Journal: Journal of Clinical Endocrinology and Metabolism. 2011;96:412-21.

Authors: Sinclair DC, Mastroyannis A, Taylor HS.

Study from: Yale University School of Medicine

Problem: Women with submucous fibroids have decreased fertility, increased miscarriage rates, and heavy menstrual bleeding. Why this happens has not been well understood. The authors tested to see if proteins that interfere with fertility and/or cause heavy bleeding were produced by fibroids.

Study: Sophisticated laboratory tests were performed on fibroids and normal uterine muscle to see if the cells made proteins that could cause infertility or heavy bleeding.

Results: Fibroids make different amounts of proteins than normal uterine muscle and these proteins make it more difficult for a fertilized egg to stick to the uterine lining. Fibroids also make other proteins that interfere with the blood clotting in the uterine lining which causes heavy bleeding.

Dr. Parker’s Comments: This is cutting edge science from the fertility group at Yale. Using techniques from molecular biology, the authors showed that fibroids make proteins that both decrease fertility and increase menstrual bleeding. We knew these effects existed, but now we have a better idea as to why.

I prefer to have a myomectomy, but I only want to be cut on one time and since I have to have an abdominal myomectomy I thought it would be best to go ahead and do the hysterectomy since there is a very good chance the fibroids will return.

This is an interesting and important topic. I just finished writing a chapter on fibroids for Berek and Novak’s Gynecology textbook – these are a few excerpts with my additional comments in brackets:

• Individual fibroids, once removed, do not grow back. Fibroids detected after myomectomy, often referred to as “recurrence”, result either from failure of fibroids to be removed at the time of surgery or they are newly developed fibroids. Perhaps this circumstance is best designated “new-appearance” of fibroids.
• Routine ultrasound follow-up is sensitive, but detects many clinically insignificant fibroids (will not cause symptoms). A study of 40 women who had a normal sonogram 2 weeks following abdominal myomectomy (no fibroids left behind by the surgeon) found that the risk of sonographically detected new fibroids larger than 2 cm was 15% over 3 years.
• Meaningful information for a woman considering treatment for her fibroids is the approximate risk of developing symptoms that would require yet additional treatment. A study of 125 women followed by symptoms and clinical examination after a first abdominal myomectomy found that a second surgery was required during the follow-up period (average time was 8 years) for 11% of women who had one fibroid removed initially and for 26% of women who had three or more fibroids removed. (reference: Malone L., Myomectomy: recurrence after removal of solitary and multiple myomas. Obstetrics & Gynecology 1969;34:200-203)
• New appearance of fibroids is not more common following laparoscopic myomectomy when compared with abdominal myomectomy (when performed by skilled laparoscopic surgeons). Eighty-one women randomized to either laparoscopic or abdominal myomectomy were followed with transvaginal sonography every 6 months for at least 40 months. Fibroids larger than 1 cm (so, not clinically significant) were detected in 27% of women following laparoscopic myomectomy compared to 23% in the abdominal myomectomy group, and no woman in either group required any further intervention. (reference: Rossetti A, Sizzi O, Soranna L, et al. Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy. Hum Reprod 2001;16:770-774).

Bill Parker, MD

Dear. Dr. Parker

I need your Second Opinion, as am preparing for the second Laparoscopy surgery in order to remove 11.5 cm fibroid, after six years of Abdominal Myomectomy..

I was planning to conceive by IVF treatment, but unfortunately by doing MIR scanning thy found large size fibroid 11.5cm.

Thank you

Reda,

Fibroids only interfere with fertility if they bulge into, or are very near, the uterine cavity.  If not, pregnancy is possible.  Also, fibroids only very, very rarely interfere with an ongoing pregnancy.  See these webpages for more information: http://www.fibroidsecondopinion.com/fibroids-and-pregnancy/ , http://www.fibroidsecondopinion.com/2010/11/fibroids-leiomyomas-at-routine-second-trimester-ultrasound-examination-and-adverse-obstetric-outcomes/

Bill Parker, MD

Journal: Procedings of the National Acadamy of Science U S A. 2008 Dec 16;105(50):19887-92.

Authors: Peddada SD, Laughlin SK, Miner K, Guyon JP, Haneke K, Vahdat HL, Semelka RC, Kowalik A, Armao D, Davis B, Baird DD.

Study from: National Institute of Environmental Health Sciences, NC

Problem: Fibroids are the leading cause of hysterectomy in the United States. Black women have a greater fibroid burden than whites, yet no study has systematically evaluated the growth of fibroids in blacks and whites.

Study: The authors tracked growth of 262 fibroids (size range: 1-13 cm in diameter) from 72 premenopausal participants (38 black and 34 white women). Fibroid volume was measured by computerized analysis of up to four MRI scans over 12 months.

Results: The average growth rate over 12 months was 9%, but the difference among women was very large: from -89% to +138%.  Seven percent of fibroids got smaller (>20% shrinkage). Fibroids from the same woman grew at different rates.

Black and white women younger than 35 had similar fibroid growth rates. However, growth rates declined with age for white, but not for black women.  Growth rates were not dependant on initial fibroid size, location in the uterus, women’s weight, or number of children.

Most fibroids did not grow (0% change), but other fibroids either grew or got smaller.

Authors’ Conclusions: 1) fibroids can get smaller; 2) fibroids from the same woman grow at different rates, despite exposure to the same hormones in the blood; 3) initial fibroid size does not predict its growth rate; 4) as black women age, they do not experience slower fibroid growth which may explain why black women have more fibroid-related symptoms.

Dr. Parker’s Comments: This is the first study to accurately track fibroid growth, both in different women and different fibroids in the same woman. I (and other gynecologists) have been telling women for 30 years that fibroids do not get smaller until after menopause – this study proves that idea wrong.  I have also been telling women that fibroid growth is unpredictable, some fibroids grow slowly, others fast and others go through growth spurts and then slow down (see next study below).  This idea turns out to be correct.  We do not understand what makes fibroids grow (or shrink), but it is clearly NOT estrogen excess.  If this were the case, as specifically addressed in this article, all fibroids in the same women, and thus exposed to the same hormone levels, would either grow or not grow.  And, that clearly does not happen.  Unfortunately, we still have a lot to learn about fibroid growth.

Short-term change in growth of uterine leiomyoma: tumor growth spurts.

Journal: Fertility & Sterility. 2011 Jan;95(1):242-6.

Authors: Baird DD, Garrett TA, Laughlin SK, Davis B, Semelka RC, Peddada SD.

Study from: National Institute of Environmental Health Sciences, North Carolina

Problem: No one has ever followed fibroid growth closely enough to see what happens over 3 month periods.

Study: 18 black and 18 white premenopausal women had 101 fibroids measured with MRI at the study beginning and again at 3, 6, and 12 months. Growth spurts were defined by growth rates greater than 30% in 3 months.

Results: Growth spurts were seen in 37 of the 101 fibroids. Fibroids from the same woman did not have similar growth, nor were age, race/ethnicity, number of children or a woman’s weight related to growth spurts.  However,fibroids smaller than 5 cm went through growth spurts more often than larger fibroids.

Authors’ Conclusions: Short spurts of growth are common for fibroids.

Dr. Parker’s Comments: As noted above, we do not understand what causes fibroids to grow, but these two studies show that fibroid growth is unpredictable and that small fibroids are likely to grow more quickly than larger (>5 cm) fibroids.

Journal: British Journal of Obstetrics and Gynecology  2011;118:936–944.

Study From: North Glasgow University Hospitals, Glasgow, UK

Problem: Women with uterine fibroids now have a number of treatment options available. Very few studies have compared the results of treatment with different options.

Study: This study was designed to compare the results for women who had uterine artery embolization with women who had surgery (myomectomy or hysterectomy) five years after treatment.  Women filled out quality-of-life questionnaires and the authors recorded any complications from treatment or the need for women to have additional treatment for fibroids during the 5 years of follow-up.

Results: 106 women were randomized to UAE and 51 to surgery (42 had abdominal hysterectomy and 9 had abdominal myomectomy).  Symptom reduction and patient satisfaction with both treatments were very high and there were no significant differences between the UAE and surgery groups.

Rates of adverse events were similar in both groups.  In the surgery groups there were 5 wound problems (either infections or blood collections), 2 surgeries with excessive blood loss, and 2 anesthetic complications.  In the UAE group there were 2 women with pain and infection needing readmission to the hospital, 4 with fibroid expulsion, 1 pelvic abscess requiring hysterectomy, 2 with persistent pain requiring hysterectomy and 1 woman with heavy bleeding that required blood transfusion.

The need for further treatment during the 5 years was 32% for UAE and 4% for surgery.  In the UAE group, 4 women had repeat UAE and 13 women had hysterectomies.  In the surgery group, 1 woman had a hysterectomy due to technical difficulties (I imagine due to surgeon inexperience?) during her myomectomy.

Authors’ Conclusions: UAE is a satisfactory alternative to surgery for fibroids. The less invasive nature of UAE needs to be balanced against the need for further treatment in almost a third of patients. The choice should lie with the informed patient.

Dr. Parker’s Comments: This study shows that most women will do well with either UAE or surgery as treatment for fibroids.  Although not discussed in this paper, the recovery from UAE is usually much easier than from abdominal surgery and a bit easier than from laparoscopic or robotic surgery.  On the other hand, this study found that more women required additional procedures after UAE than after surgery.

The author’s last sentence is a guiding principle: “the choice of treatment should lie with the informed patient”.  For any patient, each of these treatment options is going to have pros and cons.  I see my job as a physician as one figuring out what the pelvic examination plus imagining studies (MRI or ultrasound) reveals about the sizes and positions of the fibroids.  Then my role is helping each woman understand which symptoms are caused (or not caused) by her fibroids.  I then describe the different treatment options and how they might help her situation.  Then, the decision of which option to choose, including watchful waiting, is up to the patient.

Dr. Parker,

Thank you for writing your book.  I ordered it and read it cover to cover in 2 days.  It was so informative and well written!  I have made an appointment to see you. I read your website and did not see any articles about treating fibroids with birth control pills as an option.  I am a 46, had an ablation which worked for almost 1 year but then I developed more fibroids. The ablation treated only the internal fibroids, but I have them inside and outside the uterus.

I have been to 3 different physicians.  The 1st insisted on hysterectomy, I fled.  The second performed ablation surgery. The 3rd also recommended hysterectomy but I wanted to try some other options first.  He put me on Lo Loestrin FE.  For the 1st 3 months I bled almost the entire time, continued to have clots and severe cramps.  He said he could give me a stronger pill but it would have more side effects. I agreed to wait one more month for my body to try to adapt to the pills.  During the 4th month I did not bleed for 3 weeks and was elated, thinking it had kicked in.  But on day 19 while still taking the pills my period arrived, that was 9 days ago and it is still going strong, horrible clotting, intermittent, unpredictable, profuse bleeding, plus irritability and mentally horrified.  I have a demanding job and I am the boss, so I can’t just call in sick.

I run from public restroom to restroom, come up with clever ways to shorten meetings, carry paper towels in my car for traffic jams, wear mostly black clothing…no way to live.  Please note that I am in excellent health otherwise and no signs of menopause except that I missed one period in January of this year.  I was so hopeful but it seems Aunt Flo is not leaving any time soon.  My question is this, is there a pill that will control the symptoms until menopause?

Sorry to hear about your problem. In my experience, birth control pills don’t work if any of the fibroids are near or bulging into the uterine cavity.  No one pill is necessarily any better than another – it is trial and error to see if another pill might work.  Other options would include uterine artery embolization or myomectomy (possibly laparoscopic depending on the size and number of fibroids).  Hysterectomy should be a last resort.   Embolization might be worth thinking about – it is essentially non-invasive and has good results for heavy bleeding.

More about this here: http://www.fibroidsecondopinion.com/uterine-artery-embolization/

I hope this is helpful,

Bill Parker, MD

Hi Dr. Parker

Im about to have surgery to remove 3 fibroids , the biggest one being 9cm and 2 small ones.

the large one is on the anterior wall and the other two are on the posterior wall. My question is should I have them removed if I plan on getting pregnant or leave well enough alone. You see Im scared to death of the myomectomy turning into a full hysterectomy and my sister said its a paper I can sign so that they can not do a hysterectomy if i have a problem during surgery.

Please help

having surgery soon

want to have more kids

L,

The only fibroids that interfere with fertility are those that bulge into the uterine cavity (submucous).

See more about this here: http://www.fibroidsecondopinion.com/fibroids-and-pregnancy/

A hysterectomy should not be necessary and you should consider a second opinion with a doctor who does myomectomies on a regular basis and who will not ask you to sign a consent for hysterectomy.

Bill Parker, MD

Thank you very much for the information you provide on your website. It is the single most useful resource I have come across.

The surgeon I have seen has suggested laparoscopic removal of a 12cm fibroid. I am preparing for a second appointment and my question is: why is there a ‘cut-off point’ for how large a fidroid a surgeon will remove laparoscopically?

Yours sincerely,

B

B,

Each surgeon will have his/her level of expertise and experience which will determine the largest size and the number of fibroids they are comfortable removing.  You might consider asking the doctor: how many women have you operated on with fibroids as large as mine?  How many times have you needed to change to abdominal surgery in those cases?  How many of the women have required blood transfusion?  How many times have you had to perform a hysterectomy for those cases?

You should be able to get an idea of experience and expertise with these questions.

I hope this is helpful,

Bill Parker, MD

Journal: Human Reproduction. 2011;26:834-9.

Authors: Somigliana E, De Benedictis S, Vercellini P, Nicolosi AE, Benaglia L, Scarduelli C, Ragni G, Fedele L.

Study from: Department of Obset/Gynecol-Fondazione Cà Granda, Milano, Italy.

Problem: Other studies show that fibroids that bulge into the uterine cavity (submucous) decrease fertility and removal of these fibroids increases fertility.  Fibroids outside the uterine wall do not influence fertility.  Although some studies show a small decrease in fertility for fibroids within the uterine wall (intramural) other studies show no change in fertility.  This study compared the rate of success of in vitro fertilization (IVF) in women with and without intramural fibroids smaller than 5 cm diameter (2”).

Study: Women with intramural fibroids with a diameter below 5 cm who needed  IVF were compared to similar women without fibroids also having IVF

Results: There was no difference in the number of pregnancies and healthy deliveries between the 80 women with intramural fibroids less than 5 cm and the 119 women without fibroids.

Authors’ Conclusions: In patients selected for IVF, small fibroids not encroaching the endometrial cavity did not impact on the rate of success of the procedure.

Dr. Parker’s Comments: This study adds to other studies that show no decreased fertility in women with medium size fibroids within the wall, but not bulging into the cavity, of the uterus.  The benefit of studies using IVF is that all the other factors that might influence fertility are minimize during IVF.  Each of the fertility studies to date, including this one, have included only a small number of women.  But, when added all together, the studies demonstrate that neither  surgery, UAE nor focused ultrasound treatment is needed for these women before they try to conceive.

Dear Dr. Parker,

I would like to thank you very much for the most comprehensive website on fibroids and their treatment.  The time and effort you put into maintaining and updating that site is greatly appreciate by every woman who has to deal with them.

I know you are a very busy man, but wanted to ask you a quick question.  If fibroids shrink by 50% after menopause, what would be an approximate shrinkage of the 20-22 week uterus with multiple fibroids (the largest being around 10-12cm) and how long it may take for the symtomps of bulk and pressure to go down?  On your web site, you mentioned that it could happen 6 months or more after the last period for firboids to start shrinking.  Can I expect that my uterus may shrink from 20-22 weeks to 12-14 weeks, or more like 16-18-weeks?  If that is the case, is abdominal myomectomy reasonable at the age of 55 with periods happening every 3-4 months now?

Thank you very much for you opinion.

The 50% shrinkage number is based on volume (not diameter), so it would more likely be closer to 16 weeks about 6 months after your last period.  An abdominal myomectomy is certainly reasonable – I have done myomectomies for women even after menopause, when they did not get enough shrinkage to make them comfortable.

Thanks for the kind words about the website,

Bill Parker, MD