Note: In addition to this page, Dr. Parker has an entire web site dedicated to information and treatment options availble for fibroids at http://www.fibroidsecondopinion.com/
One afternoon last spring, Emily, a new patient to my practice, came bounding angrily into my office. Her regular gyncecologist had recommended a hysterectomy for fibroids, but Emily was resistant to that idea. She was hoping for another solution and would only consider major surgery as a last resort. Emily, a 45-year-old mother of two grown children, was injured in an automobile accident 7 years before. The accident had been quite serious, and Emily had to endure many months of pain and treatment. As part of her rehabilitation, she began to lift weights. She had never been the least bit athletic or even interested in fitness prior to this time. Much to her delight and to the shock of her family, Emily loved wieight-lifting and began to crave her daily workout. From the original emphasis on rehabilitating her injured body, Emily began to train seriously. The "cuts" of her muscles became an enormous new source of pride and self-esteem to this woman who had spent years exclusively as a full-time mother and homemaker. In her second year of body-building Emily started competing at body-building events.
For a year she had been having heavy and irregular bleeding. By the time she saw her gynecologist, she was changing menstrual pads every hour for four of the seven days of her period. The bleeding was sapping her strength; she was often exhausted. When her gynecologist diagnosed fibroids, he recommended a hysterectomy. Although she realized that a hysterectomy would provide a permanent solution to her problem, having to stop training for two months while recovering from major surgery wasn't acceptable. She came to my office seeking a second opinion.
After examining her, I noted that she had small fibroids, all together about the size of a lemon. First, a simple procedure called a hysteroscopy was performed in the office and revealed a small fibroid protruding into the cavity of the uterus. Based on this information and Emily's desire for a rapid recovery, I recommended a procedure called resectoscopic myomectomy and endometrial ablation. This procedure was performed as an outpatient in the hospital without any incisions. A small telescope was inserted through the vagina into the uterus, and the fibroid was removed. I also removed the lining cells of the uterus so that her periods would decrease or stop altogether. Emily spent less than four hours in the hospital. She was back lifting weights in two days and was able to successfully compete in her next body-building competition.
Fibroids are non-cancerous (benign) growths of the muscle wall of the uterus. They are probably responsible for more unnecessary gynecologic surgery than any other condition. It is a staggering number, but about 600,000 American women have a hysterectomy every year. And about 30% of those hysterectomies, 180,000 in all, are performed because of fibroids. For many years these growths have been surgically removed, often because of fear of the problems they might cause in the future. And, those problems are often overstated. While approximately 30% of all women will have fibroids during their lifetimes, the vast majority of these women will never have symptoms and will never require treatment. And, for the rare patient that does have problems, there are a number of sound and effective options available. Hysterectomy should be the solution of last resort.
While there is much we don't know about fibroids, we do know that each individual fibroid starts from a single cell growing the wrong way. But, despite ongoing research, the reason why this one cell grows to cause a fibroid remains a mystery. However, we do know that the female hormone estrogen is neccesary for fibroids to grow. We know this because fibroids do not occur before puberty when estrogen production begins, and once a woman has a fibroid it will shrink after the menopause when estrogen production ceases. Recent evidence suggests that progesterone may also be necessary for the growth of fibroids to occur. It appears that fibroids may result from a single cell mutation, but growth of the fibroid requires the complex interaction of estrogen, progesterone and cell growth-factors. However, women with fibroids are not more prone to "fibrocystic" changes in the breast, a totally different and unrelated condition. And they are not more prone to develop any other benign or cancerous conditions.
It is not uncommon for fibroids to cause an increase in the amount of menstrual bleeding. There are a number of theories as to why this happens. At the time of the menstrual period, when the uterine lining is shed, the inside of the uterus is raw and bleeding. The uterus is a muscle and has the unique ability to contract and squeeze the bleeding vessels of the uterus. Much like stepping on a hose, this prevents any more blood from being lost. Now imagine the fibroids as marbles within the uterine wall. They don't allow the uterus to squeeze down properly, and it can't stop the flow of blood from the vessels.
Other medical conditions may also cause heavy bleeding or bleeding in between periods. For example, hormonal changes, polyps, overgrowth of the uterine lining, or rarely, even precancer or cancer of the uterus can all result in abnormal bleeding. Therefore, any abnormal bleeding should be reported to your physician, and you should get a thorough examination.
Your uterus is just under the bladder, just above the rectum, and surrounded by the intestines. Since it is so near to these other organs, growth of the uterus from fibroids may cause pressure or, rarely, pain in the pelvis. The uterus is normally about the size of a small pear. But with fibroids, the uterus may enlarge to the size of a small watermelon. If the fibroids grow toward your back, pressure can cause pain in the lower back, discomfort with activity or intercourse or constipation. If the fibroids press on the bladder, frequency of urination or incontinence can ocurr. If the uterus grows as large as a cantaloupe, the enlarged uterus may cause enough discomfort or enough visible change to warrant treatment.
If you do need treatment for fibroids, it is fortunate that there are a number of options available to you. The choices regarding treatment of uterine fibroids are guided by the medical problems the fibroids are causing, your desire to have children, and your feelings and thoughts about surgery. I think it is helpful for you to know all of the options available. Fibroids almost never need urgent or immediate treatment. For the vast majority of women, there is plenty of time for careful thought and planning.
Unfortunately, there are no medications which are able to prevent the formation of fibroids or permanently shrink them once they are present. With medication we are often buying time or reducing symptoms. For some women, a reduction in discomfort is enough to indefinitely postpone surgery. For still others, the medication allows a more relaxed time period to prepare emotionally and physically for what may be an inevitable surgery. The medications may also temporarily reduce the size of the fibroids enough to allow for a less invasive surgery with a quicker recovery. For some women who are approaching the menopause, the "bought time" may lead them right into menopause, when the natural loss of estrogen shrinks the fibroids. Once again, hysterectomy is the choice of last resort.
Myomectomy means the surgical removal of just the fibroid, with reconstruction and repair of the uterus. This procedure is excellent for women who wish to maintain their ability to have children, or who just prefer to avoid removal of the uterus. The standard method of performing a myomectomy is by laparotomy, making a 4-6 inch "bikini" incision just below the pubic hair line. The covering of the uterus overlying the fibroid is cut, and the fibroids are separated away from the normal uterine muscle. Following this, the remaining normal uterine muscle is sewn back together. This procedure takes about 1-2 hours to perform, depending on the number and position of the fibroids. The hospital stay is 3-4 days.
The short answer is no. Some doctors and some managed care organizations have policies stating that a myomectomy cannot be attempted if the uterus is bigger than a certain size – hysterectomy is the only option that they will offer. However, skilled gynecologic surgeons can perform a myomectomy on just about any size uterus. One of the risks of a myomectomy is bleeding from the uterus during surgery. However, there are a number of techniques that can be used to reduce bleeding. A medication can be injected into the uterus that causes the blood vessels in the muscle to constrict, and less blood will seep out of the incisions in the uterine wall. Other doctors place an elastic tourniquet around the lower portion of the uterus to decrease the blood flow to the uterus. For very large fibroids, some doctors use a machine, called a cell-saver, during surgery. Blood that pools around the uterine incisions is removed, filtered by the cell-saver and replaced back into the patient’s circulation through a vein. Thus, the patient receives an immediate transfusion of her own blood, and there is no risk of HIV infection or mismatched blood. Many gynecologists don’t have training in these techniques and so don’t offer them. Ask your doctor and get some clarification on this issue.
Laparoscopic myomectomy is another way to surgically remove fibroids. Laparoscopic surgery is usually performed as outpatient surgery under general anesthesia and has absolutely revolutionized gynecologic surgery because of the short hospital stay and quick recovery that results. The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Two or three small, 1/2 inch incisions are made below the pubic hair line. Instruments are passed through these small incisions to perform the surgery. The procedure can take one to three hours depending on the number, size and depth of the fibroids within the muscle wall. Following laparoscopic myomectomy many women are able to leave the hospital the same day as surgery. For more extensive surgery, a one or two day stay may be necessary. Because the incisions are small, recuperation is usually associated with minimal discomfort and most women return to normal activity, work and exercise within two weeks.
Laparoscopic myomectomy is technically difficult surgery, so that your physician should have the extra training and experience that it requires. It is your right to ask about qualifications - how were you trained to do this surgery?, how many of these operations have you performed for women with a situation like mine? have you had any complications? - when talking to your doctor or interviewing a gynecologic surgeon.
Resectoscope myomectomy is a technique that can be performed only if the fibroids causing the symptoms are within the uterine cavity. A small telescope, the resectoscope, is passed through the cervix, and the internal uterine cavity is seen. Electricity is passed through a thin wire attachment of the telescope allowing the instrument to cut through the fibroid like a hot knife through butter. This procedure is performed as outpatient surgery, without any incisions and most patients are able to go back to normal activity in one or two days.
When resectoscope myomectomy is performed for heavy bleeding, nearly 90% of patients return to normal menstrual flow. When fibroids are the cause of infertility, pregnancy rates following this procedure have been about 50%. Only a few years ago, treatment for fibroids in the cavity of the uterus involved major surgery - an abdominal incision and either cutting open the entire uterus to remove the fibroid, or performing a hysterectomy. Resectoscope myomectomy has been a major advance in the treatment of women who have submucous fibroids.
Uterine artery embolization (U.F.E.) is a non-surgical technique that shrinks fibroids without removing them. The procedure is performed by an interventional radiologist (an M.D.) who guides a long thin catheter (tube) into the blood vessels that supply the uterus while monitoring the process under x-ray. Small plastic particles are pushed through the catheter until they form a blockade to the blood flowing to the uterus. Fibroids have a limited supply of blood vessels, and with the blood flow blocked, the fibroid cells start to die off. The surrounding normal uterine muscle has a better blood supply and is able to survive. Deprived of blood, nutrition and oxygen, fibroids shrink like prunes for the three to six months following embolization, and the symptoms from the fibroids often lessen as well.
Embolization has been used in medicine for many years and has been used in gynecology since 1972 to stop heavy bleeding from cervical cancer or heavy bleeding from the uterus that rarely occurs after childbirth. Embolization has been very effective for those women, with success rates of 85-100%. Embolization was first used to treat fibroids by the French physician Dr. Jaques Ravina in 1995. Interestingly, his idea was to stop the vaginal bleeding caused by large fibroids prior to performing an abdominal myomectomy. To his surprise, many of the women who were scheduled to come back for surgery after embolization cancelled surgery because most of their symptoms had disappeared as a result of the embolization. It became clear to Dr. Ravina that embolization might be more than a preparation for surgery; it might be the only treatment needed. Shortly after Dr. Ravina published his findings, uterine fibroid embolization became available in many countries around the world. It has now been performed in over 25,000 women.
Embolization is still a relatively new procedure, and selecting the appropriate women who will clearly benefit from UAE is still a work in progress. There remains some difference of opinion amongst interventional radiologists, and even more differences between gynecologists and interventional radiologists as to who should have the procedure. Obviously, the first criteria for treatment would be the presence of fibroid symptoms bothersome enough to require that something be done. As is true for fibroid treatment in general, the option of doing nothing exists unless the fibroids are causing significant anemia or the fibroids are blocking the ureters and threatening harm to the kidneys.
UAE works well for women who have large fibroids that are causing discomfort or pain because of their size. If shrinking the fibroids to a little more than half their present size would relieve your symptoms, then UFE may be right for you. However, UAE may not be very helpful for women with extremely large fibroids because they may not shrink enough to make a difference in the symptoms.
Women with fibroids on a stalk outside the uterus, called pedunculated fibroids, should not have UFE. Embolization can cause the stalk to deteriorate and allow the fibroid to float around the abdominal cavity. The dead tissue causes an inflammation inside the abdomen resulting in pain and fever. Surgery may be required to remove the degenerating fibroid. Fibroids that mostly bulge inside the uterine cavity, submucous fibroids, may also detach and float inside the uterine cavity after embolization. The uterus will then cramp and contract in order to expel the fibroid. Discharge and blood may accompany this process, and sometimes infection develops. If the fibroid is not expelled, surgery may be needed to remove it.
UFE works well for women who have fibroids that are causing heavy bleeding. If your fibroids are small, endometrial ablation may alleviate your symptoms. This outpatient procedure also allows you to avoid hysterectomy and is painless, inexpensive, fast and has a one-day recovery period. However, ablation may not be technically possible if your fibroids are very large. Embolization works very well for women with bleeding and large fibroids
I believe hysterectomy for uterine fibroids should be performed as a last resort. The many issues concerning hysterectomy are fully discussed in the "Hysterectomy" chapter of A Gynecologist's Second Opinion. Hysterectomy is a major operation and carries with it risks of infection, injury to other organs, anesthesia risks, and blood loss that can sometimes result in the need for transfusion. While complications are uncommon, they should not be taken lightly. Also, recovery from abdominal hysterectomy, with the incision made through the abdomen, takes 4-6 weeks, and recovery from vaginal hysterectomy may take 4 weeks. That's a large chunk out of your life. The cost of surgery is expensive, including doctor's fees, anesthesia fees, hospital charges, and operating room charges. So, if major surgery can be avoided, that's preferable.
For the woman who has symptoms from fibroids that require her to have surgery and who does not wish any, or any more, children, removal of the uterus should be discussed. Hysterectomy may be appropriate for a woman who has multiple fibroids, or very large fibroids, and who does not want to take a chance that another surgery may be needed for fibroids at a later time. Hysterectomy can be an option for women who have fibroids, but only when fertility is not an issue, only when other options have been tried, only when they are emotionally prepared, only as a last resort.
For more information about fibroids, please visit http://www.fibroidsecondopinion.com/
|Order A Gynecologist's
Second Opinion directly from Amazon.com by
or visiting the Amazon.com web site.
Disclaimer: The ideas, procedures and suggestions contained on this web site are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision.