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A Hysterectomy Is Not the Only Option for Treating Fibroids

Some women need a hysterectomy because they have been diagnosed with uterine cancer. But, in the majority of cases, the operation is performed to treat other conditions such as fibroids.
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QUESTION: I have been diagnosed with two huge uterine fibroids. They have caused me a great deal of discomfort. A gynecologist has recommended that I should have a hysterectomy -- an operation that would remove my uterus. Are there any other treatments that would permit me to keep my uterus?

ANSWER: There are numerous treatments for fibroids -- and some of them may be appropriate for you. So, you are certainly prudent to consider other options.

Each year, more than 40,000 Canadian women lose their uteruses to this invasive procedure. In fact, hysterectomies were among the top five reasons for inpatient surgeries in Canadian hospitals between 2012 and 2013, according to a study by the Canadian Institute of Health Information (CIHI).

Another CIHI study identified huge variations in the rates that these operations are performed across Canada. The rates range from 311 a year for every 100,000 people in British Columbia to 512 per 100,000 in Prince Edward Island. You'll also find signification variations within many provinces.

Some women need a hysterectomy because they have been diagnosed with uterine cancer. But, in the majority of cases, the operation is performed to treat other conditions such as fibroids.

The big variation in hysterectomy rates suggest that many women may not be aware of all their options, or may have limited access to alternative treatments. Either way, that's not a good thing -- especially considering that fibroids are extremely common.

Up to 70 per cent of women will develop uterine fibroids -- spherical masses of tissue in the womb. Some women have multiple fibroids.

The hormone estrogen spurs their growth. When women reach menopause, and estrogen production dwindles, fibroids tend to shrink and cease to be a problem.

About 50 per cent of women with fibroids "experience symptoms related to these growths, ranging from mild to severe," says Dr. Elizabeth David, an interventional radiologist at Sunnybrook Health Sciences Centre.

The symptoms really depend on the location of the fibroids.

"If the fibroids are close to the endometrial canal, where the baby would grow, they can produce painful and heavy bleeding," during the woman's monthly menstrual cycle, says Dr. David. Loss of blood, in turn, can lead to anemia, fatigue and may require blood transfusions.

If the fibroids are embedded deep in the wall of the womb, symptoms may be minimal or non-existent.

If they are on the outside of the uterus, they can press against other tissues and organs including the bladder, colon and kidneys. The woman may feel bloated, need to urinate frequently or suffer from chronic constipation.

Fibroids can take an economic toll, too. Some women miss time from work due to heavy menstrual bleeding.

"These are severe symptoms, they obviously need treatment," says Dr. David.

Certain medications can help shrink fibroids and ease symptoms. But serious cases usually require other therapies.

The most invasive treatment is a traditional hysterectomy, in which all or part of the uterus is removed through a 15 to 20-centimetre-long incision in the abdomen.

It takes a long time to heal from this operation, ranging from six to eight weeks, says Dr. Grace Liu, an obstetrician-gynecologist at Sunnybrook.

In some cases, the operation can be done using a less invasive technique known as a laparoscopic hysterectomy. A miniature video camera and medical instruments are inserted through tiny keyhole incisions in the abdomen. The surgeon guides the tools while watching on a TV monitor.

A laparoscopic hysterectomy results in a much speedier recovery than an open-abdominal hysterectomy. Some women may be perfectly happy with any type of hysterectomy, knowing that their fibroid troubles are finally over.

However, if you want to preserve the uterus - and maintain the ability to become pregnant at some future date -- you need another type of surgery altogether.

One such operation is called a myomectomy. The surgeon cuts out just the fibroids, essentially leaving most of the uterus intact.

A myomectomy can be done though an open cut across the stomach or with a less invasive laparoscopic "keyhole" operation. As well, the surgeon might be able to remove the fibroids by inserting the instruments through the vagina and cervix to reach the uterus - a procedure known as a hysteroscopic myomectomy.

The number of fibroids and their exact location will determine which one of these surgical techniques is appropriate -- or even possible. If a woman has multiple fibroids in difficult-to-reach locations, an open cut across the abdomen may be necessary.

In recent years, there have been big advances in two new, minimally invasive procedures that involve very little or no surgery. The patient is in and out of the hospital the same day.

The first of these procedures is called Uterine Artery Embolization. A needle is inserted into an artery in the patient's leg. Then a flexible catheter is inserted into the blood vessel and threaded along until it reaches the uterus. Once in place, the catheter releases tiny particles that cut off the fibroid's blood supply. Within months, the fibroid shrinks away.

"The patients can take about seven to 10 days to recover," says Dr. David. "They may have mild cramping, like a period, but that's it."

The second significant change in the treatment of fibroids has come from a procedure called Magnetic Resonance guided High Intensity Ultra Sound -- or MRgHIFU for short.

It is a combination of two technologies -- an MRI scanner that locates the fibroids and ultrasound waves that destroys the growths.

The patient lies on her stomach in the MRI scanner. The focused sound beam vibrates the cells so they heat up to over 60 Celsius and that kills them.

"We do a few cells at a time," explains Dr. David. "We start in the middle and go all the way around until we get most of the fibroid." The treatment takes several hours.

"The patients don't feel anything aside from a mild warmth along the skin," she says. And there's no downtime required for recovery. The patient is sent home in about an hour after the procedure.

Dr. David says this treatment wouldn't be suitable for all patients. The fibroids must be in a spot where they can be reached by the ultrasound beam. If the growths are too deep in the body or other organs are in the way, then it won't work.

There are only two Ontario medical centres that currently use MRgHIFU to treat fibroids -- Sunnybrook and Thunder Bay Regional Health Sciences Centre. Both centres are part of an international clinical trial that's assessing the effectiveness of the therapy.

A study released in March 2015 found that expanded use of MRgHIFU could save the Ontario health-care system money by reducing the time that patients spend in hospitals. "It could potentially result in 1-year savings of about $1.38-million if implemented in two centres, or $4.15-million if implemented in 6 centres," said the report, which was commissioned by Health-Quality Ontario (HQO), an agency of the provincial government.

Although the study did not take into account the up-front costs of buying the high-tech equipment, "the bottom line of this analysis is that MR-guided high-intensity focused ultrasound provides pretty good value for the money," says Dr. Irfan Dhalla, Vice-President Evidence Development and Standards at HQO.

"Making less-invasive treatment more available would be helpful to thousands of women in Ontario," he adds

Dr. Liu says women with fibroids should explore their options. "Don't be afraid to seek a second opinion," she advises.

But keep in mind that what works best for you will largely be determined by your specific medical circumstances -- especially the position of your fibroids. "A lot depends on their location - much like real estate," says Dr. David.

Co-authored by Paul Taylor, Sunnybrook's Patient Navigation Advisor



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