Myomectomy is the surgical removal of uterine fibroids without hysterectomy. The following questions and answers discuss the issues involved in this type of alternative to hysterectomy
Uterine Fibroids
What Are Uterine Fibroids?
Fibroids are common benign tumors that arise from the muscle tissue of the uterus; they may be single or multiple. About 25% of all women over the age of 35 have fibroids; among African-American women, fibroids are even more common. These tumors may grow into the uterine cavity (submucous fibroids); they may be located in the uterine wall (mural) or protrude outside of the uterine wall (subserous).
What Symptoms Do Fibroids Cause?
Submucous fibroids are the type that most commonly causes significant problems; even small tumors located in or bulging into the uterine cavity may cause heavy bleeding, anemia, pain, infertility, or miscarriage. Mural fibroids (located in the uterine wall) and subserous fibroids (protruding outside the uterine wall) may reach a large size before causing symptoms. These symptoms may include pressure on the bladder with difficulty voiding or urinary frequency and urgency, pressure on the rectum with constipation, lower back and abdominal pain, as well as heavy bleeding. A large fibroid uterus may also compress the ureter as it enters the pelvis and lead to hydronephrosis (swelling of kidneys due to accumulation of urine because of obstruction of ureters) because of obstructed urine flow from that kidney.
What is the Conventional Treatment for Fibroids?
Every year over 550,000 American women undergo hysterectomy, the majority for benign non-life threatening conditions. In 33% of all hysterectomies, the reason for surgery is problems related to fibroid tumors.
When fibroids are small and cause no symptoms, no treatment is required. In the presence of symptomatic or large fibroids, a woman who wishes to preserve her fertility may be offered a myomectomy, an operation that removes the fibroids while sparing the uterus. However, the conventional treatment for women 40 years of age and older is hysterectomy and bilateral oophorectomy (removal of both ovaries). Even women younger than 40 who have completed childbearing are usually offered hysterectomy. The rationale for this approach is as follows: hysterectomy and oophorectomy are viewed as definitive solutions for the presenting medical problem (i.e., bleeding, anemia, pain, etc.) and as preventive measures against the risk of malignancy in the pelvic organs. The prevailing attitude is that a woman who does not desire more children no longer “needs her uterus.” Another justification for the conventional approach of hysterectomy is the fact that, depending on the number, location, and size of fibroids, a successful myomectomy requires more expertise and surgical skill than a hysterectomy. When performed by a surgeon without extensive experience, myomectomy is more likely to result in prolonged surgery, significant blood loss requiring blood transfusion, and other postoperative complications. Therefore, it is not surprising that the average gynecologist tends to offer hysterectomy as a treatment for fibroids, rather than a myomectomy. Despite these views, we firmly advocate myomectomy with the preservation of the uterus and ovaries. The rationale for these will follow.
What are a Woman’s Options if She Wishes to Preserve Her Uterus? (Are there safe and effective alternatives to hysterectomy?)
Changing Attitudes Among Women
In recent years, as more women have become better informed on health issues, they have sought treatments that preserve the pelvic organs, especially in the presence of a benign disease. In addition, research has demonstrated that, while hysterectomy solves some problems, it may also lead to other problems. For example, following hysterectomy, there is an increased prevalence of problems related to sagging pelvic organs such as “dropped bladder” (in medical terms these are known as genital prolapse, such as vaginal vault prolapse, enterocele, cystocele, and rectocele). These conditions may cause symptoms, such as urination and defecation disorders, and may require surgical repair. Several studies suggest that even without sagging of the vaginal walls, about 30% of women develop urinary leakage, urinary frequency, or slow transit constipation after hysterectomy.
It has been shown that after hysterectomy, even without removal of the ovaries (oophorectomy), women tend to enter menopause earlier, by as much as four years according to one study. Estrogen produced by the ovaries may reduce the risk of coronary artery (heart) disease and helps prevent osteoporosis (thinning and weakening of the bones). Studies indicate that hysterectomy before natural menopause, even without oophorectomy, increases the risk of heart disease (by up to 300%, according to one study) during the remaining premenopausal years. Hysterectomy with prophylactic (preventive) oophorectomy eliminates the risk of death from uterine or ovarian cancer (lifelong probability of death 1.3%), but increases the risk of death from heart disease (lifelong probability of death 33%) and osteoporosis. Estrogen replacement therapy may prevent the negative consequences of surgically induced menopause. However, a large proportion of women discontinue hormonal replacement therapy after a few months and therefore lose this protective effect. Also, there is concern that hormone replacement therapy (containing both estrogen and progesterone) may increase the risk of heart disease and breast cancer, and this concern leads many women to avoid taking hormone replacement. In fact, recently medical authorities recommended restriction of hormone replacement therapy only to be used for relief of hot flashes and/or dryness in the vagina and discontinuation of the treatment as soon as possible. Given the new reality, it is more important than ever before to preserve ovarian function for as long as possible. Hysterectomy, with or without oophorectomy, shortens the functional life span of the ovaries significantly. Preservation of ovarian function requires preservation of the uterus.
The uterus has great psychological significance for many women. Although many women have no emotional difficulties after surgery, post-hysterectomy problems such as depression, anxiety, and sexual dysfunction have been described. Some women complain of decreased quality of sexual response after hysterectomy, specifically, a change in the quality of orgasm. This change may be the result of the absence of rhythmic uterine contractions during orgasm. Finally, many women are strongly opposed, in principle, to the removal of any organs, genital or otherwise, unless absolutely necessary.
A Physician’s Response
My conviction as a physician is to respect the personal aspirations and viewpoints of every patient. If an informed patient wishes to preserve her uterus in the presence of a benign condition and if her medical problem can be safely resolved without a hysterectomy, the physician should comply with the patient’s desire, even if this involves referring her to another specialist.
Effective Treatment for Uterine Fibroids
Myomectomy, when performed by an expert, is a safe and effective alternative to hysterectomy. This operation can usually be accomplished with minimal blood loss. When the operation is performed with the optimal technique by a highly experienced surgeon the need for blood transfusions is limited to very few cases. Likewise, in an expert’s hands, it is rare that a myomectomy is converted during surgery to an unplanned hysterectomy because of uncontrollable bleeding. The gynecological surgeon who has extensive experience with myomectomy is able to remove all fibroids regardless of their location. A successful myomectomy should result in the resolution of all symptoms related to fibroids.
Myomectomy
The Operation
Depending upon the location of the fibroid(s), myomectomy can be accomplished by either an abdominal or vaginal approach. When the fibroid causing symptoms is bulging into the uterine cavity (submucous), it is usually possible to remove it by using hysteroscopic technique. This technique involves using an operating “telescope” which is inserted into the uterus through the vagina. Hysteroscopic myomectomy is performed on an out-patient basis; the short recovery period at home is 2-3 days before the resumption of full activity. However, there are limitations with hysteroscopic myomectomy. If the submucous fibroid is located mostly within the uterine wall, hysteroscopic resection is not possible. If, in addition to the submucous fibroid(s), there are other clinically significant fibroids within the uterine wall, then abdominal myomectomy is necessary. In the presence of large fibroids in the uterine wall (mural) or bulging out of the uterus (subserosal), abdominal myomectomy through an abdominal incision is usually required. In most cases this can be accomplished through a low horizontal incision along the bikini line, resulting in a minimally visible scar. Following an uncomplicated abdominal myomectomy, discharge from the hospital is usually possible within two days. There is a variable recovery period at home of two to six weeks depending upon individual factors and lifestyle.
A critical part of a successful myomectomy is an optimal reconstruction of the uterus after the fibroids have been removed. The irregular defects created in the uterine wall by the removal of the fibroids must be meticulously repaired so that potential sites of bleeding and/or infection are eliminated. A poorly reconstructed uterus may rupture during a subsequent pregnancy or delivery. In this regard, removing large fibroids through the laparoscope (telescope inserted through the navel) is not advisable in most cases because optimal reconstruction of the uterus is not accomplished in this manner. Suboptimal reconstruction may also lead to post-operative bleeding which may require an emergency hysterectomy and/or blood transfusions. In addition, internal bleeding (with or without infection) may cause pelvic adhesions, tubal occlusion and infertility, and/or chronic pelvic pain.
Laparoscopic Myomectomy
Laparoscopic myomectomy entails the removal of uterine fibroids using a laparoscopic technique instead of the traditional surgical approach through a sizable incision. A laparoscope is a telescope-like instrument, which is inserted into the abdominal cavity, usually through the navel. The surgeon uses the laparoscope to see inside the abdominal and pelvic cavity and perform surgical procedures without large incisions. Additional entry sites into the abdomen are created through tiny incisions in the lower abdomen. These additional tiny incisions allow for the introduction of surgical instruments and for the removal of the resected fibroids in small pieces.
A few successful pregnancies have been reported following laparoscopic myomectomy. However, there are also reports of uterine rupture during pregnancy following laparoscopic myomectomy. The rupture is caused by poor reconstruction of the uterine wall following the removal of the fibroids resulting in a weakened uterine wall. Adequate reconstruction of the uterus following myomectomy demands meticulous placement of multiple sutures, which is too time-consuming to be performed through the laparoscope. Consequently, too few such sutures are applied during laparoscopic repair, resulting in a weakened uterine wall. It is therefore advisable to avoid laparoscopic myomectomy when a future pregnancy is a consideration.
Another important aspect of uterine reconstruction after myomectomy is the need to eliminate the so-called “dead spaces” within the uterine wall created by the removal of fibroids. These “dead spaces” are potential sites for bleeding during and after the operation, which may lead to infection, pelvic adhesions, and early or late bowel obstruction. It is much more difficult to achieve optimal uterine reconstruction during laparoscopic surgery. The main advantage of laparoscopic myomectomy, the avoidance of a larger abdominal incision, has to be weighed against the disadvantages of a prolonged procedure time with more anesthesia, a much weaker uterus, and a higher potential for major complications.
Bleeding During Myomectomy
There are numerous surgical techniques for performing a myomectomy. However, the important goal common to all is minimizing blood loss and other complications. It is critical to prevent significant blood loss during and after surgery, as this may result in postoperative complications such as anemia, fever, infection, and the requirement for blood transfusion. Bleeding and/or infection may lead to pelvic adhesions which, in turn, may cause pain or bowel obstruction in the short or long term. The expert in myomectomy should be able to assure the patient prior to surgery that the intended myomectomy will not turn into an unplanned hysterectomy because of uncontrollable blood loss.
What if Cancer is Found?
About 1 in 200 women with fibroids is found at surgery to have a malignant tumor of the uterus (sarcoma). Therefore, the preoperative discussion between the woman and her surgeon should include consideration of this unlikely circumstance. The patient should be counseled regarding the importance of hysterectomy and the removal of both ovaries as a life-saving procedure when cancer is found during the operation. It is important, however, to understand that an “ugly necrotic” fibroid is not necessarily a sarcoma (tumor). Intraoperative evaluation of suspicious tumors by “frozen section” is required in order to ensure that hysterectomy is performed only for a malignant tumor. It is also important to understand that a frozen section will not detect all cases of sarcoma and that it is theoretically possible that a fibroid that was negative on frozen section is found later, upon further studies after surgery, to be malignant. In such a rare event the patient may have to return to the OR for hysterectomy.
What is the Role of Hormone Treatment?
Some physicians advocate hormone treatment with GnRH agonists, such as Lupron, in preparation for myomectomy. This treatment postpones the operation for 2-4 months. During this time the fibroids decrease in size and the bleeding is markedly reduced. Although some surgeons feel that this makes the operation easier and diminishes blood loss, many other experienced surgeons find this very expensive treatment unnecessary with a few exceptions. In fact, this treatment is often detrimental. Following GnRH treatment, the fibroids usually become temporarily smaller. However, as a result of the GnRH treatment, the fibroids also become much more difficult to separate from the surrounding uterine tissue. As a result, myomectomy is more difficult technically. Even so, it is generally agreed that if a woman is very anemic, hormone treatment along with iron supplements is indicated as it promotes recovery from the anemia prior to surgery. Concern has been raised that GnRH treatment may shrink small fibroids which could, therefore, be missed at surgery only to enlarge again and cause problems later. Recently, it was reported that the anti-progesterone agent RU486 (mifepristone) may shrink fibroids temporarily in preparation for a myomectomy. The clinical value of this agent is still under study.
What Kind of Imaging Tests May Be Helpful Prior to Surgery?
The role of imaging studies in women with fibroids is to: a) confirm the clinically suspected diagnosis of fibroids, b) exclude other causes of uterine enlargement or pelvic masses such as adenomyosis, uterine malignancy, and benign or malignant ovarian masses, c)identify normal ovaries in the presence of an enlarged uterus, d) examine the kidneys and urinary tract for obstruction due to the pelvic mass, and e) determine precisely the number, size, and location of the fibroids. The latter is particularly important for a successful myomectomy because it helps the surgeon determine ahead of time what kind of operation is required. The type of imaging test depends upon the individual findings in a given woman and the availability of certain equipment/techniques. The tests commonly used are pelvic ultrasound (both transabdominal and vaginal) and x-rays of the kidneys and urinary tract (IVP). Newer imaging modalities that may be used in selected cases include MRI and sonohysterography. MRI helps determine the size and location of fibroids in the giant uterus. It can also detect adenomyosis as an additional diagnosis or as the sole diagnosis instead of fibroids. However, MRI must follow strict conditions. This pelvic MRI is done with IV contrast medium gadolinium. There should be 4mm thick contiguous sections through the uterus. Sonohysterography is an ultrasound study performed after the introduction of saline into the uterine cavity. It helps define the location of the cavity and the presence of submucous or intracavitary fibroids. Both pelvic MRI and sonohysterography, in expert hands, will generally detect 92% or more cases of adenomyosis.
Other Alternative Treatment Modalities for Fibroids
Myolysis
Myolysis is the destruction of fibroids (necrosis) by different methods, including coagulation of the tumors with bipolar or unipolar electrodes or laser beams. Another technique for the destruction of fibroids utilizes a freezing probe (cryo-myolysis). The probe is inserted into fibroids through the laparoscope and the electrical, laser, or freezing apparatus is activated, resulting in necrosis of the affected portions inside the fibroid. This is repeated several times, at different locations inside the individual fibroid, until the extent of the necrosis inflicted in a certain fibroid is considered sufficient.
Such techniques, in different versions, have been used since the early nineties. They are time-consuming and are usually limited to the treatment of moderate-sized fibroids. Frequently, the patient is first treated with Lupron injections over several months prior to the procedure in order to reduce fibroid size and vascularity (blood supply to fibroids). The procedure is performed through a laparoscope so that no large abdominal incision is required.
Following the procedure, the holes created by the probe on the uterine surface tend to ooze serosanguinous (blood-stained) fluid. This may lead to infection and pelvic adhesions. The procedure may destroy large portions of the uterine muscle. Consequently, a pregnancy following myolysis is ill-advised. Failure of the myolysis procedure to solve abnormal bleeding, pain, or other clinical problems happens frequently and additional surgery may then be required, usually a hysterectomy.
Prevailing views today call for the abandonment of myolysis as a treatment for fibroids.
Endometrial Ablation
Endometrial ablation destroys the endometrial lining to varying extents (depending on technique and skill). There are numerous different techniques to achieve endometrial ablation that lead essentially to the same end result. These techniques include hot water balloon, cryoablation (freezing the endometrium), laser ablation, roller ball cautery, and electric loop resection of the endometrium. These techniques destroy the endometrial lining and may reduce bleeding, but only temporarily.
These procedures are quite effective for the treatment of true functional uterine bleeding (bleeding due to hormonal imbalance without the presence of any anatomical abnormality). However, in the presence of submucous fibroids, endometrial ablation usually fails (unless an effective myomectomy is also performed at the same time). Ablation also fails when the bleeding is caused by deep adenomyosis. Unfortunately, failure to recognize the presence of adenomyosis occurs frequently.
Questions to Ask Before Choosing a Surgeon to Perform Myomectomy
- How often do you perform myomectomy?
- How many years have you performed myomectomy and how many myomectomies have you performed?
- What was the outcome of these myomectomies: How often was the operation converted into hysterectomy?
- In what percentage of cases were blood transfusions required?
- How long do your patients stay in the hospital after surgery?
These questions are important because they help pinpoint the experience and “track record” of a doctor. An experienced, confident surgeon will not find these questions threatening and should be readily forthcoming with these facts and figures. On the other hand, if a physician’s surgical skill is limited primarily to hysterectomy, these questions will reveal inexperience or poor results with myomectomy. For further reassurance, consider speaking with other women who have undergone myomectomy by the surgeon under consideration.
Conclusions
As women become increasingly aware of the important issues related to fibroids and hysterectomy, there is growing interest in alternative treatments. Many of these issues are controversial among both professionals and laypersons. The ethical physician should inform the patient of the issues and options and, above all, respect her convictions and her right to make the ultimate decisions regarding her body. I hope that this presentation is helpful to the many women and their families who are facing this common problem.