Prof Saim Yılmaz, MD
"Ask for a second opinion before undergoing radical surgery"
Which treatment for which patient?
The most commonly used methods in the treatment of uterine fibroids are hysterectomy, myomectomy and uterine fibroid embolization (UFE). Hysterectomy and myomectomy are performed by obstetricians whereas embolization, HIFU and percutaneous ablation treatments are performed by interventional radiologists. For this reason, it may not be enough to get treatment opinion only from obstetricians or only from interventional radiologists. Every patient with fibroids requiring treatment should definitely get a second opinion from an active and experienced interventional radiologist, especially before an irreversible operation such as hysterectomy is performed. While doing this, it should be kept in mind that the vast majority of fibroid patients are suitable for non-surgical treatments such as embolization. Before deciding which treatment to choose for patients with fibroids, the following factors should be considered:
Number, size and location of fibroids
Number, size and location of fibroids in the Uterus
The number of fibroids in the uterus is one of the most important criteria in determining the treatment method to be applied. Fibroids in the uterus are usually numerous and of different size. The more fibroids are in the uterus, the more difficult it will be to remove all of the fibroids, the more will be the blood loss and other complications from myomectomy, and the greater the risk will be that the surgery will turn into a hysterectomy. In addition, in multiple fibroids, it may become impossible to determine which of the many fibroids are causing the patient's complaints. In this case, if myomectomy is insisted, the chance of success of the operation decreases, the risks increase, and if the complaints do not go away, a second operation (usually hysterectomy) may be required. However, in such patients, all fibroids can be effectively treated without removal of the uterus with embolization therapy. Therefore, embolization should be the treatment of choice in patients with more than one uterine fibroid. In more than 20 years that we practiced embolization therapy, we have seen many patients with multiple fibroids who have had recurrence after multiple (sometimes 6-7 times) myomectomies, that we then successfully treated with embolization. In fact, these patients were not suitable for myomectomy from the very beginning, and the fibroids removed in repetitive operations were actually the fibroids that were attached to the uterus with a stalk and grow outward, which are easy for surgery. The fibroids that could not be removed were intramural and large fibroids that are difficult to operate. In such patients, myomectomy should not be performed at all, or if it recurs once done, myomectomy should not be insisted on and these patients should be sent for embolization.
The location of the fibroids in the uterus is also important in determining the treatment method to be applied. In general, embolization is effective on fibroids in all layers of the uterus. However, fibroids that grow out of the uterus (subserosal) and attach to the uterus tissue with a narrow neck (stem) may not be ideal for embolization. These types of fibroids may detach from the uterus after embolization and fall into the abdominal cavity, causing some pain. On the contrary, such fibroids can be easily removed by myomectomy since their connection with the uterus is weak. Therefore, if subserosal pedunculated fibroids are detected, myomectomy should be the treatment of choice.
In order for these criteria to be used ideally, the number and location of uterine fibroids must be accurately determined. Today, the methods that best show uterine fibroids are ultrasonography (US) and magnetic resonance imaging (MRI). However, MRI is superior to US in this regard. With MRI, both the number and location of fibroids can be shown much better than with US. MRI is also the best method to show diseases such as adenomyosis and endometriosis that mimic the symptoms of fibroids. Therefore, before deciding which treatment method to choose in myoma patients, a “Contrast-enhanced pelvic MRI” examination of the uterus and ovaries should be performed.
If a patient with uterine fibroids is additionally diagnosed with cancer by biopsy of the uterus or ovaries, the ideal treatment for this patient is hysterectomy and/or oophorectomy. If a patient with fibroids has a familial predisposition to ovarian cancer, the ovaries can be removed as a precaution, while hysterectomy can be performed. If the possibility of uterine or ovarian cancer is considered very strong in a patient with fibroids as a result of age, symptoms and US+MR examinations, hysterectomy and oophorectomy can be performed together.
However, except for these rare cases, performing hysterectomy in a normal patient with uterine fibroids only to protect the patient from future uterine or ovarian cancer is not accepted as a scientific approach today. Because the probability of dying from uterine or ovarian cancer during the remaining life of a woman of childbearing age is less than 1%, while the probability of dying from cardiovascular diseases is around 50%. In many studies, it has been shown that cardiovascular diseases increase up to 3 times in patients whose uterus is removed, and this increase is much higher if their ovaries are also removed. Therefore, hysterectomy or oophorectomy performed to protect against uterine and ovarian cancer does not prolong the life of patients, on the contrary, they shorten the average life span by increasing cardiovascular diseases. In addition, osteoporosis and related fractures, dementia, depression and psychosexual problems are more common in patients whose uterus and/or ovaries are removed. For all these reasons, hysterectomy should be avoided in patients with fibroids, except for a small group of patients who have proven cancer or have a very high risk of cancer.
Video: Which treatment should be applied to which patient, Prof Dr Saim Yılmaz
Hysterectomy, one of the fibroid treatment options, definitely and permanently eliminates the chance of fertility, so it cannot be applied to patients with fibroids who want to have children. Current treatment options for fibroids who want to preserve their fertility are myomectomy, embolization, HIFU, and percutaneous ablation. Among them, the most commonly applied methods are myomectomy and embolization. Both methods have advantages and disadvantages. In recent studies, pregnancy rates were found to be similar after treatment in both methods (Piscove et al, Fertil Steril 2010). Therefore, in patients with fibroids who want to become pregnant, any of the above methods can be applied according to the number and location of fibroids and the preference of the patient and the doctor. However, no matter what treatment is applied, it should be known that getting pregnant depends on many factors other than fibroids, and no treatment method can provide any guarantee for getting pregnant even if it is applied successfully.
In many patients, all or some of the above-mentioned methods may be appropriate in the treatment of uterine fibroids. In this case, the advantages and disadvantages of each of the treatments that can be applied to the patient should be explained and the patient's own decision regarding an organ of his own body should be respected.