Fibroids


What are fibroid tumors?

Fibroid tumors are also called myomas or leiomyomas(latin for fibroid). They are almost always benign tumors. The normal uterine muscle tissue looks pink while most fibroids are white in appearance. They were originally called fibroids because they were white like fibrous tissue. When the microscope was developed their true origin was understood.

What causes fibroids?
Each fibroid represents an individual mutation of a single uterine muscle cell. They are more common in women of African descent(80% lifetime risk) than Asian, Hispanic, and Caucasian women(70% risk). They tend to run in families, indicating a possible genetic link.
Estrogen is involved in fibroid growth. We know they shrink after menopause or when medications are given that temporarily stop ovarian estrogen production. Also, progesterone plays a role in growth. Medication that are progesterone blockers shrink fibroids while estrogen levels from the ovary are elevated.

Is there a concern that they could be cancerous?
The incidence of cancer in fibroid tumors is 1-2/1000 cases in premenopausal women. Neither rapid growth nor degeneration has been shown to predict cancer preoperatively. The American College of OB/GYN(ACOG) recommends treating fibroids as benign. Women with small fibroids and minimal problems should be encouraged to wait to intervene, as it may not be necessary, without worry. The medical and surgical options should be discussed in relation to symptoms and individualized to the patient.

What are the symptoms of fibroids?
Common symptoms are:

  • Abnormal uterine bleeding - As fibroids grow they can cause heavier and abnormal bleeding as they distort the cavity. Several of our patients report bleeding so bad they go through super products in 30 minutes or less during the worst part of their period, sometimes for as many as 2-4.
  • Increased cramping - The normal uterine muscle contracts against the fibroid tumor which seems to be a plausible explanation for the pain.
  • Infertility – Submucosal and larger intramural/interstitial fibroids that distort the uterine cavity have been shown to affect pregnancy rates. Not all fibroids need to be removed before a woman tries to conceive.  It is important for a woman considering pregnancy to talk to her physician about her risk based on number, size, and location of fibroids.
  • Bladder pressure - The bladder is located between the pubic bone and the uterus. As uterine fibroids grow there is less room for the bladder to expand. This causes more frequent urination.  Fibroid enlargement has been known to cause urinary retention and the need for catheterization.
  • Rectal pressure - The rectum is located behind the uterus and as the fibroids grow and expand, this may create the sensation of constipation, and make bowel movements uncomfortable.
  • Pain with intercourse – Some fibroids are dense and firm and act as brick wall to the normally flexible and soft vagina. This causes pain during intercourse.
  • Feeling an abdominal mass - As fibroids grow they can be felt in the tummy area as a hard spot(or mass). Women cannot buckle their jeans and begin to look pregnant.
  • Pelvic and abdominal pain – Some women with fibroids may also have adenomyosis, which can cause the uterus to be painful to the touch.

 

What is the best way to diagnose whether a woman has fibroid tumors?

Fibroid tumors are suspected when the uterus is enlarged on pelvic examination. Not all uterine enlargement is caused by fibroids and sometimes the uterus is not large when submucosal fibroids are present.
Ultrasound is the most cost effective technique to diagnose fibroids. CT- scans or MRI are seldom necessary.

How many women get fibroid tumors?
By age 40 some 30-40% of women have fibroid tumors. The percentages rise between 40 and 50. Approximately 50% of women with fibroids will require surgery. Just because a woman has a fibroid does not automatically necessitate an operation.

What are the chances that my fibroids will return after they have been removed?
Approximately 30-50% of women are likely to develop new fibroids within 5 years of their operation. Some women will have to undergo a second operation. The younger a woman is when diagnosed, the more likely she will require another procedure. Women who have more than 3 fibroids at the time of surgery are more likely to have recurrence than women who have less than 3.

Isn't there something that can be done to shrink my fibroids if I don't want to have surgery?
There are medications that can shrink fibroids called GnRH agonist. This medication prevents the ovaries from producing estrogen and will shrink the fibroids by 10-50% in 3 months in preparation for surgery.
Depo-medroxyprogesterone acetate also reduces ovarian estrogen production. This medication can be used to keep fibroids from growing larger, but does not appear to shrink fibroids. Ru-486 is a progesterone antagonist which is best known as the abortion pill. When RU-486 is given to women with fibroids Investigators observe significant shrinkage similar to GnRH agonists.

Is it possible that my fibroids could shrink with herbal therapy, a special diet, or acupuncture?
We know of no scientific information that shows that herbs, diet, or acupuncture actually shrink fibroids. A controlled scientific trial of therapy is more important than opinion. Recommendations from this practice are base on available scientific literature.

What are the treatment options if I am diagnosed with fibroid tumors?
There are several options available depending upon your circumstances. After an accurate diagnosis we will discuss the most common options and then the procedure and recovery. The first option we consider is, “ do you need to anything right away or ever”.

Hysteroscopic Myomectomy - A slender scope known as a resectoscope is passed through the cervix to remove submucosal fibroids. Hysteroscopic myomectomy can be performed with epidural, spinal, or general anesthesia in an ambulatory facility. Return to work is 2-4 days and full recovery about one week.
The same scope is used to remove polyps from the uterine cavity. The procedure is called hysteroscopic polypectomy, and recovery is the same as hysteroscopic myomectomy.

Laparoscopic Myomectomy - Instead of making an open abdominal incision to remove large fibroids, a scope is inserted for visualization and instruments are introduced through other small access ports. The uterus is opened with laparoscopic scissors. The fibroid is removed, and the uterus is closed with laparoscopic standard suture material. The fibroid is then removed through a process called morcellation. The procedure is performed on an outpatient basis. Return to work is anticipated in 10-14 days and full recovery in 3 weeks.
The power morcellator is a mechanical instrument that shaves off small strips of fibroid tissue until the entire tumor is removed. Manual morcellation is another way to remove fibroids laparoscopically, even when the uterus is up to the umbilicus. Each woman must weigh the risk and benefit of any procedure.

4 - 8 inch incision

Centers that specialize in laparoscopic surgery have reported that more than 95% of hysterectomies for benign disease could be done laparoscopically instead of open.

Over 700 laparoscopic myomectomy procedures have been performed by AWHI. The procedure was successful laparoscopically in 98% of causes. Only 2% of patients were opened for their myomectomy.

Abdominal Myomectomy - Abdominal myomectomy typically involves a 4-8 inch abdominal incision. The fibroids are removed and the uterus is sutured back together. The hospital stay is usually 2-4 days. The average time off work is 6 weeks, and full recovery takes much longer than the laparoscopic alternative.

4 - 8 inch incision

Vaginal Hysterectomy
Vaginal hysterectomy is an alternative to abdominal hysterectomy when a woman has a normal-sized or only slightly enlarged uterus. Because no abdominal incisions are made, the patients tend to leave the hospital in 1-2 days. Women typically take 4 weeks off work.

Laparoscopic  Hysterectomy

Laparoscopically Assisted Vaginal Hysterectomy
This procedure was introduced in the late 1980s so a woman with a larger uterus could avoid an open hysterectomy. The uterine vascular supply can be secured laparoscopically, thus avoiding the large abdominal incision. The uterus is then removed vaginally along with the cervix. The recovery is more rapid than TAH and similar to vaginal hysterectomy.


Total Laparoscopic Hysterectomy
This procedure was developed to allow the woman with an enlarged uterus to avoid an open hysterectomy. The uterine vascular supply can be secured laparoscopically, thus avoiding the large abdominal incision. The vagina is entered from above instead of through the vagina. The uterus is then removed vaginally along with the cervix. The recovery is more rapid than TAH and similar to vaginal hysterectomy.

Laparoscopic Supracervical Hysterectomy (LSH)
LSH is the least painful form of hysterectomy, with the fastest recovery, ever described. Women who have LSH can go home the day of the surgery up to 90% of the time. Office workers are back to work in as few as 4 days, typically 4-6 hours. Most take 1-2 weeks off. Full recovery and return to exercise takes about 3-5 weeks. Women in physical jobs that require heavy lifting(more than 50 pounds) mostly need 6 weeks.
When the cervix is preserved the vaginal and pelvic floor anatomy is not altered.
Whether LSH is less likely to create sexual and bladder dysfunction compared to traditional forms of hysterectomy is controversial. A randomized controlled trial did not show a difference in sexual and bladder function 12-18 months after open total abdominal hysterectomy compared to LSH. No study has 15-20 year outcome data which might be when differences show up.
A study about pelvic prolapse repair reported fewer complications when the LSH was performed compared to Total laparoscopic hysterectomy.

Laparoscopic Intrafascial Hysterectomy (LIH)
LIH is similar to LSH for post op recovery. The difference is how the cervical canal is treated.
Critics of LSH focus on continued risk of cervical cancer and post operative cervical bleeding, either cyclic or random. The pap smear has virtually eliminated cervical cancer but dealing with an abnormal PAP is stressful and costly. Cervical bleeding problems also make for an unhappy patient.
During the LIH procedure a donut hole like incision is made to remove the cervical canal. The cervical tissue is closed with suture. Reducing the risk of cervical cancer along with bleeding while still leaving the pelvic floor anatomy, nerve supply and blood flow as close to normal as possible is the purpose of LIH.

4 - 8 inch incision

4 - 8 inch incision

Uterine Artery Embolization(UAE) - The procedure is performed by an interventional radiologist. A catheter is inserted into the femoral artery at the groin and guided to the uterine arteries which are then completely blocked with plastic particles, thus cutting off the blood and oxygen supply to the fibroid and the uterus. The first 12-24 hours are reported to be extremely painful. It is like a heart attack in the uterus. Heart attacks occur because arteries become clogged off by a blood clot.
The appeal of UAE is avoiding open abdominal surgery and the long recovery. The majority of women who pursue UAE are not opposed to hysterectomy. Available data shows, in the 3-5 years following UAE 25-30% of women will undergo a second surgery. In a comparison study on fibroids, 3 years after open myomectomy 3% of patients required a second procedure vs 30% who had UAE. Studies have compared laparoscopic surgery and UAE and have concluded greater patient satisfaction with laparoscopic surgery.
UAE can result in premature menopause and should not be offered to women who might have any desire for pregnancy or disruption of ovarian function.

Magnetic Resonance guided Focused Ultrasound(MRgFUS) – Ultrasound for pelvic imaging of fibroids uses very low energy. By increasing the energy and focusing the sound beam the inside of the fibroid it can be superheated. The internal tissue then undergoes necrosis(death) and the fibroid shrinks. 
MRgFUS takes 2-3 hours to treat 1 or 2 fibroids, meaning multiple sessions could be required. Most insurance companies have resisted paying for MRgFUS because of its cost and limitaitons.

Myolysis – This was described in the 1990s as a laparoscopic procedure to shrink fibroids tumors and was the first laparoscopic alternative to hysterectomy. To shrink the fibroid, either a laser fiber or a bipolar cautery needle was inserted many times into different locations through the tumor, which got smaller over the next several weeks. The majority of patients wanted laparoscopic myomectomy once we were able to offer it. They wanted the fibroids out and gone.

Laparoscopic radio frequency alblation(LRFA) -- This is a new, FDA approved, laparoscopic procedure to accomplish the same end result as myolysis, LFRA may result in better outcomes than myolysis because only one insertion is made. More studies are needed to understand its benefit. It may be difficult to get covered by insurance since it is new. It is an alternative to hysterectomy if laparoscopic myomectomy is not an available option.

Hysterectomy
Some women choose hysterectomy when diagnosed with fibroids. No more periods, no more cramps and no more fibroid again has some appeal.
The woman who researches will find there are different options for hysterectomy. For the woman who feels comfortable with hysterectomy is it a good procedure. No woman should be told hysterectomy is her only option.
There are several forms of hysterectomy:

  • Abdominal hysterectomy
  • Vaginal hysterectomy
  • Laparoscopic-assisted vaginal hysterectomy
  • Total laparoscopic hysterectomy
  • Laparoscopic supracervical hysterectomy
  • Laparoscopic intrafascial hysterectomy
  • Abdominal Hysterectomy

The abdominal hysterectomy is the most common approach to hysterectomy in the United States. About 60-70% of hysterectomies are abdominal. Hospital stay is 2-4 days, and patients typically take 6 weeks off work. Full recovery may take up to a year.

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Types of Fibroids

Submucosal Myoma -
This kind of fibroid arises close to uterine cavity and grows into the it. This causes heavy and/or prolonged flow, bleeding between periods and worsening cramps. Submucosal fibroids may create symptoms even when small. Ultrasound is the best way to diagnose the submucosal fibroid.

Interstitial(or intramural) Myoma -
Fibroids that arise in the middle of the uterine muscle wall are called interstitial, or intramural fibroid. If an interstitial fibroid grows large it may be called a transmural myoma. As these interstitial fibroids grow larger they distort the cavity causing abnormal bleeding and bulk pressure symptoms.

Subserosal Myoma -
The fibroid grows from the uterine muscle wall outwardly into the abdominal cavity. They can grow on stalks, which would be known as a pedunculated myoma. This type of fibroid does not cause bleeding issues generally. They are generally diagnosed accidentally at an annual exam or when the woman presents because of bulk symptoms(frequent urination or rectal pressure) or abdominal mass.