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Myomectomy can be performed in several different ways, depending on the size and location of the fibroids. In a laparotomy, a surgeon can go into the uterus through an incision in the abdomen. In another approach, a laparoscopy, the surgeon inserts a telescope-like instrument (laparoscope) through the navel and inserts other instruments through very small incisions in the abdomen. Scialli does not generally recommend a laparoscopic myomectomy for women having a subsequent pregnancy because it may weaken the uterine wall more than a myomectomy done through a larger abdominal incision.

Another method of myomectomy involves using a hysteroscope and small surgical instruments inserted into the uterus through the cervix to cut out the fibroids. Sometimes, the surgeon uses a special type of hysteroscope called a resectoscope. This instrument has a built-in wire loop and uses electrical current to cut out the fibroid. Even after a myomectomy, fibroids can still be a problem, says Scialli. "I've seen patients who never have fibroids return and patients whose fibroids recur every bit as badly within a year."

Uterine Fibroid Embolization

Uterine fibroid embolization (UFE) — also called uterine artery embolization (UAE) — is a minimally invasive procedure that blocks the arteries carrying blood to the fibroids. Because the procedure is performed by a specially trained physician called an interventional radiologist, a woman should first be examined by a gynecologist, says Lyons. The gynecologist will take the patient's medical history and perform tests to rule out any problems that may be causing the bleeding and that would require a different treatment.

In the procedure, which is done under local anesthesia, the radiologist threads a small tube (catheter) from the groin into the uterine artery. The radiologist then injects a dye into the artery and views moving X-ray images on a monitor to see the flow of blood to the fibroids. Very small particles, called embolic agents, are slowly injected through the catheter to the uterine artery in order to block the blood supply to the fibroids. (See "Uterine Fibroid Embolization.") A clot forms around the particles, which are about the size of grains of sand and are usually made from plastic (polyvinyl alcohol) or gelatin sponge.

"Uterine artery embolization is a procedure that doctors have been doing as long as 20 years, but not specifically for uterine fibroids," says the FDA's Pollard. "The procedure has been used for postpartum hemorrhaging and to stop bleeding when treating some kinds of cancer."

Since the mid-1990s, the use of uterine artery embolization to treat fibroids has grown. According to the Society of Cardiovascular and Interventional Radiology, more than 10,000 procedures have been done worldwide, of which about 8,600 were performed in the United States. Three deaths have been reported.

Although the FDA has not cleared the UFE procedure for general use, it is being studied in FDA-approved clinical trials. "It is not a trivial procedure and is not without risks," says Pollard. "And we're not sure how those risks weigh up against drug therapy, myomectomy, and hysterectomy." Potential risks include infection, ovarian failure leading to early menopause, and expulsion of the fibroid from the uterus at a later date, requiring another procedure. Additional risks include leakage of the embolic particles out of the blood vessels, complications from radiation exposure, blood clotting in the veins of the inner thigh or leg (deep vein thrombosis), blockage of an artery in the lungs (pulmonary embolus), and death.

Unlike a hysterectomy, UFE leaves the uterus intact, with the potential for childbearing. However, current research is lacking on the ability to become pregnant and carry a baby to full-term, says Pollard.

More Data Needed

Compared to hysterectomy, minimally invasive surgeries to treat uterine problems are relatively unknown territory. "While these are promising technologies, we don't have data on their long-term safety, effectiveness, and fertility," says Amy Allina, program director of the National Women's Health Network, a nonprofit women's health advocacy organization in Washington, D.C. "It's a matter of choice. I don't consider any of these options perfect for everybody."

Nevertheless, women today do have a multitude of good options to choose from to maintain their health, says Lyons. "Information about these options is out there but individuals must access this knowledge in order to take advantage of these choices. Be proactive and know all you can know to best serve yourself and your families."

Tags: Women's Health

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