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From the 34th Annual Meeting - Chicago, Illinois - November 2005
Good afternoon, I am Dr Charles Miller from Chicago. I would like to talk with you about current options for the treatment of symptomatic uterine fibroids.
When I talk with patients, I basically talk about three different options: medical treatment, radiologic treatment, as well as surgical treatment. From a standpoint of medical treatment, I do not recommend birth control pills. Birth control pills can actually stimulate the growth of uterine fibroids. The only treatment available at the present time that really offers the ability to shrink fibroids and to prevent their growth is the use of GnRH agonists. The most popular one is Lupron in the United States. Now Lupron causes a marked decrease in both estrogen and progesterone production. In so doing, the fibroids will shrink upward of 30% to 40%. A problem can come if you take the patient off the Lupron, the fibroids will return, so this treatment is usually done prior to surgery. In a patient who has a number of fibroids and is not a candidate for surgery at the present time, she may, in fact, use Lupron for the long-term. If that is going to be the case, you must use what we call add-back therapy; that is, estrogen and progesterone to prevent bone loss that is caused by the GnRH agonist.
A second type of treatment is radiologic treatment. That is the use of uterine artery embolization. Basically, the vessels to the uterus, the uterine arteries, are blocked through a catheter that is placed through the groin in radiology. Ultimately, those vessels are blocked, causing decreased flow to the uterus and to the fibroids. Again, the fibroid will shrink approximately 30% to 40%. The advantage of the procedure is that it is non-surgical. Patients are generally on their feet within about 72 hours. There is approximately a 90% success rate with control of pain and an 85% success rate with control of bulk symptoms. I think I said that wrong, about a 90% success rate in control of bleeding and an 85% control of pain associated with the fibroids. But all is not perfect with uterine artery embolization. For example, women over the age of 40, women in their mid-40s, are at a high risk of menopause after uterine artery embolization. Ultimately, 15% to 20%. Secondly, there is a concern we have of post-embolization syndrome. That is when in approximately 30 days, patients can have problems with fevers, general lethargy and tiredness and feeling out of sorts. Those are concerns we have with uterine artery embolization. Finally, there is about a 30% recurrence with UAE.
So after speaking about medical and radiologic options, our last option is surgical. Surgical can be just dealing with the fibroids themselves. Myomectomy, either through use of the laparoscope, an abdominal incision or a hysteroscope. Depending on the placement of the fibroid, a vaginal approach use of a telescope that goes in the uterus called a hysteroscope is the best option. But that means the fibroid has to be actually in the cavity of the uterus. If the fibroid is in the muscle of the uterus or outside the uterus near or next to the abdominal cavity, then a laparoscopic myomectomy or an open myomectomy through a laparotomy incision, a big incision has to be performed. Now when it comes to that type of approach, I generally definitely favor a laparoscopic approach. Laparoscopic approach has been shown to cause fewer adhesion formations and there is definitely quicker recovery. Finally, we get into hysterectomy. Still the number one reason for hysterectomy in the United States is uterine fibroids: 40% of hysterectomies in the United States are due to uterine fibroids. We can use two techniques: either a total laparoscopic hysterectomy or a total hysterectomy, where all of the uterus and the cervix plus the fibroids are removed or a laparoscopic supracervical hysterectomy where one only removes the upper portion of the uterus plus the fibroids; the cervix remains. I mention the word laparoscopic and I probably should not say that right off the bat because there are three techniques to performing hysterectomy: open technique through the laparotomy incision, we call it an abdominal hysterectomy; through the vagina, a vaginal hysterectomy; or laparoscopic. Again, if one is doing a total laparoscopic hysterectomy, removing the cervix, as well, a vaginal approach is fine and certainly an excellent approach if that can be the technique the surgeon uses. Unfortunately, often times, the uterus is too large. Ultimately, it comes down to laparotomy or laparoscopy. Again, I favor a laparoscopic technique because of quicker recovery, less morbidity, fewer problems, fewer complications with the procedure.
At the end of the day, however, you have to discuss your case with your physician and develop a plan. The important thing for you to know is your physician must give you options. If there is no other option than hysterectomy, you need to get a second opinion. Thanks for your time.