Other Options
Other Treatment Methods

   Available Options
 Are there any other methods available for me

Once the diagnosis of the fibroid tumors is established, other treatment options for fibroid tumors include:

 + Observation

The “wait and see” approach is recommended for women who are not suffering symptoms of fibroid disease and who have not developed anemia from heavy menstrual bleeding. Since fibroids generally continue to grow until menopause, women without symptoms should continue to undergo regular gynecological follow up.

 + Medical Therapy

There are a number of drugs that can be used for the treatment of fibroids. Including:

  • Birth-control pills
  • Progestins (e.g., Megace)
  • GnRH analogues (e.g., Lupron)

In addition, nonsteroidal anti-inflammatory drugs (e.g., Motrin) can also be helpful in controlling many of the symptoms caused by fibroids. GnRH agonists (e.g., Lupron ®) are most often used as a temporizing measure to avoid transfusion. If these therapies are unsuccessful, UFE or surgical approaches such as endometrial ablation, myolysis, myomectomy or hysterectomy are often performed.

+ MR guided focused ultrasound (ExAblate)

A novel and non-invasive image-guided surgery 
(with permission from InSightec - www.insightec.com)

  Focused Ultrasound 

The ultrasound is focused in a manner similar to how a magnifying glass focuses light.  The ultrasound waves are directed from a transducer (a device that converts electrical energy into ultrasound energy) into a small focal volume.  During treatment, the beam of focused ultrasound energy penetrates through soft tissue and produces well defined regions of protein denaturation, irreversible cell damage, and coagulative necrosis, at specific target locations.  A single exposure of focused ultrasound energy is called a “sonication.”  Multiple sonications are necessary to ablate the targeted tissue.  Tight focusing is designed to limit the ablation to the targeted location. 

  MR guidance

 Prior to the treatment, anatomical MR images, capable of showing the tumor and surrounding organs, are used to position the patient and plan the treatment.  As the treatment is performed, the MR thermal mapping system displays the relative tissue temperature as a color map superimposed on an anatomical MR image.  This allows the physician to observe temperature changes inside the body in real time during treatment.  Based on these observed temperature changes, the physician can adjust treatment parameters accordingly to ensure safe and effective thermal ablation.  Following the treatment, anatomical MR images are used to evaluate treatment outcome.  T1 weighted images with Gadolinium contrast agent is often used to determine which regions have become ablated. 
 

The patient lies in the prone position on a patient table inside the MRI during the treatment.
 (Courtesy of InSightec).

Focused ultrasound waves are directed towards the fibroid. During each “sonification” (dose of focused ultrasound), a small volume of the fibroid is ablated. After multiple sonifications the entire fibroid is ablated. Focused ultrasound generates heat, ablating tissue only at the focal point. The effect is similar to a magnifying glass used to focus the sun’s energy on a single point
(Courtesy of InSightec).

The figure on the left of a sigittal T2-weighted MR image clearly shows the presence of multiple fibroids (red circles) in the uterus (blue circle) in front of spine (arrow lines)
(Courtesy of InSightec).

+ MR Guided Focused Ultrasound (ExAblate) clinical results


FDA approval is based on the results of a multi-national trial conducted in 109 women with symptomatic uterine fibroids at seven medical centers around the world.   After six months, 70.6 percent of the women reported a significant improvement in fibroid related symptoms. The study compared the results of ExAblate treatment with total abdominal hysterectomy. Patients treated with the ExAblate missed 1.4 working days, on average compared to an average of 18 days for the hysterectomy group. They returned to normal activity in less than three days, compared to 17 days for the hysterectomy group. Adverse events, while rare, included minor skin burns and a few instances of nerve injury, all of which resolved within one year.

A coronal view of pelvic MRI during ExAblate treatment shows the fibroid (blue colored) being targeted for  MRgFUS
(Courtesy of InSightec).

A coronal view of contrast enhanced pelvic MRI after ExAblate treatment on the same patient above shows necrosis (dark area due to no blood supply caused by the treatment) (Courtesy of InSightec).

+ Benefits of ExAblate (MR guided Focused Ultrasound) Treatment

  • Incisionless thermal ablation of soft tissue.

  • Integrated MR imaging for treatment planning.

  • Real time visualization, monitoring, and control of treatment.

  • No ionizing radiation, means repeatable treatments.

  • Many potential applications.

A sagittal view of pelvic MRI (T2-weighted) on another patient showed a large fibroid in the uterus
(Courtesy of Sheba Medical Center, Tel Aviv, Israel)..

A contrast enhance sagittal view of pelvic MRI on the same patient  one month after ExAblate treatment shows necrosis (dark area in the uterus) of the fibroid with some shrinkage
(Courtesy of Sheba Medical Center, Tel Aviv, Israel)..

 

Another follow-up contrast enhanced pelvic MRI of the same patient above (36 months after treatment)  shows persistent necrosis (dark area due to no blood supply) of the fibroid with further tumor shrinkage
(Courtesy of Sheba Medical Center, Tel Aviv, Israel).

+ Surgery

  • Some women may be advised to have their fibroids removed. Surgery may be recommended if:  

  • The initial evaluation was not able to determine whether a growth is a fibroid or another type of tumor
  • There is a rapid increase in the growth of a fibroid
  • Very large fibroids with significant symptoms
  • When conservative treatments, such as medications and hormone therapy, fail

 

             + Myomectomy

Myomectomy is a surgical procedure that involves removing the fibroids and repairing the uterus as much as possible. Depending on the location and size of the fibroids, myomectomy can be performed through an incison made in the abdomen (Lapartomy),  through a laparoscope (Laparoscopic myomectomy), or through a hysteroscope (Hysteroscopic myomectomy). The fibroids that are located deep in the walls of uterus cannot be removed by myomectomy.  Fibroids may recur in 20-40% of cases, and more surgery may be needed. Myomectomy is often recommended for woman who wants to keep her uterus and maintain their child bearing potential. However, myomectomy can cause internal scarring resulting in infertility. Although myomectomy has been the standard therapy for women with fibroids who desire future fertility, UFE can be considered as an option if myomectomy seems unfavorable or patients strongly desire to avoid surgery.

             + Hysterectomy

Hysterectomy, or removal of the uterus, is a major surgical procedure, and is performed through an incision in the abdomen or through the vagina. General anesthesia is usually used for the operation and the patient stays in the hospital for a few days after the surgery. Hysterectomy is the most frequent operation performed on woman.  After a hysterectomy, a woman no longer has periods and is unable to become pregnant. Hysterectomy for uterine fibroids  should be reserved for patients who do not respond to, who cannot tolerate medical therapy, and who do not desire future fertility. For those patients who desire future fertility, myomectomy or other alternatives such as UFE should be considered .

 

  + Myolysis

Myolysis is a laparoscopic procedure in which electric current is applied repeatedly to each fibroid. This coagulates both the tumor and its blood supply. The fibroid dies, shrinks in size and is incapable of growing again. This approach is best used either alone or in combination with laparoscopic myomectomy when multiple fibroids are encountered.