( Alternative Treatment Options for Uterine  Fibroids)

 A 48 year old African-American schoolteacher and mother of three comes to see me for a consult. She tells me that her menstrual cycles have become heavier over the past two years, that her pants are feeling tighter and that intercourse has become more painful. She presents me with an ultrasound report which reveals that her uterine size is that of a large grapefruit.  When she saw her gynecologist last year, she was told that her uterus was the size of a lemon. 

What are my patient’s options? Does she wait until menopause and do nothing? Does she undergo a total abdominal hysterectomy? Or, does she have other options?

Gynecologists in the United States perform well over 600,000 hysterectomies each year. The number one indication for a hysterectomy is a symptomatic fibroid uterus with its associated pain and bleeding.  With the advent of laparoscopy or minimally invasive surgery in the late 1970’s and the rapid improvement of laparoscopic equipment and techniques over the years, a woman who has a symptomatic fibroid uterus or other dysfunctional uterine bleeding due to another benign condition knows as adenomyosis may be offered a laparoscopic supracervical hysterectomy or a laparoscopic assisted vaginal hysterectomy. Both of these procedures involve only three small incisions on the abdomen instead of the typical bikini cut that most women experience when they undergo a total abdominal hysterectomy. During a laparoscopic supracervical hysterectomy, the cervix is maintained, thereby preventing  pelvic prolapse in the future and maintaining the plexus of nerves on the cervix which are so important for sexual pleasure during intercourse. In a laparoscopic assisted vaginal hysterectomy, most of the surgery is performed through three small incisions; however, the surgeon then removes the uterus and cervix vaginally. Patients who undergo these laparoscopic procedures are usually discharged from the hospital the following day and can return to work in one to two weeks.

What if a woman cannot afford to take two to six weeks off from work or simply wishes to avoid the risks of major surgery?  Uterine artery embolization (UAE) is a viable option.   UAE involves the injection of the uterine arteries (which are the main blood supply to the uterus) with small inert particles by an interventional radiologist.  This procedure is typically performed in a hospital setting so that the patient can be admitted overnight for pain management. As for now, UAE is contraindicated in women who wish to maintain their fertility. Conversely, UAE should not be used as contraception as women have been known to become pregnant after the procedure with often devastating consequences to both mother and child.   By eliminating half of the blood supply to the uterus, UAE allows the size of the uterus and fibroids to shrink by up to 50% in the first year following the procedure.  This is associated with a significant reduction in bleeding and pain.  Approximately 15% of patients undergoing UAE will need a hysterectomy for persistent symptoms.

What if a woman’s fibroids are determined to be inside the endometrial cavity (uterine lining) and not in the walls of the uterus. This patient would do well with a hysteroscopic vaginal myomectomy. This procedure involves entering the uterine cavity with a hysteroscope, allowing the surgeon to see inside the uterus. The fibroid can then be excised from the endometrial cavity and removed vaginally. This simple outpatient procedure allows the patient to return to work the following day without any abdominal scars.

Lastly, a new  procedure known as magnetic resonance guided focused ultrasound (MRgFUS) was approved by the FDA in October, 2004 as the first non-invasive treatment for uterine fibroids. MRgFUS uses hightly focused ultrasound to locate the fibroid and then ablate it with pinpoint precision. The procedure lasts a few hours, can be performed in an outpatient setting, has minimal post-procedure pain, and allows the patient to return to normal activities almost immediately. Similar to the contraindications with uterine artery embolization, women who wish to become pregnant should not undergo this procedure.

MRgFUS is offered in seven different locations around the United States. It is a costly procedure which is presently not covered by major insurance companies. Prices for the procedure range from $10,000 to $20,000 per session.

Women with symptomatic fibroids have numerous options these days. No longer does a woman need to undergo major surgery with its associated costs, recovery and time away from work and family. Speak with your gynecologist about your options and determine which procedure is right for you.

Dr. Tara A. Solomon,  FACOG

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