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

Study From: Georgetown University Hospital, Cleveland Clinic, University of Pittsburgh, Walter Reed Army Medical Center, and United BioSource Inc.

Journal: Obstet Gynecol. 2010;116:641-52.

Problem: There are very few studies that measure how women feel after treatment for fibroids.

Study: Four medical centers collaborated to measure fibroid symptoms and quality-of- life both before and after hysterectomy, myomectomy, or uterine artery embolization (UAE) compared to each other and to women without fibroids.

Findings: 101 women without fibroids, 107 women having an embolization for fibroids, 61 having a myomectomy and 106 women having a hysterectomy for fibroids participated in the study. At the beginning of the study, the women filled out questionnaires asking about their level of activity, energy level, sexual function, pain, social functioning, general health and mental health. Women with fibroids scored much worse than women without fibroids.

With treatment, no women in any group died or had a permanent injury.

Six and 12 months later, questionnaires showed that, after any of the three fibroid treatments, most women felt as good as women without fibroids. At 12 months, women who had a hysterectomy had fewer symptoms (no bleeding) than women who had myomectomies or UAE.

Authors’ Conclusions: One year after treatment, all three fibroid treatments resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy. The authors felt this was because after hysterectomy women had no further bleeding.

Dr. Parker’s Comments: UAE, myomectomy and hysterectomy all make women feel better than before they had treatment and most women return to feeling normal. There were a few short-comings of the study, though. First, the study is a statistical analysis of groups of women and it is not possible to tell from the article if some women did not improve or had bothersome side-effects after treatment. Also, each woman chose her treatment and, therefore, might be inclined to score the questionnaires higher to support her choice. However, this is what happens in real life and if you feel better, who cares what the scientists think??

Authors: Sharan C, Halder SK, Thota C, Jaleel T, Nair S, Al-Hendy A.

Study From: Meharry Medical College, Nashville, Tennessee

Journal: Fertility and Sterility, 2010, Aug 23. E-pub

Problem: Women are looking for something they can do to control fibroid growth. Dietary changes and vitamin supplements would be one possible thing they can easily modify.

Laboratory Study: Human fibroid cell cultures were treated with vitamin D and the effect of vitamin D on fibroid genes and proteins was measured.

Results: Vitamin D interfered with the way human fibroid cells make enzymes that either use or block estrogen and inhibited the growth of fibroid cells by 47%.

Authors’ Conclusions: Since Vitamin D inhibits growth of human fibroid cells a deficiency of vitamin D might allow fibroids to grow. The authors reference another article that found that while 45% of African-American women have vitamin D deficiency, only 4% of white women have this deficiency.

Dr. Parker’s Comments: While it is always good to be cautious when interpreting laboratory studies, vitamin D has also been shown to regulate cell growth and inhibit cancer cells. It also helps the body absorb calcium. And, when taken in recommended doses (800-1,000 units per day), the side-effects and risks appear to be almost non-existent. So, even though these results are very preliminary, vitamin D might be worth a try

Authors: Devrim Ertunc, Roza Uzun, Ekrem C Tok, Arzu Doruk, and Saffet Dilek

Study from: Mersin University School of Medicine, Mersin, Turkey.

Journal: Journal of Sexual Medicine, 2009;6:1032-38.

Problem: To my knowledge this is the first good study of sexual issues for women with fibroids before and after myomectomy surgery.

Study: The authors studied 80 women with fibroids and 75 women without fibroids using an established questionnaire to determine how women felt about sexual matters before and after myomectomy surgery. Specifically, the questionnaires asked about libido, arousal, lubrication, orgasm, satisfaction and pain with intercourse.

Findings: Women with fibroids had worse pain and over-all sexual satisfaction scores than women without fibroids, but there were no differences in libido, arousal, lubrication or orgasm. Fibroids on the top of the uterus (fundal) and in the back wall of the uterus (posterior) caused more pain with intercourse. Women with a very large fibroid uterus had worse sexual satisfaction and pain with intercourse. Due to the relief of pain, total sexual satisfaction improved for most women after a myomectomy.

Author’s Conclusions: Fibroids appear to interfere with sexual satisfaction mainly due to pain during sexual intercourse, although fibroids do not seem to have an effect on libido, arousal, lubrication or orgasm. Myomectomy may alleviate pain during intercourse, and thereby improve sexual satisfaction.

Dr Parker’s Comments: There have been very few studies examining the effect of fibroids on women’s sexual satisfaction, and even fewer on the effects of different treatment options on sexual satisfaction. For that reason, the current findings that women with fibroids have more pelvic pain with intercourse and that myomectomy appears to help many of these women are good steps in helping women understand their symptoms. Similar research with regard to other treatment options including uterine artery embolization, focused ultrasound, mefipristone, etc, are sorely needed.

Study: Eighteen women, ages 31-49, who suffered from symptoms of fibroids and who had undergone a hysterectomy or myomectomy in the past 2 years were interviewed by the author. All of the women had further education or specialist professional training after high school.

Findings: Women choosing myomectomy believed the uterus had a purpose other than fertility. They were more likely to not trust their doctor’s recommendation to have a hysterectomy, and more likely to have sought out other gynecologists’ opinions. A similar number of male and female doctors suggested hysterectomy. Patients were more likely to have traveled to another area or state, and to pay some expenses out of pocket, in order to obtain myomectomy surgery.

Women who had a hysterectomy were more likely to have trusted what their regular gynecologist told them and had that doctor perform the surgery. Some of these women, in hindsight, felt that they should have sought out more information before having a hysterectomy. One reason women chose hysterectomy was because they believed their gynecologist’s comment that “the fibroids will just grow back” after a myomectomy.

Conclusions: The author concluded that women need to have access to more reliable information. “Information sources should include specialists other than one’s regular gynecologist, particularly if alternatives to hysterectomy are outside of the gynecologist’s preferences or areas of skill.” The internet played an important role for women accessing information.

Dr. Parker’s Comment: I think many women will identify with the points made in this study. I often see women for a second (or third, or fourth) opinion who have been told to have a hysterectomy based on uninformed or outdated information. Some doctors will not recommend a procedure they do not know how to do, or a procedure that may be more difficult for them to perform. Once fibroids are removed they do not “grow back” and the chance of new fibroids growing is very small.
See: http://www.fibroidsecondopinion.com/can-fibroids-grow/

If you are recommended to have a hysterectomy (or any surgical procedure) you should ask about alternatives available, and whether your doctor knows how to perform them or not. The internet, when used carefully, can be an excellent source of information.

1)   About 18% of African-American women and 8% of white women have fibroids during pregnancy.

2)   Only 30% of women have fibroids grow during pregnancy and most of the growth is within first three months.

3)   The risk of fibroid degeneration that leads to pain and early contractions is very small (5%).

4)   There is a small increased risk of early delivery (3 weeks or more) in women with fibroids (19% v 13% of women without fibroids).

5)   There is a small increased risk of heavy bleeding after delivery of the baby in women with fibroids (8% v 3% of women without fibroids).

6)   There is an increased risk of breech (13% v 8% of women without fibroids).

7)   There is a greater risk of having a Cesarean Section (49% v 21% of women without fibroids)

8)   There is essentially no risk of fibroids injuring the baby.

Also see this webpage: www.fibroidsecondopinion.com/fibroids-and-pregnancy

Dr. Bill Catherino, head of a fibroid research group at the NIH, presented new findings about what causes fibroids to grow and what possible treatments, diets, environmental changes might be used to reduce the health impact of fibroids.  The less-than-good-news is that none of the following research was performed in humans, so the results are very preliminary.

Hormonal Influences

Women with fibroids have normal blood levels of estrogen and progesterone.  Estrogen dominance does not cause fibroids.

Fibroid cells can make their own estrogen, so the level of estrogen inside fibroids is higher than in blood or other tissues.

Estrogen and progesterone receptors, parts of the fibroid cells that cause them to respond to estrogen and progesterone, are more prevalent in fibroid cells than normal uterine muscle cells.

Fibroids have more collagen than normal uterine muscle cells and more glycosaminoglycans (GAG).  GAGs draw water into the cells and make them swell.  Lupron causes a decrease in GAGs, which dehydrates the fibroid cells and causes shrinking of the fibroids.  When Lupron is stopped, the cells take on water again and swell again.

Dietary Factors

Vitamin D – decreases fibroid cell size and disrupt the formation of fibroid muscle cells.

Resveratrol (found in grapes) – decreases growth and increases death of fibroid cells in a test tube.

Curcumin (spice) – decreases growth and increases death of fibroid cells in a test tube.

Licorice (isoliquiritigenin) – decreases growth and increases death of fibroid cells in a test tube.

Green Tea (epigallocatechin gallate) – decreases growth of fibroid cells in a test tube.

“I am just so pleased with the live telesurgery demonstration,” said the Conference Program Chair C.Y. Liu, MD.  “Dr. Parker did such a wonderful job – he mesmerized the entire audience with his fluid and skillful live demonstration of how the laparoscopic myomectomy could be used and should be done. I am thankful for his willingness to share his expert surgical technique with us.”

During the procedure, Dr. Parker explained what he was doing as he operated, and he answered questions from the audience as well as for the doctors watching over the Internet around the world. This surgery was the first time the American Association of Gynecologic Laparoscopists had used the Internet to transmit a live surgery. A short, edited video of the procedure may be viewed at http://www.fibroidsecondopinion.com/laparoscopic-myomectomy/.

www.youtube.com/watch?v=Fvw3dUesfdI

“Minimally invasive fibroid surgery offers the benefit of outpatient surgery with minimal discomfort and seven to 10 days to full recovery,” Dr. Parker said about the procedure. “Women really benefit from these advantages and they appreciate a quick return to their daily lives.”

Authors: Bagaria M, Suneja A, Vaid NB, Guleria K, Mishra K.

Study from: Department of Obstetrics and Gynaecology, University College of Medical Sciences, Delhi, India.

Problem: So far, no medication has worked to relieve symptoms of fibroids. In early studies, one drug that appeared to be promising was Mefipristone (RU-486).  Progesterone causes fibroid cells to grow and Mefipristone blocks this effect.

Study: The study included 40 women with bothersome symptoms from fibroids; 20 women were taking mifepristone and 20 were taking a placebo. None of the women or their doctors knew what pill they were taking.

Fibroid-related symptoms, the size of the uterus and size of the largest fibroid were measured with ultrasound at the beginning of the study and every month for three months. A biopsy of the uterine lining cells was done at the beginning and again at the end of treatment.

Results: Women who were taking Mefipristone had a 95% decrease in menstrual blood loss after three months   Complete relief of menstrual cramping occurred in 80%, but only 33% patients were free of pelvic pain.  Women taking the placebo pills had no change in any symptoms. Backache, bladder problems and pain with intercourse were not better in either group.

The size of the uterus and size of the largest fibroid were about 30% smaller by the end of the third month of therapy. Women taking Mefipristone had an increase in haemoglobin (red blood cells) from 9.5 to 11.2 . However, 63% of women taking mefipristone had benign overgrowth of the uterine lining cells (endometrial hyperplasia without atypia).

Authors’ Conclusions: A low dose of mifepristone taken for three months is effective in reducing menstrual bleeding and reducing uterine and fibroid sizes, but has the side-effect of causing uterine lining cell overgrowth.

Dr. Parker’s Comments: It would be great if there was a pill available to treat the symptoms of fibroids with few side-effects.  So far, all the tested medications have either not worked or had bothersome side-effects. Mefipristone is given orally and has few side-effects.  It is well-known that progesterone causes fibroids to grow.  Mefipristone works by blocking the action of progesterone and has been shown to shrink fibroids and decrease bleeding.  However, progesterone decreases the growth of the uterine lining cells and since mefipristone blocks this action it allows the lining cells to overgrow.  After just 3 months almost 2/3 of women had benign overgrowth. While benign overgrowth does not turn into precancer or cancer, the worry is that longer treatment with Mefipristone could stimulate actual cancer cells to form.  Further study will be needed, but this study is discouraging.

For more about medical treatment for fibroids see: http://www.fibroidsecondopinion.com/treatment-for-fibroids/

Dr. Parker’s Note: I have summarized most of the information from this paper in a new web page: Caring for Yourself After Surgery.

Authors: Minig, L; Trimble, E; Sarsotti, C; Sebastiani, M; Spong, C.

Journal: Obstetrics & Gynecology:  October 2009 – Volume 114, pp 892-900

Study from: National Institutes of Health, Bethesda, Maryland

Problem:  Following surgery, doctors give fairly standard instructions regarding what activities the patient can, and cannot, do.  Unfortunately, there is little science to back up these recommendations.

Study: The authors reviewed studies related to post-operative instructions from medical journals, medical textbooks in obstetrics, gynecology, and general surgery, the American College of Obstetricians and Gynecologists Practice Bulletins and Committee Opinions and clinical guidelines of Royal College of Obstetricians and Gynecologists of the United Kingdom in order to evaluate current recommendations.

Authors’ Conclusions: Resumption of usual activities after gynecologic surgery helps integrate women back into their normal life. Available data do not support many of the recommendations previously provided. Restrictions on lifting and climbing stairs should be reconsidered. Guidance on driving should focus on the concern about driving while using narcotic medications rather than concern about opening the wound. Much more study is needed to better define all the above issues.

Dr. Parker’s Comments: As the authors state in the introduction to the article, “recommendations for activity after discharge remain based on tradition and anecdote”.  To the authors’ credit, they investigated current recommendations and came up with little evidence to support what we usually tell women.

The authors suggest that the new recommendations be fully tested by scientific study, but since this is unlikely to happen soon (or ever), it is best to discuss the new recommendations with your doctor.

Patients are often each others’ best resource for finding and sharing information about recovery after surgery. I encourage you to post comments on this post if you have something helpful to share.

Problem: There are a number of small studies that show either a small risk or no risk for pregnancies conceived after UAE. Small studies are hard to interpret because the statisticians cannot make sense out of small numbers of women. Also, no study has ever compared the results to women with similar fibroids who had not been treated.

Study: These authors combined the results of many already-published studies and analyzed the information as if it was one, larger study (called a meta-analysis). They compared the results of 227 women who got pregnant after UAE with 4,454 women who were the same ages and who had similar fibroids, but who had not been treated before they got pregnant.

Results: Miscarriage rates were higher in UAE pregnancies (35.2%) compared with women who had fibroids but no treatment fibroid (16.5%). The women who had UAE before their pregnancies were also more likely to experience excessive bleeding after delivery (13.9% after UAE vs. 2.5% in women with fibroids but no treatment). There were no differences in the rates of early delivery, underweight babies, or breech babies.

Conclusions: For women who get pregnant after UAE, the risk of miscarriage and the risk of excessive bleeding after delivery seem to be greater.

Dr. Parker’s Comments: While studies with just a few women are hard to interpret, a study such as this (meta-analysis) isn’t perfect either. Since the authors never see ANY of the women in the outside studies, it is possible that differences in the separate groups of women were present, but not reported in the original articles. Nevertheless, since it is unlikely that any interventional radiologist will have 227 women in their practice who will get pregnant after UAE, this kind of study may be the best information we can get.
Most interventional radiologists in the US advise women not to get pregnant after UAE. This advice is given not because they know that UAE causes harm during pregnancy, but mostly because there is not enough experience with UAE and pregnancy to tell women everything should be OK. For now, that advice is likely to stay the same as before.