Gynecology - Treatment for Uterine Fibroid
A fibroid is a benign (not cancerous) tumor in the uterus and is a very common problem in women. Up to 25% of women in the reproductive age group, i.e. between the ages of 18 to 50, have symptomatic fibroid uterus. Upward to 70% of women have uterine fibroids, many of which are small and cause no symptoms. There can be one or many fibroids of varying sizes within the uterus, causing different symptoms.
Symptoms of Uterine Fibroids
- Abnormal uterine bleeding. Women with uterine fibroids may have prolonged, heavy, frequent, and irregular vaginal bleeding from the uterus. Often there are clots passed with the vaginal bleeding, frequently associated with cramping. Usually fibroid tumors within the uterine cavity or those distorting the uterine cavity cause abnormal bleeding. The fibroid tumors need not be large to cause bleeding problems if they are interfering with the menstrual mechanics of the endometrium within the uterine cavity. The abnormal uterine bleeding can often lead to anemia and fatigue.
- Pelvic pain and pressure. Fibroid tumors usually do not cause pain except those distorting the uterine cavity causing cramping with abnormal uterine bleeding. Also, if a fibroid tumor degenerates, it can cause pain. More frequently, as a fibroid uterus enlarges, it compresses the other pelvic organs, such as the bladder and bowel, causing pressure symptoms. These symptoms can be urinary frequency, urgency, constipation, and back pain, especially around the menstrual period. A very large fibroid uterus can cause leg swelling and even the inability to urinate.
- Infertility. The fibroids distorting the uterine cavity can potentially interfere with the implantation of an embryo, contributing to infertility. Also, some of the fibroids may interfere with the placenta development causing miscarriage. During pregnancy, the uterine fibroids can grow rapidly, outstripping the blood supply and causing the degeneration of the fibroids, which can lead to severe pelvic pain and even pregnancy loss.
Diagnosis of Uterine Fibroids
Uterine fibroids, especially the larger ones, can be felt by pelvic examination. A more objective way to diagnose uterine fibroids is by pelvic ultrasound imaging. The smaller fibroids within the uterine cavity may be visualized better by hysterosonography, which is performing a pelvic ultrasound with fluid infused into the uterine cavity to enhance the imaging. MRI is a very effective imaging tool to diagnose uterine fibroids, but it is quite expensive.
Treatment of Uterine Fibroids
Medical Therapy - Medication, such as Depo-Lupron, can decrease the stimulating effect of estrogen to the fibroids. The fibroids may shrink, and, in turn, the symptoms such as abnormal bleeding or pelvic pressure may decrease. Other new drugs that block either the estrogen or progesterone from stimulating the fibroids are being developed but are not available in the foreseeable future for clinical use.
The drawbacks of Depo-Lupron are that it causes menopausal symptoms and bone loss and can only be used for up to six months. After stopping the treatment, the fibroids tend to grow back in size along with the associated symptoms.
Surgical Therapy - Minimally invasive surgery has been developed to remove uterine fibroids and preserve the uterus and reproductive function. Fibroids within the uterine cavity or reachable through the uterine cavity can be resected by hysteroscopic myomectomy (removal of the fibroid). A hysteroscope is a telescope inserted into the uterine cavity through the cervix to visualize the cavity. Using a resecting electric loop, the fibroid can be shaved off and cauterized under the image guidance through the hysteroscope. For patients with abnormal bleeding problems and infertility problems due to the fibroids, hysteroscopic myomectomy offers a good conservative surgical treatment option.
For uterine fibroids not approachable through the hysteroscope, laparoscopic myomectomy offers a minimally invasive conservative surgical option to treat fibroids. Using a laparoscope through the belly button for imaging and other small ports through the abdominal wall, the fibroid tumors can be resected by laparoscopic instruments and then be removed through the ports after breaking them into small pieces by a Morcellator. The incisions in the uterus will then be repaired by suturing laparoscopically.
If the patient with uterine fibroids has completed childbearing already and wants to have a definitive surgical solution, laparoscopic hysterectomy can be performed using laparoscopic instruments involving only two small incisions in the abdomen. The recovery in general is quite brief. Only the uterus needs to be removed and the ovaries are left alone; thus, there is no change in the patient's hormonal status and no need to take hormone replacement therapy after the hysterectomy. Even a fibroid uterus of a large size can be treated with laparoscopic hysterectomy, using specialized instruments, thus affording a brief recovery period.
New Technologies to Treat Uterine Fibroids
Uterine Artery Embolization (UAE) - By threading a catheter into the arteries supplying the uterus under x-ray imaging, small plastic beads can be delivered to block the arteries to the uterus and fibroid tumors. Depriving the fibroid of its blood supply will cause it to shrink significantly, and the symptoms from the fibroid will decrease.
High Intensity Focused Ultrasound (HIFU) Treatment of Fibroids - High energy ultrasound can be focused, like a magnifying glass can focus light, to deliver powerful energy to the fibroid targets through the abdominal wall without any need of incisions. The HIFU heats up the fibroid tissue to a temperature high enough to destroy the fibroid tissue, causing the fibroid to shrink and the symptoms to decrease. This is an exciting "non-invasive" procedure that involves no cutting of tissue at all. The patient should have very little discomfort after the procedure and can resume her normal activities almost right away. HIFU treatment of uterine fibroids has been used under MRI guidance. The MRI guided HIFU treatment takes up to three to four hours to do and is quite expensive.
Dr. Michael Lau has been helping to develop an office based ultrasound guided HIFU fibroid treatment system that can ablate the fibroids within half an hour and avoid the high cost of MRI. This ultrasound guided HIFU fibroid therapy can offer a very promising non-invasive, conservative solution to uterine fibroids in the near future. Currently, all the clinical studies for this project are conducted abroad and not available in the U.S.
Dr. Lau will consult with patients to advise on the diagnosis and treatment options for uterine fibroids. However, he is not providing surgical services for fibroid treatment.