Philosophy of Management
|The management of the
uterine fibroids is varied and even
controversial. Our experience dictates
that the management depends upon the
size of the uterus, the symptoms present
and the desire of the patient.
If the uterus is less than 12 weeks
in size and there are no symptoms, then
the patient can be followed without
any treatment. However, if the uterus
is 12 weeks in size or greater, the
most important consideration is "what
is the desire of the patient."
What would be her preference if she
were symptomatic now or in the future?
If the patient preferred to salvage
her uterus, she should have that option
and her treatment should be accordingly.
The choice would therefore be a myomectomy.
most important consideration
is the desire of the
Myomectomy was first recorded as being
performed in 1884, and became more popular
in the 1930’s. However, the procedure
was complicated by excessive bleeding and
infection followed by the development of
adhesions in the pelvis. The resultant adhesion
formation also often compromised childbearing
function. The blood loss often required
Today, conventional myomectomy is still
associated with excessive bleeding and adhesion
formation. Therefore, this procedure had
primarily been reserved for the preservation
of childbearing capacity.
However, since the introduction of laser
methods and the addition of adhesion prevention
methods into surgical techniques, myomectomy
has become more popular and we can now expand
the criteria. Now myomectomy need not be
limited only to women who wish to preserve
their reproductive capacity. Instead, any
woman who prefers to preserve her reproductive
organs should have the choice to participate
in the decision-making process. Nowhere
is choice more important than when a woman
faces the possible loss of her reproductive
The Fibroid Center of
At The Fibroid Center of New Orleans we
have performed more that 1000 myomectomies.
Our experience has been that blood loss
has been minimized and we have not given
a blood transfusion for surgical blood loss.
We have minimized the formation of pelvic
adhesions which can compromise fertility
and/or cause pelvic pain, and we have had
many patients who have become pregnant and
delivered a baby. However, we have had 15%
of patients with recurrent fibroids which
required a second myomectomy or hysterectomy.
Again, the choice of the procedure was based
upon the patient’s desire.
There are other treatment modalities available,
but they are temporizing methods at best.
These treatments are listed as drug therapy,
myolysis and even uterine artery embolization.
Because these treatment modalities are relatively
recent in medical practice, the long-term
result is still unknown. There are several
known factors that speak against these treatments
as being definitive. The first is that the
uterus is a very vascular organ and neoangiogenesis
is a physiological mechanism by which the
uterus repairs itself (new growth of blood
vessels and blood supply). Therefore, over
a period of time the uterus and the fibroid
tissue would have recovery ability and growth.
Lastly, fibroids are often numerous and
multifaceted; therefore, all areas may not
respond or may respond differently. The
future expectation with drug therapy is
that the fibroids may be prevented or treated
medically. If clinical trials continue to
confirm the efficacy of experimental drugs,
long-term medical treatment of fibroids
could become a practical option.
Management should be all-encompassing:
- Pre-operative - would
be to prepare the patient physically and
emotionally for surgery. An informed patient
responds more rapidly.
- Intra-operative - emphasizing
good, meticulous surgical technique and
concentrating on adhesion prevention produces
the best over-all result.
- Post-operative - patient
is aware of post-operative care and methods
to reduce risk of complications.