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Hysterectomy and uterine fibroids; Leiomyoma; Myoma
A myomectomy surgically removes only the fibroids and leaves the uterus intact, often preserving fertility. Myomectomy may also help regulate abnormal uterine bleeding caused by fibroids. Not all women are candidates for myomectomy. If the fibroids are numerous or large, myomectomy can become complicated, resulting in increased blood loss. If cancer is found, conversion to a full hysterectomy may be necessary.
To perform a myomectomy, the surgeon may use a standard "open" surgical approach (laparotomy) or less invasive ones (hysteroscopy or laparoscopy).
Complications. The risks for myomectomy are generally the same of those for other surgical procedures, including bleeding and infection.
Recurrence of Fibroids. Myomectomy is not necessarily a permanent solution for fibroids. They can recur after these procedures.
Uterine artery embolization (UAE), also called uterine fibroid embolization (UFE), is a relatively new way of treating fibroids. UAE deprives fibroids of their blood supply, causing them to shrink. UAE is a minimally invasive radiology treatment and is technically a nonsurgical therapy. It is much less invasive than hysterectomy and myomectomy, and involves a shorter recovery time than the other procedures. The patient remains conscious, although sedated, during the procedure, which takes around 60 - 90 minutes.
The procedure is typically performed in the following manner:
Effect on Fertility. In general, UAE is considered an option for only those who have completed childbearing. Although UAE may protect fertility in many women, the procedure does pose some risk for ovarian failure and infertility. The American College of Obstetricians and Gynecologists advises women who wish to have children that it is not yet known how this procedure affects their potential for becoming pregnant.
Complications. UAE has a lower rate of complication than hysterectomy and laparotic myomectomy and a shorter hospital stay. Compared to other procedures, women who have UAE miss fewer days of work. Serious complications occur in fewer than 0.5% of cases. Postoperative effects may include.
Success Rates. Studies on uterine artery embolization show high patient satisfaction (over 90%) and low complication rates. Uterine artery embolization is effective for a large majority of patients. However, some women may have fibroid recurrence and may need future procedures (repeat embolization or hysterectomy).
Some studies suggest that women with large fibroids are not good candidates for UAE.
Endometrial ablation destroys the lining of the uterus (the endometrium) and is usually performed to stop heavy menstrual bleeding. It may also be used to treat women with small fibroids. It is not helpful for large fibroids or for fibroids that have grown outside of the interior uterine lining. For most women, this procedure stops the monthly menstrual flow. In some women, menstrual flow is not stopped but is significantly reduced.
Endometrial ablation procedures use some form of heat (radiofrequency, heated fluid, microwave) to destroy the uterine lining. The procedure is typically performed on an outpatient basis and can take as few as 10 minutes to perform. Recovery generally takes a few days, although women experience watery or bloody discharge that can last for several weeks.
Endometrial ablation significantly decreases the likelihood a woman will become pregnant. However, pregnancy can still occur and this procedure increases the risks of complications, including miscarriage. Women who have this procedure must be committed to not becoming pregnant and to using birth control. A main concern of endometrial ablation is that it may delay or make it more difficult to diagnose uterine cancer in the future. [For more information, see In-Depth Report #100: Menstrual disorders.]
MRgFUS is a non-invasive procedure that uses high-intensity ultrasound waves to heat and destroy (ablate) uterine fibroids. This “thermal ablation” procedure is performed with a device that combines magnetic resonance imaging (MRI) with ultrasound. The Food and Drug Administration approved this device, the ExAblate 2000 System, in 2004.
During the 3-hour procedure, the patient lies inside an MRI machine. The patient receives a mild sedative to help relax but remains conscious throughout the procedure. The radiologist uses the MRI to target the fibroid tissue and direct the ultrasound beam. The MRI also helps the radiologist monitor the temperature generated by the ultrasound.
MRgFUS is appropriate only for women who have completed childbearing or who do not intend to become pregnant. The procedure cannot treat all types of fibroids. Fibroids that are located near the bowel and bladder, or outside of the imaging area, cannot be treated.
However, this procedure is new and long-term results are not yet available. Likewise, it requires an extensive period of time involving MRI equipment. Many insurance companies do not pay for this treatment.
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