s Surgery Center, is the procedure of choice. LAAM can be used for fibroid removal for any size uterus. This procedure is minimally invasive, and is the best option for those patients who want to preserve the uterus so they may become pregnant. Abdominal myomectomy – a procedure requiring a large incision – has no advantages over LAAM. Abdominal myomectomy usually results in increased blood loss, pain, prolonged hospital stay, and long recovery of 6 to 8 weeks. Note that uterine artery embolization should not be used for treatment of fibroids if pregnancy is desired. Recent studies have indicated that embolization procedures can cause infertility due to decreased blood flow to the uterus, thereby affecting implantation of the embryo into the uterine lining. LAAM allows patients to be discharged home from the hospital the day after surgery, and uses very small incisions. The procedure is extremely safe, with minimal blood loss and fast recovery of less than 2 weeks. LAAM has almost eliminated the need to perform necessary hysterectomy at the time of myomectomy (due to excessive bleeding) when using techniques developed at the Women’s Surgery Center. It is important to understand that myomectomy is not indicated in all patients. Those patients who do not want to become pregnant and have a massively enlarged fibroid uterus should consider hysterectomy as the best option. Myomectomy will not prevent recurrence of fibroids, but will remove those fibroids present in the uterus at the time of surgery.
Comparison Chart of Myomectomy Treatment Options
| LAAM-BUAL | Laparoscopic Myomectomy | Open Myomectomy | |
|---|---|---|---|
| Discharge Home | 24 hours or less | 24 hours or less | 2 to 4 days |
| Recovery Time | 2 weeks or less | 2 weeks or less | 6 to 8 weeks |
| Incision Size | 3 - ¼ inch 1 – 1.5 to 2 inch | 3 – ¼ inch 1 - 1 inch | 1 – 6 to 8 inch |
| Pain Tolerance | Very Good | Excellent | Poor |
| Fibroid Size | Unlimited – fibroids of all size, all locations, all depths | Very limited – small to moderate only, external fibroids | Unlimited – all sizes, depths, locations |
| Blood Control | Excellent | Fair | Fair to Good |
| Muscle Closure | Excellent | Fair to Poor | Excellent |
| Procedure Time | 60 - 90 minutes | 1 to 3 hours or more | 2 hours of less |
What is hysterectomy?
Hysterectomy refers to removal of only the uterus, not the ovaries, for treatment. It is important to note that the uterus is a muscle, and does not make hormones such as estrogen. If the uterus is removed, patients will not go into menopause (change of life) as long as the ovaries are not removed at the same time. For more information on the role of the uterus, ovaries, and hormones, please refer to the Learning Center (Hysterectomy, Ovaries, and Hormones).
Hysterectomy is the only cure for fibroids. If the uterus is removed, the fibroids will not grow back or recur. At the Women’s Surgery Center, Laparoscopic Hysterectomy is the procedure of choice. Using advanced laparoscopic techniques, fibroids of any size up to approximately the size of a 40-week, or fully pregnant uterus can be removed laparoscopically. Four incisions are used, three at ¼ of an inch in size, and the fourth at ¾ of an inch. The blood supply of the fibroids is blocked during the procedure, and the fibroids broken up so that they can be fully removed without a large incision. Depending on the size of the Fibroids removed, patients leave the hospital the same day or the next day, and have a recovery time of 7 to 14 days with much less pain than traditional open surgical procedures requiring large incisions.
The Women's Surgery Center routinely treats patients for fibroids who have been told they are not candidates for laproscopic surgery for their fibroids. This is because most other surgeons do not use the advanced laparscopic techniques that we have been specially trained to use. These sophisticated techniques allow us to achieve far more challenging and complex surgeries laparoscopically than other physicians can. If you've been told you can't have laparoscopic surgery for your fibroids, we invite you to make an appointment for a second opinion with one of our physicians.
For more information about laparoscopic hysterectomy with the Women's Surgery Center, please see Treatment Options: Laparoscopic Procedures.
Have more questions about Fibroids?
Please refer to our Learning Center for more information.