Surgery
The primary treatment for large and symptomatic fibroids is surgery. Hysterectomy (surgical removal of the entire uterus) is the most frequent operative technique used to treat this disorder. Hysterectomy provides a true "cure" for fibroids, although associated with a much higher morbidity than any other treatment option. Moreover, it is only an option for women who are not planning future pregnancies. Uterine fibroids were the most common indication for hysterectomy in England in 1993-1994. In USA, 30 % of the women would have had a hysterectomy by the age of 60 of which 60% would be for uterine fibroids

If childbearing potential is to be preserved, the options available are Myomectomy, UAE or TCRF (transcervical resection of fibroid). Myomectomy is a surgical procedure in which individual fibroids are removed. The incision may either be a lower abdominal transverse incision (bikini line incision) or a midline incision from above the pubic hairline to the belly button or beyond. The size of the fibroids determines the choice of the incision!

Myomectomy may also be performed through a telescope for small submucous or subserous fibroids. The telescope is introduced through the cervix for submucous fibroids (Hysteroscopy) and through an incision below the belly button, into the abdominal cavity (laparoscopy) for the subserous fibroids.

Submucous fibroids less than 10 cm in diameter can be treated by hysteroscopic resection (TCRF). Ususally a GnRH analogue is given either as subcutaneous injections or intranasally prios to the procedure. This will reduce the estrogen levels in circulation resulting in shrinkage of the fibroid together with thinning of the endometrium thus making the operation easier. The fibroid is resected using a wire loop passed down an operating hysteroscope, an instrument of up to 9mm in diameter which is introduced into the uterus via the cervix after it has been gently dilated (stretched) to allow the hysteroscope to pass. A new diathermy instrument called a versapoint and some lasers can be used in a similar fashion, to cut through the base of the fibroid or, at higher power settings, they can completely vaporise smaller fibroids.

Laparoscopic myomectomy for small subserous fibroids has minimal complications. However large sbserous fibroids up to 10 cm diameter and intramural fibroids require two or threee additional incisions 10mm in width. The principal difficulty with laparoscopic myomectomy is the repair of the uterus after the fibroid has been removed. This is done using laparoscopically applied sutures which requires considerable experience, training and a great deal of patience. After removal of the fibroid it has to be cut into thin strips of 10mm in diameter so that it can be removed, piecemeal through one of the laparoscopic ports. This is done with an instrument called a morcellator which consists of two concentric cylinders, the inner one has a sharp blade at the end and is driven to rotate by an electric motor. Although myomectomy diminishes menorrhagia in about 80% of patients there is approximately a 50% risk of recurrence within 1-10 years with 10% of women requiring another major procedure.

Myolysis involves delivering electric current via needles to a fibroid at the time of laparoscopy. Cryomyolysis involves using a freezing probe in a similar manner.

Uterine Artery Embolisation is now available on the NHS. The procedure is carried out by the radiologist after being assessed by a gynaecologist. A catheter is placed into an artery through a small incision in the groin. Under Xray control the catheter is guided into the uterine arteries. Once there, the catheter is used to deliver agents that block off these major blood vessels. These particles are like tiny grains of sand silt up the vessels around the fibroids which, deprived of their nutrition, die and shrink. The normal uterine tissue is not damaged. The procedure involves two nights stay in hospital and a week off work.

As a result the fibroids preferentially shrink over the next few months. There is a reduction in the size of the fibroids and an improvent of symptoms upto 80%. The range of shrinkage is estimated at 10-70%. No anaesthetic is required although conscious sedation is used along with strong pain relief to combat the pain that ensues. Although considered effective in controlling symptoms, the effect on childbearing potential has not been studied in scientific trials. Complications reported are sepsis resulting in a hysterectomy being performed. A few cases of premature menopause have been reported although this is more likely in an older woman approaching menopause. Haematoma formation, nausea and vomiting, bowel damage or obstruction, expulsion of fibroid, and a number of other rare complications.


The National Institute for Clinical Excellence has issued guidelines on UAE for fibroids. As the procedure is comparatively new and there is a lack of scientific evidence, a Rgistry has been set up in order to collect data on all UAE procedures being carried out in UK. Collection of data is done anonymously.