Surgery for Fibroids

Medical treatments such as the contraceptive pill or progestins (synthetic progestogens that have progestinic effects similar to progesterone) are effective treatments for heavy periods for some women. These hormone treatments often improve the symptoms of fibroid-related menorrhagia (heavy periods), but do not shrink or treat the fibroids. They also improve menorrhagia in women who do not have fibroids, and can control the irregular ovulation that responds to treatment with hormones.

Gynaecologists find that if the symptoms of menorrhagia do not improve with several cycles of hormonal treatment, it is unlikely that swapping brands will help. At this stage gynaecologists often move towards advising surgical treatment for uterine fibroids.

There are several surgical treatments for fibroids. These include:

  • Hysteroscopic myomectomy, endometrial ablation, vaginal myomectomy (surgery inside the uterus). 
  • Laparoscopic myomectomy, laparoscopic myolysis
  • Abdominal myomectomy.

Surgery inside the uterus

Hysteroscopic myomectomy

If a woman continues to have symptoms such as menorrhagia from her fibroids then it is important to investigate whether there is a submucosal fibroid that can be removed surgically via a hysteroscope. The following investigations can be used to diagnose a submucosal fibroid: transvaginal ultrasound, sonohysterogram hysterosalpingogram (HSG) or diagnostic hysteroscopy.

Hysteroscopy can be used for diagnosis and can also as a way of treating uterine leiomyomata. Some gynaecologists have commented that hysteroscopic myomectomy is probably underused as a therapeutic option for uterine myomas.

A hysteroscopic myomectomy can be used to remove small submucosal uterine fibroids by breaking them into small pieces and removing them through the cervix. There are several advantages to removing a submucosal fibroid by hysteroscopic resection: It can usually be done as an outpatient procedure and is minimally invasive. A variety of choices of anaesthetic may be available for this type of surgery depending on the facilities of the hospital. There is a short recovery time. This is sometimes as quick as 1 to 2 days and is usually less than a week.

Gynaecologists who specialise in this area have stated that it appears to be safe for future pregnancies and is therefore ideal for young women who wish to have children in the future. It enables early intervention because small submucosal fibroids are simpler to remove than larger ones.

A vital factor in whether a submucosal fibroid can be removed using hysteroscopic surgery is the size of the submucosal fibroid. To some extent how larger a fibroid can be removed depends on the experience of the surgeon and the equipment available. Gynaecologists advise that generally myomata that are less than 3 cm in size can be removed hysteroscopically by most surgeons who operate via a hysteroscope. For expert hysteroscopists it is possible for larger leiomyomas in the range of 3 to 5 cm to be removed. Sometimes medication can be used to shrink larger fibroids to enable resection in this way. Generally hysteroscopic myomectomy is not advised for leiomyomata that are classified type II in the European Society of hysteroscopic classification.

There are several surgical instruments that can be utilised to remove a uterine myoma via a hysteroscopy. The traditional device is the resectoscope. This is a rigid scope that was originally used in prostate surgery and which has subsequently been adapted for use by gynaecological surgeons. Hysteroscopes that are used in a surgical operating room are larger than hysteroscopes that are used by gynaecologists in their outpatient offices. This is because hysteroscopes that are used in hospital operating rooms need to accommodate the use of operative equipment. These larger hysteroscopes typically use a wire loop electrode which allows pieces of the fibroid to be cut out and removed. When using resectoscopes gynaecologists generally use a non-salt containing solution such as glycine or sorbitol to fill the uterus. This is because a saline solution would affect the electric current used by the resecto scope and prevented it from working properly. A major problem with these fluids is that they can be absorbed into the body. The uterus can act like a sponge and absorb the fluid into the bloodstream or the fluid can pass out through the fallopian tubes and is then more slowly absorbed into the bloodstream through the abdominal cavity. The absorption of these fluids is a problem because it may alter the electrolyte balance of the body. Prevention is the first step in minimising the complications that may occur with sorbitol and glycine. Hospitals will usually have fluid monitoring devices and pre-arranged stop points. Even if this is not the case and a significant electrolyte imbalance develops then prompt recognition and treatment with a change in intravenous fluid and diuretics can treat this problem. Fortunately there are newer generations of hysteroscopes that have been designed to work with saline containing solutions. Examples include resectoscopes that work with saline and a new system that uses mechanical resection. This device also removes with suction the pieces of fibroid which are cut out from the uterus and reduces the amount of operating time needed. Because this is a simpler system, it may also be easier to use than traditional devices.

Endometrial ablation

Another surgical treatment for managing fibroid-related heavy bleeding is to simply ignore the fibroids within the uterus and to destroy the uterine lining. The principle behind this is that, if there is no uterine lining, then there is nothing to bleed even in the presence of fibroids. The procedure for destroying the uterine lining in a minimally invasive way is known as endometrial ablation. Unfortunately the devices that have been designed for endometrial ablation have typically been designed for and tested on women who do not have uterine fibroids. Although these devices are widely used by gynaecologists to treat women with fibroid-related menorrhagia, there main use is for treating heavy menstrual bleeding in those women who have a structurally normal womb. Because of this there are two issues that have to be addressed before an endometrial ablation can be carried out. Initially a thorough assessment of the endometrial cavity is carried out by the gynaecologist to see whether a submucosal fibroid is present. If a fibroid is discovered then an endometrial ablation can be performed along with a hysteroscopic myomectomy. Secondly, there are some devices which are used for endometrial ablation that are able to accommodate an irregular cavity. However there are some devices that are unable to accommodate an irregular cavity.

There are several devices that are used for endometrial ablation. These are listed below with their mechanisms of action, advantages and disadvantages.

Resectoscope.

This can physically remove the endometrial with a loop or destroy the endometrium by direct contact using a roll bar or rollerball. The advantages are that it can accommodate any size of uterine cavity. The same equipment is used for hysteroscope and it is able to provide a specimen for histology. The disadvantages are that it requires advanced surgical skills, best results are obtained with a thin endometrium and medical pre-treatment is often needed.

Thermal balloon (Cavaterm, Thermachoice).

This works using water that is contained within the balloon. The heat leads to thermal destruction of the endometrium. The advantage of this device is that it is easy to use. The disadvantages are that only limited size and shape of uterine cavities can be treated and ablation is based on time so variations in endometrium are limiting.

Microwave (MEA).

MEA uses high frequency microwave energy to cause rapid but shallow heating of the endometrium. The heat destroys the lining of the womb. Many women have been treated with MEA already been treated and studies have shown a satisfactory outcome in almost 90% of women, with menstrual bleeding stopping completely or being significantly reduced. It has also been shown that approximately 70% of women treated with MEA also find that period pain disappears completely or is far less severe than before treatment. The microwaves that are used are cleverly selected in order that the maximum depth of endometrium destroyed is 6mm.

The microwaves are delivered by means of a wand or applicator that is gently inserted into the uterine cavity through the cervical opening. When the applicator is inside the uterus, the microwaves are applied while the applicator is slowly withdrawn with a sweeping movement to ensure that all of the lining of the uterus is treated. There is a link to a control unit that ensures that the surgeon is able to monitor and control the temperature of the treatment. This type of microwave treatment takes only about 5-10 minutes to complete and can be performed using a local or general anaesthetic.

One advantage of MEA is that women with fibroids were included in the original trials. Disadvantages of MEA are that the moving wand is operator dependent and the procedure requires assessment with ultrasound to measure the thickness of the uterine wall before treatment.

Bipolar mesh (Novasure).

This uses a bipolar electrode mesh that conforms (moulds) to the cavity. It uses radio frequency (RF) energy that vaporizes and coagulates the endometrial lining. There is a suction device that removes the steam and tissue as the ablation is carried out. The advantages are that it is easy to use, the cavity is checked to ensure that it is intact before ablation is performed, the impedance-regulated device can accommodate a variety of endometrial thicknesses and the device conforms to irregular cavities.

The main disadvantage is that the treatment only works in small uterine cavities.

Hydrotherm ablation.

This uses free-flowing hot water with hysteroscopic visualization. The advantage of this treatment is that it can be used on any size uterine cavity and there is real-time visualization. The main disadvantage is the possibility of vaginal burns. Women who have had treatment with endometrial ablation and who had a normal uterine cavity (i.e. no fibroids) often have amenorrhoea (no periods) following this treatment.

Gynaecology specialists report that amenorrhoea is unusual in women with fibroids who have undergone endometrial ablation. However most women with leiomyomata and menorrhagia find that their heavy bleeding is much reduced following endometrial ablation.

Endometrial ablation is not an option for women who wish to have children. This is because the treatment destroys the entire endometrial lining, including the basalis layer, and following ablation the normal lining of the womb does not grow back. The destruction of the basalis layer is the reason that endometrial ablation is much more effective than the old-fashioned procedure of dilatation and curettage (D&C) that was very common in the past. It is important to note that women should still use contraception following endometrial ablation. Destroying the lining of the uterus does not prevent conception, it only makes a sub-optimal environment for the pregnancy to implant in the womb. It is possible for pregnancies to grow outside the uterus and fallopian tube and cervical pregnancies are still possible. Although very rare, even pregnancies within the uterine cavity have been documented following endometrial ablation. It should not be assumed that the endometrial lining is completely destroyed following an ablation and endometrial pregnancies have happened following an ablation that was incomplete.

If an abnormal pattern of menstrual bleeding occurs in a woman who has previously undergone an endometrial ablation, it is still important to exclude endometrial cancer by carrying out an endometrial biopsy. There has been concern among gynaecologists that following an endometrial ablation a carcinoma of the endometrium may develop but not present with warning symptoms of bleeding. This does not seem to be the case, but women who do not ovulate regularly or who are obese (and are therefore at risk of endometrial hyperplasia) may not be ideal patients for endometrial ablation and should be advised accordingly about this potential risk.

Mirena intrauterine device (IUD)

An IUD or “coil” that contains a progestogen (progestin) can also be used to cause what some doctors call a “reversible medical endometrial ablation”. The brand name of the IUD is Mirena. The intrauterine device with progestogen is a hormonal intrauterine device which was originally developed as a long-acting reversible contraceptive. It is an extremely effective means of contraception. In the United Kingdom, the IUD with progestogen is referred to as an intrauterine system (IUS) or intrauterine contraceptive (IUC). The Mirena IUD is a small 'T'-shaped piece of plastic that contains levonorgestrel, a form of progestogen. The cylinder of the device contains the progestogen hormone and is coated with a membrane that regulates the release of levonorgestrel. The device releases the hormone at an initial rate of 20 micrograms per day and declines to a rate of 14 micrograms after 5 years. The hormonal IUD releases the levonorgestrel directly into the womb. Almost all of the hormone remains within the womb, and only a tiny amount is absorbed into the rest of the body.

Studies have found that surgical endometrial ablation results in a greater reduction in blood loss and is a more effective treatment for menorrhagia than the Mirena coil. However both are effective treatments for women (including those with and without leiomyomata) with heavy periods. For those women who also require contraception and who is uncertain about her plans for future pregnancies a Mirena IUD is a better option.

Non-medicated IUDs do not have the same beneficial effect on bleeding and can often lead to heavier periods.

Vaginal Myomectomy

In rare cases a submucosal fibroid can pass out through the cervix and appear in the vagina. If this occurs the woman often experiences pain that is like the labour pain of childbirth. This type of fibroid pain occurs because a lot of labour involves dilatation or gradual opening of the cervical canal. When the fibroid is being passed through the cervical canal, this results in pain from the dilatation of the cervix. Women also tend to experience intermittent gushing-type bleeding with this process. Occasionally women will have the bleeding symptoms but not experience the fibroid pain.

A fibroid that has passed through the cervix and into the top of the vagina can be seen by a doctor when a speculum is inserted into the vagina. The fibroid is often the size of a golf ball. Fibroids that are located in the cervix before moving into the vagina tend to be difficult to visualize with most scans and diagnostic imaging techniques. Because this is a rare occurrence and doctors are not used to looking for a dilated cervical canal in these circumstances, a fibroid in the cervix is often missed, even when ultrasound and HSG is used for diagnosis. If a doctor is not looking for this type of fibroid then they may miss it. Once the submucosal myoma has passed through the cervical canal and is in the vagina, it is easy to diagnose and it is important to excise the fibroid soon to prevent the problem of infection spreading up from the vagina into the uterus. Gynaecologists rarely have to excise these types of fibroids.

Gynaecologists who specialise in treating fibroids find that removing fibroids that extruded into the vagina can be difficult because of problems controlling the bleeding. These fibroids often have very thick stalks containing large blood vessels. They find that it can be a challenge to get around the fibroid to clamp, tie or cauterize the stalk. If you experience the particular type of fibroid pain described above (like labour pain), then discuss this immediately with your gynaecologist and ideally seek treatment from a doctor who specialises in treating fibroids.

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