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Uterine Fibroids: More Treatment Options Now Available By Shirley Bennett, MD U TERINE FIBROIDS (myomas, leiomyomas) remain one of the most significant issues in women's health. The lifetime incidence of fibroids is 70 to 80 percent, with approximately 25 to 30 percent of those women reporting symptoms, including heavy menstrual bleeding, pelvic pain and/or pressure, dyspareunia, urinary frequency, and infertility. Fibroids are the most common indication for hysterectomy, with approximately 200,000 cases reported annually. Estimated U.S. direct and indirect costs of fibroids are as high as $34 billion annually. Medical therapy (usually hormonal) may provide temporary successful palliative therapy if administered on an ongoing basis. Curative therapy, however, requires a procedure to destroy or remove the fibroids. Available procedures include hysterectomy, myomectomy, uterine artery embolization and the newly FDAcleared Acessa procedure. The Acessa procedure uses a technology called radiofrequency ablation. It is a minimally invasive, outpatient gynecologic procedure requiring just two abdominal incisions no larger than 1 cm. Laparoscopy and laparoscopic ultrasound are used for visualization and guidance of a hand piece with a deployable array into the target myoma. Monopolar radiofrequency energy is then applied, producing coagulative necrosis and destroying the tumor while sparing the normal surrounding myometrium. The ablated fibroid is completely, or partially, reabsorbed. Coagulation of the needle tract occurs during withdrawal of the hand piece, ensuring hemostasis. More than 99 percent of all fibroids can be treated with the Acessa system. Recovery is rapid (four to five days) and the incidence of perioperative complication is very low. The minimal postoperative pain is usually treated with NSAIDS alone. Although not yet FDA approved for women desiring future childbearing, five uncomplicated term births have occurred. Interim data reports indicate a cumulative re-intervention rate of 7 percent at three years with 98 percent of patients reporting that they would recommend the procedure to a friend. Hysterectomy provides definitive therapy, but potential negatives to hysterectomy include loss of fertility, premature menopause if oophorectomy is performed, adhesion formation, future pelvic organ prolapse and negatively impacted psychosexual health. Most hysterectomies for fibroids are performed by laparotomy and result in prolonged recovery with increased disability/pain compared to minimally invasive treatments or laparoscopic hysterectomy. Reported overall complication rates are as high as 23 percent. Myomectomy is currently the standard for women who want to preserve future childbearing potential and is most often performed via laparotomy. The procedure involves incision of the uterine serosa and myometrium to remove accessible fibroids followed by skilled and rapid closure of the defects. Robotic myomectomy is associated with less intraoperative blood loss and longer surgical times. Recently, laparoscopic ultrasound has been introduced during myomectomy to image fibroids that would otherwise not be discoverable. Laparoscopic myomectomy is generally limited to removal of three to four fibroids due to operative time and blood loss. The estimated risk of adhesions post myomectomy is approximately 80 percent. The reported recurrence rate after myomectomy is approximately 30 percent at three years. Uterine artery embolization, a uterine-conserving radiologic procedure, involves fluoroscopic imaging by an interventional radiologist, who inserts a catheter from the femoral to the uterine arteries. Permanent microspheres are injected to decrease uterine blood flow, producing ischemic necrosis. It is not generally recommended for patients with larger myomas (larger than 6 to 8 cm) or for patients desiring future childbearing. Intravenous narcotics are administered for pain control during the one- to two-night hospitalization. The reported short-term (30 days) complication rate is 10.5 percent. Embolization of non-targeted tissues — such as the gluteal region, pelvic floor muscles, labia and ovaries — has been reported. Post embolization syndrome, marked by fever, abdominal pain, elevated WBC and malaise, occurs in 2 to 7 percent of patients. Myoma passage occurs up to one year post-procedure in 1.6 to 7 percent of patients. The re-intervention rate at five years for complications or recurrence was 32 percent in the REST trial. In summary, for patients with symptomatic fibroids, technological advances have increased the number of available treatment options, which is good news for patients, physicians and the healthcare dollar. Dr. Shirley Bennett is a board-certified obstetrician/gynecologist on the medical staff at Southwest General. She has special medical interests in minimally invasive surgery, endometrial ablation, obstetrics and abnormal Pap smears. I SEPTEMBER- OCTOBER 2013 I MDNEWS.COM I MD NEWS Cleveland/Akron/Canton | 33