Uterine Fibroids and Hysterectomy - Surgery

Surgery

If nonsurgical strategies do not relieve symptoms, surgery may be the best option for treatment. Surgery may be indicated depending on a number of factors:

Intractable Side Effects. Surgery may be warranted if fibroids are causing distressing and intractable symptoms that have not been relieved by nonsurgical or minimally invasive therapies. Assuming, however, that symptoms do not pose serious health or life-threatening conditions, a woman should make her own decision based on any factors she deems important (the desire for children, for example).

Ureteral Obstruction. Large fibroids sometimes press down on the ureters (the tubes going from each kidney to the bladder), thereby blocking urine from emptying into the bladder. Because ureteral obstructions can permanently damage kidneys, surgery may be indicated.

Inability to Evaluate Ovaries. The risk for missing a diagnosis of ovarian cancer is higher when fibroids are too large to permit evaluation of the ovaries by pelvic examination or ultrasound. Ovarian cancer is particularly deadly because it is so difficult to catch early enough for curative treatment. The risk for this cancer, however, is very low in women without a family history, especially before menopause. Women with a family history of ovarian cancer and large fibroids may need to consider surgery.

Enlarging Fibroids. Rapidly growing fibroids may signify cancer (leiomyosarcoma), which must be ruled out. In postmenopausal women, even slow growth raises suspicions for cancer. It should be noted, however, that many hysterectomies have been inappropriately performed because of large nonmalignant fibroids that were only suspected to be cancerous. Women should be sure that diagnostic procedures have been as thorough as possible if they want to avoid an unnecessary hysterectomy.

Severe Anemia from Heavy Bleeding. When iron supplementation, resection (surgical removal) of submucous fibroids by hysteroscopy, or GnRH agonist therapy fails to resolve anemia and bleeding, major surgery may be recommended (myomectomy or hysterectomy).

Basic Surgical Options

• Hysterectomy. Until recently, hysterectomy was the only surgical option for uterine fibroids. This procedure involves the surgical removal of the uterus and is often accompanied by oophorectomy (the removal of the ovaries). With this procedure, fertility is not preserved. Other options may be available for many women, even some with large fibroids. They should discuss all possibilities with their physician.
• Myomectomy. Myomectomy involves surgical removal only of one or more fibroids. It may be accomplished by performing a laparotomy (a procedure that uses a wide abdominal incision) or with less invasive surgical techniques such as laparoscopy and hysteroscopy. In such cases, unlike hysterectomy, fertility may be preserved.
• Other Procedures. Endometrial ablation (destruction of the lining of the uterus) may be useful in women with small fibroids and heavy bleeding. More investigative procedures include myolysis and uterine artery embolism, which apply unique techniques to shut off the blood supply to the fibroids.

Women should discuss each option with their physician. Deciding on the surgical procedure depends on the location, size, and number of fibroids and the experience of the physician. The risk for bleeding increases with the surgeon's inexperience, so patients are urged to investigate the surgeon's track record.