Dr. Parker's Fibroids Blog

Hysterectomy Improves Sexual Response? Addressing a Crucial Omission in the Literature

January 24, 2012 – 8:30 am

Journal: The Journal of Minimally Invasive Gynecology, Volume 18, Pages 288-295, May 2011

Authors: Barry R. Komisaruk, Eleni Frangos, Beverly Whipple

Study from: University of Medicine and Dentistry of New Jersey

Problem: The prevailing view in the medical literature is that hysterectomy improves the quality of life. This is based on claims that hysterectomy relieves painful intercourse and abnormal bleeding and improves sexual response. Because hysterectomy requires cutting the sensory nerves that supply the cervix and uterus, it is surprising that the reports of negative effects on sexual response are so limited. However, almost all articles report that some women find that hysterectomy is detrimental to their sexual response. It is likely that the degree to which a woman’s sexual response and pleasure are affected by hysterectomy depends not only on which nerves were severed by the surgery, but also the genital regions whose stimulation the woman enjoys for eliciting sexual response.

Study: A review of the medical literature regarding female sexual response and the effects of hysterectomy on sexual response.

Results:

While most women report improvement of sexual functioning after hysterectomy, this may be the result of relief of symptoms after removal of a diseased uterus, such as vaginal bleeding and pain with intercourse.
Hysterectomy may eliminate anxiety about cancer risk (uterine, cervix, ovarian) and unwanted pregnancy.
Multiple factors may be related to the negative effects of hysterectomy on sexual response including:
1. For some women, uterine contractions are an important aspect of orgasm and hysterectomy eliminates this sexual response.
2. Scar tissue at the top of the vagina (when the cervix is removed) may make intercourse difficult because the top of the vagina is less elastic.
3. Internal scarring or nerve damage may cause pain or may interfere with feeling sexual pleasure.
4. Surgical removal of some of the vaginal wall may result in decreased vaginal blood flow, which may decrease sexual arousal and the possibility of multiple orgasms.
The vagina and cervix have a plentiful nerve supply. The hypogastric nerves come from the uterus and cervix, the pelvic nerves come from the vagina and the pudendal nerves come from the clitoris, labia majora, and labia minora. The ilioinguinal and genitofemoral nerves come from the mons pubis, labia, and vulvar skin.

When a woman is lying on her back, the region of the vagina near 12-o’clock (the “G spot”) is often the most sensitive area to physical stimulation and more likely to produce orgasm than stimulation of other regions of the vagina.

One study reported that 35% of 128 healthy women said they experience orgasm from penile stimulation of the cervix during sexual intercourse, 63% reported that they experience orgasm from vaginal stimulation, and 94% reported that they experience orgasm from clitoral stimulation.

Authors’ Conclusions: Based on the nerve supply of the clitoris, vagina, and cervix, it would not be surprising if responses to genital stimulation are decreased by hysterectomy. There is a glaring omission in the literature on the effects of hysterectomy on sexual response; women’s reports of their preferred source of genital stimulation have not been included in any studies and their sexual response may depend on whether a woman’s preferred genital site of stimulation is desensitized by hysterectomy.

Further research that considers these factors may help to reconcile the reported variability of the effects of hysterectomy on sexual response.

Dr. Parker’s Comments: For women who are considering a hysterectomy for severe adenomyosis or failure of less invasive treatment options, the issue of sexual response is important to think about. Unfortunately, there are no studies about sexual response following myomectomy or UAE.

Although some women report improvement of sexual response after a hysterectomy, this is usually related to the relief of symptoms, such as vaginal bleeding and pain with intercourse. However, some women note a change in sexual response for the worse. This article beautifully outlines the issues and describes why the medical literature about sexuality and hysterectomy has been so unhelpful for women. Not one study has asked women what they find pleasurable before surgery, or whether there is any difference in what they find pleasurable after surgery.

I have been discussing this issue with women for years and the conversation is interesting and sometimes humorous. I review the differences in pleasurable sexual response among women (stimulation of clitoris, vagina, cervix, and uterine contractions) and some women know exactly what gives them pleasure. And, some women say, “what the heck are you talking about?” The next step is a homework assignment – see what works for you before you decide on surgery.

Since fibroids or adenomyosis almost never involve the cervix and since removing the cervix does cut nerves and support ligaments to the pelvis, many women who chose to have a hysterectomy wish to leave the cervix. My feeling is, if the cervix isn’t broken, don’t fix it. Other issues regarding hysterectomy are discussed here: http://www.fibroidsecondopinion.com/hysterectomy-for-fibroids/

Although not explored here, if your ovaries are removed major hormonal changes are likely to occur, which can lead to vaginal dryness and loss of vaginal elasticity. Decreased sleep quality and resultant fatigue can also influence sexuality. For women who are not an increased risk of ovarian cancer due to family history, keeping your ovaries decreases the risk of heart disease, stroke, lung cancer and osteoporosis. More about the benefits of keeping your ovaries can be found at the bottom of this page: http://www.fibroidsecondopinion.com/hysterectomy-for-fibroids/

Until the proper studies are done, we will not be able to make any general conclusions about sexual response following surgery (or UAE, HIFU). However, because sexual response can be so different for different women, no matter what future studies show the questions about sexual response will always need to be considered by each woman for herself.

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Using MRI to Determine Surgical Treatment Options for Women with Fibroids

January 10, 2012 – 8:37 am

The utility of MRI for the surgical treatment of women with uterine fibroid tumors

Journal: American Journal of Obstetrics and Gynecology (in press, available now on-line for subscribers)

Authors: William Parker

From: UCLA School of Medicine, Los Angeles, CA.

Problem: Fibroids can usually be diagnosed by pelvic examination and ultrasound, but neither gives us exact information about the sizes, number, and positions of all fibroids present. Excellent studies show that MRI is the most accurate way to get all this information, but most gynecologists do not order MRIs or know how to interpret them.

Clinical Opinion: This article describes how MRI works, illustrates normal pelvic anatomy and the appearance of fibroids (and adenomyosis) on MRI and discusses the ways to limit the number of images and, therefore, the cost of an MRI. Three actual cases from my practice are presented to show how MRI can change the treatment options available to women with fibroids.

Authors’ (Dr. Parker’s) Conclusions: If your gynecologist is able to perform only a hysterectomy, then precise imaging of fibroids is not necessary since they will all be removed with the uterus. However, with many other treatment options now available, magnetic resonance imaging (MRI) can help tell us which options may be best. If your gynecologist does not offer the available, often less invasive, treatment options, accurate information allows you to find a gynecologist who has the skills to take care of you.

By admin | Posted in Recent Fibroid Research | Tagged fibroid treatment options, fibroids, fibroids and pelvic exam, hysterectomy, magnetic resonance imaging, minimally invasive treatment options for fibroids, MRI, no hysterectomy, ultrasound | Comments (0)

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How do Fibroids Cause Infertility and Heavy Menstrual Bleeding?

January 3, 2012 – 8:32 am

Leiomyoma simultaneously impair endometrial BMP-2-mediated decidualization and anticoagulant expression through secretion of TGF-β3.

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.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged decreased fertility, fibroids and fertility, fibroids and miscarriage, fibroids and pregnancy, Heavy menstrual bleeding, molecular biology, submucosal fibroid | Comments (1)

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Risk of Fibroid “Recurrence” Following Myomectomy

December 21, 2011 – 11:06 pm

(Excerpted from http://health.groups.yahoo.com/group/uterinefibroids/)

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

By Bill Parker, MD | Posted in Interesting questions for Dr. Parker | Tagged additional treatment, fibroids, grow back, growing back, new appearance of fibroids, recurrence, repeat treatment | Comments (0)

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Fibroids and Fertility

November 26, 2011 – 2:35 pm

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

By Bill Parker, MD | Posted in Interesting questions for Dr. Parker | Tagged myomectomy pregnancy, pregnancy | Comments (0)

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Predicting Fibroid Growth: Two Studies

October 24, 2011 – 8:35 am

Growth of uterine leiomyomata among premenopausal black and white women.

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.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged black women, excess estrogen, fibroid growth, fibroid growth rate, fibroids, fibroids and menopause, fibroids getting smaller, hysterectomy for fibroids, MRI, shrinking fibroids, white women | Comments (2)

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Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results.

September 12, 2011 – 8:30 am

Authors: Moss J, Cooper K, Khaund A, Murray L, Murray G, Wu O, Craig L, Lumsden M.

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.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged deciding between uterine artery embolization and surgery for fibroids, differences between UAE and surgery for fibroids, fibroid study, fibroid treatment, symptomatic uterine fibroids, treatment for fibroids, UAE, uterine artery embolization | Comments (0)

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Will Birth Control Pills Stop Bleeding From Fibroids?

September 4, 2011 – 5:25 pm

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

By Bill Parker, MD | Posted in Interesting questions for Dr. Parker | Tagged birth control pills to treat bleeding from fibroids, embolization for bleeding from fibroids, fibroids and birth control pills, hysterectomy last resort | Comments (0)

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Laparoscopy for Large Fibroids

July 4, 2011 – 5:27 pm

Dear Dr. Parker,

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,
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

By Bill Parker, MD | Posted in Interesting questions for Dr. Parker | Tagged laparoscopic myomectomy, laparoscopy for large fibroids, surgeon skill | Comments (2)

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Disclaimer: The ideas, procedures and suggestions contained on this web site are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision.