Fibroids are one of the leading indications for hysterectomy in the US.
There are other alternatives, however.
* If there are no symptoms, do nothing. There can be cancerous fibroids, but they are uncommon. There is no reliable way to differentiate cancerous fibroids from benign ones, though they are more common in women 40 to 60 years old and in African American women. Cancerous fibroids are usually single and tend to be larger. The only way to diagnose them is by removing them for pathologic evaluation. If the clinician has any doubt, the fibroid should be removed.
* For women who want to get pregnant and for whom the fibroid(s) are causing symptoms, it is possible to shrink them with medications called GnRh agonists. See here:
Can Fibroids Be Treated With Medication? .The fibroids can then be removed surgically (myomectomy). The route of removal depends on the size and location of the fibroid. Some can be removed from inside the uterus with the hysteroscope, a telescope inserted through the cervix; others may require placing a telescope into the abdomen (laparoscope). The problem with medication alone is that there are significant side effects which limit the duration of use, it is not usually possible to get pregnant while using the medication, and the fibroids tend to regrow after the medication is stopped. For women nearing menopause, the medication may be used to bridge the time interval until periods stop, but fibroids may increase in size if postmenopausal estrogen is used. Periods generally stop during GnRH agonist use.
* Fibroids can be treated with two methods that destroy the fibroid without removing it.
One method, uterine artery embolization, involves inserting a catheter into the vessels to the fibroid and blocking it with microscopic plastic spheres. This cuts off blood flow to the fibroid and causes it to shrink. See the details here:
http://www.fibroidworld.com/UAE.htm . This procedure requires only a local anesthetic, but there is sometimes significant pain afterwards and some patients grow new fibroids in the future. A newer method uses an electric current to destroy the fibroid. See here:
Laparoscopic Radiofrequency Ablation Treats Uterine Fibroids | February 2009 | Primary Care Connections | UCSF Medical Center .This procedure is done with a telescope inside the abdomen and does require an anesthetic.
* For women with multiple or large fibroids who have significant pain, bleeding, or pressure symptoms, who do not desire further pregnancies, and who are remote from menopause, hysterectomy may offer the best chance of long term success. Many times it can be done laparosopically or vaginally, with day surgery or an overnight stay. The vaginal approach is frequently used if there are anatomic problems with the vagina related to childbirth which need a little plastic surgery to repair. Vaginal hysterectomy can be performed with an epidural anesthetic, similar to what is used for Cesarean section. I have known many women who have had hysterectomies, and many have commented that they wish they had done it sooner. Few have had regrets, and at least one of them had it done before she had exhausted all her infertility treatment options.
* For small fibroids, it may be possible to treat abnormal bleeding by destroying the uterine lining, a process called endometrial ablation. This is done by inserting the hysteroscope, and several systems can be used. Some use heated water, others use electrically generated heat, and some mechanically remove the tissue. The method used is generally based on the surgeon's experience and preference. Ablation can be combined with removal of fibroids.
Progesterone is used to treat bleeding disorders related to problems with not ovulating. It may be helpful if there is an ovulation issue separate from the presence of the fibroids, but it will not treat fibroids themselves. Many insurance companies will require a trial on hormone medication before paying for surgery if the primary symptom is abnormal bleeding. Fibroids located right under the uterine lining can cause bleeding unresponsive to hormones.
Many women find their quality of life greatly improved with hysterectomy. No bleeding, no pain, improved sex life, less anemia. For those of you with concerns about anesthesia, some of the other methods might have appeal.
On a final note. The terms "total" and "partial" hysterectomy should be discarded. They are imprecise and misleading. To the gynecologist, a "total hysterectomy" means the entire uterus, including the cervix, is removed. "Oophorectomy" is used to refer to removal of the ovaries, and may be left, right, or bilateral. There is no"partial hysterectomy." If the upper body of the uterus is removed and the cervix left in place, the term is "subtotal hysterectomy."
Current evidence is that premenopausal women with healthy ovaries should consider keeping the ovaries if they have a hysterectomy to prevent some of the health conditions associated with a premature surgical menopause. Women with a significant risk of developing ovarian or breast cancer may want to discuss removal of the ovaries and hormone replacement therapy.
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