The Management of Chronic Gynecologic Conditions During COVID and Beyond - Episode 9
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Expert gynecologists review the benefits and complications associated with surgical options used to treat heavy menstrual bleeding from uterine fibroids.
Ayman Al-Hendy, MD, PhD: We want to talk about the role of surgery and procedures options for the management of uterine fibroids. I’m a very strong believer that like in any other disease, we should always try with medical therapy, and only if that fails or the patient cannot tolerate it, or if the patient is not a good candidate for medical therapy, then we should move to a more invasive therapy such as surgery. However, I believe in the fibroid field we tend to think of surgery as a first line because traditionally, until recently, there was really not a lot of good, durable, long-term treatment options. We’ll come to the medical treatment in a second.
As far as who would be a good candidate for a surgical option, I would say what comes to mind is the FIGO type 0 and type 1, the same patients that Linda was talking about a minute ago, those with a single intracavitary or more than 50% in the cavity uterine fibroid, and those certainly can benefit from a simple hysteroscopic myomectomy and the symptoms usually improve dramatically.
Also the same group that I mentioned just a second ago, those who would not be good candidates for medical therapy, most of the effective long-term medical therapy now includes estrogen as a component, and of course we know some patients, those with thromboembolic disease or have high risk for developing thromboembolic issues, would not be good candidates for estrogen. For them, obviously, surgery would be a good candidate.
Traditionally, we think of patients who have completed their families, maybe they had a tubal ligation, maybe they’re in their forties or approaching menopause, we tend to have a lower threshold for surgical options. I say that just as traditionally what’s out there, but to be honest, I disagree with that. I think this group would be excellent candidates for medical therapy to bridge them into menopause. That’s kind of in a nutshell what I think would be good candidates for surgery.
Now, of course, for myomectomy, we do about 30,000 myomectomies in the US every year, and most of those patients are those who are seeking fertility or maybe they have unexplained infertility and they have fibroids. We tend to do myomectomy to enhance their fertility chances, although the evidence, again other than the submucosal or FIGO 0 and 1, is that myomectomy would actually help their fertility opportunity is rather limited.
With that, I’ll go to you, Eric, and we want to talk about the risk and benefits specifically of various surgical and procedural interventions. We can go through them 1 by 1: myomectomy and hysterectomy, both with or without bilateral salpingo-oophorectomy. Also we can touch on the uterine artery embolization, ablation, and focused ultrasound.
Eric Surrey, MD: Myomectomy is a big box because there’s so many different approaches. Typically, the goal would be for the woman who wants to preserve her uterus, particularly with a goal for future children, and frankly just wants to preserve their uterus. It is a bigger undertaking when this is done abdominally. I agree with you completely, I think there’s no indication, except to maybe stabilize a patient, for anything but a hysteroscopic myomectomy in a patient with a submucosal fibroid, unless there’s significant myometrial extension that would be much harder to resect. This is a straightforward surgery; it has relatively low complications and can be done on an outpatient basis very rapidly.
With regard to abdominal myomectomy, whether it’s done as an open laparoscopic or robotic, clearly an open procedure has been well shown to have more recovery and higher complication rates, but there are some patients who will benefit from an open procedure. I think to take this out of the armamentarium entirely is wrong. There certainly is the controversy regarding morcellation, which I don’t feel is resolved, but it still exists, and sometimes it can be a lot faster to do an abdominal procedure with a mini laparotomy than a rather lengthy laparoscopic procedure.
The question of laparoscopic myomectomy versus robotic myomectomy is a debate that doesn’t need to be held during election season. I would frankly say there’s virtually no data to show that one is better than the other. There’s a very nice poster that was just presented at the ASRM meeting this year, the virtual ASRM meeting, that did a review, and it showed that when you look at long-term outcomes for myomectomy, the technique is irrelevant. The outcomes are the same procedures, whether done laparoscopically, robotically, or laparotomy.
I think we can definitely say that a hysterectomy will cure uterine fibroids. This is a 100% curative procedure. It’s not appropriate for all patients. I would say that removing the uterus and the ovaries, there can a little controversy with endometriosis, but the only reason to remove ovaries is for the indication of the patient herself, not the fibroids. Depending on her age, if there’s a concern for ovarian cancer prevention, certainly removing the fallopian tubes, of course there’s no reason to leave them in situ. Whether we leave ovaries has nothing to do with the fibroids.
With regard to less aggressive therapies, there is data on UAE with pregnancy. It’s not great data. I personally am of the bias that a woman who wants to get pregnant should not have uterine artery embolization or MRI guided therapy because you create a necrotic lesion in the uterus. Yes, there are pregnancies reported, but the series are small, and I just get very concerned about that. It’s another relatively noninvasive procedure, but long-term outcome for controlling the symptoms is very good. Uterine artery occlusion, which isn’t done very much anymore, is less successful than all that.
The last piece of whether to perform an ablation, I think of that as more of an adjunctive procedure than a primary therapy for bleeding and fibroids. If you have a patient who is unstable in their past, you consider doing an ablation without thinking of the surgery. Now, as I know we’ll talk about in a few minutes, we have alternatives where you can control the bleeding without doing an ablation, which again has the highest recurrence rates are probably in treatment for fibroids.
Transcript edited for clarity.
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