The traditional treatment of fibroids over the years has been hysterectomy. Although the first hysterectomy was performed in 1483, the majority of patients who had this procedure died, mainly from sepsis, and it was only with the introduction of anaesthesia, antibiotics and aseptic techniques that hysterectomy began to become a safer procedure. It involved the removal of the uterus and uterus containing the fibroids and usually the cervix. The problem with it is that it is a major surgical operation and hysterectomy for fibroids carrying a serious complication rate of around 4-6% and a death rate of approximately 1-1500; approximately 30,000 hysterectomies for fibroids are carried out in the UK alone. There is a long list of possible complications from hysterectomy which include damage to the bladder, bowel and ureters (tubes leading from the kidneys to the bladder), infection, abscesses, haemorrhages, wound prolapse and sometimes more chronically bowel dysfunction and vaginal prolapse. A lot of the complications require another major surgical operation. Sometimes, the uterus is removed through the vagina. In recent years, many alternative treatments for fibroids have been devised.
The usual medical treatment is to give patients a drug called a GNRH analogue (gonadotrophin releasing hormone analogue) which affects the release of hormones from the pituitary gland and produces an artificial menopause: Zoladex would be a typical example. The problem is these drugs are only effective in less than 50% of women and they may have unpleasant menopausal side effects and have to be stopped after 3 or 4 months or they can cause more problems. When the GNRH treatment is stopped, the fibroids tend to grow back very quickly. Thus these days when there are alternatives to major surgery procedures like hysterectomy, it is dubious whether GNRH analogues are indicated in the treatment of patients with severe fibroid symptoms unless there is a really good reason for a temporising measure.
Another problem with GNRH analogues is if they are given a definitive treatment like fibroid embolisation has to be delayed for 3 months following the last injection.
In patients wishing to become pregnant who have fibroids, patients are usually offered a myomectomy. This is a procedure where the fibroid is cut out. This is usually done as an open operation but in some cases it can be done laparoscopically if the fibroids are small and in an accessible position. The problem with myomectomy in patients with multiple fibroids is that there is a very high recurrence rate; in fact over 70% and, in addition, a significant percentage of patients who have myomectomies will require reoperation for fibroids and 25% of them will have a hysterectomy within 5 years. Serious complications may occur after myomectomy similar to those from hysterectomy eg bowel perforation, adhesion formation, damage to the urinary tract, infection and haemorrhage.
Another technique for treating fibroids is MRI guided ablation either laser ablation or ultrasound ablation. Essentially under the control of MRI fibroids are subjected to intense internal heating which kills off the heated tissue. The problem with the procedure is that it quite often only destroys part of the fibroid leaving viable tissue which grows and is only indicated for certain fibroids in certain positions. In addition, significant long term studies have not been published despite the decade or more the procedure has been available, unlike the case of embolisation.
Fibroid embolisation of course in contrast can be used to treat single or multiple fibroids has the advantage of killing all the fibroids at one session with only a minimal recurrence rate.