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Fibroids

Uterine fibroids. The vast majority of hysterectomies are performed due to the presence of uterine fibroids.

Possibly as many as 80% of all women have uterine fibroids. While the majority usually have no symptoms, 1 in 4 end up with symptoms severe enough to require treatment.

The more you know about uterine fibroids and your reproductive system, the better equipped you are to understand your treatment options and how to maintain and/or achieve a higher Quality of Life, regardless of the presence of this disease. Hysterectomy is certainly a treatment option. It isn't, necessarily, your only option.

What are Fibroids?

Uterine leiomyomas, commonly known as fibroids, are well-circumscribed, non-cancerous tumors arising from the myometrium (smooth muscle layer) of the uterus. In addition to smooth muscle, leiomyomas are also composed of extracellular matrix (i.e., collagen, proteoglycan, fibronectin). Other names for these tumors include fibromyomas, fibromas, myofibromas, and myomas.

Leiomyomas are the most common solid pelvic tumor in women, causing symptoms in approximately 25% of reproductive age women. However, with careful pathologic inspection of the uterus, the overall prevalence of leiomyomas increases to over 70%, because leiomyomas can be present but not symptomatic in many women. The average affected uterus has six to seven fibroids.

Leiomyomas are usually detected in women in their 30's and 40's and will shrink after menopause in the absence of post-menopausal oestrogen replacement therapy. They are two to five times more prevalent in black women than white women. Risk for developing leiomyomas is also higher in women who are heavy for their height and is lower in women who are smokers and in women who have given birth. Although the high oestrogen levels in oral contraceptive pills has led some clinicians to advise women with leiomyomas to avoid using them, there is good epidemiologic evidence to suggest that oral contraceptive use decreases the risk of leiomyomas.

Treatments

If treating the symptoms of uterine fibroids is ineffective in bringing about relief and your Quality of Life is dwindling away, it may be time to move on to more aggressive methods of dealing with your uterine fibroids. It may be time to switch from Treating the Symptoms to Treating the Fibroids.

Additionally, you may want to learn more about your surgical risks and review a list of questions you can discuss with your physician that will help you learn more about your treatment options.

Treating the Fibroids

The more you know about uterine fibroids and your reproductive system, the better equipped you are to understand your treatment options and how to maintain and/or achieve a higher Quality of Life, regardless of the presence of this disease. Hysterectomy is certainly a treatment option. It isn't, necessarily, your only option.

There are a variety of treatment options for benign uterine fibroids which allow you to retain your uterus. These include:

  • Watch & Wait
  • Myomectomy
  • Uterine Fibroid Embolization (UFE)
  • Myolysis

Many women choose to do nothing and simply treat the symptoms since fibroids often shrink in size and become asymptomatic as a woman goes through menopause. The average age of menopause is 51. Can you watch & wait?

Myomectomy

Myomectomy is a type of surgery that removes the fibroid without removing the uterus. For women over the age of 35, this procedure may provide adequate relief until the age of menopause when fibroids shrink naturally due to a decline in hormones.

There are numerous ways that doctors perform a myomectomy. The type, size and location of your fibroids determine which of the following myomectomies might be recommended:

  • Laparoscopic Myomectomy
  • Hysteroscopic Myomectomy
  • Laparotomy (Abdominal Myomectomy)
  • Laparoscopic Myomectomy with Mini-Laparotomy
  • Laparoscopic Assisted Vaginal Myomectomy (LAVM)
  • Laparoscopic Myomectomy involves removing pedunculated subserosal fibroids through the navel and abdomen with the use of a laparoscope -- a thin tube-like instrument with a light.
  • Hysteroscopic Myomectomy involves the vaginal removal of submucosal fibroids through the use of a hysteroscope -- a thin telescope-like instrument that is inserted through the cervix and into the uterus.
  • Laparotomy (Abdominal Myomectomy) involves an abdominal incision that allows for the removal of all fibroids no matter their location, size, or number.
  • Laparoscopic Myomectomy with Mini-Laparotomy allows for the removal of slightly larger subserosal fibroids than what the laparoscope alone can handle and generally includes a relatively small incision of 3 inches or less in the abdomen.
  • Laparoscopic Assisted Vaginal Myomectomy (LAVM) allows for the laparoscopic removal of subserosal fibroids from the uterus with the total removal of fibroid material through a vaginal incision.

Uterine Fibroid Embolization (UFE)

Uterine fibroid embolization (UFE, also known as uterine artery embolization UAE) is a minimally-invasive, non-surgical procedure performed by an interventional radiologist (IR). This procedure involves placing a catheter into the artery and guiding it to the uterus. Small particles are then injected into the artery. The particles block the blood supply feeding the fibroids. The whole procedure only takes about an hour.

Within minutes after the procedure the fibroids begin dying. Generally, but not always, there is an overnight stay in the hospital because many women feel intense abdominal cramping and pain. Pain from this procedure is usually controlled through the use of narcotics.

Because this is a non-surgical procedure, recovery is extremely fast and most women return to work within one week.

UFE works to stop the blood flow to all types of fibroids in the uterus. However, it is generally recommended that pedunculated submucosal fibroids and pedunculated subserosal fibroids be removed through hysteroscopy or laparoscopy first. Pedunculated submucosal fibroids that die and detach from the uterus as a result of UFE may be expelled from your body vaginally. If, however, you have detached submucosal fibroid material that is too large for your body to expel, it is extremely important that it be removed as quickly as possible through hysteroscopic resection to avoid serious infection potentially requiring hysterectomy.

Myolysis

Myolysis involves surgical instruments that are inserted through a laparoscopic incision in the abdomen (usually your navel) and a high frequency electrical current that is sent to the fibroid. The electrical current causes the blood vessels to vaso-constrict (become very small or close down) and this basically cuts off the blood flow to the fibroids. The fibroids remain in place and are not surgically removed. Without a blood supply, the fibroids eventually die and shrink.
Myolysis is only performed on subserosal fibroids that fit a certain size range.

Hysterectomy

There are three primary forms of hysterectomy.

  • Subtotal Hysterectomy
  • Total Hysterectomy 
  • Radical Hysterectomy

Subtotal Hysterectomy involves only the removal of the uterus. The pelvic structural ligaments are not cut and the cervix is left in place. Fallopian tubes and ovaries may or may not be removed. This procedure is always done through the abdomen.

Total Hysterectomy involves removing both the body of the uterus and the cervix, which is the lower part of the uterus. It can sometimes be done through the vagina (vaginal hysterectomy); at other times, a surgical incision in the abdomen is preferable. For example, if you have large fibroid tumors, it is difficult to safely remove the uterus through the vagina. Vaginal hysterectomy, when it can be safely performed, generally involves fewer complications, a shorter recovery period and no visible scar.

In a total hysterectomy and bilateral (both sides) salpingo-oophorectomy, the ovaries and fallopian tubes are removed, along with the uterus and cervix.
Radical Hysterectomy is reserved for serious disease such as cancer. The entire uterus and usually both tubes and ovaries as well as the pelvic lymph nodes are removed through the abdomen.

There are a variety of surgical methods which a physician may use in performing a hysterectomy. It is extremely important to talk with your doctor about the kind of surgical method recommended for you.

In addition to the direct surgical risks, there may be longer-term physical and psychological effects, potentially including depression and loss of sexual pleasure. If the ovaries are removed along with the uterus prior to menopause, there is an increased risk of osteoporosis and heart disease as well.

In making a decision, you should consider that a hysterectomy is not reversible. After a hysterectomy, you will no longer be able to bear children and you will no longer menstruate.

A hysterectomy may be life-saving in the case of cancer. It can also relieve the symptoms of bleeding, discomfort, or uterine prolapse related to fibroids. However, you may find other treatment choices allowing you to retain your uterus more reasonable for the treatment of your benign uterine fibroids.

Surgical Risks

The surgical risks of hysterectomy and myomectomy include the risks of any major operation. You may have a fever during recovery. You may have a bladder infection or wound infection. A blood transfusion before surgery may be necessary because of anemia or during surgery for blood loss. Complications related to anesthesia may occur.

As with any major abdominal or pelvic operation, serious complications such as blood clots, severe infection, adhesions, postoperative (after surgery) hemorrhage, bowel obstruction or injury to the urinary tract can happen. Rarely, even death can occur. (Eleven women die for every 10,000 hysterectomies performed.)

Questions to Ask

The following questions may help you to begin a discussion with your physician about recommended treatment options for your uterine fibroids.

  • Have all of the necessary diagnostic tests been performed? trans-vaginal ultrasound or MRI? endometrial biopsy? blood tests? Why or why not?
  • Why do I need to have a hysterectomy? Will my ovaries be removed? If so, why? Will my cervix be removed? If so, why? What are the actual statistical risks (from the National Cancer Institute) that cancer may occur? 
  • Are there alternatives for me besides a hysterectomy? 
  • What are the advantages, risks, benefits of each treatment option? 
  • How will my sex life be affected? 
  • Will I experience menopause (change of life)? Can the symptoms of menopause be treated? What are the risks and benefits of treatment(s) for the symptoms of menopause? 
  • What can I expect in the hospital? pre-operative procedures? length of stay? anesthesia? infection? transfusion? urinary catheter? 
  • What kind of care will I need after treatment? How should I prepare for coming home from the hospital? 
  • How soon can I resume normal activities and return to work? 
  • When can I resume sexual activity?

We can can offer you more information and support if you need it, please contact us at the Brunswick offices for more help.