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From the 34th Annual Meeting - Chicago, Illinois - November 2005
Barbara Nesbitt: Hi, I am Barbara Nesbitt. I am at the AAGL in Chicago, and I have the pleasure of talking with Dr. Paul Indman from San Jose, California, who is on our Board. He is going to talk to you about different techniques and treatments for fibroids.
Paul D Indman, MD: Hello! Fibroid treatment can be divided into a number of options. First of all, most fibroids do not need to be treated. Many women have fibroids, and unless they are causing symptoms, or are very, very large, you can leave them in place. Fibroids may affect pregnancy, depending on their location, and it is a very individual decision on how they should be managed.
Treatment of fibroids can be divided into several types of treatment. One treatment is trying to treat the fibroids with medicines. Currently there are no medicines available in the United States that will permanently shrink fibroids. They are investigations going on, however, there are a lot of side effects to these medications. So we are really talking about surgical treatment.
The old traditional treatment was to take out the whole uterus. That does have an advantage. There is a guaranty, the fibroids will never come back, and there will never be any bleeding. On the other hand that is not an option for someone who wants fertility, and many women would prefer not to have their uterus removed. Fortunately, that is rarely essential in treating fibroids.
Other treatments are removing the fibroids. Now, this is just like real estate, it is location, location, location. Fibroids that are on the outside of the uterus can often be removed through a laparoscope, unless they are very, very large. Fibroids in the wall of the uterus can be removed depending on the size. They can be removed though an incision, or we may use a laparoscope. The most important thing is what kind of job are we doing in the uterus? Are we destroying it or are we leaving the uterus to function normally? To me that is far more important than the incision.
Fibroids that are on the inside of the uterus, they are called sub-mucous fibroids, can often be removed with a resectoscope. That is a procedure that is very nice since we can go through the cervix without any incisions, and recovery is generally about a day, rarely any more.
Complex procedures should only be done by a surgeon who routinely does them. A regular obstetrician doing that occasionally is not going to have the skills.
So, we talked about removing the whole uterus and removing the fibroids. The third choice is destroying the fibroids. You will hear from Dr. Goldfarb who has developed a technique of cooking the fibroids, shall we say, with an electrical current applied through a laparoscope. There are other ways of freezing through a laparoscope. Then we have uterine artery embolization, which is a technique where an interventional radiologist will go through the groin and little catheters have pellets that block the blood vessels feeding the fibroids, and the fibroids die. The average shrinkage in fibroids is about 50% in volume. Well, unfortunately going back to your junior high school math that is only about a 20% decrease in diameter.
There is an ExAblate treatment, which is a focused ultrasound that causes even less shrinkage, about 30% in volume, which is closer to 10% to 15% decrease in diameter. So, although it is not very invasive it is not very effective.
There is investigation work that hopefully will be available in a year or two, probably a couple of years that puts just a clamp on the cervix. It stays there all day and that blocks the blood supply without any surgery, without any other intervention, and the fibroids then shrink. Early studies look very promising.
So, to sum up, we have three general categories of fibroid treatment: taking out the whole uterus; removing the fibroids through one of many sources; or trying to destroy the fibroids. The decision should be made with a surgeon who is experienced in all the methods so that you are not just offered one option, the option that the surgeon does.