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If you’re considering a myomectomy or hysterectomy for fibroids, our specialists are ready to provide an evaluation of your symptoms and condition(s) and recommend an appropriate solution.
WHAT ARE UTERINE FIBROIDS?
Uterine fibroids, or simply fibroids, are noncancerous growths that originate from the muscle of the womb and can occur anywhere in the uterus. As the most common complex GYN condition, fibroids affect approximately 80 percent of women¹. A high percentage of these women also have complications such as heavy bleeding, pain, and/or infertility. African American women have fibroids at a rate two to three times higher than Caucasian or Hispanic women, and they can develop fibroid problems at an earlier age². Because of this, they have a much higher chance of fibroids growing larger and causing more problems.
Fibroids must be treated early, or they can grow and become very large. Watchful waiting can result in fibroids destroying the normal architecture and function of the uterus, and will result in severe damage to the uterus at the time of myomectomy, leading to infertility. Early detection and removal can prevent long-term complications.
The most effective fibroid removal surgery techniques are either a laparoscopic myomectomy for those desiring fertility, or a laparoscopic hysterectomy for women who are done with childbearing.
At The Center for Innovative GYN Care® (CIGC®), we take into consideration your future plans, such as whether you intend to have children or if you are willing to undergo future surgeries should additional tumors grow. We provide personalized care to every patient to ensure that they are getting the treatment that is right for them.
Fibroids can occur anywhere in the uterus and are named for their location. Cervical growths are considered rare, as most fibroids develop from the muscle of the uterus, the myometrium.
- Subserosal — These develop on the outside of the uterus and involve the serosal lining
- Pedunculated — These develop on stalks outside of the uterus
- Intramural — These develop within the uterine muscle
- Submucosal — These involve the endometrial lining
- Hormones — Estrogen causes fibroids: There are no other causes for fibroid growth in the body, and alternative therapies that do not affect estrogen production should not be used
- Estrogen production can be decreased by stopping ovulation (for example birth control pills). Decreasing the production of estrogen will not stop fibroid growth, but may slow down growth in some patients.
- Genetics (runs in families) — Some patients have a genetic tendency to grow fibroids to a greater extent and faster than others, and these patients need special care and counseling to ensure that fibroids are controlled
- Generally, patients of African descent are genetically at greater risk for fibroid development and need to be followed closely by a fibroid specialist to ensure that ultrasounds follow growth accurately, and symptoms are kept under control. This is especially important for those patients interested in fertility.
Fibroids don’t always present with symptoms, but when they do, the most apparent symptoms include heavy bleeding, severe pain with the menstrual cycle, and infertility³.
Other symptoms of fibroids include:
- Frequent urination and urinary retention (difficulty voiding)
- Pain in the pelvis, legs, and back; and pelvic pressure, bloating, and distension; pain with intercourse
- Constipation and diarrhea
- Clots in the legs and pelvis
When it comes to fertility, fibroids can make it difficult to become pregnant because of their location.
As can be seen in the picture above, submucosal fibroids can prevent implantation of the embryo into the uterine lining. Some intramural fibroids can also cause this problem if they are near to the lining, and larger in size. Fibroids in these locations can cause infertility and should be removed. If fibroids block the fallopian tubes, eggs may not be able to become fertilized, or
fertilized eggs may not be able to reach the uterus, resulting in an ectopic pregnancy.
An accurate diagnosis is crucial for detecting and treating fibroids, since fibroids may not present symptoms. Without early diagnosis, small fibroids will become larger fibroids, which can cause all of the symptoms above. Pelvic exams are not effective in the diagnosis and management of fibroids. A pelvic exam will just indicate how big a uterus is, and can completely miss a fibroid diagnosis. Further, a pelvic exam will not indicate where the fibroids are in the uterus, and will not be able to determine the number and size of fibroids present. Always ask your doctor for an ultrasound, even though it may not be discussed at the time of the consultation. This is especially true in many OBGYN practices, where the focus is mostly on Obstetrics, and not fibroids. An ultrasound is a simple, inexpensive, and very effective method for diagnosing the size, number, and location of fibroids.
Ultrasounds: Abdominal ultrasounds examine fibroids through the abdomen, whereas transvaginal ultrasounds examine fibroids through the vagina. Transvaginal sonograms are very effective since the ultrasound device is directly placed on the uterus through the vagina. Ultrasounds can easily see the number, location, and size of the fibroids. They are cost-effective, and should be used to follow growths that are enlarging or causing symptoms.
Saline sonograms: Saline sonograms use salt water in the uterine cavity at the time of the ultrasound to increase the sonogram’s ability to evaluate fibroids in or near the cavity of the uterus. Saline sonograms also help OBGYNs see other structures in the cavity that may be missed by a regular ultrasound, such as growths in the cavity.
MRI: An MRI is an expensive technique for imaging fibroids. Although it is more sensitive than an ultrasound, it is not necessary for the majority of fibroid patients.
Office hysteroscopy: Hysteroscopy is used to evaluate the uterine cavity. Saline sonograms can provide similar information. Office hysteroscopy has become more popular with OBGYNs as it is a procedure that can be easily performed in the office. Growths that are identified in an office visit usually cannot be removed, and most patients will require an operating visit for treatment. For this reason, office hysteroscopy is not recommended routinely for evaluation of fibroids in the uterine cavity.
HSG: HSG, or hysterosalpingogram, is an evaluation of the uterine cavity and the tubes, using a radiopaque dye passed into the uterus through the cervix. Radiopaque means the dye can be seen with fluoroscopy — a radiological test that shows the dye passing through the uterus and the tubes. It is mostly used to ensure that the fallopian tubes are open. Although it can identify fibroids, polyps, or scarring in the cavity, it is generally not used for diagnosing fibroids.
Pelvic exams: Pelvic exams may be helpful but are very limited in their ability to identify the size, number, and location of fibroids. Pelvic exams can also confuse pelvic masses with fibroids, and have significant limitations in patients with prior surgery, other GYN conditions such as endometriosis, and in heavier patients. Pelvic exams can also be painful both during and after exams.
A Laparoscopic View of the Uterus and Fibroids
If allowed to grow, fibroids can have serious complications, including:
- Severe pain or heavy bleeding
- Infertility — This occurs when enlarging fibroids destroy the normal architecture and function of the uterus
- Fibroids in or impinging on the uterine cavity, preventing proper childbirth and causing heavy bleeding
- Fibroids in the uterine muscle. Larger fibroids can obstruct fallopian tubes, thereby preventing pregnancy, and can also affect normal delivery by preventing delivery of the baby through the vagina. In addition, muscle fibroids can significantly affect fetal growth at larger sizes, and should be removed.
- Fibroid removal (myomectomy) and fertility. As fibroids grow into the muscle and cavity of the uterus, removal will cause scarring to the cavity, the tubes, and abnormal healing leading to problems with muscle healing and infertility. Watching and waiting leads to enlarged growth, and is a practice that should never be allowed for any patient, since it will cause significant problems to the uterus after fibroid removal.
- Urinary tract complications — Fibroids can obstruct the urinary tract, causing severe urinary retention and urinary tract infections, and urinary frequency can also become a serious problem, such as with fatigue from loss of sleep and dysfunction in normal activities of daily living
- Bowel complications — These include severe constipation, bloating, and distension
- Problems at delivery — These include premature birth and Intrauterine Growth Restriction (IUGR)
- Twisting of the fibroids causing severe pain and the need for emergency surgery
Fibroid Risk Factors
All women are at risk for fibroids, but African American women have fibroids two to three times more than other races⁴. African American women can develop problems at an earlier age, with the tumors growing faster, becoming larger, and causing more bleeding and anemia than with women of other races.
Additional risks for fibroids include:
- Age (older women are more at risk)
- Family history of uterine fibroids
- No history of pregnancy
The following factors may lower the risk of developing fibroids:
- Long-term use of oral or injectable contraceptives
How Are Fibroids Treated?
Fibroid treatment is either surgical, medical, or radiological.
For any surgery to be performed, there needs to be an “indication,” or a reason for the procedure. Indications for fibroid removal surgery may include any of the following:
- Symptoms such as bleeding, pain, pressure, and/or frequent urination
- Bloating and Distension
- Failed medical or radiological treatment
- Return of fibroids after prior surgical treatment
There are two surgical treatment options for fibroids:
1. Myomectomy, removal of fibroids only — Many women are candidates for myomectomy for fertility. In fact, myomectomy is the procedure of choice for those patients who desire to preserve fertility. Other options such as embolization, radiofrequency ablation (Acessa), and MRI-guided ultrasound can damage the uterus and increase the risk of miscarriages and infertility. The CIGC exclusive LAAM® myomectomy is an advanced fibroid removal procedure using only two small incisions to remove fibroids, large and small.
However, some fibroids can cause too much damage to the uterus for a secure repair for childbearing after myomectomy. Myomectomy is not the safest option for women who are past childbearing, and hysterectomy or other options should be considered.
2. Hysterectomy, removal of uterus and fibroids — A hysterectomy is a cure for fibroids, and is a good option for women who are prone to recurring fibroids, and who no longer wish to or are no longer able to conceive. The DualPortGYN® minimally invasive hysterectomy approach used at CIGC allows women to recover in about one week.
Medical therapy is the treatment of fibroids without surgery or radiological procedures. This type of treatment is limited and often not helpful for most patients with bleeding, pain, and growth of the fibroids continuing over the long term. Medical therapy may help to decrease the bleeding associated with fibroids over the short term.
Oral contraceptives (birth control pills): These pills are not helpful in the treatment of fibroids, but may decrease bleeding in some patients.
Progesterone: Progesterone is the anti-estrogen and may help decrease the bleeding caused by fibroids by causing atrophy or thinning of the uterine lining. Progesterone can be given as a pill or an injection. Progesterone does not decrease the growth of fibroids.
Lupron/Orilissa: Lupron/Orilissa is an effective but temporary medical therapy for fibroids. This drug blocks the production of both estrogen and progesterone. For most patients, this means bleeding slows down or stops, the growths shrink, and blood counts increase. Lupron cannot be prescribed for more than a year, and the side effects often limit its use. When the Lupron is stopped, the tumors will regrow and the symptoms will return.
NSAIDs/Pain relievers: NSAIDs such as ibuprofen (Motrin) and pain relievers such as acetaminophen (Tylenol) that can decrease pain but will not affect fibroid growth.
Danazol: This is a male type steroid that stops the production of estrogen, causing a decrease in menstrual periods and bleeding. It does not decrease tumor growth and has many side effects, limiting its use.
Treatment of fibroids through radiology refers to locating the growths to be treated in the uterus by some type of radiological test, and then treating the fibroid either through:
- Embolization or blockage of its blood supply
- Ultrasound waves, or through other methods
- Ultrasound waves (MRI guided ultrasound)
- Radiofrequency Ablation (Acessa)
Fertility Patients: Embolization and most all forms of radiological fibroid treatments such as MRI guided ultrasound and Acessa, are not recommended for patients interested in fertility. These treatments can damage the uterine muscle and the ability of the uterus to successfully allow for pregnancy to occur. A higher risk of miscarriage and other complications are significant with these procedures, and myomectomy (surgical removal of fibroids) is always the first choice for those patients desiring pregnancy. Further, these treatments will not remove fibroids in the uterine cavity or close to the cavity in a reasonable time frame, and it is these fibroids which commonly cause infertility.
Non Fertilty Patients: For patients with larger fibroids not interested in fertility, any of these forms of radiological treatment are limited in their ability to control the growth of larger fibroids, multiple fibroids, and do not prevent the growth of new fibroids.
- Fibroids are not removed with these procedures. This means that “bulk” symptoms such as urinary frequency, pelvic pain and pressure, bloating and distension will not resolve quickly but may require months or even years . In many cases in patients with larger fibroids, these symptoms will not resolve at all.
- Recovery rates for many of these procedures are longer secondary to the pain associated with the treatment (death of the fibroids in the uterus leading to pain and cramping), and in many cases are longer than the Dualport approach to hysterectomy or even LAAM procedures for fibroid removal.
- Fibroids that are pedunculated should not be treated with these approaches since the results are much less effective.
- Fibroids in the uterine cavity also should not be treated due to extensive and long term vaginal discharge with death of the fibroid in the cavity. This discharge can be foul smelling.
- Fibroids greater than 6 to 7 cm are also not effectively treated with these procedures, including embolization, due to the size of the fibroids.
- Patients with many fibroids in the uterus, specifically those with many larger fibroids or a combination of larger and smaller fibroids, will not be effectively treated with any of these approaches over the short and long term. This is because as the uterus becomes larger, the blood supply is from many different sources, and embolization – which relies on blockage of the fibroid blood supply – is less effective with increasing size and number of fibroids, and with a larger uterus. Smaller fibroids are not treated with this approach, and will grow despite treatment of larger fibroids.
Be sure to discuss these options for treatment with a CIGC surgeon to fully understand what your best options are, and to also consider the minimally invasive Dualport and LAAM procedures for fibroid removal. In many cases, these approaches are better short and long term options compared to radiological approaches.
Uterine Artery Embolization (UAE) & Uterine Fibroids Embolization (UFE): UAE or UFE rely on blocking the blood supply either to the uterine artery or to the fibroid. This approach uses plastic particles or some other method to eliminate blood flow to the tumor. Using fluoroscopy — a radiological test that uses radiation and dye to locate the uterine artery — a needle is inserted into the large artery of the groin. A small plastic tube is then inserted through the needle, and the blood supply to where the uterus and fibroids are located. Small plastic particles or “beads” are then inserted into the blood supply of the fibroid, blocking the supply. This causes “necrosis” or death of the fibroid. Since there are two uterine arteries — one on each side of the uterus — both arteries need to undergo UAE to achieve optimum results⁶.
MRI-Guided Ultrasound: In this nonsurgical procedure, MRI — Magnetic Resonance Imaging — is used to identify fibroids in the uterus, and then ultrasound waves are focused on the tumor to destroy it. This procedure cannot be used on patients who want to become pregnant, or for adenomyosis. It is not effective for larger growths, for more than five fibroids in the uterus, or for fibroids that have decreased blood supply. Although some reports are encouraging for this procedure, it takes multiple treatment visits, is expensive, and cannot be used if other organs such as the bowel are in front of the growths, since damage can result.
Radiofrequency Ablation (Acessa): Also called myolysis, this is the destruction of tissue using heat or freezing. A new procedure using radio waves has been introduced, but also has limited use and effectiveness for multiple or larger fibroids⁶.
The CIGC Difference
The Center for Innovative GYN Care techniques are exclusive to our practice.
DualPortGYN and LAAM-BUAO® (laparoscopic assisted abdominal myomectomy) were developed by the CIGC minimally invasive GYN specialists to improve the outcomes of GYN surgery. DualPortGYN and LAAM take advantage of advanced techniques that enhance the safety of each procedure. These procedures have drastically reduced surgery time, decreased the number and size of incisions, identified optimum placement of the incisions, all of which lead to reduced recovery time and pain. CIGC procedures are performed in an outpatient setting, so patients can return home the same day.
There are many treatments for fibroids, but in general for those patients who desire to become pregnant, fibroid removal by surgery — also known as myomectomy — is the preferred option. Removal of the fibroids allows for the bulk of the fibroids to be removed and gets the uterus back to normal in most cases to allow for pregnancy. As fibroids become larger, however, the risks of fibroid removal increase. For fertility patients, these risks include scarring to the cavity of the uterus and tubes, as well as abnormal healing leading to infertility. Other options such as embolization, radiofrequency ablation (Acessa), MRI-guided ultrasound, and others that do not remove the fibroids should not be considered. These techniques may decrease the size of the fibroids, but may also cause problems such as an increased incidence of miscarriage as well as difficulty in becoming pregnant or maintaining a pregnancy.
Only in cases of very large fibroids. Even the largest fibroids have a maximum weight of five to 10 pounds. Fibroids are bulky, but do not weigh a lot. A five-pound fibroid, for example, may be as large as a small watermelon.
No. Fibroids grow through estrogen production, which occurs throughout a woman’s life until menopause. At menopause, estrogen production stops, and fibroids can shrink. It is important to note that fibroids never completely go away. A large fibroid may only decrease in size by one half after menopause, and this may take years. Fibroids can also undergo “degeneration” after menopause and loss of blood supply. Calcific degeneration, for example, “calcifies” the fibroids, turning them into very hard masses that are difficult to remove. This is a common form of degeneration for fibroids, and can cause significant discomfort.
Removal of fibroids depends on location, symptoms, and the desire for fertility. A 1 cm fibroid — about one half an inch — can cause severe bleeding if it is in the uterine cavity, and can also cause infertility. Fibroids this size should be removed. The same fibroid in the muscle or outside of the uterus does not require removal. Larger fibroids should be removed, since fibroids rarely stay the same size, but continue to grow as long as estrogen is being made (i.e., before menopause occurs).
Related Blog Posts
1 Downes E, Sikirica V, Gilabert-Estelles J, et al. The burden of uterine fibroids in five European countries. Eur J Obstet Gynecol Reprod Biol. 2010;152:96-102.
2 Baird D, Dunson D, Hill M, et al. High Cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188(1): 100-7.
3 Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Human Reproduction Update. 2016;22(6):665-686.
4 Eltoukhi H, Modi M, Weston M. The health disparities of uterine fibroids for African American women: a public health issue.AJOG. 2014;210(3):194-199.
5 Stewart E, Cookson C, Gandolfo R, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017;124(10):1501-1512.
6 Khan AT, Shehmar M, Gupta JK. Uterine fibroids: current perspectives. Int J Womens Health. 2014;6:95–114.