Surgery

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Medication to treat fibroid symptoms usually only works while you are taking it. Many women who have severe pain and heavy menstrual bleeding end up considering surgery as an option. There are a number of different types of surgical treatments, each with its own pros and cons.

Surgery is done in the hope that it can permanently stop the symptoms of uterine fibroids. Some women do, in fact, experience long-term relief. But surgery always carries risks too. Whether or not surgery is an option – and, if so, what kind of surgery – will depend on how the woman feels about the different advantages and disadvantages. The size, number and location of the fibroids will also influence the choice of treatment. Not all types of surgery are suitable for women who still want to have children.

Your doctor may recommend taking hormones such as GnRH analogues several weeks before having surgery. These kinds of artificial hormones are used to shrink the fibroids. Doctors can then make smaller cuts during surgery, allowing the womb (uterus) to recover more quickly. The drug ulipristal acetate is sometimes used for this purpose too.

But removing individual fibroids isn't a good idea if it might cause too much scarring in the womb, or if the risk of bleeding during or after surgery is too high. Plus, it isn't always absolutely certain that the symptoms will improve after surgery. Hysterectomy (surgical removal of the womb) is then an option – or possibly another non-surgical treatment approach such as uterine artery embolization (UAE, sometimes also called uterine artery embolization, or UFE). Uterine artery embolization cuts off the blood supply to the fibroid.

Myomectomy (surgical removal of fibroids)

In myomectomy, only the fibroids are removed. The womb remains intact. The fibroids can be removed in different ways:

  • Through the vagina (hysteroscopic myomectomy)
  • Through small cuts in your abdomen (laparoscopic myomectomy)
  • Through a cut across your abdomen (laparotomy)

General anesthetic is needed for all of these procedures. The most suitable treatment options will depend on the number, location and size of the fibroids. Laparotomies are usually avoided because they aren't as gentle as the other procedures and leave a larger scar in the abdominal wall. Laparoscopy or hysteroscopic myomectomy aren't always possible if the fibroids are very large or if there are so many of them that the womb has grown bigger.

Laparoscopy and laparotomy also make it possible to remove fibroids outside of the womb that have grown into the abdominal cavity. This includes pedunculated fibroids (fibroids with a thin, “stem-like” attachment) and subserosal fibroids (located on the outer wall of the womb). These procedures can also be used to remove intramural fibroids (in the wall of the womb) that bulge outward, and intraligamentary fibroids (next to the womb).

Operating through the vagina is most suitable for fibroids that protrude into the space inside the womb. This may be the case with intramural fibroids (in the wall of the womb) or submucosal fibroids (just under the lining of the womb). Then removing the fibroids through the vagina is generally a more gentle approach than laparoscopy. Studies suggest that operating through the vagina is usually quicker and associated with less blood loss.

 Illustration: Different types of fibroids – as described in the articleFibroids: Different types

How does myomectomy affect the symptoms?

Most women who have had fibroid symptoms for a long time notice a major improvement after surgery, or no longer have any symptoms at all. Research shows that about 90 out of 100 women who have this procedure are still satisfied with the results one to two years afterwards. In up to 20 out of 100 women, fibroids grow again within the first few years after the procedure.

What risks are associated with myomectomy?

Studies on myomectomy have shown that about 5 out of 100 women have complications such as injury to organs in the abdomen, or need to have the procedure again. Fewer than 1 out of 100 women needed to have a hysterectomy because of uncontrollable bleeding after myomectomy. Temporary problems like fever or wound infections may occur.

Laparoscopy causes less blood loss than laparotomy, and complications are equally rare after both procedures.

Surgery-related scar tissue may lead to adhesions in the abdominal cavity over the long term. These strands of connective tissue may cause organs to attach to the abdominal wall. Scars and adhesions can cause pain in the lower abdomen. Depending on their location, they may cause bowel problems or affect fertility too.

How does myomectomy affect fertility?

Having a myomectomy doesn't usually affect fertility – unless adhesions form later on, and hinder the ovaries or fallopian tubes. Studies have looked into whether the type of procedure influences a woman’s chances of becoming pregnant. The results showed no differences between laparotomy and laparoscopy. About one third of women in both groups gave birth within two years.

Sometimes fibroids are removed with the aim of improving fertility. A fibroid located under the lining of the womb may prevent a fertilized egg from attaching to it. But there has been very little good-quality research on the question of whether a myomectomy can improve a woman’s chances of getting pregnant. The few studies that are available don't allow any conclusions to be drawn about whether surgery helps.

Hysterectomy (surgical removal of the uterus)

Hysterectomy is an option for women who have very many or very large fibroids, or fibroids that can only be removed with great difficulty. They may decide to have a hysterectomy in the hope that their symptoms will go away once and for all.

Like with myomectomy, there are a number of different ways to do a hysterectomy: using a cut across the abdomen (laparotomy), small cuts in the abdomen (laparoscopy) or through the vagina. The last two approaches aren't possible for all women due to medical reasons. Another approach uses additional laparoscopy to help guide vaginal hysterectomy.

Hysterectomies may remove all or part of the womb. In a partial hysterectomy, just the main body of the womb is removed. The cervix (opening of the womb) is left intact.

How do hysterectomies affect the symptoms?

A hysterectomy removes any fibroids along with the womb. Because a woman’s periods stop after this surgery, the associated symptoms also go away. Some women report that they continue to have abdominal pain or cramps. These kinds of symptoms may be caused by the operation, but they might also have other causes that were there beforehand.

There isn't enough research on how the different hysterectomy approaches affect the symptoms over the long term.

What are the possible complications?

Up to 5 out of 100 women have more serious complications during the procedure. These include damage to neighboring organs (bladder, ureter, bowel) or to blood vessels. About 2 out of 100 women may need to have more surgery or return to the hospital.

Immediately after surgery, bladder or wound infections may occur, and fever is possible too. These problems can usually be treated effectively if they are caught in time, and then typically disappear within a few days.

The risk of complications will depend on things like the type of procedure and possibly on how experienced the surgeons are.

Are any of the procedures associated with a smaller risk?

Vaginal hysterectomy is considered to be a more gentle procedure than laparotomy. The recovery time is about ten days shorter and there is no abdominal scarring.

Laparoscopy has similar advantages over laparotomy: The women recover more quickly and have a lower risk of wound infection. But laparoscopy is associated with a higher risk of injury to the ureter or bladder. These kinds of injuries happen in about 2 out of 100 women who have a laparoscopy, and in about 1 out of 100 women who have a laparotomy.

Overall, complications and side effects are similarly rare following laparoscopy and vaginal hysterectomy.

What are the potential effects of a hysterectomy?

Many women feel satisfied with the outcome and don't regret having it done. But not everyone feels that way. Some women feel that by losing their womb they have also lost an important part of being a woman. They don't consider their womb to be a “dispensable organ,” as some doctors might put it. But how women react to having a hysterectomy varies quite a bit. Some women’s sex life may not be affected, or may even improve after the surgery. Other women say that it got worse instead.

Menopause will probably start a little earlier in women who have had a hysterectomy. It is thought that this is because there is less blood flow to the ovaries after the surgery, causing the production of hormones to decrease. If the ovaries are removed along with the womb, menopause starts very suddenly.

A hysterectomy may also affect the function of the bladder, but most women who have this operation don't have that kind of problem. The procedure might also increase the risk of urinary incontinence (“stress incontinence”), which means that small amounts of urine may leak out when coughing, sneezing, laughing or lifting heavy objects.

The cervix is closely connected with the bladder and bowel. After a hysterectomy, the bladder or bowel may lose support and start to sink. The vagina can also sink downwards after a hysterectomy. This can cause a feeling of pressure in the abdomen. Women with a weak pelvic floor are at a higher risk of organs moving downwards (prolapse).

It's not clear whether a partial hysterectomy has any advantages over a full hysterectomy. The research doesn't show any short- or long-term differences in bladder function or sexuality. Women may continue to have weak menstrual periods after a partial hysterectomy. This happens if the tissue that lines the womb (endometrium) still also lines the cervix, and is shed from there.

Comparing myomectomy and hysterectomy

The risk of short-term complications is about the same when just the fibroids are removed through a large abdominal incision and when the womb is removed through a large abdominal incision. But the long-term pros and cons of these two approaches can't be compared because there hasn't been any research in this area.

Removing only the fibroids (myomectomy) has the advantage of leaving the womb intact, so the woman can still become pregnant after the operation. This procedure often relieves fibroid symptoms just as well as removing the whole womb (hysterectomy) does. But fibroids can grow back again after a myomectomy, and then cause associated symptoms. This can't happen after a hysterectomy.

Making a decision

Myomectomy is usually not an emergency procedure, so it's generally possible to get plenty of information about the treatment options before making a decision. It can help to use a decision aid, which briefly summarizes and compares the main pros and cons of the different treatments.

If you feel that your doctor is pressuring you to opt for a specific procedure, it might be a good idea to get a second opinion. Friends or family might also push you towards making a particular decision. Besides the medical circumstances, the right treatment will depend very much on your individual situation and preferences.

Your surgical options will also depend on which procedures the surgeons have the most experience with, and which types they offer. Many hospitals and clinics have specialized in particular types of procedures and only offer those ones. So if only one treatment is offered at your hospital, or if they don't really consider any alternatives, it may be a good idea to get a second opinion.