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Hysterectomy is the most common major gynecologic procedure done in Canada, with more than 100 performed daily. This procedure involves the removal of all or part of the uterus, and may or may not include the cervix, Fallopian tubes, and ovaries.
Fibroids are the most common reason for hysterectomy, but the procedure can also be used to treat a variety of conditions including unmanageable uterine bleeding, prolapse, and precancerous changes. Hysterectomy can also be part of a treatment plan for cancers of the reproductive organs or to help prevent cancer.
Fibroids are also known as leiomyomas, affecting up to 70 per cent of women. They may grow in the cavity, wall, or outer surface of the uterus. They can vary in size, shape, and location.
Fibroids grow most in perimenopause but can develop any time. They tend to grow over the course of a woman’s reproductive years but generally become smaller after menopause.
Between 35 and 50 per cent of women with fibroids have no symptoms, and their fibroids are first detected during a routine pelvic exam or ultrasound. Others may have longer, heavier, more painful or more frequent periods, bleeding between periods, anemia, pelvic pain, pain during sex, abdominal cramps, constipation or a frequent need to urinate. Women with certain types of fibroids are also at higher risk for infertility and miscarriage.
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Patients will often visit the gynaecologist simply because they’re found to have fibroids. But, it’s important to emphasize that fibroids themselves are not a problem; having fibroids that cause symptoms is a problem.
One misconception is that fibroids increase the risk of cancer. Though some people refer to them as fibroid tumours, tumour is a word that defines both benign and cancerous growths. The risk of cancer in this kind of tumour is very low.
Decades ago, hysterectomy was one of the very few options for treating symptomatic fibroids. The procedure can be done through a cut (laparotomy), which involves a large abdominal incision and requires up to six weeks’ recovery time, laparoscopically, robotically, or vaginally. The latter procedures are being done via keyhole incisions and/or a vaginal cut and requires about a third of the recovery time. Another surgical treatment option includes a procedure that allows doctors to remove the fibroids called myomectomy. This option leaves the uterus intact and might help if the fibroids are contributing to infertility. It, too, can be done through open surgery, hysteroscopy (via the cervix), laparoscopy, robotics, or vaginally, depending on the size and location.
Fibroid symptoms are commonly managed with medication. One option is ulipristal acetate, which was first approved by Health Canada in 2013 under the brand name Fibristal. It helps shrink fibroids by blocking the effect of progesterone on the fibroid. Another medication called leuprolide, which is also known by its brand name Lupron, blocks the production of sex steroids, which in turn reduces the fibroid’s size.
Other non-surgical options for bleeding control include non-steroidal anti-inflammatories, tranexamic acid (Cyklokapron), a hormonal intrauterine system (Mirena), combined hormonal contraceptives or progestins.
High-frequency ultrasound has been used to heat and destroy fibroid tissue. Uterine fibroid embolization can be done through interventional radiology, and blocks blood flow to the fibroid allowing it to shrink.
If a patient requires surgery, pre-treating with medication can help reduce the amount of time spent in surgery, decrease blood loss and lower the risk of other complications by shrinking the fibroids ahead of time. They can also allow a surgeon to perform a less invasive procedure instead of an open one.
In my practice, the minority of women who come to see me because of abnormal uterine bleeding have a hysterectomy. All options should be discussed and the risks and benefits of each weighed. Your own medical history, personal circumstances and patient preference will help determine which treatment is right for you.
Dr. Michelle Jacobson is a lecturer in the Department of Obstetrics and Gynaecology at the University of Toronto. She is also the co-director of the Familial Ovarian Cancer Clinic at Women’s College Hospital. Katie Tucker is pursuing a Master of Health Science in the Translational Research Program at U of T and worked as a medical research associate at Allergan, which owns Fibristal, between 2016 and 2017. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine.