Services

Fibroid Treatment Options

With more than 20 years of experience in minimally invasive surgery, Dr. Miller prides himself in providing fibroid treatment services to patients throughout Seattle. If you and your care provider determine that you have uterine fibroids, it is a good idea to have a discussion with an expert in regards to the implications, follow-up and the various treatment options for fibroids that may be available to you.  These may include watchful waiting, medication,  HIFU,  uterine fibroid embolization (UFE), or a minimally invasive surgical procedure.

NON-INVASIVE | LESS INVASIVE | SURGICAL

Non-Invasive Treatments

DIAGNOSIS AND WATCHFUL WAITING

If your fibroids do not cause symptoms, there maybe no need to treat them. Your doctor will want to watch them and monitor for any fibroid growth at each of your annual gynecological (OB-GYN) examinations. Some women may have fibroids, but not experience symptoms that affect their daily life but this doesn’t mean treatment is not in order.  As fibroids enlarge over time the treatment options become more complex and limited so it is important to have the opinion of an expert in regards to the need or timing of any potential procedure.

HORMONE TREATMENT

Medications for uterine fibroids (GNRH agonists) target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids, but may temporarily (during treatment) shrink them. The temporary side effects of using these medications are similar to the symptoms experienced as a result of hormonal changes during and after menopause. These may include some weight gain, hot flashes, vaginal dryness, mood swings, and changes in metabolism which resolve after the treatment course. In almost all cases, once hormone therapy has been stopped, fibroids grow back, usually reaching their original size again. This often occurs if the use of hormone therapy is not accompanied by another treatment.  Hormone treatment is a temporizing measure and is primarily used in preparation for surgery either to reduce the size of the fibroids to afford a minimally invasive approach or to bring up the patients blood volume prior to surgery.  If a patient is close to menopause the use of these agents can in some cases result in the avoidance of surgery altogether by bridging this gap.

MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND SURGERY (MRgFUS or HIFU)

High intensity focused ultrasound waves are used to heat an area of the fibroid, causing cell death. Pulses of ultrasound energy are repeatedly applied to treat the fibroid. During treatment, magnetic resonance images are used to enable the doctor to see the fibroid and surrounding organs in 3-D, pinpoint, guide, and continuously monitor the treatment in a non-invasive manner. The procedure can take 3-4 hours and requires you to lie on your stomach. Sedation and pain-relieving medication will be given to help you relax. You will be conscious throughout the procedure and will probably feel some warm sensation over the abdomen during the treatment. Patients may experience some abdominal pain, cramping or nausea.

This treatment option has limited success and is primarily useful if there is a single solitary fibroid that isn’t too large.  This treatment option is not available in the Pacific Northwest but referrals are available.  It is of utmost importance in consideration of this modality of treatment that it be pursued at an experienced and recognized center.

Less Invasive Treatment Options

UTERINE FIBROID EMBOLIZATION (UFE)

The uterine fibroid embolization procedure is performed by an Interventional Radiologist and not a Gynecologist.  It begins with a tiny incision in the groin area. This incision provides the Interventional Radiologist (IR) with access to the femoral artery in the upper thigh. Using specialized X-ray equipment, the IR passes a catheter (small tube) into the femoral artery, to the uterine artery, and guides it near the location of the fibroid tumor. When the IR has reached the location of the fibroids, embolic material (small spheres) are injected through the catheter and into the blood flow leading to the uterine fibroid tumors. The embolic material blocks the vessels around the fibroid, depriving it of oxygenated blood. The oxygen deprivation results in fibroids shrinking. The embolic material remains permanently in the blood vessels at the fibroid site. The catheter is then moved to the other side of the uterus, usually using the same incision in the thigh. Once the IR has completed embolization of the uterine artery on both sides, the catheter is gently removed and the IR places finger pressure over the small incision in your thigh. After holding the puncture site for a few minutes to help stop any bleeding, the IR may close the incision using a vascular closure device. The entire fibroid treatment typically lasts less than one hour, and is performed as an outpatient therapy. Patients usually stay anywhere from four to 23 hours after the procedure is complete.

Embolization can be a good treatment option for fibroids in many cases but this course of treatment is a complex decision that depends on many factors.  Embolization should be pursued in partnership with a gynecologist and only after consultation with a gynecologist who has extensive experience in the management and treatment of fibroids.  This treatment option is limited to those NOT pursuing future fertility.  Patients have gotten pregnant and had babies after embolization BUT it is not recommended in this patient population due to potential complications!   Interventional Radiologists have no training in obstetrics or gynecology. 

ENDOMETRIAL ABLATION

A procedure called endometrial ablation destroys the endometrium – the lining of your uterus – with the goal of reducing your menstrual flow. In some women, menstrual flow may stop completely. No incisions are needed for endometrial ablation. Your doctor inserts slender tools through your cervix — the passageway between your vagina and your uterus. The tools vary, depending on the method used to destroy the endometrium. Some types of endometrial ablation use extreme cold, while other methods depend on heated fluids, microwave energy or high-energy radio frequencies.

Endometrial ablation is not typically used to treat the fibroids themselves BUT can decrease or potentially eliminate the bleeding that is a result of fibroid change.  In the vast majority of cases the fibroids will continue to grow after an ablation procedure is performed.  

Surgical Treatments

HYSTEROSCOPIC MYOMECTOMY

In this procedure a long, thin scope with a light is passed through the vagina and cervix into the uterus. No incision is needed. A video camera camera is typically used with the scope. Submucosal or intracavitary fibroids are easily visualized and can be resected or removed using a wire loop or similar device. Patients usually are sent home after the procedure.The hospital stay can last from 30 minutes to 2 hours and recovery time is generally 1-2 days. Generally only fibroids that have a significant portion in the uterine cavity and are small (less than 4 cm) can be accessed and treated this way.  It can be very successful in these cases!

LAPAROSCOPIC MYOMECTOMY

The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Three small, 5 mm incisions are made below the belly button and instruments are passed through these small incisions to perform the surgery. Typically 4 total small incisions are needed.  Next, a small scissors-like instrument is used to open the thin covering of the uterus. The fibroid is found underneath this covering, grasped, and freed from its attachments to the normal uterine muscle. The defect in the uterus is then sewn closed.  After the fibroid is removed from the uterus, it must be brought out of abdominal cavity. The fibroid is cut into small pieces and the pieces are removed through one of the small incisions. This reduction in size of the fibroid for removal can be accomplished by hand or with a morcellator and is performed within specialized containment systems in order to avoid tissue spread.  (There is an FDA advisory with regards to the use of a morcellator in these cases BUT it can still be a good choice depending on the age of the patient and their desire for future child bearing.)  Most women are able to leave the hospital the same day as surgery. For more extensive surgery, a one-day stay may be required. Patients can usually walk on the day of surgery, drive in about a week and return to normal activity, work, and exercise within two weeks.

Experience is important in fibroid surgery as the most critical part of the case is sewing closed the defect where the fibroid was.  If the defect is not closed properly this will leave a very weak area in the uterine muscle and increase the risk of uterine rupture in future pregnancies. It takes years of experience and training to master laparoscopic sewing adequately.  

ROBOTIC-ASSISTED MYOMECTOMY

In this procedure, four standard, quarter-inch incisions are made and ports are inserted for the robot’s camera and instrument arms. The robot platform is attached to the camera and instruments and the surgeon then sits at an immersive 3-D computer console beside the patient and controls the instruments and camera performing the surgery.  The technical approach to the procedure within the patient are no different from conventional laparoscopic surgery.  The fibroid is removed, the defect is sewn closed and the fibroid is removed from the patient.  The advantages to the surgeon are comfort, better visualization and ease of sewing closed the defect in the uterus where the fibroid was.  The recovery is the same as with conventional laparoscopy.

Experience is important in fibroid surgery as the most critical part of the case is sewing closed the defect where the fibroid was.  If the defect is not closed properly this will leave a very weak area in the uterine muscle and increase the risk of uterine rupture in future pregnancies. It takes years of experience and training to master laparoscopic sewing adequately. 

ABDOMINAL MYOMECTOMY

In this operation, a surgeon enters the pelvic cavity through one or two incisions, depending on the size of the fibroid(s). A vertical incision is made from the middle of the abdomen, extends from just below the navel to just above the pubic bone. A vertical incision might be recommended if the uterus has reached or exceeded the size of a grapefruit. This incision might also be considered if a fibroid is in a ligament between the uterus and pelvic wall. In other cases, a CSX type of incision may be considered. This incision follows your natural skin lines, so it usually results in a thinner scar and causes less pain than a vertical incision. Because it limits the surgeon’s access to your pelvic cavity, a bikini-line incision may not be appropriate if you have a large fibroid. Abdominal myomectomy usually requires a hospital stay of two to three days. Recovery takes four to six weeks.

No one wants this type of surgery!  Large abdominal incisions are associated with a prolonged recovery, increased blood loss and infections.  This type of surgery can be avoided in many if not most cases.  Most of the choices surrounding surgical options have to do with the experience of the gynecologist making the recommendations.  Make sure you get a second opinion if this is what is being offered or suggested.

VAGINAL HYSTERECTOMY

The uterus is removed through the vaginal opening. This procedure is most often used in cases of uterine prolapse, or when vaginal repairs are necessary for related conditions. During a vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes and upper vagina, as well as from the blood vessels and connective tissue that support it. The uterus is then removed through the vagina. However, if your uterus is enlarged or you haven’t had any children, vaginal hysterectomy may not be possible.

LAPAROSCOPIC SUPRACERVCIAL or TOTAL HYSTERECTOMY (LSH or TLH)

Both of these types of hysterectomies are performed completely through very small incisions. These are surgical procedures using a laparoscope (a thin, flexible tube containing a video camera) to guide the removal of the uterus, possibly the cervix and/or fallopian tubes and in some cases the ovaries.  Typically 4 small 5 mm incisions are made below the level of the navel to place instruments – the scope for visualization is placed at the navel and the instrument “ports/trocars” (thin tubes) below.  The procedure is performed through these small incisions and the specimen is either removed through the vagina (TLH) or in the case of an LSH placed in a containment system, reduced in size and removed through the navel.  The quick recovery from these procedures is typically on the order of 2 weeks and usually requires less than a 24 hour stay in the hospital. 

LSH leaves the cervix in place due to concerns about sexual functioning, recovery and pelvic support although some of these advantages are difficult to substantiate in the medical literature.  An LSH requires the specimen to be morcellated either with a powered device or by hand.  There is an FDA advisory in regards to power morcellation but it is still a reasonable option depending on the patients age.

TLH removes the cervix with the uterus.  The advantage here is that the entire specimen can be removed through the vagina.  At 2 weeks the recovery is similar to an LSH but intercourse cannot be reinitiated funtil 8 weeks after surgery.

ROBOTIC-ASSISTED LAPAROSCOPIC HYSTERECTOMY

The standard robotic-assisted laparoscopic hysterectomy uses a computer to control the surgical instruments during the surgery. The surgeon controls the movements of the instruments from a computer station in the operating room beside the patient.  At this point, three or four 8 mm incisions will be made within and below the belly button. Gas is placed into your belly to distend it to give your surgeon a better view and more room to work. The laparoscope is inserted into the abdomen; while other surgical instruments will be inserted through the other incisions. The surgeon will attach the laparoscope and the instruments to the robotic arms and then move to the computer console beside the OR table to perform the surgery. Depending on the type of hysterectomy (LSH vs TLH) as discussed in the previous heading the quick recovery period is on the order of 2 weeks, specimen removal can vary and these are considered outpatient procedures.

There is no patient advantage with regards to recovery between a conventional laparoscopic vs a robotic procedure.  The primary advantage of the robotic procedure is the superior comfort and visualization of and by your surgeon as well as ease the of tissue dissection and specimen manipulation.  

The single site application of the robot allows a single incision hidden in the navel to be used to perform the entire procedure.  The cosmetic result is superior and recovery similar to the standard robotic procedure.  This approach to the procedure can be used for less complex cases.  

ABDOMINAL HYSTERECTOMY

In this operation, a surgeon enters the pelvic cavity through one of two large incisions, depending on the size of the uterus. A vertical incision is made from the middle of the abdomen, extends from just below the navel to just above the pubic bone. A vertical incision might be recommended if the uterus has reached or exceeded the level of the navel. This incision might also be considered if there is a fibroid is in a ligament between the uterus and pelvic wall. In other cases, a CSX type of incision may be considered. This incision follows your natural skin lines, so it usually results in a thinner scar and causes less pain than a vertical incision. Because it limits the surgeon’s access to your pelvic cavity, a bikini-line incision may not be considered appropriate if you have a very large uterus. Abdominal hysterectomy usually requires a hospital stay of two to three days. Recovery takes four to six weeks.

No one wants this type of surgery!  Large abdominal incisions are associated with a prolonged recovery, increased blood loss and infections.  This type of surgery can be avoided in many but not all cases.  Most of the choices surrounding surgical options have to do with the experience of the gynecologist making the recommendations.  Make sure you get a second opinion if this is what is being offered or suggested.