Presented By
Presented By
The Association of Minimally
Invasive Gynecologic Surgeons
...dedicated to healthy lifestyles and safe, state-of-the-art surgery for women of all ages.
Certified In Minimally Invasive Surgery
R. Wayne Whitted MD, MPH Paul A. Pietro MD
Fibroids: Myths and Management
Objectives
Objectives
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Discuss the definition of fibroids
Discuss the definition of fibroids
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Outline the causes
Outline the causes
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Define the symptoms
Define the symptoms
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Review the old treatment approaches
Review the old treatment approaches
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Demonstrate the 21
Demonstrate the 21
st
st
Century approaches
Century approaches
What are Fibroids
What are Fibroids
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True term is
True term is
Leiomyoma
Leiomyoma
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Other names:
Other names:
fibroma
fibroma
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Genetic component
Genetic component
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Definition: muscles growths in the uterus
Definition: muscles growths in the uterus
that affect 30
that affect 30
-
-
40% of women.
40% of women.
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Usually asymptomatic
Usually asymptomatic
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Rarely malignant (1/1000)
Rarely malignant (1/1000)
Common Symptoms
Common Symptoms
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Pain (usually cramping in the lower pelvic
Pain (usually cramping in the lower pelvic
area)
area)
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Bleeding (abnormal)
Bleeding (abnormal)
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•
Urinary frequency and bladder pressure
Urinary frequency and bladder pressure
(related to size of uterus)
(related to size of uterus)
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•
Rapid growth
Rapid growth
Fibroids are classified by Location
Fibroids are classified by Location
in the Uterus
in the Uterus
Diagnosis of Fibroids
Diagnosis of Fibroids
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History, pelvic exam, and ultrasound
History, pelvic exam, and ultrasound
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Office Hysteroscopy and Saline infusion
Office Hysteroscopy and Saline infusion
sonography
sonography
define
define
intracavitary
intracavitary
and sub
and sub
-
-
mucosal ones.
mucosal ones.
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•
Occasional MRI will outline fibroid
Occasional MRI will outline fibroid
locations. This may be important in
locations. This may be important in
minimally invasive surgery
minimally invasive surgery
Historical Algorithm for the
Historical Algorithm for the
Management of Fibroids
Management of Fibroids
History & Physical, CBC, TSH, Pap,
endometrial Biopsy, only recently ultrasound
Medical Management (MPA, thyroid, etc)
Dilation and Curretage
Dilation and Curretage
Total Abdominal Hysterectomy 70-80%
Total Vaginal Hysterectomy 20-30%
History & Physical, Pap
History & Physical, Pap
CBC, TSH, Endo BX
CBC, TSH, Endo BX
Ultrasound/SIS,
Ultrasound/SIS,
Office Hysteroscopy
Office Hysteroscopy
Other Blood Work, MRI (?)
Other Blood Work, MRI (?)
Abnormal
Abnormal
Uterine Anatomy
Uterine Anatomy
LSC SupraCervical Hysterectomy
Fibroid Management Algorithm
Fibroid Management Algorithm
HSC Myomectomy
HSC Myomectomy
LSC Myomectomy
LSC Myomectomy
Endometrial Ablation
Endometrial Ablation
LSC assisted Vag Hysterectomy
Vaginal Hysterectomy
Total Abdominal Hysterectomy
Uterine Artery Embolization
MRI guided Ultrasouond
Hysterectomy Options
Common Symptoms: bleeding, pain, pressure, cramps,
abdomen getting larger
ABD Myomectomy
ABD Myomectomy
Non-Hysterectomy Options
Radiologic Procedures
Accupuncture
Lupron Therapy
Anti-Progestin
Accupuncture
Accupuncture
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Purported to reduce fibroid size and
Purported to reduce fibroid size and
bleeding
bleeding
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No randomized, double
No randomized, double
-
-
blinded, placebo
blinded, placebo
-
-
controlled trial to date.
controlled trial to date.
GnRH
GnRH
Agonist Therapy:
Agonist Therapy:
Lupron
Lupron
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Monthly or every three month injections
Monthly or every three month injections
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Reduces estrogen production to
Reduces estrogen production to
postmenopause
postmenopause
levels
levels
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Reduces fibroids 20
Reduces fibroids 20
-
-
30% in 3 months
30% in 3 months
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Temporary
Temporary
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Usually in preparation for surgery
Usually in preparation for surgery
Anti
Anti
-
-
Progestin Therapy:
Progestin Therapy:
Mifepristone
Mifepristone
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Investigational
Investigational
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Reduced fibroid size in some studies
Reduced fibroid size in some studies
MRI guided Ultrasound Therapy
MRI guided Ultrasound Therapy
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FDA approved October 22, 2004
FDA approved October 22, 2004
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Trade Name:
Trade Name:
ExAblate
ExAblate
2000 System
2000 System
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Can be used to treat some fibroids
Can be used to treat some fibroids
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Fibroids close to sensitive organs (bowel,
Fibroids close to sensitive organs (bowel,
bladder, vessels) and those outside image
bladder, vessels) and those outside image
area cannot be treated.
area cannot be treated.
FDA Approval Trial
FDA Approval Trial
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109 women from 7 medical centers around the
109 women from 7 medical centers around the
world enrolled compared to 82 women who had
world enrolled compared to 82 women who had
hysterectomies.
hysterectomies.
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Follow up was in 6 months
Follow up was in 6 months
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71% had reduced fibroid symptoms
71% had reduced fibroid symptoms
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21% needed alternative surgical therapy within
21% needed alternative surgical therapy within
a year.
a year.
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FDA requires a 3 year post market study to
FDA requires a 3 year post market study to
assess the long
assess the long
-
-
term safety and effectiveness
term safety and effectiveness
ExAblate
ExAblate
2000
2000
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Only 2 treatments performed in a 2 week
Only 2 treatments performed in a 2 week
period.
period.
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Takes approximately 4 hours
Takes approximately 4 hours
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Requires sedation
Requires sedation
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Following the procedure rest for 2 hours
Following the procedure rest for 2 hours
and resume
and resume
nl
nl
activity in 2 days
activity in 2 days
Uterine Artery
Uterine Artery
Embolization
Embolization
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Plastic particles are inserted in the uterine artery
Plastic particles are inserted in the uterine artery
on each side of the uterus.
on each side of the uterus.
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Main indication for bleeding
Main indication for bleeding
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•
78
78
-
-
94% experienced significant reduction in
94% experienced significant reduction in
bleeding, pain , and other symptoms.
bleeding, pain , and other symptoms.
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Risks: mod
Risks: mod
-
-
severe pain, nausea and fever,
severe pain, nausea and fever,
uterine infection, 1% chance of hysterectomy,
uterine infection, 1% chance of hysterectomy,
injury to ovaries producing menopause.
injury to ovaries producing menopause.
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30% reduction in fibroids size report at 1 year.
30% reduction in fibroids size report at 1 year.
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Contraindicated with
Contraindicated with
intracavitary
intracavitary
fibroids
fibroids
Hysteroscopic
Hysteroscopic
Myomectomy
Myomectomy
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Outpatient procedure
Outpatient procedure
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Minimal anesthesia
Minimal anesthesia
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Risks: bleeding, infection,
Risks: bleeding, infection,
possible, injury to organs
possible, injury to organs
if perforation occurs
if perforation occurs
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Perforation
Perforation
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Fluid overload/electrolyte
Fluid overload/electrolyte
imbalance
imbalance
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Failure to complete the
Failure to complete the
operation
operation
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Average time of
Average time of
operation: 15 minutes
operation: 15 minutes
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Success: >90%
Success: >90%
Endometrial Ablation
Endometrial Ablation
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For abnormal bleeding
For abnormal bleeding
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Outpatient
Outpatient
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Minimal anesthesia
Minimal anesthesia
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Risks: same as
Risks: same as
myomectomy
myomectomy
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Average operating time:
Average operating time:
20 minutes
20 minutes
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Success: 90%
Success: 90%
Laparoscopic
Laparoscopic
Myomectomy
Myomectomy
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Useful when a discreet number of fibroids
Useful when a discreet number of fibroids
present, easily visualized during
present, easily visualized during
laparoscopy, operator must be able to
laparoscopy, operator must be able to
suture laparoscopically
suture laparoscopically
Abdominal
Abdominal
Myomectomy
Myomectomy
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Useful with large numbers of fibroids/large size
Useful with large numbers of fibroids/large size
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Useful with
Useful with
transmural
transmural
fibroids
fibroids
Laparoscopic
Laparoscopic
SupraCervical
SupraCervical
Hysterectomy
Hysterectomy
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Any size uterus OK
Any size uterus OK
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99.9% success in our
99.9% success in our
hands
hands
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Can be outpatient
Can be outpatient
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3 little incisions
3 little incisions
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1
1
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-
4 week recovery
4 week recovery
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90 minute operation
90 minute operation
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General anesthesia
General anesthesia
Laparoscopic Assisted Vaginal
Laparoscopic Assisted Vaginal
Hysterectomy
Hysterectomy
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Indicated with history of adhesions, for
Indicated with history of adhesions, for
ovarian retrieval, endometriosis, inability
ovarian retrieval, endometriosis, inability
to access the uterus vaginally
to access the uterus vaginally
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Loose the support of the cervix which
Loose the support of the cervix which
differentiates this hysterectomy from
differentiates this hysterectomy from
supracervical
supracervical
hysterectomy
hysterectomy
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Similar risks as in all hysterectomies
Similar risks as in all hysterectomies
Vaginal Hysterectomy
Vaginal Hysterectomy
Size of uterus and operator skill impacts success
Exam under anesthesia most accurate predictor
Abdominal Hysterectomy
Abdominal Hysterectomy
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This is the Last Resort Hysterectomy
This is the Last Resort Hysterectomy
Conclusions
Conclusions
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Fibroid management is diverse
Fibroid management is diverse
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Medicinal,
Medicinal,
radiologic
radiologic
, and surgical options
, and surgical options
available
available
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•
Surgical options require skill
Surgical options require skill
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Non
Non
-
-
surgical options have failure rate and
surgical options have failure rate and
recurrence rate that needs to be considered
recurrence rate that needs to be considered
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•
Radiologic
Radiologic
procedures need long
procedures need long
-
-
term evaluation
term evaluation