UTERINE FIBROIDS
MINIMALLY INVASIVE PROCEDURES
For some patients medications don't help sufficiently and symptoms persist. In these cases, it might be necessary to consider more invasive treatment options. Besides traditional procedures such as myomectomies and hysterectomies, there are now a host of other less invasive procedures for the treatment of uterine fibroids. Each treatment comes with its own sets of advantages and disadvantages. As a general rule of thumb, minimally invasive procedures rarely eliminate fibroids, but rather reduce their size. However, minimally invasive procedures can be compatible with subsequent pregnancy, if the fibroids shrink sufficiently after the treatment.
MRI-guided focussed ultrasound (MRgFUS)
This is still a relatively new technology which uses MRI guidance to focus high-intensity ultrasound waves on a particular traget in the body to destroy it. In the US, uterine fibroids were actually the first condition for which MRgFUS was approved by the FDA in 2004. Since then, the FDA has also approved MRgFUS for conditions such as essential tremor (2016) and osteoid osteoma, a benign bone tumor (2020). It is currently being studied for a host of other conditions, including a variety of cancers, neurologic and psychiatric disorders. MRgFUS works in the following way: Focused ultrasound waves emitted from an MRI-like machine heat up the fibroid tissue until the fibroid cells are destroyed. This is usually after about 2-4 hours of treatment. No surgical incision or anesthesia is required and the procedure can be performed out-patient. After the procedure it still takes a few weeks to months for the body to metabolize the dead cells out of the system as waste products. This is why fibroids usually shrink gradually after MRgFUS treatment. According to recent studies, about 90% of participants reported significant symptom improvement 12 months after the procedure. However, MRgFUS does not eliminate fibroids and fibroids may regrow at the same or a different location. Therefore, this procedure is best for patients with smaller or medium sized fibroids. Depending on the size of the fibroids, more than one treatment session may be necessary over the course of several years. The compatibility of MRgFUS with pregnancy is still being studied, however recent research has found that about 90% of pregnancies are carried to full term when conceived at about 8 months after MRgFUS treatment.
Radio frequency ablation
This technique is similar to MRgFUS, except that radio waves are used instead of ultrasound waves to heat up and destroy the fibroid tissue. Radio frequency ablation was approved by the FDA for uterine fibroids in 2012. However, in contrast to MRgFUS, radio frequency ablation is carried out under general anesthesia. Small incisions are made in the abdomen to insert a laparoscope (a small tube with a microscope) for visualization of the fibroids and a radio frequency ablation needle to target them with the radio waves
Laparoscopic cryomyolysis
This technique is similar to radio frequency ablation except that a small cryo-probe is inserted laparoscopically to target and ablate the fibroids.
Uterine artery embolization
In this procedure, which is performed since the 1990s, small embolic agents (beads) are used to infiltrate the arteries leading towards the uterine fibroids. A small incision is made and the beads are injected into a larger artery in the groin with a catheter (thin plastic tube) under fluoroscopy guidance (X-Ray). They are small enough to pass through these larger blood vessels without complications. However, as the beads reach the smaller arteries directly feeding into the fibroids, they clog up those arteries thus effectively cutting off blood flow in these vessel. The fibroids, which have no other connection to the blood stream, are unable to receive oxygen and die. Similarly to previously discussed techniques, the dead tissue is then metabolized by the body over the next weeks or months. Although this technique reduces the size of the fibroids, it does not completely eliminate them, and new fibroids may grow in different regions of the uterine lining. Because this technique targets the blood stream, there is a slight risk that beads will end up cutting off blood flow to other healthy organs, such as the ovaries, which can cause infertility. Because an incision is required, this is an inpatient procedure, usually with 1-3 nights of hospital stay. There is still controversy about the possibility of future pregnancy after this procedure.
Endometrial ablation
In this technique, a probe is inserted into the uterus vaginally through the cervix. The endometrium (uterine lining) is then destroyed. Any fibroids at the inside of the uterus can also be ablated at this time (however, fibroids at the outside of the uterine wall cannot be targeted with this procedure). Because the uterine lining is destroyed, it can no longer thicken during the normal menstrual cycle. Therefore, uterine bleeds are reduced. Different techniques can be used to perform endometrial ablation, including electrosurgery, radio frequency and cryosurgical ablation. Because the embryo implants in the endometrium after fertilization, ablating the endometrium usually prevents future pregnancies. However, endometrial ablation is not considered a sterilization, as ectopic pregnancy (pregnancy in the fallopian tubes) is still possible. In rare cases, the embryo can also attach directly to the smooth muscles the uterine wall. This causes placenta accreta, which comes with an increased risk of miscarriage and both fetal and maternal mortality. Women who have an endometrial ablation are therefore recommended to take birth control until they reach menopause. Endometrial ablation is usually performed under general anesthesia, and can be either an inpatient or outpatient procedure.