Obgyno Wino Podcast Episode 84 - Alternatives to Hysterectomy in the Management of Leiomyomas
"If we want to find safe alternatives to obstetrics, we must rediscover midwifery. To rediscover midwifery is the same as giving back childbirth to women. And imagine the future if surgical teams were at the service of the midwives and the women instead of controlling them." - Michel Odent
PB#96 - Published August 2008 (Reaffirmed 2019)
1. Estrogen + progestin or progestin alone may be useful for managing heavy AUB in the short run, but they come with a high failure rate and crossover to surgical therapies
2. GnRH agonist leuprolide is approved by the FDA for preoperative administration (in addition to iron supplementation) to boost hematocrit in those patients who are anemic due to fibroids.
3. Assessment of fibroid location and size w/ surgery to correct a resultant distorted uterine cavity is recommended before fertility treatments.
4. While hysterectomy is certainly a definitive way to manage heavy AUB, medications and UAE are reasonable and safe alternatives.
5. No sufficient data to suggest any benefit from operating on asymptomatic benign fibroids.
- leiomyomas ("fibroids") can lead to abdominal and pelvic discomfort along with heavy or prolonged menstrual bleeding
- they can exist concurrently with other causes of heavy menstrual bleeding
- generally don't cause pain but rather pressure and discomfort due to their pressing on nearby organs (e.g. constipation, dyspareunia, bladder symptoms)
- prevalence: 70% among white women, 80% among black women
- three categories: subserosal, submucosal, or intramural (often in combination)
- treatment options vary based on fibroid size, number, and location
- most of the time, they are managed surgically due to the lack of effective non-surgical options
Why not just take the uterus out?
- it's a major surgery, and large fibroid uteruses often require open surgery or VERY long laparoscopic surgery
- surgery carries risks, especially if the patient has co-morbidities
- these risks include damage to nearby organs, blood loos, death, blood clots, and prolonged recovery time
- patient may still desire future fertility, and they can't have a baby without a uterus (duh)
- medications, myomectomy, uterine artery embolization,
- estrogen + progestin or progestin alone (progestin = synthetic progesterone; commonly used in birth control and hormone replacement therapy)
- classical scenario: woman with heavy bleeding and presence of fibroids, prescribe a combined oral contraceptive (COC) to shut down ovulation and thus menstruation --> problem solved (right?)
- high failure rate and crossover to surgical therapies (plus women are much less enthusiastic about chemical castration nowadays)
- some studies have shown that progestins may actually stimulate the growth of fibroids (others suggest that they inhibit growth of fibroids)
- therefore, if your patient opts for this method, you'll know if the therapy isn't working if (a) she's still bleeding like stink or (b) her uterus/fibroids are getting bigger
- levonorgestrel intrauterine systems are associated with minimal systemic effects while providing good control of abnormal uterine bleeding (AUB) in most patients, but high expulsion rate in patients with submucosal fibroids (plus the normal finding of vaginal spotting early in its use)
Gonadotropin-Releasing Hormone Agonists
- 35-65% reduction in fibroid volume within 3 months of treatment
- leads to amenorrhea is the vast majority of women
- useful even for women with large fibroids
- GnRH agonist leuprolide is approved by the FDA for preoperative administration (in addition to iron supplementation) to boost hematocrit in those patients who are anemic due to fibroids (74% of women saw improvement compared to 46% with iron alone)
- it effectively throws you into pseudomenopause and therefore limiting its use to 6 months or less is recommended in order to avoid the consequences of hypoestrogenism (e.g. decreased bone density)
- if patient opts to go beyond 6 months, progestin add-back therapy may mitigate these effects to some degree, though it comes with the cost of increased mean uterine volume nearly to baseline within 24 months (not a great option long-term)
Recall: GnRH agonists will initially stimulate the pituitary to release FSH and LH, but in due time, pituitary GnRH receptors will be downregulated and FSH/LH release will be downregulated. GnRH antagonists exist and are not associated with the initial gonadotropin flare
- blocks ovarian and peripheral estrogen production within 1 day of initiating treatment
- fewer side effects than GnRH analogs
- little data to suggest how well they work to shrink fibroids or improve AUB (not FDA approved)
- antiprogesterone agents that act at progesterone receptors on fibroids
- high dose mifepristone can reduce leiomyoma volume by 25-75%
- mifepristone: 90% chance of amenorrhea, stable bone density (unlike the GnRH analogs)
- mifepristone: side effects include endometrial hyperplasia without atypia (14-28% risk; lower risk with lower doses) and transaminitis (4%)
- mifepristone: hard to get as it must come from a compounding pharmacy
- further study is needed with these agents
- goal: remove as many fibroids as feasible surgically then reconstruct the uterus
- various techniques come with pros and cons
- abdominal incision vertical or horizontal (as big as necessary)
- similar risks compared to hysterectomy
- 80% chance of resolving AUB and pelvic pressure
- risk of recurrence; lesser risk for women who experience childbirth after a myomectomy
- mixed evidence as to whether preoperative use of GnRH agonists affects recurrence risk
- in women with only a single fibroid, 27% chance of recurrence, 11% chance of future hysterectomy
- in women with multiple fibroids, 60% chance of recurrence, 25% chance of repeat myomectomy, hysterectomy, or both
- <1% chance of requiring hysterectomy intraoperatively during myomectomy, even with large uteri
- risk of transfusion increases with larger uteri
- pro: smaller incisions; therefore, faster recovery
- con: you have to be a damn good surgeon
- complication rate is ~10%
- subsequence pregnancy rate is 57-69%
- faster surgery, less anesthesia requirement, and less blood loss when compared to mini-lap technique
- laparoscopic myomectomy: available evidence suggests greater operative time and blood loss even if myomas are >80g, but no difference in overall complication rate or
- risk of recurrence is 12% by 1 year out, 84% by 8 years out (7% risk of reoperation for recurrence by 5 years, 16% by 8 years)
- limited evidence on robot-assisted laparoscopic techniques
- excellent option for submucosal fibroids (at least partially culprit for 5-10% of women with heavy AUB or infertility)
- this includes FIGO type 0, I, and II (see diagram above)
- 85-95% chance of successful removal with initial hysteroscopy (76% chance of retained success at 5 years)
- 5-15% chance of reoperation
- type 0 and I are more likely to be successful, but even type II has high chance of full hysteroscopic resection at 3 years (though in the biggest retrospective study type 0, I, and II were included but underwent concomitant endometrial ablation)
- 1-5% complication rate (e.g. fluid overload w/ secondary hyponatremia, pulmonary edema, cerebral edema, intraoperative and postop bleeding, uterine perforation, gas embolism, and infection)
Uterine artery embolization (UAE)
- your friendly interventional radiologist will put the patient to sleep, run a catheter up to the uterine arteries bilaterally by means of the femoral arteries, and occlude the vessels using trisacryl gelatin microsphere
- 42% reduction in fibroid volume along with degree of AUB, dysmenorrhea, and urinary symptoms
- the EMMY trial compared UAE to abdominal hysterectomy: less postop pain 24 hrs after and faster recovery in the UAE group, similar rates of major complications (5% for UAE group versus 2.7% in hyst group), and higher rates of minor complications in UAE (58% versus 40%) including vaginal discharge, fibroid expulsion, and hematoma along with readmission rates (11% versus 0%)
- in 5-year follow-up studies of UAE: 20% operation rate (14% hyst, 4% myomectomy, and 2% repeat embolization) and 25% had persistent severe symptoms
- most IR docs will prefer that patient not have received a GnRH analog within 3 months prior to UAE as the effects of the drug make it more difficult to access the uterine arteries
What are the pros and cons of GnRH analog administration preoperatively?
- pro: can boost hematocrit in those patients who are anemic due to fibroids
- con: it's expensive! (and remember: 74% of women saw improvement compared to 46% with iron alone); also, it can make fibroids softer and make it more difficult to find tissue planes intraoperatively
- GnRH antagonists work faster, but they're not FDA approved for preoperative therapy
Are there any adjuvants that can minimize intraoperative blood loss?
- a tourniquet around the lower uterine segment can compress the uterine arteries bilaterally and minimize blood loss intraoperatively
- studies have compared injected vasopressin into the myometrium against tourniquet method, and results were mixed
Now that my patient has had a myomectomy, are they resigned to c-section if they become pregnant?
- there is very little literature to guide this decision-making officially; in general, "trial of labor is recommended in patients at high risk of uterine rupture, including those with previous classical or T-shaped uterine incisions or extensive transfundal uterine surgery."
- a common practice is to recommend against trial of labor if the the uterine cavity was entered during the myomectomy
- same logic applies for patients in whom uterine perforation occurred during hysteroscopy or D&C
- surgeons: if you do a myomectomy, and you feel that the wall of the uterus will be sufficiently weakened in any way, you may add into your operative report that you would recommend against trial of labor (you're the only one that knows!)
Can a myomectomy improve fertility?
- in a woman with asymptomatic fibroids, surgery isn't indicated
- if mildly symptomatic, reasonable to intervene, but operate as close to desired pregnancy as possible given the risk of recurrence
- if very symptomatic or fibroids big enough, operation may confer some benefit to pregnancy
- fibroids are present in 5-10% of women with infertility; in only 1-2.4% of women with infertility will fibroids be the primary factor (most likely any of the other factors that may influence fertility...include male factor!)
- no great data to comment on the effectiveness of myomectomy on patients with fibroids and fertility; some studies have suggested 40-60% pregnancy rates 1-2 years after myomectomy, but it's difficult to determine the role that other fertility treatments may have contributed to this positive effect
- in studies of patients undergoing IVF, it seems clear that large fibroids that distort the uterine cavity can impact fertility (so assessment of fibroid location and size w/ surgery to correct a resultant distorted uterine cavity is recommended before fertility treatments)
- some people have recommended prophylactic myomectomy for women who desire pregnancy, but, given risk of recurrence and risk of surgery, why bother?
How does UAE impact future fertility?
- successful pregnancy can occur after UAE
- two issues to consider, though: 1) cutting off uterine arteries may lead to decreased ovarian blood flow and amenorrhea (3% risk in young women), 2) there may be an increased risk of abnormal placentation (data is all over)
What if I'm menopausal and take HRT? Will I have issues with my fibroids?
- many women will see their fibroid issues dissolve after menopause
- if taking HRT, AUB may persist, but limited data
Should anything be done if I have asymptomatic fibroids?
- it used to be argued that having a large uterus was reason alone to have treatment
- in this same light, one might argue that operating early on in the growth of a fibroid uterus is safer and easier in a fibroid uterus
- another reason to operate might be if an enlarged uterus is compressing the ureters, but no studies have found a connection between uterine size and renal dysfunction
- rapid uterine growth may also represent a sarcoma rather a benign fibroid, but low absolute risk (possibly a higher risk if: history of prior pelvic radiation, tamoxifen use, rare genetic predisposition resulting in hereditary leiomyomatosis and renal cell carcinoma syndrome) --> consider EMB or MRI to help distinguish