Scoping out uterine fibroids

Radiological embolization used to be the only game in town for fibroid treatment. Meet the new kid in the womb: laparoscopy

By henry Peters

Half of all black women and a quarter of all white women will develop uterine fibroids at some point in their life. While many are of these benign neoplasms are asymptomatic, others cause pain, urinary frequency or urgency, constipation, recurrent miscarriages, and infertility.

Until recently, the only practical treatments for them involved major surgery -- either myomectomy or hysterectomy. Multiple myomectomy is a particularly difficult operation, and often leaves behind precious little normal myometrium. And it's by no means guaranteed that the uterus can be restored after such surgery.

A more recent gold standard treatment is radiological embolisation, first tried in 1995. Gentler than myomectomy, it's still no picnic for the patient. Post-treatment pain can be quite severe, and young women with multiple fibroids still face a significant threat to their fertility from both the disease and its treatment.

But the uterus is a site that could have been designed for endoscopic intervention. A team of Norwegian doctors decided to investigate an endoscopic approach to uterine fibroids. Their research is published in the American Journal of Obstetrics and Gynecology.

This study involved 46 premenopausal women, whose average age was 43. They were split into a 24-strong radiological embolization group and a group of 22 treated by laparoscopic occlusion of the uterine vessels. There was no attempt at randomization, and the authors acknowledge that women with larger fibroids were generally treated in the embolization group.

Laparoscopic closure of the uterine vessels was successful in all 22 patients treated with the technique, and embolization was technically successful in all but one of 24 women. The exception was a patient who required hysterectomy four months after embolization.

While there was no significant difference in the levels of pain reported by the two groups, the researchers found that the laparoscopy group required on average only 16mg of ketobemidon to control pain after treatment, compared to 38mg in the embolization group.

At six months follow-up, there was no significant difference between outcomes in the two groups, measured in terms of dominant fibroid volume, uterine volume and bleeding reduction.

"It is possible for gynecologists with an interest in endoscopy to treat fibroids conservatively with less postoperative pain and with identical results as radiological embolization," said Dr Olav Istre from the University of Oslo.

Laparoscopic occlusion of uterine vessels is "suitable for conservative treatment of uterine fibroids and especially in younger women with multiple fibroids where hysterectomy is out of the question," he said.

In these women, the largest fibroids can be removed laparoscopically, while the others can be treated with arterial occlusion, leaving the fibroids to shrink over time, Dr Istre explained. "The heavy menstrual bleeding will be reduced, and the patient might be able to conceive."