Topics of Interest

Outcomes from fibroid (leiomyoma) therapies: comparison with normal controls.

Journal: Obstetetrics and Gynecology. 2010 Sep;116(3):641-52.

Authors: Spies JB, Bradley LD, Guido R, Maxwell GL, Levine BA, Coyne K.

Study from: Georgetown University Hospital Department of Radiology, Washington, DC

Problem: Despite the very common occurrence of fibroids, very few studies have evaluated the severity of symptoms caused by uterine fibroids, their effect on health-related quality-of-life, or the changes in symptoms after treatment compared with women who do not have fibroids.

Study: Groups of women with fibroids who were scheduled for hysterectomy, myomectomy, or uterine artery embolization, as well as women without fibroids were assessed using questionnaires designed to measure quality of life and symptoms, including physical functioning, pain, sexual function, vitality, energy/mood, social functioning and mental health. Questionnaires were completed before treatment and again at 6 and 12 months after treatment.

Results: A total of 375 women Participated in the study: 101 without fibroids, 107 who had embolization, 61 who had a myomectomy, and 106 who had a hysterectomy. Before treatment women with fibroids had more severe symptoms than women without fibroids. At both 6 and 12 months after treatment, women having treatment for their fibroids had as few symptoms as women who did not have fibroids. One year after treatment, the women who had a hysterectomy reported less symptoms and better health-related quality of life than women who had embolization or myomectomies. However, the majority of the benefit of hysterectomy was attributed to the absence of menstrual periods.

Authors’ Conclusions: At 12 months after treatment, all three leiomyoma therapies resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy due to the absence of menstrual periods.

Dr. Parker’s Comments: Since myomectomy, embolization and hysterectomy all reduce symptoms to the levels seen with women without fibroids, all three treatments should be very effective for women who have bothersome symptoms related to fibroids. Therefore, a woman’s choice for treatment should depend on other individual factors including the desire for fertility, the desire to preserve her uterus, willingness to undergo surgery and anesthesia, willingness to undergo embolization, etc. The other point here is that the women choosing to have treatment had significant symptoms; most women with minor symptoms will often choose watchful waiting and wait for menopause when fibroids shrink and bleeding stops.

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6 Comments

  1. Susan
    Posted December 10, 2010 at 4:45 pm | Permalink

    Dr. Parker,

    The results of this study have been bothering me since the day you posted the research. I am very curious about how the questionnaires were designed and whether, as you pointed out earlier, women tended to score the questionnaires higher to support their choices.

    When a gynecologist told me to have a TAH, I asked the opinion of a friend who had this surgery several years ago. She told me she had the best quality of life ever, mainly because of no more monthly inconvenience. Of course! After I did some homework, I started to ask more details. Then she admitted that her sex life was over since the surgery. But she added that it didn’t bother her, and that her partner understood. By the way, I don’t know if the so-called “worrel-ing” trick could have helped her or not.

    If my friend were asked to take the questionnaire, I believe she definitely would support her choice. Although well-intended, my friend’s opinion could have influenced my judgment if I had not known the whole story when I was making an important decision. So could this study impact women greatly when they are evaluating their options.

    Su

  2. Posted December 10, 2010 at 10:00 pm | Permalink

    Su,

    I agree with what you say here. It also appears from the study that women were not given the choice of all three treatments and the doctors may have, in fact, influenced what treatment the women chose to have.

    The issue for me is that every woman (or man) brings their own very personal values to the table when they make a medical decision like this. Women often ask me, “what would you do about this medical problem if you were me?” I try not to answer unless there is a life-threatening situation present (almost never the case with fibroids). I sometimes see patients make decisions I might not make; some women have very large fibroids that limit their activity or they bleed so heavily that they are confined to the house for many days every month. I like to be active and under these circumstances would chose to be treated so that I could do the things I like to do.

    What concerns me is that gynecologists often offer women only the procedures that they know how to do (like abdominal hysterectomy), without any regard for alternatives that might serve her better. So, I try to give patients all the medical information I have and answer every question posed to me, but allow each woman to make her own decision based on her own symptoms, values and needs. The assumption, though, is that most women are getting all the information they need to make the right decision and that may not be true in many situations. Doing your own research, asking your doctor lots of questions, and getting a second or third opinion from someone who takes care of your specific problem on a frequent basis is the best way to get what you need.

    Bill Parker, MD

  3. Angie Pfeifer
    Posted January 17, 2011 at 11:41 am | Permalink

    Research like this really makes me nuts. And you’ll probably be able to tell that I’ve heard the H-word one time too many, and from every quarter. This particular brand of misogyny is rampant and we tolerater it and perpetuate it ourselves. I cannot tolerate the idea that the abnormal lack of even normal female function (menstruation) is considered a medical benefit. Even more noteworthy, is that they’re only talking about relief from symptoms of a sick uterus, which any of the therapies seem to give. But no one is talking (or caring much) about the REAL effects of hysterectomy, because as women who have fallen victim to the fear and self-hatred inculcated in us by our doctors, we’re too busy being grateful for our mass-mutilations. We take the loss of libido and sexual functioning; early onset of menopause as the ovaries abandoned by the uterus shut down prematurely; and surgical complications as a matter of course, no less than we deserve apparantly. If we were focused on male libido and function, would testicular surgery be the first-line of defense? Would we even be having this discussion?

  4. Posted January 21, 2011 at 11:57 am | Permalink

    You are right about informed consent and unethical doctors who only recommend what they know how to do. I see women in my office every day who have been told absolute nonsense about what treatment may or may not be possible and it is beyond frustrating. I receive virtually no referrals from gynecologists in my own community who know what procedures I can do, but choose to recommend hysterectomies to all their patients. By the way, the South has the highest rate of hysterectomies in the country and the US has much higher hysterectomy rates than most European countries.

    I worry about women who do not have knowledgeable, ethical doctors or who do not seek out good information on the web. That’s one reason I set up the website. Thanks for the kind words about the website and good luck with your own situation,

    Bill Parker, MD

  5. Amy
    Posted July 2, 2011 at 5:03 am | Permalink

    Two points, I really hate it when I hear that fibroids shrink after menopause, because I don’t hear the caveat that if one is on HRT, they won’t – it may seem to be common sense to doctors, but I think this needs to be specifically noted. If one chooses against treatment thinking they just have to wait, but then due to horrible symptoms they end up taking estrogen, those fibroids definitely don’t shrink! If I’d realized that, I would have had my fibroids out a lot sooner. I finally had mine out, but not before I had one doctor refuse to operate because I was “too old” at 53!

    I also want to echo the above. Before my surgery two relatively well known doctors in the Bay Area just recently suggested I have a hysterectomy instead of a myomectomy. One (albeit not a gynecologist) stated that all of the women he’s known who have had one had no regrets. Aside from the fact that I hate absolutes, if a woman is having horrible symptoms from fibroids or other uterine conditions, of course they will be very thankful to be free from those symptoms and relieved they had the procedure done… but it certainly doesn’t mean the hysterectomy was the best choice! As with the first post above, if this doctor had dug a little deeper, would he have started to find out more? I suspect the bar for a lot of these women was very low in the first place – we are used to making the best of bad situations, being grateful for any improvements and moving on.
    Thanks for this website!

  6. Posted July 4, 2011 at 5:18 pm | Permalink

    Most women who take hormones after menopause will still have shrinkage of fibroids, since the doses used for treatment are usually very low. And, for women who have had a decrease in fibroid size with menopause and then choose to start hormones, most will not have re-growth of the fibroids. As noted below, it appears that the risk of growth may be slightly higher with transdermal patches (and likely creams, as well).

    This is from a paper I wrote for Fertility and Sterility:

    Postmenopausal women with myomas treated with 0.625 of conjugated equine estrogen (CEE) and 5 mg MPA were compared over 3 years to a similar group of women not taking hormone therapy. (37) Although a few women in treated and control groups had very slight increases (1.5 cm3) in myoma volumes after the first and second years, by the end of the third year, only 3 of 34 (8%) treated and 1 of 34 (3%) untreated women had any increase in myoma volume over baseline. Postmenopausal women with known myomas, followed with sonography, were noted to have an average 0.5 cm increase in the diameter of myoma after using transdermal estrogen patches plus oral progesterone for 12 months. Women taking oral estrogen and progesterone had no increase in size. (38)

    References:
    37. Yang CH, Lee JN, Hsu SC, Kuo CH, Tsai EM. Effect of hormone replacement therapy on uterine fibroids in postmenopausal women–a 3-year study. Maturitas 2002;43:35-9.
    38. Reed SD, Cushing-Haugen KL, Daling JR, Scholes D, Schwartz SM. Postmenopausal estrogen and progestogen therapy and the risk of uterine leiomyomas. Menopause 2004;11:214-22.

    I have been in practice for 33 years and have seen this shrinkage occur for almost all women, although it seems to take longer for some women than for others. Also, if fibroids are calcified, they will not shrink.

    I am glad you like the website,

    Bill Parker, MD

Fibroid Doctor William H. Parker

Dr. William H. Parker is a board-certified Fellow in the American College of Obstetricians and Gynecologists. Dr. Parker is an internationally recognized expert in fibroid surgery and research. Based in San Diego, California, he is considered one of the best fibroid surgeons for abdominal and laparoscopic myomectomy in the United States and abroad. He has been chosen for Best Doctors in America and Top Doctors every year beginning in the late 90's.

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