Fibroids are non-cancerous growths that originate from the muscle of the womb. They can occur anywhere in the uterus. Fibroids affect approximately 80 percent of ALL women, and some patients suffer from heavy bleeding, pain and/or infertility. At CIGC, we are dedicated to the techniques & procedures that optimize the surgical care & recovery of women with complex GYN conditions.
THE CIGC ADVANTAGE
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.
NOTE: LAAM is only performed on patients who are able to retain fertility.
A WOMAN’S AGE IS THE SINGLE MOST IMPORTANT FACTOR AFFECTING HER FERTILITY.
Rates of fertility decrease as a woman reaches her mid-30s, and women who conceive later are at a greater risk of pregnancy complications. Women in their late 30s are approximately 40 percent less fertile than women in their early 20s.
However, once a woman is in her 40s, rates of fertility decrease exponentially. Ovarian reserve is diminished, and the lower quality of the eggs affects the quality of the potential embryo, leading to high rates of complications, including miscarriage.
At age 40, fertility has fallen by half. (At age 30, the chance of conceiving each month is about 20%; at age 40 the chance of conceiving is about 5%.)
At age 43-44, women have a 1% chance of getting pregnant with IVF. The integrity of the eggs, and the embryos that form are 80% likely to have chromosomal abnormalities.
Without IVF, women aged 43-44 have less than 1% chance of getting pregnant.
WHY THIS MATTERS FOR FIBROID REMOVAL
When fertility is no longer a viable option (1% or less), and fibroids are controlling your life, a myomectomy is not recommended.
Performing fibroid removal alone (a myomectomy), versus removing the uterus (hysterectomy), when fertility is no longer possible increases the risks to the patient. Women 43 or over, unless they have arranged to have a donor egg prior to having fibroid removal, should consider the benefits of a hysterectomy to ensure fibroids do not grow back.
A DualPortGYN hysterectomy at CIGC has a faster recovery than all other hysterectomy procedures, as well as any myomectomy procedure, and the recovery is less painful. Leaving the ovaries intact if they are healthy, a hysterectomy does not have to mean early menopause. The hormones that make estrogen are not affected by the removal of the uterus.
LAAM has no limit for fibroid size, number, or location. Even large growths can be removed through the LAAM technique, as long as the uterus can be reconstructed. The CIGC practice specialists have removed up to 164 fibroids from one patient.
Our experienced laparoscopic specialists determine if a patient is a candidate for this surgery. For many patients, if the uterus is too damaged, or fertility potential is extremely low, LAAM is not recommended.
Many patients require a hysterectomy as their fibroid removal surgery, which cures the patient from recurrence. In many cases, patients can retain their ovaries and avoid going through early menopause. A DualPortGYN hysterectomy has tiny incisions that are practically invisible a couple of months after surgery. Both surgery time and recovery time exceed all other types of hysterectomy, with less pain overall.
THE CIGC SPECIALISTS
At CIGC, we are advanced-trained GYN specialists. 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 get to know each and every patient on a personal level to ensure that they are getting the treatment that is right for them.
For complex GYN conditions, choosing a specialist is essential. At CIGC, our careers are dedicated to the techniques and procedures that optimize the surgical care and recovery of women. We are board-certified, fellowship-trained in minimally invasive surgery or gynecologic oncology. Since we get a high volume of patients needing gynecological surgery, we have the experience to have mastered the procedures and skill.
As a patient, we urge you to find peace of mind in the form of the expertise and care of our surgical experts. Our physicians will help you to fully understand your condition as well as your options. We promise to employ only the most effective and least invasive surgical techniques to facilitate a swift recovery.
BY THE NUMBERS
In 2016, the CIGC specialists performed over 2,000 procedures.
On average, our specialists perform an average of 400 hysterectomies per year. By comparison, OBGYNs perform an average of 27 hysterectomies per year, which makes sense, as their primary focus is obstetrics. When it comes to surgery, volume matters.
WHAT ARE FIBROIDS?
Fibroids are non-cancerous growths (tumors) that occur from the muscle of the womb. The womb is also called the uterus. Fibroids are “fibrous” tough masses that require estrogen and progesterone – the female hormones – for growth.
WHERE ARE FIBROIDS IN MY UTERUS?
Fibroids can occur anywhere in the uterus, and are named for their location. Cervical growths are rare. Most develop from the muscle or myometrium.
- Serosal – 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.
HOW COMMON ARE FIBROIDS?
Eighty percent of ALL women have fibroids in their womb, with 12 to 25% having problems from them such as heavy bleeding and pain. It is the most common GYN condition in women.
AM I AT GREATER RISK OF HAVING FIBROIDS?
African-American women have fibroids two to three times more than Caucasian or Hispanic women. Also, African American women have a much higher chance of them growing larger and causing problems than in Caucasian women. African-American women 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.
DO MEDICATIONS, MY DIET, OR SMOKING AFFECT THEIR GROWTH?
- Medications: Birth control pills do not cause fibroids to grow, but may control some of the symptoms. Injections of Depo-Provera, or progesterone (the anti-estrogen) has been shown to protect against growths. Medicines used for fertility have no effect on fibroid growth.
- Diet: Caffeine will not cause an increase in growth or developing new tumors. Foods that have been shown to have an association with increased fibroid growth include beef and red meat, ham, and alcohol. Green vegetables, dairy products and fruit will decrease the risk. Soy will not affect growth.
- Smoking: Smoking has a possible decreased effect on fibroid development and growth. Smoking, of course, is not a reasonable option, as it is associated with higher risks of lung, bladder, and cervical cancer.
WHAT TYPES OF SYMPTOMS CAN FIBROIDS CAUSE?
The following is a list of common symptoms from most to least frequent:
- Heavy bleeding and clots with the menstrual cycle resulting in anemia (low blood count) and tiredness
- Severe pain with the menstrual cycle
- Frequent urination
- Pain in the legs and back, pelvic pressure, swelling of the abdomen, pain with intercourse
- Clots in the legs and pelvis
CAN FIBROIDS CAUSE INFERTILITY?
Submucosal growths can cause infertility by preventing implantation. Implantation occurs when the embryo (the egg and the sperm combined) attaches to the endometrial lining, with the placenta developing and obtaining blood supply from the uterine muscle.
Submucosal growths can prevent implantation, and can cause problems with conception (the ability to become pregnant) or can result in miscarriage (loss of the pregnancy). Intramural fibroids (in the muscle) can also prevent conception. Tumors can also obstruct the fallopian tubes, resulting in difficulty in becoming pregnant. Blockage of the tube will not allow the embryo to pass into the uterine cavity, and implant on the endometrial lining.
Problems during pregnancy can include:
- Placental abruption – detachment of the placenta, causing bleeding and loss of pregnancy.
- Abnormal growth of the pregnancy – if blood flow is compromised or a growth is very large that can prevent the baby from growing properly.
- Pre-term labor and birth – preventing normal growth leading to contractions and early labor. Early labor may lead to an early delivery of the baby and possible developmental problems.
DOES THE LOCATION OF THE GROWTHS CAUSE DIFFERENT TYPES OF SYMPTOMS?
Yes. Fibroid location is important in understanding how fibroids cause problems.
Submucosal growths can cause severe bleeding, even if they are small, by increasing the area of the lining, and also increase menstrual flow and decrease the normal ability of the lining to stop the bleeding.
Intramural fibroids that are larger or close to the cavity will increase blood flow to the uterus and affect the normal systems that control bleeding in the uterus. These will also increase the size of the cavity of the uterus, thereby increasing bleeding.
BLEEDING AND PAIN
Fibroids that increase bleeding into the cavity of the uterus, such as submucosal and intramural, result in the formation of clots in the cavity. Pain is caused by distension of the cavity and passage of the clots.
Many patients pass very large clots and have extreme pain with their menstrual cycle due to clot formation.
PAIN AND PRESSURE
- Larger intramural and serosal tumors increase pain with the menstrual cycle, and can also “degenerate”, or lose their blood supply, causing severe pain.
- Subserosal growths can also take up space and push against other structures like the spine and pelvis causing pelvic pressure and pain, and pain to the back.
- Pedunculated fibroids often lose their blood supply and degenerate. These can also twist on themselves, causing very severe pain.
Intramural and subserosal fibroids can increase the size of the uterus, which can press on the bladder. The bladder cannot fill to its capacity, and empties more frequently. Growths in the back of the uterus cause this problem frequently by pushing the uterus toward the front and compressing the bladder, and also can cause back pain.
Constipation is a less common symptom, which results from large fibroids in the back of the uterus that can obstruct or block the rectum, leading to back up of stool and constipation.
Many patients have alternating bouts of constipation and diarrhea. This is the result of growths blocking the passage of stool, which then “sits” in the rectum. The function of the rectum is to absorb water from the stool. The longer the stool sits, the more water is absorbed, and the result is hard stools that do not pass, causing constipation. Diarrhea occurs when the pressure in the rectum builds to a point that exceeds the blockage. The result is passage of loose stool beyond the blockage point, causing diarrhea.
PAIN WITH INTERCOURSE
Pain with intercourse, also caused dysmenorrhea, can occur from fibroids at the front or top of the uterus. This is an unusual symptom, but it can occur.
More common causes of dysmenorrhea include endometriosis and scar tissue to the pelvis.
LESS COMMON SYMPTOMS
Clots in the pelvis and legs. Very large fibroids pressing on the sides of the pelvis can block the large veins draining blood from the legs. This results in slow movement of blood in the veins, also called “stasis”, which results in clots. Clots cause swelling to the legs, and also can result in clots breaking off and passing to the lungs. This is called a pulmonary (lung) embolism (clot) and can be life-threatening.
Obstruction of the ureters. Very large fibroids pressing on the side of the pelvis can also cause partial blockage of urine from the ureters. The ureters are the tubes that allow urine to flow from the kidney to the bladder in the pelvis. This can result in hydronephrosis (hydro = water, nephrosis = kidney), or swelling of the kidney due to accumulation of urine in the kidney. Usually this is mild, and does not compromise kidney function. In more severe cases, back pain can occur as well as loss of function to the kidney over time.
Prolapse of cervical fibroids. Passage of fibroids from the cervix or cavity can cause bleeding, pain, and infection. These are generally rare and are treated with vaginal removal.
HOW ARE FIBROIDS DIAGNOSED?
Ultrasound is a simple, inexpensive, and very effective method for diagnosing the size, number, and location of fibroids, and is very well tolerated by the patient. MRI, or Magnetic Resonance Imaging, is usually not needed, but can provide more information about the specific location of growths and rule out adenomyosis. CT scans, or Computed Tomography, are not helpful, and should not be performed. Pelvic exams may be helpful, but are very limited in their ability to identify the size, number, and location. 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.
ULTRASOUND OR SONOGRAM
Ultrasounds are easy to perform with minimal pain. Abdominal ultrasounds examine fibroids from the abdomen, whereas transvaginal ultrasounds examine the 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 use saline, or salt water, in the uterine cavity at the time of the ultrasound. This increases the ability of the sonogram to evaluate fibroids in or near the cavity of the uterus, and helps to see other structures in the cavity that may be missed by a regular ultrasound, such as growths in the cavity.
MRI [MAGNETIC RESONANCE IMAGING]
MRI, or Magnetic Resonance Imaging, is an expensive technique for imaging fibroids. Although it is more sensitive than an ultrasound, it is not necessary for the majority of patients with fibroids.
Indications for MRI:
- Adenomyosis. MRI is helpful in identifying adenomyosis. Adenomyosis occurs when the endometrial lining of the uterus grows into the muscle. Patients with this condition have bleeding into the muscle with every menstrual cycle, which can cause severe pain and heavy bleeding. Extensive adenomyosis can result in the formation of an “adenomyoma’, or collection of adenomyosis, which an ultrasound sometimes detects as a fibroid. Adenomyomas should not be removed, since the removal of an adenomyoma also results in the removal of a portion of the muscle of the uterus.
- Embolization. MRI is usually indicated when embolization procedures are being considered. MRI will help to determine planning for embolization and the potential success of the procedure.
Hysteroscopy is used to evaluate the uterine cavity. There are better, less expensive options. Saline sonograms can provide similar information. Office hysteroscopy has become more popular with OB/GYNs as a procedure that is 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. The result is a second surgical procedure for the patient, and two billable procedures for the surgeon. For this reason, office hysteroscopy is not recommended routinely for evaluation of fibroids in the uterine cavity.
HSG, or hystero (uterus) salpingo (tubes) gram, is an evaluation of the uterine cavity and the tubes, using dye passed into the uterus through the cervix that is radio-opaque. Radio-opaque 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.
COMPARING FIBROID TREATMENTS
It is essential that all CIGC patients are well informed about the landscape of fibroid treatment options, and why our procedures are unparalleled. Understanding the benefits and risks of all types of treatments can help each patient choose her best path. Fibroids are unpredictable, and their growth can affect day to day life, as well as fertility.
HOW ARE FIBROIDS TREATED?
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, frequent urination
- Increasing abdominal girth due to enlarged uterus
- Failed medical or radiologic treatment
- Return of fibroids after prior surgical treatment
There are two surgical treatment options for fibroids:
- Myomectomy — removal of fibroids only. (Many women are candidates for myomectomy for fertility. However, some fibroids can cause too much damage to the uterus for a secure repair for childbearing. Myomectomy is not a safe option for women who are past childbearing.)
- Hysterectomy — removal of uterus and fibroids. (Hysterectomy is a cure for fibroids.)
Medical therapy means treatment without surgery or radiological procedures. Medical therapy 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. Estrogen and progesterone encourages growth. Types of medical therapy may include hormones that block the effect of estrogen or progesterone, or reduce or eliminate the production of these hormones from the ovaries.
- Oral Contraceptives: Oral contraceptives, or birth control pills, are not helpful in the treatment of fibroids, but may decrease bleeding in some patients. Birth control pills do not decrease the size or number of growths. It is thought that birth control pills may treat other problems causing bleeding in those patients with fibroids. This explains why bleeding is decreased in some patients who use birth control pills.
- 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: Lupron is the most effective medical therapy there is for fibroids. This drug works by blocking the production of both estrogen and progesterone. For most patients, this means bleeding slows down or stops, the growths shrink, and blood counts increase. When the Lupron is stopped, the tumors will regrow and the symptoms will recur.
- Lupron Side Effects: Hot flashes, mood swings, anxiety, depression, sleep problems, vaginal dryness, muscle and joint pain, osteoporosis (loss of bone mass). Patients will lose up to six percent of their bone mass when using Lupron for one year, with only half of this regained after the Lupron is stopped.
- Uses: Lupron is not used over the long term due to the above side effects and osteoporosis. Since the tumors regrow when Lupron is stopped, the only real use is before surgery to stop bleeding and treat “anemia”, or low blood counts, if necessary. Iron supplements will also increase blood counts, are much cheaper, and have far fewer side effects.
- NSAIDS: There are Non-Steroidal Anti-Inflammatory Drugs such as ibuprofen (Motrin) or acetaminophen (Tylenol) that can decrease the pain, but will not affect growth.
- Danazol: This is a male type steroid (androgenic = male, estrogenic = female) 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.
NON-FDA APPROVED DRUGS
- Mifepristone: This is the drug RU-486, used to medically terminate pregnancies. It has been shown to decrease the size and bleeding from fibroids at lower doses of five to 50 mg per day over a six-month period. These doses are not available in the US.
- Ulipristal: This affects progesterone receptors, does not affect estrogen levels, and can decrease bleeding and the size of the fibroids without causing the negative side effects of Lupron. Most patients ultimately need surgery, and there may be an increased risk of precancerous or cancerous conditions of the uterus.
- Aromatase Inhibitors: These drugs block the enzyme that converts male type hormones in the body to the female hormone estrogen. By decreasing the production of estrogen, these drugs have been shown to shrink fibroids and decrease the symptoms of fibroids. Further studies are needed to determine if these drugs are helpful in the treatment of fibroids.
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.
UTERINE ARTERY EMBOLIZATION (UAE)
Also known as UFE (uterine fibroid embolization), this type of treatment relies on blocking the blood supply, using plastic particles or some other method to eliminate blood flow to the tumor. Using fluoroscopy – a radiological test that uses 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 the uterus and fibroids is 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 the best results. The procedure is done twice, once to the left groin, and then once to the right groin.
ARE ALL PATIENTS CANDIDATES FOR UAE?
- Patients who want to become pregnant should not consider UAE as an option. UAE can cause problems with miscarriage, placental problems (the placenta feeds the baby), and pre-term delivery. It has been noted that the rates of becoming pregnant are higher in patients who had myomectomy (surgical removal of fibroids) rather than embolization.
- Patients with adenomyosis have much poorer success rates with UAE. Adenomyosis (figure, same as above) occurs when the lining of the uterus, also known as the endometrial lining, grows into the muscle of the uterus. Adenomyosis is very common in patients aged 35 and older, and causes severe pain and bleeding. UAE is not helpful in the treatment of adenomyosis, with hysterectomy being the best option for these patients.
- Large fibroids are not as well-treated with UAE as with myomectomy. Larger growths may have multiple blood supplies and larger-sized vessels that cannot be completely treated with UAE procedures. They have a much higher chance of continued or regrowth after UAE treatment.
- Submucosal fibroids can detach from the uterine wall, and then pass out through the vagina or require removal if they are larger in size. Passage can happen up to a year or longer after the procedure, and can be associated with foul smelling discharge or severe pain.
- Pedunculated fibroids are not treated very well with UAE. Higher complications are seen when UAE is conducted on these types of fibroids, including twisting of the fibroid and pain, separation of the fibroid from the uterus and others.
- UAE should never be conducted on any patient that may have a precancer or cancer of the uterus. This includes uterine and cervical cancer, as well as overgrowth of the uterine lining called hyperplasia. Pap smears to check for cervical cancer, and uterine biopsy or D&C should be done for those patients in which cancer may be an issue.
WHAT TESTS ARE DONE BEFORE UAE IS PERFORMED?
A pregnancy test is necessary to make sure a pregnancy is not present.
MRI, also known as Magnetic Resonance Imaging, is performed before UAE. This helps to identify the number, size, and location of each fibroid. MRI is the best way to identify adenomyosis, which is usually not treated with UAE but with hysterectomy.
WHAT CAN I EXPECT IN THE FIRST TWO WEEKS AFTER THE PROCEDURE?
- Pain. Almost all women after UAE will have pain. This is due to loss of blood supply to the uterus and the fibroids, and can be mild to very severe. All patients are usually admitted to the hospital after UAE with a morphine pump, or PCA (patient-controlled analgesia) to control the pain.
- Post-UAE Syndrome. Most patients undergoing UAE will experience this syndrome, which includes pain, cramping, nausea, vomiting, fever, tiredness, body aches. Most of these problems occur within the first two days of the procedure, and will decrease over the next seven days. Admission to the hospital after UAE may be necessary to control both the pain issues and the syndrome above.
WHAT COMPLICATIONS CAN OCCUR AFTER UAE?
Loss of ovarian function is the most common complication. Decreased ovarian blood supply and menopause can occur after UAE due to movement of some of the particles into the blood supply of the ovaries. This happens more often in those patients who are greater than 45 years of age (up to 10 percent), and less often in those patients less than 45 (three percent).
Other less common complications include:
- Fever in up to four percent of patients;
- Passage of a fibroid through the vagina in up to five percent of patients;
- Readmission to the hospital in up to three and a half percent of patients;
- Need for surgery in two and a half percent of patients;
- Allergic reaction in two and a half percent of patients; or
- Bleeding and life-threatening event in up to one percent of patients.
Results on UAE are reported for the short term, which is three years and less, and for the long term, which is more than five years.
Short-term data is much better than long-term data. The most reliable information comes from the Society of Interventional Radiology on over 1,200 patients. Three years after UAE the following results were reported:
- Ninety five percent with improvement in symptoms and quality of life;
- Twenty nine percent with no bleeding reported after the procedure; and
- Surgery was required for 14.4 percent of patients after UAE, either with hysterectomy, removal of the fibroids, or repeated UAE.
Results more than five years after UAE show 20 percent of patients requiring a surgical procedure to control fibroid symptoms, including hysterectomy, myomectomy or repeated UAE. This means that UAE was unsuccessful in one-fifth of the patients, and recurrence of bleeding, pain, or other symptoms due to enlargement or growth of new fibroids required surgical removal due to failure of the UAE procedure.
In this non-surgical 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 (RFA)
Also called myolysis, this is 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 fibroids.
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