Myomectomy vs Hysterectomy: Fibroid Procedures Compared

Myomectomy vs hysterectomy is a choice between keeping and removing the uterus. Myomectomy removes only the fibroids, so it suits women who want children or wish to keep their uterus, but fibroids can return. Hysterectomy removes the uterus with the fibroids and is the definitive cure, suited to women over 40 who have completed their families. Uterine artery embolisation, a day procedure, shrinks fibroids by cutting their blood supply.

Dr. Supriya Malhotra, Senior Consultant Obstetrics & Gynaecology, Fortis La Femme, Greater Kailash II, New Delhi, India, described surgery as "the definitive treatment but not the only treatment" for fibroids. The decision between procedures turns on the woman's age, whether she wants to preserve fertility, and the size, number and position of her fibroids. This article compares the options and covers the questions that follow them: how long to wait before conceiving after a myomectomy, how to deliver, what happens to the ovaries at hysterectomy and when hormone replacement is needed. Symptoms and diagnosis are covered in the complete guide to uterine fibroids, and drug treatment in medical management of uterine fibroids.

Myomectomy vs hysterectomy at a glance

When myomectomy is the right choice

Myomectomy removes the fibroids and leaves the uterus intact. Dr. Malhotra described it as a fertility-preserving and fertility-enhancing operation, and named four situations in which she recommends it:

1. A large fibroid in a woman planning pregnancy. A fibroid larger than 8 to 10 cm will cause problems in pregnancy and is better removed first.
2. A submucosal fibroid. A fibroid growing into the cavity must be removed before a woman tries to conceive, because it impairs conception and causes miscarriage.
3. A young woman who wants more children. For example, a woman who has had one child and wants to keep her uterus for future pregnancies.
4. A woman who wants to keep her uterus. Even a woman of 30 to 35 who does not plan more children may decline hysterectomy, and myomectomy is reasonable if her fibroids can be dealt with this way.

How myomectomy is performed

Open surgery through an abdominal incision, a laparotomy, was once the standard approach. Dr. Malhotra noted that it is now rarely used, although a few indications remain. Most fibroid surgery is minimally invasive:

• Hysteroscopic, for a fibroid inside the cavity, with a camera and instruments passed through the cervix and no incision.
• Laparoscopic (keyhole surgery), for intramural fibroids and subserosal fibroids bulging from the outer surface.
• Robotic, the newest approach, which Dr. Malhotra described as even less invasive than laparoscopy. Dr. Deepika Aggarwal's article on robotic surgery for fibroids covers this approach in detail.

Do fibroids come back after myomectomy?

Fibroids can come back after myomectomy, and Dr. Malhotra counsels every patient on this central limitation before surgery. The operation removes only the fibroids the surgeon can see. Seedling fibroids too small to see may grow, and new fibroids can develop, because the hormonal environment that produced the first fibroids is unchanged until menopause. While a woman is still in her reproductive years, recurrence cannot be prevented.

Pregnancy after myomectomy

How long to wait before pregnancy after myomectomy

Dr. Malhotra advises waiting about six months before conceiving after myomectomy if the muscle wall was not opened, and at least one and a half to two years if it was; general guidance is shorter, at about three to six months, the time imaging studies show the uterine scar needs to heal. A myomectomy leaves a scar in the uterus, and the scar needs time to heal before it is stretched by a pregnancy. Dr. Malhotra draws the comparison with a caesarean section, after which she advises women to wait two years before another pregnancy. After myomectomy, the interval depends on whether the myometrium, the muscle wall of the uterus, was opened:

• Myometrium not opened. After a laparoscopic myomectomy for a pedunculated subserosal fibroid, removed at its stalk without cutting into the muscle wall, a woman can conceive after about six months.
• Myometrium opened. Where the muscle wall was cut to remove the fibroid, Dr. Malhotra advises waiting at least one and a half to two years, longer than the three to six months that most guidance considers sufficient.

How to deliver after myomectomy

The same distinction governs delivery. If the uterine cavity was opened during the myomectomy, Dr. Malhotra plans an elective caesarean section. If only a subserosal fibroid on a stalk was removed, the muscle has barely been touched and a vaginal delivery is possible. In either case, delivery must take place in hospital, never at home: complications can arise during labour, and an emergency caesarean must be available immediately.

When conception does not follow

Asked about a woman who has had a myomectomy and has been unable to conceive for a long time afterwards, Dr. Malhotra saw no reason to keep waiting. She would move to in vitro fertilisation (IVF). Dr. Shelly Singh's article on fibroids and uterine surgery before IVF explains which fibroids need correcting before an IVF cycle.

When hysterectomy is the right choice

Hysterectomy removes the whole uterus with its fibroids and is the definitive cure. Dr. Malhotra recommends it for a woman who has completed childbearing or does not want children, is over about 40 to 45 or approaching menopause, and has multiple or very large fibroids, particularly when she does not want to go on living with heavy bleeding and taking medication indefinitely. Asked about hysterectomy for a woman who has completed her family, she called it a very good option for a woman over 40, because it ends the effects of the fibroids.

What happens to the ovaries

Hysterectomy for fibroids does not automatically mean removing the ovaries. Dr. Malhotra's practice depends on age and on what the surgeon finds:

• Under 50: healthy ovaries are normally left in place. With the ovaries preserved, there is no surgical menopause.
• Over 50: the ovaries are normally removed as well.
• Unhealthy-looking ovaries in a younger woman are removed rather than left. Leaving them risks a second operation a year or two later for an ovarian cyst or tumour.

Hormone replacement after early removal of the ovaries

If the ovaries are removed before the natural age of menopause, which Dr. Malhotra put at 48 to 52, she gives hormone replacement therapy (HRT) until about 52 or 53. Surgical menopause is far more abrupt and severe than natural menopause, with marked mood swings, hot flushes, vaginal dryness, depression, anxiety and palpitations. HRT is no longer recommended for very long periods, she noted, so the aim is to bridge the woman to the normal age of menopause, not beyond it.

Uterine artery embolisation for fibroids

Uterine artery embolisation (UAE), also called uterine fibroid embolisation, treats fibroids through a blood vessel rather than an incision. It is performed by an interventional radiologist working with the gynaecologist.

How it is done

The technique resembles coronary stenting. The radiologist punctures the artery in the groin, passes a catheter and, watching on a monitor under fluoroscopy (live X-ray), guides it into the uterine artery and then into the vessel feeding the fibroid. Tiny particles of polyvinyl alcohol, about 500 microns across and the size of grains of sand, are injected. They block the fibroid's blood supply, and the fibroid shrinks over time.

Advantages

Dr. Malhotra listed the advantages:

• It is an outpatient procedure; the patient does not need to be admitted.
• The incision is very small, and no general anaesthesia is needed.
• The procedure takes less than an hour, and recovery is quick.
• It has been in use for more than 25 years and is regarded as safe and effective, although about a third of women need further treatment within five to ten years.
• Pregnancy remains possible. For women who plan to conceive, major gynaecology guidelines generally favour myomectomy, because evidence on pregnancy after embolisation is more limited.

Who it suits and who it does not

Embolisation suits women with symptomatic, often large fibroids who are not ready for surgery, do not want it or cannot safely have it, and who wish to keep the uterus. Compared with myomectomy, Dr. Malhotra regards it as less invasive and better for patients who are suitable for it. It cannot be used for every fibroid. Suspected cancer, active infection of the uterus and very large fibroids rule it out.

Radiofrequency ablation and focused ultrasound

Two newer techniques aim to destroy fibroid tissue with energy. In radiofrequency ablation, a needle placed into the fibroid under ultrasound guidance delivers heat. In magnetic resonance-guided focused ultrasound, ultrasound waves are focused on the fibroid from outside the body, with no needle. Dr. Malhotra considers both promising but not yet ready for routine use: in her assessment, more trials are needed before they enter everyday practice, and uterine artery embolisation remains the minimally invasive procedure in use today. Both techniques are offered in some centres, but evidence on their long-term results and on later pregnancy remains limited.

When fibroids are found in pregnancy

Fibroids are common, so they are commonly found in pregnancy, either for the first time on a pregnancy scan or in a woman known to have them. Many pregnancies proceed without any problem. Dr. Malhotra nonetheless treats every pregnancy with fibroids as high-risk and monitors it closely, because fibroids can cause:

• Early miscarriage.
• Pain, and growth of the fibroid in the first trimester as blood flow to the uterus increases. Once grown, fibroids do not enlarge much further in the second and third trimesters, and they shrink back to their original size after delivery.
• Degeneration, infection or necrosis when a fibroid outgrows its central blood supply, producing an acute abdomen with severe pain, nausea, vomiting and a mild fever.
• Malpresentation, a breech or transverse lie, when a fibroid low in the uterus stops the baby's head engaging.
• Preterm labour.
• Incoordinate uterine contractions in labour, which raise the caesarean rate.
• Postpartum haemorrhage.

Complications are more likely with larger fibroids and with fibroids in the lower part of the uterus.

A painful degenerating fibroid is managed in hospital with rest, adequate hydration, intravenous antibiotics and painkillers. Dr. Malhotra avoids surgery in pregnancy wherever possible because it can harm the fetus. When a fibroid cannot be managed any other way, she waits for the patient to pass the first three months and performs the myomectomy in the second trimester, the safest window for an operation. Dr. Suman Lal's article on fibroids and pregnancy covers fertility and pregnancy risks from a second specialist's perspective.

Choosing between the options

The choice reduces to three questions. Does the woman want a future pregnancy, or to keep her uterus? If so, myomectomy, or embolisation in selected cases, preserves that option at the cost of possible recurrence. Has she completed her family and reached her forties? Then hysterectomy offers a permanent end to symptoms, with the ovaries kept if she is under 50 and they are healthy. Is she unwilling or unfit for surgery? Then embolisation, provided her fibroids are suitable.

The questions doctors put to Dr. Malhotra on embolisation, myomectomy and recurrence are collected in the Live Discussion, and indicative prices for fibroid surgery are on the myomectomy cost page, with hysteroscopic removal on the hysteroscopy cost page. Dr. Malhotra's profile lists her areas of practice.