Fibroids are non-cancerous growths that originate from the muscle of the womb. They affect 80 percent of ALL women, and some patients suffer from heavy bleeding & pain. At CIGC, we are dedicated to the techniques & procedures that optimize the surgical care & recovery of women with fibroids.
WHAT ARE FIBROIDS?
Fibroids are non-cancerous growths 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?
The uterus is composed of the cervix – the lower portion – and the fundus – the upper portion. The uterus is attached to the vagina through supporting ligaments, which are strong bands of tissue. These are the cardinal and uterosacral ligaments. These ligaments are attached to the vagina, not the cervix.
The cervix is the opening of the womb, and functions to allow delivery of the baby. During delivery, the cervix “dilates” and allows the baby to be delivered through the vagina. The cervix has no other role. The cervix does not have a “support” function, and does NOT support the uterus, bladder, or rectum and prevent them from falling out of the vagina. This is because the cervix does not directly attach to the supporting ligaments of the vagina, the cardinal and uterosacral ligaments. These ligaments are attached to the vagina. The tubes and ovaries are attached to the uterus.
The blood supply to the uterus is through the uterine arteries, the ovarian arteries, and the cervical and vaginal arteries. The “serosa” is the outer lining of the uterus, while the “endometrium” is the lining of the cavity of the uterus. The endometrium is also called the submucosal lining. The muscle of the uterus, or the “myometrium”, is where fibroids develop.
Fibroids can occur anywhere in the uterus, and are named for their location. Cervical fibroids are rare, whereas most fibroids develop from the muscle or myometrium.
- Serosal fibroids – Fibroids developing on the outside of the uterus, and involve the serosal lining.
- Pedunculated fibroids – Fibroids developing on stalks.
- Intramural fibroids – Fibroids developing within the muscle.
- Submucosal fibroids – Fibroids involving the endometrial lining.
HOW COMMON ARE FIBROIDS?
Fibroids are the most common growth in women. Eighty percent of ALL women have fibroids in their womb, with 12 to 25% having problems from fibroids such as heavy bleeding and pain.
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 fibroids growing larger and causing problems than in Caucasian women. African American women develop problems with fibroids at an earlier age, with the fibroids growing faster, becoming larger, and causing more bleeding and anemia than with women of other races.
DO MEDICATIONS, MY DIET, OR SMOKING AFFECT FIBROID GROWTH?
- Medications: Birth control pills do not cause fibroids to grow, but may control some of the symptoms associated with fibroids. Injections of Depo-Provera, or progesterone (the anti-estrogen) has been shown to protect against fibroid growth. Medicines used for fertility have no effect on fibroid growth.
- Diet: Caffeine will not cause an increase in new fibroids or growth of fibroids. 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 fibroid growth.
- Smoking: Smoking has a possible decreased effect on fibroid development and growth. Smoking, of course, is not a reasonable option for preventing fibroids, 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?
Fibroids in the cavity of the uterus, also known as submucosal fibroids, can prevent implantation. Implantation occurs when the embryo (the egg and the sperm combined) attach to the endometrial lining, with the placenta developing and obtaining blood supply from the uterine muscle. Submucosal fibroids 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 (fibroids in the muscle) can also prevent conception. Fibroids can also obstruct the fallopian tubes, resulting in difficulty in becoming pregnant. Fibroid blockage of the tube will not allow the embryo to pass into the uterine cavity, and implant on the endometrial lining.
Fibroids can also cause problems during pregnancy. These include:
- Placental abruption – detachment of the placenta, causing bleeding and loss of pregnancy.
- Abnormal growth of the pregnancy – occurring from fibroids affecting blood flow or the size of the fibroids, preventing 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 FIBROIDS CAUSE DIFFERENT TYPES OF SYMPTOMS?
Yes. Fibroid location is important in understanding how fibroids cause problems.
Submucosal fibroids can cause severe bleeding, even if they are small. These fibroids can increase 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 fibroids 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 fibroids, 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 fibroids increase pain with the menstrual cycle, and can also “degenerate”, or lose their blood supply, causing severe pain.
- Subserosal fibroids 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 fibroids can also twist on themselves, causing very severe pain.
Intramural fibroids 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. Fibroids 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 fibroids 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 or fibroids in the cavity. 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 fibroids 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 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.
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 fibroids 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 polyps or fibroids 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.
This procedure is used to evaluate the uterine cavity for fibroids. There are better, less expensive options for patients to evaluate fibroids in the cavity. 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. Fibroids or polyps 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.
HOW ARE FIBROIDS TREATED?
Treatment of fibroids 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 surgery may include any of the following:
- Undesired 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
- Hysterectomy — removal of uterus and fibroids
To help you choose the right procedure, please answer the following:
- Are you planning to have children?
- Are you willing to undergo additional surgeries in the future if the fibroids return?
If your answer is YES to either of the questions, please click here to learn more about the myomectomy procedure. If your answer is NO to both questions, the hysterectomy may be a better option for you. Please click here to learn more about the hysterectomy procedure.
Medical therapy means treating fibroids without surgery or radiological procedures. Medical therapy is not helpful for most patients with bleeding, pain, and growth of the fibroids continuing over the long term, but may help to decrease the bleeding associated with fibroids over the short term. Estrogen and progesterone make fibroids grow, and are produced from the ovaries of all women. Types of medical therapy 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 fibroids. 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 fibroids shrink, and blood counts increase. When the Lupron is stopped, the fibroids 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 fibroids 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 associated with fibroids, 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 fibroid 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.
RADIOLOGICAL TREATMENT OF FIBROIDS
Treatment of fibroids through radiology refers to locating the fibroids 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 fibroid. 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 fibroids 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.
- Fibroids on stalks, also called 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 (removal of fibroids) 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 fibroid to destroy it. This procedure cannot be used for patients who want to become pregnant, or for adenomyosis. It is not effective for larger fibroids, 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 fibroids, since damage can result.
RADIOFREQUENCY ABLATION (RFA)
Also called myolysis, this is destruction of fibroid 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.
WHY CIGC FOR FIBROID TREATMENT?
Finding out that you have fibroids can cause a mixture of relief and worry. It is helpful to finally understand why you are having uncomfortable symptoms, but choosing where to obtain your treatment is a big decision.
Many of our patients require a hysterectomy as their fibroid removal surgery. Did you know that our surgeons perform an average of 400 hysterectomies per year, as opposed to the 27 performed by the average OB/GYN?
Why shouldn’t I get treatment from my OB/GYN? There is no doubt that your OB/GYN is a skilled practitioner in Obstetrics. However, studies have shown that GYN surgery is merely a secondary component of what an OB/GYN does. Nearly every OB/GYN website states that the doctors are qualified to perform laparoscopic surgery, but very few of these doctors actually perform the procedures often enough to gain tenured experience and expertise.
At CIGC, our careers are dedicated to the techniques and procedures that optimize the surgical care and recovery of women. CIGC surgeons are true GYN surgical specialists – not simply doctors who are taking advantage of the “marketing of medicine.” While your OB/GYN’s main focus is Obstetrics, our main focus is advanced laparoscopic surgery. We are board-certified, fellowship-trained in Minimally Invasive Surgery or Gynecologic Oncology, and completely focused on GYN surgery. Since we get a high volume of patients needing gynecological surgery, we have the experience to have mastered the procedures and skill.
We do not perform Obstetrics – we leave that to the experts in that field, and we are experts in our own.
When you need fibroid removal surgery, we can offer you options. 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 the fibroids return. 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.
CIGC will always choose the least invasive fibroid surgery possible in order to decrease your pain and increase your recovery time. Knowing which procedure to perform requires comprehensive knowledge about each available option and the technology and practices that make them work.
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.
We have offices in Bethesda and Annapolis, Maryland, as well as in Reston, Virginia for your convenience. Please give us a call at (888) 787-4379.