2005

Focused Ultrasound Is a Safe Alternative to Hysterectomy to Treat Symptomatic Uterine Fibroid Tumors

Points to Remember

• Uterine fibroid tumors are one of the most common disorders women experience during the
  pre- and perimenopausal years.
• Although fibroid tumors are benign, they may cause considerable pelvic discomfort.
• Hysterectomy, surgical myomectomy, and more recently, uterine artery embolization have been the main treatment options.
• Mayo Clinic is one of 8 medical centers in the United States to offer patients focused ultrasound, a new noninvasive outpatient treatment for uterine fibroids.

Scope of Problem

Uterine fibroid tumors — also called leiomyomas — are
hormone-dependent tumors that commonly occur in the pre- and perimenopausal years, affecting an estimated 40% of women over the age of 40 years. They are the primary indication for hysterectomy, accounting for an estimated 200,000 hysterectomies annually. Although uterine fibroids are benign, they can lead to considerable disruption in family, work, and social life because of the excessive menstrual bleeding they cause. In addition to heavy bleeding, uterine fibroid tumors can cause other symptoms such as pelvic pain, uncomfortable pressure, constipation, and urinary tract problems. Various other symptoms occur when tumors reach 10 mm to 20 cm in size.

Known risk factors for the development of uterine fibroid tumors include obesity and early age of menarche, which increases a woman's lifetime exposure to estrogen. African American women are at greater risk than white women for developing uterine fibroid tumors.

Standard Treatments and Their Limitations

Enlarge

Historically, severe cases of uterine fibroid tumors have been treated surgically through hysterectomy to remove the uterus. Exposing women to the surgical risk, discomfort, and recovery time -- 1 to 3 days in the hospital and up to 6 weeks' recovery time -- deters many women from choosing hysterectomy. In the past decade, uterine artery embolization has been available for treatment as well. Inducing broad ischemia throughout the uterus with uterine artery embolization requires an invasive procedure and 1 to 2 days of hospitalization. Results are generally favorable, but bleeding and pressure symptoms persist or recur in about 10% of cases. Myomectomy is a similar surgical procedure, but it preserves the uterus. Up to one-third of women undergoing myomectomy have further problems with uterine fibroids in the future.

A New Approach: Focused Ultrasound

Focused ultrasound is the first completely noninvasive, outpatient treatment option for symptomatic uterine fibroid tumors. The device was approved for clinical use in October 2004 by the US Food and Drug Administration and this treatment is available at 8 US medical centers, including Mayo Clinic. Mayo Clinic physicians have been evaluating the procedure since 2002 and have found the results to be excellent, with roughly 80% of women reporting considerable improvement in their symptoms.

For best results, focused ultrasound requires multidisciplinary expertise and a team approach that begins with a consultation in the Department of Obstetrics and Gynecology. There the patient is evaluated to determine if focused ultrasound is, in fact, her best option. Any other relevant health issues can also be detected and discussed at this time. Radiologists with special expertise then perform the procedure.

Focused ultrasound technology relies on the precise delivery of high-energy sound waves to destroy noncancerous tumors that have grown on the uterine lining. Treatment is done with an MRI-guided ultrasound machine in a single session that lasts 2 to 4 hours, with a typical session lasting 3 hours. The patient is given a mild sedative before and during the procedure and lies face down while the radiologist uses a computer to guide the MRI machine and locate the fibroids. Once located, the tumor core receives a series of high-frequency, high-energy sound waves. The patient may feel a sensation of warmth or a cramping sensation in her pelvis. No hospitalization is necessary. Generally patients require no pain medication after the procedure.

Advantages of Focused Ultrasound

Demand for this procedure is high because women want a noninvasive, safe, effective alternative to hysterectomy or myomectomy for this common problem. Patients treated with focused ultrasound leave the physician's office several hours after the procedure and resume activities the following day. Although they may experience a sensation of heat or cramping in the lower abdomen during the 20-second applications of the ultrasound beam, recovery is usually painless.

Disadvantages

Focused ultrasound is not widely available. It requires travel to a medical center where the procedure is offered. Some women have required a second treatment for optimal results.

Indications for Treatment With Focused Ultrasound

The ideal patient for focused ultrasound treatment is premenopausal, is in her mid 30s to mid 50s, and must have finished childbearing or does not wish to bear children. She is bothered by uterine bleeding so profuse that it soaks a menstrual pad in less than 2 hours, requiring multiple changes throughout the day, or is troubled by pelvic pressure, urinary frequency, or constipation due to uterine fibroids.

Contraindications

Focused ultrasound is not suited for women who still desire to bear children. While it may be tempting to view this treatment as a way to treat fibroids and preserve fertility because the uterus is not removed, as it is in hysterectomy, the implications for fertility, safe pregnancy, and delivery after treatment are unknown.