WOMEN’S HEALTH there is a risk that the fi broids will recur and the patients will require a second operation. Laparoscopic Myomectomy is an alternative to an abdominal myomectomy. This approach offers the patients the advantage of a smaller abdominal incision; quicker recovery and lower risk of surgical adhesions forming. Randomised studies have documented improved post-operative recovery and reproductive outcomes. However, laparoscopic dissection of larger fi broids is highly complex and requires advanced surgical and suturing skills. Hysteroscopic Myomectomy is an accepted method for management of abnormal uterine bleeding caused by submucous fi broids which represent fi ve to ten percent of the cases of Heavy Menstrual Loss (HML). The risk of recurrent fi broids and HML is a major draw back of this option. Its major use is for fertility patients with the fi broids entirely or mostly in the cavity. Uterine Artery Embolization (UAE) UAE is a treatment performed by an interventional radiologist. This involves inserting a catheter up through the femoral artery into the uterine artery and embolising the uterine artery circulation with PVC microspheres. In large studies the shortterm outcomes of UAE compares favorably with hysterectomy and myomectomy but there is a higher rate of minor complications that include: a higher rate of re-intervention compared with myomectomy. This procedure is not recommended until completion of child bearing. Magnetic Resonance Imaging Guided Focused Ultrasound Surgery This non-invasive treatment was approved for use in 2004 by the FDA and involves the ultrasoundguided destruction of fi broids by the heat effects of the ultrasound. At this stage, the short-term outcome is encouraging but the outcome is operator dependent. The long-term outcome is not available to confi rm its place in the treatment options. Fertility Fibroids are commonly present in the segment of our population seeking treatment with in-vitro technologies (the average age of a woman in an IVF clinic in Australia is 38 years of age). The role of fi broids in the etiology of infertility and the recommended treatment options remain uncertain and management is mostly based on Fibroids are benign pelvic tumours that affect up to 70% of women during their lifetime. Uterus & types of fi broids. expert opinion. Subserosal fi broids do not appear to have any effect on fertility. Removal would have to be based on the secondary effects caused by pressure on adjacent organs. Intramural fi broids may be associated with reduced fertility and increased miscarriage rate. Removal is justifi ed if this association is present. Submucosal fi broids are associated with reduced fertility and increased miscarriage rates. Any documented infertility in association with the submucosal fi broids justifi es the removal of the fi broids. The relative effects of multiple or different sized fi broids on fertility are uncertain but any infertile woman with symptomatic fi broids has a justifi cation for intervention by myomectomy. Both abdominal and laparoscopic myomectomy procedures are associated with cumulative pregnancy rates of 40 –60% by two years post surgery but this data also includes fertility treatment. There is no agreed timing for how soon a woman can try for a pregnancy or have IVF post myomectomy. While the documented rate of uterine rupture is low for both abdominal and laparoscopic myomectomy, most obstetricians recommend an elective caesarean. HRT and Fibroids Fibroids are estrogen responsive and will regress with menopause. HRT appears to have a small effect on fi broids when given transdermally but not as oral estrogen. Women with fi broids and especially submucous fi broids are more likely to have abnormal PV bleeding on HRT. Fibroids are not a contra-indication to HRT use. Summary Myomectomy is a safe and effective alternative to hysterectomy for the treatment of women with symptomatic fi broids. While the outcomes for abdominal and laparoscopic myomectomy are similar the laparoscopic procedure produces a more rapid recovery and less adhesions. It is possible to resect large fi broids laparoscopically but the outcome is infl uenced by the experience of the surgeon. UAE is an effective and safe option for appropriately selected women who wish to retain their uteri. This option is more commonly performed in America but is also available in Australia. It should not be recommended for a woman considering a future pregnancy. Fibroids should not be automatically considered the cause of the infertility but in appropriately selected cases the removal of the fi broids appears to improve fertility. HRT may cause a modest increase in fi broids size but this is not an indication to withhold HRT in women who desire HRT treatment. There is no reason to recommend or support a hysterectomy for asymptomatic fi broids for any reason. pm Pindara Magazine 48 Summer - Autumn | 2014
Pindara Private Hospital Magazine - Issue One
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