Medical Management

VIII. MEDICAL MANAGEMENT Treatment depends on various factors, including: •

Age

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General health

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Severity of symptoms

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Size of fibroids

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Whether you are pregnant

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If you want children in the future

Some women may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth. Treatment for fibroids may include: •

Birth control pills (oral contraceptives) to help control heavy periods

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Iron supplements to prevent anemia due to heavy periods

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Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn for cramps or pain with menstruation

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Some women may need hormonal therapy (Depo Leuprolide injections) to shrink the fibroids.

SURGICAL MANAGEMENT: Hysterectomy A hysterectomy is a surgical procedure whereby the uterus (womb) is removed. Hysterectomy is the most common non-obstetrical procedure of women in the United States. Why is a hysterectomy performed? The most common reason hysterectomy is performed is for uterine fibroids The next most common reasons are abnormal uterine bleeding, endometriosis, and uterine prolapse (including pelvic relaxation). Only 10% of hysterectomy is performed for cancer of the uterus or very severe pre-cancers (called dysplasia). Uterine fibroids (also known as uterine leiomyomata) are by far the most common reason a hysterectomy is performed. Uterine fibroids are benign growths of the uterus, the cause of which is unknown. Although they are benign, meaning they do not cause or turn into cancer, uterine fibroids can cause medical problems, such as excessive bleeding, for which hysterectomy is sometimes recommended. What tests or treatments are performed prior to a hysterectomy? Prior to having a hysterectomy for pelvic pain, women usually undergo more limited (less extensive) exploratory surgery procedures (such as laparoscopy) to rule out other causes

of pain. Prior to having a hysterectomy for abnormal uterine bleeding, women require some type of sampling of the lining of the uterus (biopsy of the endometrium) to rule out cancer or pre-cancer of the uterus. This procedure is called endometrial sampling. In a woman with pelvic pain or bleeding, a trial of medication treatment is often given before a hysterectomy is considered. How is a hysterectomy performed? Most commonly, a hysterectomy is done by an incision (cut) through the abdomen (abdominal hysterectomy) or through the vagina (vaginal hysterectomy). The hospital stay generally tends to be longer with an abdominal hysterectomy than with a vaginal hysterectomy (4 vs. 6 days on average) and hospital charges tend to be higher. The procedures seem to take comparable lengths of time (about 2 hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may take longer. What are complications of a hysterectomy? Complications of a hysterectomy include infection, pain, and bleeding in the surgical area. An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy. Aftercare After surgery, a woman will feel some degree of discomfort; this is generally greatest in abdominal hysterectomies because of the incision. Hospital stays vary from about two days (laparoscopic-assisted vaginal hysterectomy) to five or six days (abdominal hysterectomy with bilateral salpingo-oophorectomy). During the hospital stay, the doctor will probably order more blood tests. Risks Hysterectomy is a relatively safe operation, although like all major surgery it carries risks. These include unanticipated reaction to anesthesia, internal bleeding, blood clots, damage to other organs such as the bladder, and post-surgery infection. Other complications sometimes reported after a hysterectomy include changes in sex drive, weight gain, constipation, and pelvic pain. Hot flashes and other symptoms of menopause can occur if the ovaries are removed. Women who have both ovaries removed and who do not take estrogen replacement therapy run an increased risk for heart disease and osteoporosis (a condition that causes bones to be brittle). Women with a history of psychological and emotional problems before the hysterectomy are likely to experience psychological difficulties after the operation. Alternatives Women for whom a hysterectomy is recommended should discuss possible alternatives with their doctor and consider getting a second opinion , since this is major surgery with life-changing implications. Whether an alternative is appropriate for any individual woman is a decision she and her doctor should make together. Some alternative procedures to hysterectomy include:

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Embolization. During uterine artery embolization, interventional radiologists put a catheter into the artery that leads to the uterus and inject polyvinyl alcohol particles right where the artery leads to the blood vessels that nourish the fibroids. By killing off those blood vessels, the fibroids have no more blood supply, and they die off. Severe cramping and pain after the procedure is common, but serious complications are less than 5% and the procedure may protect fertility.

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Myomectomy . A myomectomy is a surgery used to remove fibroids, thus avoiding a hysterectomy. Hysteroscopic myomectomy, in which a surgical hysteroscope (telescope) is inserted into the uterus through the vagina, can be done on an outpatient basis. If there are large fibroids, however, an abdominal incision is required. Patients typically are hospitalized for two to three days after the procedure and require up to six weeks recovery. Laparoscopic myomectomies are also being done more often. They only require three small incisions in the abdomen, and have much shorter hospitalization and recovery times. Once the fibroids have been removed, the surgeon must repair the wall of the uterus to eliminate future bleeding or infection.

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Endometrial ablation. In this surgical procedure, recommended for women with small fibroids, the entire lining of the uterus is removed. After undergoing endometrial ablation, patients are no longer fertile. The uterine cavity is filled with fluid and a hysteroscope is inserted to provide a clear view of the uterus. Then, the lining of the uterus is destroyed using a laser beam or electric voltage. The procedure is typically done under anesthesia, although women can go home the same day as the surgery. Another newer procedure involves using a balloon, which is filled with superheated liquid and inflated until it fills the uterus. The liquid kills the lining, and after eight minutes the balloon is removed.

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Endometrial resection. The uterine lining is destroyed during this procedure using an electrosurgical wire loop (similar to endometrial ablation).

THE PATIENT HAD UNDERGONE: Total abdominal hysterectomy This is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy. Clearly a woman cannot bear children herself after this procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause. Abdominal hysterectomies take from one to three hours. The hospital stay is three to five days, and it takes four to eight weeks to return to normal activities.

Salpingo-Oophorectomy (Removal of the Ovaries and/or Fallopian Tubes) Salpingo-oophorectomy is the removal of the ovary and its adjacent fallopian tube. This procedure is performed for cancer of the ovary, removal of suspicious ovarian tumors, or Fallopian tube cancer (which is very rare). It may also be performed due to complications of infection, or in combination with hysterectomy for cancer. Application of Jackson-Pratt Drain A Jackson-Pratt drain, JP drain, or Bulb drain, is a suction drainage device used to pull excess fluid from the body by constant suction. The device consists of a flexible plastic bulb -- shaped something like a hand grenade -- that connects to an internal plastic drainage tube. Removing the plug and squeezing the bulb removes air, which creates a lower air pressure within the drainage tubing. The best way to accomplish this is to essentially fold the drain in half while it is uncapped, then while folded, recap the drain. This action causes fluid to be gradually sucked out of the body and into the bulb itself. The bulb may be repeatedly opened to remove the collected fluid and squeezed again to restore suction. It is best to empty drains before they are more than half full to avoid the discomfort of the weight of the drain pulling on the internal tubing. Patients or caretakers can "milk" or "strip" the drains by taking a damp towel or piece of cloth and bracing the portion of the tubing closest to the body with your fingers, run the cloth down the length of the tube to the drain bulb. One can also put a little bit of lotion or mineral oil on their fingertips to lubricate the tube to make stripping easier. The portion of the tube closest to the exit point of the drain from the body should be gripped first, and once the length of the drain is stripped, the end closest to the bulb should then be released. This increases the level of suction and helps to move clots through the drainage tube into the bulb.