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5 operations you don’t want to get– and what to do instead – CNN.com

Maybe I’m the wrong ex-patient to be telling you this: Experimental surgery erased Stage III colon cancer from my shell-shocked body six years ago. But even I’ve got to admit that all is not well in America’s operating rooms: At least 12,000 Americans die each year from unnecessary surgery, according to a Journal of the American Medical Association report. And tens of thousands more suffer complications.

Surgery is a trauma, regardless of the surgeon’s skills.

The fact is, no matter how talented the surgeon, the body doesn’t much care about the doc’s credentials. Surgery is a trauma, and the body responds as such — with major blood loss and swelling, and all manner of nerve and pain signals that can stick around sometimes for months.

Those are but a few reasons to try to minimize elective surgery. And I found even more after talking with more than 25 experts involved in various aspects of surgery and surgical care, and after reviewing a half-dozen governmental and medical think tank reports on surgery in the United States. Here’s what you need to know about five surgeries that are overused and alternative solutions that may be worth a look.

Hysterectomy

There’s long been a concern, at least among many women, about the high rates of hysterectomy (a procedure to remove the uterus) in the United States. American women undergo twice as many hysterectomies per capita as British women and four times as many as Swedish women.

The surgery is commonly used to treat persistent vaginal bleeding or to remove benign fibroids and painful endometriosis tissue. If both the uterus and ovaries are removed, it takes away sources of estrogen and testosterone. Without these hormones, the risk of heart disease and osteoporosis rises markedly. There are also potential side effects: pelvic problems, lower sexual desire and reduced pleasure. Hysterectomies got more negative press after a landmark 2005 University of California, Los Angeles study revealed that, unless a woman is at very high risk of ovarian cancer, removing her ovaries during hysterectomy actually raised her health risks.

So why are doctors still performing the double-whammy surgery? “Our profession is entrenched in terms of doing hysterectomies,” says Ernst Bartsich, M.D., a gynecological surgeon at Weill-Cornell Medical Center in New York. “I’m not proud of that. It may be an acceptable procedure, but it isn’t necessary in so many cases.” In fact, he adds, of the 617,000 hysterectomies performed annually, “from 76 to 85 percent” may be unnecessary.

Although hysterectomy should be considered for uterine cancer, some 90 percent of procedures in the United States today are performed for reasons other than treating cancer, according to William H. Parker, M.D., clinical professor of gynecology at UCLA and author of the ’05 study. The bottom line, he says: If a hysterectomy is recommended, get a second opinion and consider the alternatives.

What to do instead

Go knife-free. Endometrial ablation, a nonsurgical procedure that targets the uterine lining, is another fix for persistent vaginal bleeding.

Focus on fibroids. Fibroids are a problem for 20 to 25 percent of women, but there are several specific routes to relief that aren’t nearly as drastic as hysterectomy. For instance, myomectomy, which removes just the fibroids and not the uterus, is becoming increasingly popular. And there are other less-invasive treatments out there, too.

In France in the early 1990s, a doctor who was prepping women for fibroid surgery — by blocking, or embolizing, the arteries that supplied blood to the fibroids in the uterus — noticed a number of the benign tumors either soon shrank or disappeared, and, voila, Jacques Ravina, M.D,. had discovered uterine fibroid embolization.

Since then, interventional radiologists in the United States have expanded their use of UFE (typically a one- to three-hour procedure), using injectable pellets that shrink and “starve” fibroids into submission. Based on research from David Siegel, M.D., chief of vascular and interventional radiology at Long Island Jewish Medical Center, New Hyde Park, New York, 15,000 to 18,000 UFEs are performed here each year, and up to 80 percent of women with fibroids are candidates for it.

Another new fibroid treatment is high-intensity focused ultrasound, or HIFU. This even less invasive, more forgiving new procedure treats and shrinks fibroids. It’s what’s called a no-scalpel surgery that combines MRI (an imaging machine) mapping followed by powerful sound-wave “shaving” of tumor tissue.

Episiotomy

It can sound so simple and efficient when an OB-GYN lays out all the reasons why she performs episiotomy before delivery. After all, it’s logical that cutting or extending the vaginal opening along the perineum (between the vagina and anus) would reduce the risk of pelvic-tissue tears and ease childbirth. But studies show that severing muscles in and around the lower vaginal wall (it’s more than just skin) causes as many or more problems than it prevents. Pain, irritation, muscle tears, and incontinence are all common aftereffects of episiotomy.

Last year the American College of Obstetricians and Gynecologists released new guidelines that said that episiotomy should no longer be performed routinely — and the numbers have dropped. Many doctors now reserve episiotomy for cases when the baby is in distress. But the rates (about 25 percent in the United States) are still much too high, experts say, and some worry that it’s because women aren’t aware that they can decline the surgery.

“We asked women who’d delivered vaginally with episiotomy in 2005 whether they had a choice,” says Eugene Declercq, Ph.D., main author of the leading national survey of childbirth in America, “Listening to Mothers II,” and professor of maternal and child health at the Boston University School of Public Health. “We found that only 18 percent said they had a choice, while 73 percent said they didn’t.” In other words, about three of four women in childbirth were not asked about the surgery they would soon face in an urgent situation. “Women often were told, ‘I can get the baby out quicker,'” Declercq says, as opposed to doctors actually asking them, ‘Would you like an episiotomy?'”

What to do instead

Communicate. The time to prevent an unnecessary episiotomy is well before labor, experts agree. When choosing an OB-GYN practice, ask for its rate of episiotomy. And when you get pregnant, have your preference to avoid the surgery written on your chart.

Get ready with Kegels. Working with a nurse or midwife may reduce the chance of such surgery, experts say; she can teach Kegel exercises for stronger vaginal muscles, or perform perineal and pelvic-floor massage before and during labor.

Angioplasty

Every year in the United States, surgeons perform 1.2 million angioplasties, during which a cardiologist uses tiny balloons and implanted wire cages known as stents to unclog arteries. This Roto-Rooter-type approach is less invasive and has a shorter recovery period than bypass, which is open-heart surgery.

The problem: A groundbreaking study of more than 2,000 heart patients indicated that a completely nonsurgical method — heart medication — was just as beneficial as angioplasty and stents in keeping arteries open in many patients.

The bottom line: Angioplasty did not appear to prevent heart attacks or save lives among nonemergency heart subjects in the study.

What to do instead

Take the right meds. If the study is right, medications may be as strong as steel. “If you have chest pain and are stable, you can take medicines that do the job of angioplasty,” says William Boden, M.D., of the University of Buffalo School of Medicine, Buffalo, New York, and an author of the study. Medicines used in the study included aspirin, and blood pressure and cholesterol drugs — and they were taken along with exercise and diet changes.

“If those don’t work, then you can have angioplasty,” Boden says. “Now we can unequivocally say that.”

Of course, what’s right for you depends on the severity of your atherosclerosis risks (blood pressure, cholesterol, triglycerides) along with any heart-related pain. The onus is also on the patient to treat a doc’s lifestyle recommendations — diet and exercise guidelines — just as seriously as if they were prescription medicines.

Heartburn surgery

A whopping 60 million Americans experience heartburn at least once a month; 16 million deal with it daily. So it’s no wonder that after suffering nasty symptoms (intense stomach-acid backup or near-instant burning in the throat and chest after just a few bites), patients badly want to believe surgery can provide a quick fix. And, for some, it does.

A procedure called nissen fundoplication can help control acid reflux and its painful symptoms by restoring the open-and-close valve function of the esophagus. But Jose Remes-Troche, M.D., of the Institute of Science, Medicine, and Nutrition in Mexico, reported in The American Journal of Surgery that symptoms don’t always go away after the popular procedure, which involves wrapping a part of the stomach around the weak part of the esophagus.

“That may be because surgery doesn’t directly affect healing capacity or dietary or lifestyle choices, which in turn can lead to recurrence in a hurry,” he says.

The surgery can come undone, and side effects may include bloating and trouble swallowing. Remes-Troche believes it’s best for very serious cases of long-standing gastroesophageal reflux disease, or GERD, or for those at risk of Barrett’s esophagus, a disease of the upper gastrointestinal tract that follows years of heartburn affliction and can be a precursor to esophageal cancer.

What to do instead

Make lifestyle changes. A combination of diet, exercise, and acid-reducing medication may help sufferers beat the burn without going under the knife. But it’s a treatment that requires perseverance.

“It took me four years of appointments, diets, drugs, sleeping on slant beds — and even yoga — to keep my heartburn manageable,” says Debbie Bunten, 44, a Silicon Valley business-development manager for a software firm, who was eager to avoid surgery. “But I did it, and am glad I did.”

 

Treating Troubling Fibroids Without Surgery

Treating Troubling Fibroids Without Surgery
By: Linda Villarosa
November 23, 2004

Condoleezza Rice, the national security adviser, shares at least one thing with millions of other American women: she had fibroids, benign tumors in the uterus that required treatment.

Ms. Rice, the nominee for secretary of state, entered the hospital for an overnight stay last week to undergo a procedure – uterine artery embolization – that is rapidly becoming an alternative to major surgery for troublesome fibroids.

For most women, fibroids, consisting of muscle and fibrous tissue, are no bother. But for millions of others, fibroids can be so large (in some cases, the size of a melon) or so numerous that they cause discomfort, severe bleeding, anemia, urinary frequency and other symptoms.

What causes fibroids is unknown, although estrogen is known to promote their growth. More than one woman in five age 40 and older has the tumors, with higher rates among black women.

For decades, major surgery – a hysterectomy to remove the uterus or a myomectomy to remove selected fibroids while leaving the uterus in place – was the main therapy for women whose symptoms were not controlled by oral contraceptives or other hormonal therapies. About 30 percent of the 600,000 hysterectomies performed in the United States each year are for fibroids.

With the introduction of technologies like ultrasound, C.T. scans, magnetic resonance imaging and new drugs, however, doctors have in recent years developed a number of alternative therapies.

This year in the United States, about 13,000 women are expected, like Ms. Rice, to choose the embolization technique, which is less invasive than surgery. French doctors first reported the embolization procedure in 1995. Since then, the number of the procedures has grown, in part because of direct-to-consumer advertising by interventional radiologists, who perform them.

Embolization involves injecting pellets the size of grains of sand, made from plastic or gels, into uterine arteries to stop blood flow and shrink the tumors by starvation. The procedure is so named because the pellets are emboli, objects that lodge and stop blood flow. M.R.I. scans are often used to screen out fibroid patients who are not candidates for the embolization procedure.

In performing the procedure, interventional radiologists insert a thin tube into an artery in the groin and thread it up to the main uterine artery in the pelvis. A dye is injected that outlines the smaller arterial branches on an X-ray, producing a map that guides injection of pellets through the tube into the arteries that nourish the fibroids.

“Of the patients we see, at least a third have fibroids the size of an orange or larger,” and the size does not influence the outcome of the procedure, said Dr. John H. Rundback, an interventional radiologist at Columbia University.

The procedure, which may be painful, usually lasts 60 to 90 minutes. Most patients also experience intense pain for several hours afterward and stay overnight in the hospital. For some patients, the pain persists for several days, or even two weeks. Surgery for fibroids requires a longer hospital stay.

Additional complications from the embolization procedure can include abscesses and other infections; heavy uterine bleeding; early menopause from the pellets damaging the ovaries; or destruction of the uterus, requiring emergency surgery.

Although the procedure is safe, “there are still significant uncertainties about the procedure, especially in terms of future fertility and long-term outcomes,” said Dr. Evan R. Myers, chief of the division of clinical and epidemiologic research in Duke University’s department of obstetrics and gynecology.

Judging the safety and effectiveness of embolization compared with to other therapies is hard because randomized controlled studies are lacking and because earlier studies did not report how different symptoms responded to different treatments, Dr. Myers said.

“It is amazing that for a condition as common as fibroids, that has such significant impact on reproductive-age women, there is not a lot of high-quality scientific evidence for many of the things that are done for fibroids,” Dr. Myers said.

“There still is no gold standard randomized trial comparing embolization to the other interventions,” he added. This is largely because patients and physicians have such strong preferences for one method or another that it is hard to recruit enough patients for clinical trials comparing the embolization procedure to hysterectomy, myomectomy, hormonal and other therapies.

Dr. Myers directs a registry that the Society of Interventional Radiology has created to monitor the outcome of 3,000 women who have undergone the embolization procedure. He said that the effectiveness and complication rates for embolization seem comparable to surgery. But there is insufficient information to draw conclusions about the procedure’s safety for women who desire to become pregnant, according to Dr. Myers, the interventional society and the American College of Obstetricians and Gynecologists.

In very rare cases – less than 1 percent – fibroids are cancerous. The cancers usually develop among postmenopausal women and the embolization procedure is not recommended for that group. Biopsies are not routinely performed on fibroid patients before embolization, and even if they were done, biopsies would not be able to detect cancerous fibroids deep in the uterine muscle. So statistically, as more women undergo embolization procedures, the cancers are unlikely to be detected in the very few patients who have them.

“That small risk has to go into the counseling before the embolization procedure,” said Dr. Howard T. Sharp, chief of the general division of obstetrics and gynecology at the University of Utah.

Dr. Sharp said he believed that there were probably more cases of cancer than the single report in the medical literature, because doctors often “don’t report the bad outcomes.”

While some researchers are trying to study the embolization procedure further, others, like Dr. Elizabeth Stewart of the Brigham and Women’s Hospital in Boston, are testing another fibroid treatment, the ExAblate 2000 System, that won approval from the Food and Drug Administration last month.

The system, made by InSightec Ltd. of Israel, uses ultrasound to destroy the fibroids with heat and M.R.I. to map the uterine anatomy and monitor the degree of fibroid destruction from a repeated application of multiple ultrasound waves on the tumor. The device centers the ultrasound waves similarly to the way a magnifying glass focuses light.

The patient remains in an M.R.I. machine for about three hours and then can go home. Initial studies found that serious side effects occurred in 2 percent of cases, compared with 13 percent among women who underwent a hysterectomy, Dr. Stewart said. Additional studies are being conducted at a small number of hospitals. The procedure is intended for women who have completed childbearing or who do not intend to become pregnant.

For the original version of this article: Treating Troubling Fibroids Without Surgery

As an educational service, members of the FTC provide
questions and answers regarding fibroids. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.

 

Intrauterine Fibroids Can Now Be Treated Nonsurgically

At least a quarter of all women suffer in agony every month from intrauterine fibroids. Now, a new type of fibroid treatment could help put an end to the pain and get them back to their lives in just a couple days.

Intrauterine fibroids are noncancerous tumors inside the uterus that cause extremely painful and heavy periods.

Until now, the only choices were a hysterectomy, fibroid surgery, or a uterine artery embolization that blocks the blood supply to the fibroids and tries to kill them.

These procedures would mean a couple of weeks, maybe months, of recovery. The Food and Drug Administration is about to approve a brand new, noninvasive treatment that is quick, easy, practically pain-free and that would drastically reduce recovery time.

“It is, first of all, noninvasive in that it doesn’t require a surgical incision. It doesn’t require any probe placement into the fibroids and that allows outpatient treatment so that women can come in the morning and then go home about midday,” said Dr. Elizabeth Stewart, the lead investigator for the FDA.

The procedure is called thermal ablation therapy. Using a magnetic resonance imaging scan to see the uterus in detail, doctors precisely focus ultrasound beams on the fibroid. The heat of the intersecting energy beams essentially cooks the tumor.

“The MRI machine lets you see the fibroid, see the borders, see all the other important tissue around it, but it also allows you to monitor temperature. Many other temperature-related therapies in the past have not done well, probably because you couldn’t gauge the temperature,” Stewart said.

Ablation therapy is also currently being studied as a treatment for breast tumors and it is being considered as a possible future treatment for other types of benign and malignant tumors.

Virtua West Jersey Hospital will be one of the first in the nation to get the new technology.

Dr. Thomas Kay, a Virtua Health obstetrician and gynecologist, says that for women who suffer the pain of intrauterine fibroids, thermal ablation therapy will be a great option.

“When you’re talking about going from two to three weeks, down to a day or two, that’s a major difference,” Kay said.

For more information on thermal ablation therapy call (888) VIRTUA-3.

As an educational service, members of the FTC provide questions and answers regarding fibroids. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.

 

Fibroid method offers a choice

By: Lee Peterson

When doctors told Victoria Overton she needed a hysterectomy, she balked. She wanted to know the alternatives. But her first- and second-opinion gynecologists gave her no options. To them, a large uterine fibroid on her uterus meant that the entire organ would have to be removed.

The benign tumor was causing problems: heavy bleeding, a frequent need to urinate and pain during sex. Overton knew she had to do something. The surgery was scheduled. She was even about to bank some blood in preparation for the operation. Then the Playa del Rey woman after badgering another gynecologist, heard about an alternative, a treatment for fibroids called uterine artery embolization.

In the procedure, a doctor clogs the blood vessels leading to the tumors with tiny plastic pellets. Starved of a blood supply, the fibroids shrivel, but the uterus stays alive. The minimally invasive treatment usually is done with local anesthetic and a conscious sedation, requiring only a one-night hospital stay. It might sound like an easy choice, but the medical community is sharply divided over the new technique. The group of physicians who perform it struggle for acceptance in the eyes of gynecologists, who as a group say it is not a proven substitute for hysterectomy.

Proponents say women, at least, should be offered the choice. The only other uterus-saving operation in which a surgeon removes the fibroids but leaves the uterus was not an option for the 47-year-old software executive. Her tumor was too large. “I did not want to have surgery. I did not want to be put under anesthesia. I did not want to miss that much work,” Overton said.

Overton found Dr. Richard Reed, an interventional radiologist who performs embolization at Daniel Freeman Memorial Hospital in Inglewood, one of a handful of places where it is available in the Los Angeles area.

The American College of Obstetricians and Gynecologists said 165,000 to 175,000 hysterectomies for fibroids were performed in the United States in 1994, the most recent year reflected in the statistics. Reed said the number today is 200,000 to 250,000, with another 50,000 myomectomies in which just the fibroids are removed. While Reed and the Society of Cardiovascular & Interventional Radiology support embolization as an alternative to hysterectomy in many cases, gynecologists say there is a reason that they don’t recommend it to patients: No one has proved in a controlled, randomized study that it is safe and effective.

Radiologists argue that gynecologists, who perform hysterectomies, worry about losing part of their turf. The OB-GYNs dismiss that and say they want only what’s best for the patient.

Doctors at UCLA Medical Center performed the first uterine fibroid embolization in this country in 1995. So far, about 6,000 have been done in the United States, while a total of about 10,000 have been performed worldwide. Reed said he spends a great deal of time making the case for the procedure to health insurers, trying to show why uterine artery embolization should be covered.

The radiology society reports that about half of all health plans cover the procedure. The turf conflict is similar to how cardio-thoracic surgeons at first viewed angioplasty in which a catheter is used to reopen clogged coronary arteries of the heart, before it earned widespread acceptance. “It’s a shame,” Reed said, “that women are not at least being offered the choice between embolization and hysterectomy. There are women who suffer in silence who don’t want a hysterectomy. They bleed so much they have to stay in bed,” Reed said.

“Embolization has been used for two decades to control bleeding for other obstetrical and gynecological problems, such as postpartum hemorrhage,” Reed said. “Through those procedures, it was found that it could be used to cut off the flow of blood to fibroid tumors.”

The procedure requires a great deal of skill as the radiologist guides the catheter through a single opening in the femoral artery, through the groin’s winding arterial system, using a fluoroscope. The doctor must enter both the left and right uterine arteries, one at a time. The sterile plastic balls are sent through the tube into the uterine arteries. Care must be taken so that they do not spread to arteries supplying blood to the legs or other places where they could cause serious problems. Doctors generally use a particle of 500 microns in diameter, the size of a typical grain of sand. That’s the right size, Reed said, to block the arteries to the fibroids, but not clog vessels that will still supply the uterus with its blood.

Women who ask for embolization (non-surgical treatment for uterine fibroids) are informed that it’s going to hurt. In the first hours afterward, the pain can be very sharp as the fibroids lose their blood supply. Overton, the patient, said she had a lot of pain that first day. But it was worth it, she said, as the symptoms that had sent her to the doctor in the first place quickly faded. She spent one night in the hospital and was back to work in about a week.

Fibroid tumors are benign masses on or in the walls of the uterus, a problem common in women age 35 to 55. Even if there are no symptoms of bleeding or pain, they can cause infertility.

For fertility patients with fibroids, embolization is not offered. Instead, the woman would likely undergo myomectomy, which preserves the uterus. While embolization is not offered as a fertility treatment, Reed said there have been a number of successful, if unplanned, pregnancies after embolization.

Reed argues that unless there is a fertility issue, myomectomy is not a good alternative to hysterectomy. Doctors agree that it can leave tiny seedling fibroids that grow and require the procedure all over again. Although some gynecologists will refer patients to doctors like Reed, the OB-GYN community at large is not sold on uterin artery embolization.

It is common in Europe, doctors said, for women with fibroids to request procedures that preserve their uteri, but it is not the norm in this country. Some are trying to change cultural attitudes, however, and promote keeping the uterus the womb intact whenever possible. Gynecologists note that surgery for fibroids, whether hysterectomy or myomectomy, can be performed often in ways that make it less invasive, either laparoscopically or also in cases of hysterectomy, vaginally. This means a woman is not staying in the hospital as long and is not having to wait six weeks to drive again as with an open procedure through the abdomen.

Embolization does not have the track record nor a large, randomized study to persuade gynecologists to offer it, said Dr. Buell Miller, a clinical professor at the University of Vermont’s Maine Medical Center in Portland, Maine. As a past member of the board of directors of the American College of OB-GYNs, and as current chairman of the board of the Maine Medical Assessment Foundation, he has not been impressed with the data on embolization so far. It’s not been well-studied, Miller said. Reed said about 1,500 uterine artery embolization have been part of published medical reports, showing a complication rate of about 3 percent.

As for a large, randomized study, Reed said it would be difficult to recruit patients, because candidates would have to agree to have either hysterectomy or embolization, whichever was randomly chosen for them. And then the study’s results would take about six to 10 years to report.The jury is still out on embolization, said Dr. Jordan Phillips, chairman of the board of the American Association of Gynecologic Laparoscopists, a Sant
a Fe Springs-based organization. But Phillips expects that enough procedures will have been performed soon for the medical community to judge if it is safe and beneficial.

I’m sure that by next year, we’ll have a very clear picture of the relative benefits of this procedure, Phillips said.

If you are showing signs of fibroid symptoms and think you have fibroids, schedule an appointment for a professional diagnosis. One of our fibroid surgeons will talk to you about your symptoms and perform a pelvic exam. We may order further testing including an imaging procedure such as an ultrasound. If fibroids are diagnosed we will discuss the best fibroid treatment for you. Here at the Fibroid Treatment Collective, we offer free consultations in-office or over the phone. Feel free to contact us for more information. To learn more about fibroids, visit our homepage.

 

 

Alternatives to Hysterectomy

Alternatives to Hysterectomy

Despite a decades-old debate over its medical necessity, hysterectomy is still the most common non-obstetrical major surgery performed on women in the United States. By the time a woman reaches age 60, the chances are about 1 in 3 that she will have had her uterus removed, and possibly her ovaries as well, in order to remedy some gynecological condition, such as fibroids, uterine cancer, endometriosis, or troublesome uterine bleeding. The prevalence of the procedure has fallen about 20% in the last quarter century, thanks in part to the growing availability and awareness of alternative fibroid treatment options. However, the rate of hysterectomy varies by geographic region, as well as by a woman’s age, level of education, and insurance coverage. Nonetheless, studies suggest that when appropriate, hysterectomy can substantially improve a woman’s quality of life. Hysterectomy removes either the entire uterus (total, or simple, hysterectomy) or the uterus above the cervix (supracervical hysterectomy). Either type may include a salpingo-oophorectomy, meaning that the ovaries and fallopian tubes are removed as well. Any hysterectomy means the end of childbearing, and the removal of the ovaries and fallopian tubes causes the onset of menopause and loss of ovarian estrogen and androgen.

The long-term effects of ovary removal include an increased risk of osteoporosis and heart disease, hot flashes, vaginal dryness, decline in muscle mass, and decreased sexual desire. Some studies suggest that even when the ovaries are preserved, women who have had a hysterectomy may experience earlier menopause.

Before undergoing a hysterectomy, a woman needs to give considerable thought to its psychological as well as medical ramifications. What would the loss of the uterus or ovaries, or both, mean? Would an alternative treatment be better? For the most part, hysterectomy is necessary only for life-threatening conditions, such as cancer, uncontrollable bleeding, or an obstetrical emergency, or for severe uterine prolapse. In many other circumstances, hysterectomy is not the only option, nor should it necessarily be the first one considered.

THE MOST COMMON INDICATION:
Fibroids Benign tumors, or fibroids, are the reason for about one-third of all hysterectomies. Fibroids, also called leiomyomas or myomas, are rubbery nodules that begin as irregular cells in the muscular layers of the uterus. They develop slowly into bundles of smooth muscle and fibrous tissue that may grow to the size of a walnut or an orange. Fibroids affect 25% of women in their 30s and 40s, and they are diagnosed in African-American women two to three times more often than in Caucasian women. Although most fibroids cause no symptoms and require no treatment, some women with the condition experience excessive bleeding and discomfort in the pelvic area. When fibroids cause bleeding, they usually cause clots. The size and location of fibroids determine how much trouble they cause. Large fibroids can distend the abdomen and push against the bowel or bladder, causing constipation or frequent urination. A fibroid can interfere with pregnancy, or it may press against the pelvic nerves, causing chronic leg or pelvic pain. Most commonly, fibroids are responsible for menorrhagia, or heavy menstrual bleeding.

Although the ultimate cause of fibroids is not known, they are related to rising estrogen levels. For example, both pregnancy and hormone replacement therapy can spur fibroid growth. Fibroids are seldom found in young women who have not begun to menstruate, and they often shrink in postmenopausal women. Alterations in DNA may also have something to do with fibroid development.

Drug Therapy

Medical management is usually the first approach to fibroids. This may include nonsteroidal anti-inflammatory drugs (NSAIDs) or drugs such as birth control pills or progestins to manipulate hormone levels. One commonly used type of medication is a gonadotropin-releasing hormone (GnRH) agonist. Drugs like leuprolide (Lupron), goserelin (Zoladex), and nafarelin (Synarel) turn off estrogen and progesterone, shrinking fibroids, but also stopping menstruation and triggering menopausal symptoms. Because of their side effects, which include decreased bone density, GnRH agonists can be given for only a few months, and fibroids often return to their previous size. Long-term treatment with GnRH can also be expensive. This approach may be a good choice for women who are close to menopause and thus will need to use the drug for only a short while. GnRH agonists may also be prescribed to shrink fibroids before surgery (see sidebar below: “A Word About GnRH Agonists”).

Myomectomy

There are several approaches to the surgical fibroid removal. The standard procedure, which is performed under general anesthesia, involves removing each fibroid individually through an abdominal incision. A myomectomy to remove fibroids within the uterine cavity may be done through the vagina under local or general anesthesia, using a fiberoptic device called a hysteroscope. The hysteroscope enters the uterus through the cervix.

A myomectomy may also be done laparoscopically. A laparoscope is a device that allows the surgeon to view the patient’s pelvic organs. It is inserted into the abdomen through one of several small incisions, along with additional instruments needed to remove the fibroid(s) and repair the uterine wall. Myomectomy is the traditional treatment for women who want to preserve their fertility.

Laparoscopic myolysis

This procedure is similar to a laparoscopic myomectomy except that instead of removing the fibroid, the surgeon cauterizes it with a needle. Surgeons may use this technique when a fibroid is near a major blood vessel.

Uterine artery embolization (UAE)

This minimally invasive procedure has been used for more than two decades to treat postpartum and other traumatic pelvic bleeding but only recently for treating fibroids. This alternative fibroid treatment shrinks fibroids by cutting off their blood supply. The patient is put under mild sedation and local anesthesia, and the surgeon threads a catheter from the groin up into the uterine artery. X-rays are made while a contrast dye is injected, giving the surgeon a view of the blood vessels supplying fibroids and the uterus. An embolism agent (usually polyvinyl alcohol or FVA, particles) is then slowly pumped into the artery to block blood flow to the fibroid.

Short-term studies have found that fibroids treated by this method shrink an average of 48%-78%. Long-term controlled studies are needed to assess the procedure’s risks, its performance against other uterine conserving surgical approaches, its impact on fertility, and the long-term effects of FVA. For instance, in one center performing UAE, 15% of patients had to be re-hospitalized for “post-embolization syndrome” – fever, nausea, vomiting, and abdominal pain. Hysterectomy may be required in cases of severe post-embolization syndrome. Uterine Fibroid Embolization is not yet widely available and may not be covered by insurance.

Hysterectomy

Hysterectomy may be considered when fibroids are a source of pain, pressure, or bleeding so severe that they interfere with daily life or cause severe anemia. However, if you are told that you need a hysterectomy, you should get a second opinion (which, in any case, is often required for insurance coverage). There are many surgical options as well as varying degrees of invasiveness. Explore the possibilities thoroughly with your clinician or surgeon.

WHEN ENDOMETRIOSIS IS THE PROBLEM

Endometriosis

Endometriosis is a chronic condition in which bits of tissue from the uterine lining become displaced and implant themselves in the abdomen outside the uterus, causing inflammation, pelvic pain, severe menstrual cramps, pain during intercourse, infertility, and irregular bleeding. Endometrial tissue implanted outside the uterus responds to the menstrual cycle the same way the endometrium does: it breaks apart and bleeds at the end of the cycle. But outside the uterus, the blood has no outlet, so it causes swelling in the surrounding areas. The resulting inflammation can produce scar tissue.

Endometriosis is the second most common reason for a hysterectomy. In this case, the ovaries are almost always removed as well, to stop the production of estrogen. But there are many other options to try first.

Drug therapy

Pain from endometriosis may be relieved with medications such as ibuprofen (Motrin, Advil) or, for severe pain, codeine. Other drug treatment is aimed at disrupting hormones that govern the menstrual cycle and may be most effective when the tissue implants are small. Options include birth-control pills; progestins like Depo-Provera; danazol (Danocrine), a weak synthetic male hormone; and GnRH agonists.

Consentative surgery

Laparoscopic surgery, in which endometrial implants are cauterized or vaporized, is often effective, although endometriosis can recur. This treatment is indicated only if the surgeon can see the pelvic structures clearly through the laparoscope. Experimental procedures that disrupt pain signals between the sacral nerves and the brain are under study.

Hysterectomy

If the fibroid symptoms can’t be controlled with drugs or conservative measures, or when symptoms are caused by a related condition called adenomyosis (in which the endometrial tissue is embedded at several locations within the uterine wall), a hysterectomy may be advised.

OTHER CONDITIONS
Menorrhagia (heavy menstrual bleeding) that can’t be attributed to fibroids, endometriosis, or infection often occurs in women who are close to menopause or in younger women who have irregular periods. Menorrhagia is more annoying than it is painful, but it sometimes disrupts the quality of women’s lives enough for them to seek hysterectomies. Less invasive treatments are available and should be considered first. For some women, low-dose estrogen birth control pills or progestin-only agents offer considerable relief. At the one-year follow-up of a new study comparing a Ievonorgestrel-releasing intrauterine device to hysterectomy, researchers found that for menorrhagia, the IUD was just as effective and cost a lot less.

Enciomefrial ablation may also relieve heavy menstrual bleeding, but it stops menstruation and results in infertility, and it may have other long-term effects that are not yet known. Instruments inserted through the vagina and cervix into the uterine cavity use electrocauterization or laser energy to destroy the uterine lining, or endometrium. A technique recently approved by the Food and Drug Administration involves inserting a balloon into the uterus and filling it with a heated fluid to destroy the uterine lining. Two newer approaches are under study; one uses microwave energy and the other destroys tissue by treating it with a light-sensitive compound followed by photoactivation.

Some women undergo a hysterectomy because of uterine prolapse. The cumulative toll of age and childbearing may weaken the pelvic muscles and ligaments supporting the uterus, causing it to drop, press against the bladder, and even protrude into the vagina. If prolapse isn’t too advanced, Kegel exercises can help strengthen the pelvic muscles, or a pessary may be inserted to support the uterus (see KWHW March 2001, pp. 5-7). There are also surgical procedures less extensive than hysterectomy that tighten the supporting ligaments without removing the uterus. However, when prolapse is severe, a vaginal hysterectomy may be recommended (see HWHI/V November 2000, p. 8).

A Word About GnRH Agonists

GnRH agonists can shrink fibroids and reduce endometrial thickness. Speak with your clinician or surgeon about the advisability of taking a GnAH agonist before having a surgical procedure. A course of treatment for a few months might eliminate the need for hysterectomy for endometriosis, fibroids, or abnormal bleeding, or it might permit the use of less invasive procedures. For women facing hysterectomy, this could mean:

  • vaginal rather than abdominal surgery
  • laparoscopic rather than abdominal surgery
  • endometrial ablation rather than hysterectomy
  • myomectomy or myolysis rather than hysterectom

As an educational service, members of the FTC provide questions and answers regarding fibroids. Feel free to ask one of our fibroid specialist about alternative fibroid treatment such as fibroid embolization. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.

 

Hope Offered Against Hysterectomy

By: Kathleen Fackelmann

NEW YORK (AP) — Arleen Chatman’s mother had a hysterectomy. Her grandmother had a hysterectomy. So did her sister, two aunts and a cousin, who was only 32 when the family problem uterine fibroids struck her as they do millions of women every year.

Chatman, 57, was determined to buck her history, fight through her fibroid-related pain and find a way to avoid a hysterectomy, despite five miscarriages and periods so heavy she used a box of sanitary napkins combined with tampons in a single day.

“I got very anemic and was missing work,” said the elementary school librarian in Los Angeles. “I grew up in the old school of ‘It’s just a woman’s curse and you have to put up with it.’ Then I started reading and everybody was talking about hysterectomies being done that weren’t needed, saying there should be alternatives.”

The alternative Chatman chose three years ago is a relatively new treatment that allows women to avoid the risks and lengthy recovery periods of surgery. It’s called uterine artery embolization, and it’s done by interventional radiologists, not gynecologists.

Under local anesthesia accompanied by pain medication, a quarter-inch incision is made in the groin. A catheter the circumference of spaghetti is threaded into the two arteries that supply blood to the uterus and feed blood-dependent fibroids.

Guided by bursts of die projected by X-ray imaging, plastic particles the size of sand granules are injected into the vessels, blocking blood to the tumors while allowing the uterus to receive nourishment from other sources.

Fibroids slowly deteriorate over three months to a year after embolization, offering women an average 40 percent to 60 percent reduction that appears to be permanent, said Dr. Robert Worthington-Kirsch, a Philadelphia radiologist who has performed a little more than 600 uterine artery embolizations, the most in the United States. The procedure usually takes care of multiple fibroids, not just the prominent ones, unlike surgery.

About 4,500 women have undergone the procedure in the United States, and 6,000 to 8,000 worldwide. The procedure is successful in easing symptoms in about 90 percent of cases, Worthington-Kirsch said.

Recipients are screened by gynecologists prior to embolization to rule out uterine cancer, detect infections that could lead to complications and determine whether other problems such as endometriosis are severe enough to lead to hysterectomy anyway.

Most women spend a night or less in a hospital and resume their lives within a few days, compared to weeks of recovery after surgery. The downside is painful cramps that hit some women for a day or two after the embolization. And much more study is needed to gauge long-term effects of the procedure on fertility, among other factors.

As an educational service, members of the FTC provide questions and answers regarding fibroids. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.

 

Researchers Take Aim at Uterine Fibroids

New Techniques Expand Treatment Options to Help Women Avoid Major Surgery

By Gail McBride, Special to The Washington Post
April 6, 1999

They may affect up to half of women of childbearing age and can cause bleeding, pain and perhaps infertility. Yet until recently, medical research paid scant attention to those benign growths in the uterus called fibroids.

Now a range of new procedures–from a technique that blocks blood vessels in the uterus to experimental drugs–may allow many women more options besides major surgery to treat uterine fibroids. For years, the principal treatment has been hysterectomy, in which the whole uterus is removed, or another operation called myomectomy in which the individual fibroids are cut out. But increasingly it looks like fibroids may be forced into submission in other ways.

The newest treatment shrinks fibroids by cutting off their blood supply. Called uterine artery embolization (UAE), it was first performed in Paris in 1991 by gynecologist Jacques-Henri Ravina. Today it is done in many countries, including the United States.

In this procedure, a catheter is inserted into an artery in the groin. With X-ray guidance, a specially trained “interventional radiologist” directs the catheter into the two arteries that supply the uterus and the fibroids with blood. Small plastic or gel particles are injected through the catheter into the arteries, causing the blood to clot. The result is closure of the arteries, marked shrinkage of the fibroids and cessation of bleeding.

The procedure takes 60 to 90 minutes, according to interventional radiologist Scott Goodwin, who with gynecologist Bruce McLucas has performed more than 200 of them at UCLA Medical Center. Patients are sedated but do not have to undergo general anesthesia. Afterward, there is considerable cramp-like pelvic pain, and pain medication is necessary. Infections occasionally occur. Patients are encouraged to take a week off from work or other daily routines.

For some women, this treatment is a welcome alternative to a hysterectomy. “My uterus was full of fibroids, and I had been to four or five gynecologists,” said Susan DeBoismilon of Orinda, Calif. “They all urged me to have a hysterectomy.” Then she heard about McLucas’ work. “The procedure made sense to me, and I had it done a month later. It’s definitely the best course.”

Goodwin said that about 80 percent of the 2,000 women worldwide who underwent UAE have had relief of symptoms, shrinkage of fibroids and no need for a hysterectomy.

Six patients of Goodwin and McLucas have become pregnant and had normal or C-section deliveries after UAE, but no one really has kept close track of patients’ attempts to get pregnant until very recently. There is some concern, Goodwin said, that the blood supply to the ovaries may be damaged by UAE in 1 percent to 2 percent of cases, and he warns women about this if they want to maintain fertility.

Until the uncertainties about long-term results and pregnancy are resolved, the procedure “probably will be best for women at the end of their reproductive lives,” said Bryan Cowan, professor of obstetrics and gynecology and director of the division of reproductive endocrinology at the University of Mississippi in Jackson.

“On the other hand, someone needs to be out there doing new procedures.”

Another relatively new procedure destroys fibroids by zapping them with electricity or a laser. Called myolysis, it was introduced in the United States in 1990 by gynecologist Herbert Goldfarb of Montclair, N.J., and Manhattan.

In this approach, a woman first takes drugs such as Lupron to suppress the production of estrogen, known to enlarge fibroids, for about three months. Then after surgery to remove the uterus’s inner layer, the patient undergoes a laparoscopic procedure, in which the surgeon makes small incisions in the abdomen and uses tiny instruments employing magnification to guide the operation.

With the patient under general anesthesia, each fibroid is treated individually by repeated application of an electric current (which Goldfarb uses) or a high-intensity laser beam that destroys cells on contact. There is some pain and discomfort with the one-day procedure, Goldfarb said, although less than with UAE. Goldfarb reports a success rate of nearly 90 percent in the 400 patients he has treated.

The problem with myolysis is that scar tissue may form after the surgery and entangle internal structures, including fallopian tubes. This can interfere with pregnancy. Some gynecologists advise women who want to become pregnant to do so as soon as possible after myolysis.

Charles March, professor of obstetrics and gynecology at the University of Southern California, is cautious about both myolysis and UAE. “They are probably best suited to carefully selected patients who are not concerned about fertility or who don’t want to undergo major abdominal surgery,” he said. “Certainly, only doctors with a lot of experience should be doing them.”

Meanwhile, researchers are also looking into gene therapy and experimental drugs. At Brigham and Women’s Hospital’s Center for Uterine Fibroids in Boston, cell biologist Romana Nowak is studying two substances called growth factors that stimulate the formation of collagen or new blood vessels and accelerate the growth of tumors. Several agents that inhibit both growth factors are being considered for fibroid treatment, Nowak said.

Just what causes fibroids is not known. Cynthia Morton, a molecular geneticist at Harvard Medical School and Brigham and Women’s Hospital is looking for genetic clues. She and her colleagues are investigating two of the chromosomal abnormalities that occur in 40 percent of fibroids. In addition, they and others at the Center for Uterine Fibroids are recruiting sisters or other close family members who have fibroids in an effort to identify a common genetic factor.

Doctors point out that many women with fibroids have no symptoms. As March noted, “it’s only necessary to remove fibroids when they are causing symptoms.” Many women with symptomatic fibroids try to hang on until menopause, hoping the fibroids will shrink as their hormone levels decrease. Fibroids are sensitive to both estrogen and progesterone, said cell biologist Janet Andersen of the State University of New York at Stony Brook. After menopause, when levels of these hormones decline, many women experience relief.

For women whose symptoms require treatment, hysterectomy remains the only true cure: no uterus, no fibroids. However, hysterectomy carries the risks of all major surgical procedures. Also, recovery requires a lot of “down time,” and some patients contend there are lasting adverse effects on health and sexual function.

Moreover, many women just don’t want to lose their uteri. The only surgical alternative is myomectomy, but this operation is not always successful. Blood transfusions may be needed during surgery, and fibroids recur in 30 percent of cases. In addition, the operation can lead to problems from scar tissue.

For women who still want children, myomectomy has been the only route, although Caesarean section is required for delivery because the uterus is too weak. Now there are alternatives.

Are they better than myomectomy? “Let’s put it this way,” said McLucas. “If myomectomy were a better procedure, I wouldn’t be advocating UAE–or even myolysis. New procedures may come alon
g in a few years, but right now, if I were a woman who wanted to become pregnant, I’d consider UAE as my first alternative.”

Resources

There are at least three fibroid web sites in the Internet:

* www.fibroids.net is maintained by the Center for Uterine Fibroids, Brigham and Women’s Hospital, Boston.

* www.fibroidcorner.com is maintained by gynecologist Francis L. Hutchins Jr. and interventional radiologist Robert L. Worthington-Kirsch, both of the Philadelphia area.

* www.fibroids.org is maintained by the UCLA Medical Group Uterine Artery Embolization team.

Fibroid Tumors at a Glance

Uterine fibroids are benign tumors. They occur in more than 20 percent of women of childbearing age, although symptoms do not generally develop until the patient is in her late thirties or forties.

Fibroids are the most common cause of hysterectomies. They are named for their position in the uterus. Submucosal or intramural fibroids are often associated with abnormal bleeding, while pelvic and back pain are frequently caused by intramural and subserosal fibroids.

Source: Georgetown University Medical Center

© Copyright 1999 The Washington Post Company

As an educational service, members of the FTC provide questions and answers regarding fibroids. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.

 

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