Uterine Fibroids: Myomectomy vs. Hysterectomy
Myomectomy is the surgical removal of uterine fibroids without removing the uterus.
What are Uterine Fibroids?
Fibroids are common solid pelvic tumors.
They arise from the muscle tissue of the uterus; they may be single or multiple.
About 25% of all women over the age of 35 have fibroids; among African-American women fibroids are even more common.
What Symptoms Do Fibroids Cause?
Submucosal fibroids (grow into the uterine cavity) may cause heavy bleeding, anemia, pain, infertility, or miscarriage.
Mural fibroids (located in the uterine wall) and sub-serous fibroids (protrude outside the uterine wall) may reach a large size before causing symptoms.
These symptoms may include pressure on the bladder with difficulty voiding or urinary frequency and urgency, pressure on the rectum with constipation, lower back and abdominal pain, as well as heavy bleeding.
What is the Conventional Treatment for fibroids?
Hysterectomy remains the most common surgical treatment for fibroids because it is the only definitive treatment.
When fibroids are small and causing no symptoms, no treatment is required.
In the presence of symptomatic or large fibroids, a woman who wishes to preserve her fertility may be offered a myomectomy, an operation that removes the fibroids while sparing the uterus.
However, the conventional treatment for women 40 years of age and older is hysterectomy. Even women younger than 40 who have completed childbearing are usually offered hysterectomy.
A Physician’s Response:
My conviction as a physician is to respect the personal viewpoints of every patient.
If an informed patient wishes to preserve her uterus in the presence of a benign condition and if her medical problem can be safely resolved without hysterectomy, the physician should comply with the patient’s desire, even if this involves referring her to another specialist.
Effective Treatment for Uterine Fibroids:
Myomectomy, when performed by an expert, is a safe and effective alternative to hysterectomy.
The gynecologic surgeon who has extensive experience with myomectomy is able to remove fibroids.
The successful myomectomy should result in resolution of symptoms related to fibroids.
Myomectomy: The Operation
Depending upon the location of the fibroid(s), myomectomy can be accomplished by either an abdominal or vaginal approach.
When the fibroid causing symptoms is bulging into the uterine cavity (sub-mucous), it is usually possible to remove it by using a hysteroscopic technique.
This technique involves using an operating telescope which is inserted into the uterus through the vagina.
Hysteroscopic myomectomy is performed on an outpatient basis; the short recovery period at home is 2-3 days before the resumption of full activity.
In the presence of large fibroids in the uterine wall (mural) or bulging out of the uterus (sub-serosal), abdominal myomectomy through an abdominal incision is usually required.
In most cases, this can be accomplished through a low horizontal incision along the bikini line.
Following an uncomplicated abdominal myomectomy, discharge from the hospital is usually possible within 2-3 days. There is a variable recovery period at home of 2-6 weeks.
A critical part of a successful myomectomy is the optimal reconstruction of the uterus.
A reconstructed uterus may rupture during a subsequent pregnancy or delivery. In this regard, removing large fibroids through the laparoscope (telescope inserted through the navel) is not advisable in most cases because optimal reconstruction of the uterus is not accomplished in this manner.
What If Cancer is found?
About 1 in 200 women with fibroids is found at surgery to have a malignant tumor of the uterus (sarcoma).
Therefore, the preoperative discussion between the woman and her surgeon should include consideration of this unlikely circumstance.
The patient should be counseled regarding the importance of hysterectomy and removal of both ovaries as a life-saving procedure if cancer is found during the operation.
What is the Role of Hormone Treatment?
Some physicians advocate hormone treatment with GnRH agonists, such as Lupron, in preparation for myomectomy.
This treatment postpones the operation for 2-4 months. During this time the fibroids decrease in size and the bleeding is markedly reduced.
Although some surgeons feel that this makes the operation easier and diminishes blood loss, many other experienced surgeons find this very expensive treatment unnecessary with few exceptions.
However, it is generally agreed that if a woman is very anemic, hormone treatment along with iron supplements promotes recovery from the anemia prior to surgery.
Concern has been raised that GnRH treatment may shrink small fibroids, which could, therefore, be missed at surgery only to enlarge again and cause problems later.
As women become increasingly aware of the important issues related to fibroids and hysterectomy, there is growing interest in alternative treatments.
Many of these issues are controversial among both professionals and laypersons. The ethical physician should inform the patient of the issues and options and, above all, respect her convictions and her right to make the ultimate decisions regarding her body.
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