Alternatives to Hysterectomy : Fibroids, Treatment Options, Myomectomy

by Food and Drug Administration (FDA)

(Page 3 of 4)

Fibroids

Uterine fibroids may be a cause of abnormal uterine bleeding. About 30 percent of women between 25 to 45 are diagnosed with fibroids, according to the federal Agency for Healthcare Research and Quality.

For unknown reasons, fibroids are diagnosed in black women two to three times more frequently than in white women, and fibroids account for about twice the number of hysterectomies among black women than among white women, according to the CDC. About 200,000 hysterectomies each year are performed in the United States to treat fibroids.

Also called myomata or leiomyomata, fibroids can vary from microscopic size to the size of a melon, and no one knows what causes them.

Most fibroids do not cause symptoms and require no treatment other than regular monitoring by a physician. But some fibroids can cause heavy bleeding, debilitating pain, or both. If fibroids press on the bladder or bowel, they can cause frequent urination, constipation, painful bowel movements, and hemorrhoids.

Large fibroids may cause an enlarged uterus, resulting in a protruding abdomen. "When the uterus reaches the size of a melon, a doctor would most likely recommend a hysterectomy," says Dena Hixon, M.D., a gynecologist in the FDA's Center for Drug Evaluation and Research. No treatment other than hysterectomy can guarantee that uterine bleeding or fibroids won't recur.

Treatment Options

There are medications that will temporarily shrink fibroids. If heavy bleeding accompanies the fibroids and causes anemia, a doctor may prescribe an injection that temporarily stops estrogen production for up to three months before surgery. Most fibroids are stimulated to grow by estrogen, and without it, fibroids usually shrink. These injections, called gonadotropin-releasing hormone (GnRH) agonists, act by causing a sort of medical menopause, says Hixon. "These are drugs with significant risks and side effects that are most appropriately used when other common alternatives are inadequate or not appropriate for the individual." Because of their significant side effects, including loss of bone density, hot flashes, and mood swings, the FDA has approved GnRH agonists for use only for three months. Without surgery, the fibroids are likely to regrow after the drug is stopped.

Women with fibroids that cause pain, discomfort or bleeding have surgical options to hysterectomy. These include surgically removing only the fibroids (myomectomy), cutting off the blood supply to the fibroids (embolization), and shrinking the fibroids using electric current (myolysis). Myolysis is not currently widely used, and no long-term studies on safety and effectiveness have been done on this procedure. The most appropriate treatment for each woman will depend on the size and location of the fibroids, the severity of symptoms, and future childbearing plans.

Before treating fibroids, a gynecologist should perform a pelvic exam and sonogram, says Thomas Lyons, M.D., a gynecologist at the Center for Women's Care and Reproductive Surgery in Atlanta. If abnormal bleeding occurs a physician should also take a sample of the uterine lining to check for cancerous cells or other problems that may warrant a different treatment.

Sampling can be done by dilation and curettage (D&C) or by endometrial biopsy. D&C is a procedure that involves dilating the cervix and scraping the uterine lining. In an endometrial biopsy, a thin hollow tube is inserted through the cervix and into the uterus. Cells in the uterine lining are pulled through the tube by suction and later tested in a lab.

Uterine sarcoma, a rare cancer, cannot be diagnosed by testing samples of endometrial cells. Nevertheless, sampling is recommended to check for other cancers or disease before treating fibroids or abnormal uterine bleeding.

Myomectomy

A myomectomy is a surgery to cut away the fibroids without removing the uterus, so that a woman can maintain her ability to bear children. "It's major surgery and has the same disadvantages as hysterectomy as far as pain, disability, and scarring are concerned," says Scialli. "But if a woman wants to get pregnant, myomectomy is currently the method with the best track record." A myomectomy tends to weaken the uterine wall; children born after the procedure may need to be delivered by cesarean section.

In some cases, a myomectomy may be a more complicated procedure than a hysterectomy. "After you remove the fibroids, you have to reconstruct the uterus," says Lyons.

About the Author

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