Meet Elizabeth, G0 P0, a middle-aged White woman who had struggled with heavy vaginal bleeding and pelvic pain secondary to uterine fibroids. Like many women, her initial consultations led to discussions about hysterectomy as a first-line treatment to return to optimal health. The news left her emotionally gutted, as she did not feel comfortable losing her uterus. She was eager to explore alternative options. Was there another option? She discovered MRI-guided focused ultrasound (MRgFUS), a cutting-edge non-invasive procedure. After one outpatient procedure, she experienced significant relief from her symptoms and returned to her normal activities without the need for invasive surgery. Her story reflects the value of patient counselling and shared decision-making and the availability of less invasive treatment options for uterine fibroids.

Uterine fibroids occur in about 25% of women in their reproductive age and more than 40% of women after menopause. Studies show that over 60% of African American women and nearly 40% of White women have fibroids by age 35. Fibroids are known to be the most common indication for hysterectomy. Clinicians manage asymptomatic uterine fibroids conservatively, whereas symptomatic uterine fibroids are an indication for treatment. A national survey of 968 affected women between 29 and 59 years with fibroids conducted in the USA and published by the American Journal of Obstetrics and Gynecology revealed that 79% expressed a desire to avoid invasive surgery or long recoveries, and more than half reported a preference for uterine preservation, regardless of future fertility.

Current treatment: Minimally invasive alternatives to hysterectomy exist. They include Uterine Artery Embolization (UAE), Magnetic Resonance-Guided Focused Ultrasound Surgery (MRgFUS), and MR-guided High-Intensity Focused Ultrasound (MR-HIFU) Radiofrequency Ablation.

According to ACOG guidelines (2022), office hysteroscopy is an outpatient procedure performed on an outpatient basis. It is a simple and cost-effective treatment modality for optimizing the care of patients with submucosal uterine fibroids. Hysteroscopy is considered a safe procedure and has the advantage of diagnosing and treating these fibroids with a single minimally invasive procedure in women who present with abnormal uterine bleeding. Recovery is quicker, and complications (such as intrauterine scarring, infections, and injury to adjacent structures) occur in less than 1% of cases.

Endometrial ablation is used to manage abnormal uterine bleeding. It entails permanent destruction of the endometrial lining. It reduces the bleeding and, in some cases, stops it altogether. However, it is not used for bulk symptoms caused by large fibroids and is also not suitable for candidates seeking to preserve their fertility. There are various types, such as radiofrequency energy, heated balloon (balloon therapy), microwave energy, cryoablation, heated fluid(hydrothermal), and electrosurgery with a roller-ball-tipped microscope. 

Uterine Artery Embolization blocks the blood supply to fibroids, causing shrinkage, reducing bleeding, and preserving the uterus. According to ACOG (2020), about 3 in 4 women who had UAE got relief from fibroid symptoms, and about 1 in 5 women who had UAE later needed another surgery for their fibroids (including a second UAE, myomectomy, or hysterectomy). Also, greater than 85% of patients would recommend the procedure to a friend or family member, which speaks for itself. Some of its disadvantages are complications like post-embolization syndrome, ovarian failure, and reduced fertility.

The non-invasive MR-guided focused ultrasound ablation has been available to women in the U.S. It was approved by the Food and Drug Administration (FDA) in 2004. It uses MRI to guide ultrasound waves that target fibroid tissue. Recovery is speedy, and patients can return to daily work and lifestyle the next day. It preserves fertility, and many achieve successful pregnancies. 

HIFU is a safe, non-invasive, and highly effective standard treatment with a broad indication range for fibroids of varying sizes. It involves delivering concentrated ultrasound energy to induce thermal coagulation and necrosis of fibroid tissue—research into HIFU dates back to the early 1900s, with significant breakthroughs in recent decades. While the treatment has high efficacy and minimal complications, it is time-intensive and limited by availability at specialized centers. Despite these limitations, HIFU remains a promising option for preserving fertility and avoiding invasive surgery.

Radiofrequency ablation is a safe, versatile, and minimally invasive outpatient procedure that involves the thermal destruction of fibroids through radiofrequency. It is done through the cervix (Sonata) or laparoscopically (Acessa) and is ideal for small fibroids. RFA is used for small intramural fibroids. It preserves the uterus, and recovery time is short. Unlike myomectomy, techniques like Sonata do not involve entering the myometrium, which may protect uterine integrity. However, there is limited data on fertility outcomes following RFA.

For many women, the emotional and psychological weight of undergoing hysterectomy is profound. The potential loss of fertility triggers deep feelings of depression and a sense of loss. It also underscores the importance of offering fertility-preserving or uterus-sparing alternatives. These options empower women to make informed decisions that honor their reproductive goals and personal values without undergoing invasive surgery or sacrificing their future fertility. 

With increasing awareness and technological leaps, women like Elizabeth are embracing their autonomy and exploring alternatives to hysterectomy. The evolving standard of care in fibroid management must prioritize clinical outcomes and the voices and values of the women most affected.

References 

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