Uterine Fibroids
Fibroids are a benign tumors of the uterus, also referred to as a leiomyoma. They are a very common finding on pelvic examination and pelvic ultrasound. The symptoms of a fibroid uterus include pain, abnormal bleeding, and feeling bloated.
Uterine fibroids can be identified with a pelvic ultrasound by a very characteristic round appearance. The definitive diagnosis of a fibroid is only made by its surgical removal and examination with a microscope. Because the only definitive diagnosis of a fibroid uterus is surgical, fibroids which are not managed surgically should be followed by ultrasounds at regular intervals to document stability in size and exclude any rapid growth. Ultrasound allows the measurement of any present fibroids and a notation of their location. Fibroids can develop on the top of the uterus (subserosal fibroids), or within the wall of the uterus (intramural fibroids), or within the uterine cavity (submucosal fibroids). Fibroids may vary widely in size ranging from the size of a ea to the size of a large melon. As fibroids change the shape of the uterus and especially the shape of the uterine cavity, heavier and prolonged bleeding may become a significant problem.
Treatment for uterine fibroids largely depends on their initial size. Very large fibroids usually respond best to surgical treatment. Most fibroids, however, are small to medium size ranging from the size of a pea or marble to the size of an orange. Treatment of fibroids is only necessary when these fibroids are causing symptoms such as irregular bleeding or pain, and the first attempt at treatment should be medical.
Medical therapies center around hormonal manipulation, and in the United States that translates into a trial of birth control pills. Another medical therapy for fibroids is an injection called Lupron which induces a temporary menopause and leads to a decrease in the size of fibroids. The decrease in uterine size with Lupron is also temporary. When pain is the primary symptom of uterine fibroids, pain medication like Motrin can be used to control symptoms.
Surgical therapy for fibroids is used when medical therapy has failed to provide sufficient relief, when fibroid location is not likely to be responsive to medical therapy, and when fibroids are very large. Treatments which lead to uterine preservation and the preservation of fertility include abdominal myomectomy, the removal of fibroids within the uterus. This can be performed via a laparoscope or in though a larger abdominal incision. This mode of myomectomy is directed at intramural fibroids and serosal fibroids. Hysteroscopic myomectomy is another treatment with preserves the uterus and fertility and is associated with a easy a quick recovery. Hysteroscopic myomectomy removes submucosal fibroids which affect the uterine cavity by placing a camera into the uterus through the cervix. The camera contains instruments which then remove fibroids. This procedure does not involve any skin incisions.
Treatment for fibroids which do not preserve fertility include uterine artery embilization. This is an interventional radiology procedure which does not involve the removal of the uterus, but leads to a decrease in blood flow to the uterus aimed at shrinking the fibroids by decreasing their nutrition.
Hysterectomy is the definitive treatment for uterine fibroids and it does not preserve fertility. Hysterectomy can be performed by removing the uterus through the abdomen laparoscopically or through an abominal incision. In either of these methods the lower portion of the uterus, the cervix, can preserved – this is a supracervical hysterectomy. There is some suspicion that preserving the cervix improves pelvic support and may contribute to future sexual satisfaction. Preserving the cervix is a surgery with fewer risks involved than with a total abdominal hysterectomy. Hysterectomy can also be accomplished by removing the cervix through the vagina. The vaginal hysterectomy involves no abdominal incisions, is a very safe procedure, and is associated with a short recovery period. Laparsocopy can be used to assist with vaginal hysterectomy in some occasions.
Hysterectomy is the most invasive treatment of uterine fibroids and is the treatment reserved for women in whom other less invasive treatments have been unsuccessful or when they are not not an option. Hysterectomy is the only definitive treatment of uterine fibroids. Myomectomy, or the surgical removal of fibroids without the uterus, is associated with a high rate of recurrence. However, a hysteroscopic myomectomy, is very minimally invasive translating into short recovery periods and few postoperative complications making it a procedure which can be repeated as necessary without the same implications of an abdominal myomectomy. Abdominal myomectomy may associated with the development of scar tissue within the abdomen and weakening of the uterine wall, in addition to a longer recovery.