Most women with uterine fibroids have no symptoms or just mild symptoms and do not need treatment. For these women “watchful waiting” will allow treatment to be avoided, perhaps indefinitely.
However, serious medical conditions, such as severe anemia from heavy bleeding or, very rarely, blockage of the ureters from very large fibroids, may need to be treated with surgery. Surgery may also be used for women with very heavy bleeding, pelvic pain or pressure, urinary frequency or incontinence that interfere with quality of life. Many advances have been made in the surgical options to treat fibroids . These currently include abdominal myomectomy for even large fibroids, laparoscopic myomectomy, hysteroscopic myomectomy, endometrial ablation, uterine artery occlusion and abdominal, vaginal and laparoscopic hysterectomy.
Despite these options, women with bothersome fibroids who have completed childbearing are often inappropriately recommended to have a hysterectomy. A recent study found that fibroids were the indication for surgery in 199,000 (33%) of the 598,000 hysterectomies performed in 1999. But, only 30,000 myomectomies were performed that year and other alternatives were even less frequently performed.
What If You Have Uncontrollable Bleeding?
Surgery is indicated if you have heavy bleeding that is persistent and causes severe anemia. Anemia can lead to chronic exhaustion and light-headedness and will eventually lower your body’s resistance. We can measure the amount of blood that you have in your body by two tests; the hemoglobin and hematocrit. Normal hemoglobin amounts are about 12 to 14 grams per liter (quart) of blood. The normal hematocrit is about 40 percent. If your fibroids cause heavy bleeding and if your hemoglobin is less than 10 grams (or your hematocrit is less than 30 percent), you have a fairly significant anemia and probably will need treatment. Hysteroscopic myomectomy and/or endometrial ablation (see http://www.fibroidsecondopinion.com/hyster_myomectomy.htm) are very effective for most patients with this problem. Uterine artery embolization works well to decrease bleeding from fibroids. Other women may choose to have a myomectomy, and others with severe or unrelenting symptoms may choose to have a hysterectomy.
Can Anemia Be Treated Before Surgery?
Medications are available (erythropoietin alfa and epoetin) that are forms of the protein normally made by your kidneys that encourages blood to be produced by the bone marrow. These medications are commonly used to increase blood counts prior to heart, orthopedic and neurologic surgery. Injections of erythropoietin given weekly for the 3 weeks before surgery will increase blood counts significantly and reduce the need for blood transfusion, and have no side-effects. Lupron can also be used for a few months before surgery to stop abnormal bleeding and increase blood counts.
Can Fibroids Put You at Risk for Kidney Damage?
The ureters are thin tubes that connect the kidneys (which are below the shoulder blades) to the bladder, which is in front of the uterus. In the pelvis, the ureters are about one-half inch away from the uterus. Very rarely, fibroids may grow sideways and press against the ureters, slowing or stopping the flow of urine out of the kidney. If urine cannot flow freely from the kidney, pressure builds up in the kidney and damage the kidney. This process is slow and usually produces no symptoms. If you are being closely followed by a physician, it is very unlikely that any damage will occur to the kidneys. On examination, a doctor can feel if the fibroids are too near the ureters. Some action would then be advised, before the slow process of damage to the kidneys begins.
Blockage of a ureter can be detected by an X-ray called an intravenous pyelogram (IV P) or by a CAT scan. During these X-rays, a special iodine dye is injected into a vein of the arm. The dye then collects in the kidneys and flows down the ureters. The X-rays show the path of the dye and blockage of the ureters can be detected. In my many years of practice, I have never seen a woman suffer kidney damage from fibroids. If the IVP or CAT scan shows a risk to the kidneys, then surgery is indicated. Either myomectomy or hysterectomy can re-establish the normal flow of urine and prevent permanent damage to this vital organ.
What If There Is Concern That the Fibroids Might Be Cancer?
Uterine sarcoma, a cancer of the uterine muscle, is extremely rare, occurring in less than 1 patient per 1,000 who have surgery for fibroids. And since 80 percent of women with fibroids never even have surgery, the incidence of this cancer is extraordinarily low. Also, most patients determined to have sarcomas are postmenopausal women in their sixties or seventies, whereas most patients with fibroids are in their thirties and forties. Almost all pre-menopausal women with growing fibroids have benign uterine fibroids. Therefore, most patients with rapidly growing fibroids may be followed with frequent pelvic examinations. If you are postmenopausal and not on estrogen, growth of the uterus is more concerning and may be an indication for surgery.
However, a recent study found that by using a combination of an MRI and a blood test called LDH, the diagnosis of uterine sarcoma could be reliably made. At the time of the MRI, a liquid dye called Gadolinium is injected into a vein. The MRI picture of the fibroids should be taken 40-60 seconds after injection. If a sarcoma is present the dye will light up on the MRI. This is because the sarcoma contains more blood vessels than normal uterine muscle and the blood vessels carry the dye. The other part of the testing, the LDH blood test, measures an enzyme made in muscle cells. It turns out that sarcoma makes more LDH iso-enzyme 3 and this can be measured by the lab (but your doctor must ask for this test specifically). So, the combination of an abnormal MRI and increased LDH-3 can mean that a sarcoma is present. But, if either of these tests is normal, it is unlikely that you have a sarcoma. I am including the abstract of this article below.
Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus
Authors -A. Goto, S. Takeuchi , K. Sugimura, T. Maruo
International Journal of Gynecological Cancer, Volume 12, Page 354, July 2002
This prospective study was conducted to identify the magnetic resonance imaging (MRI) characteristics of uterine leiomyosarcoma (LMS) and to evaluate the diagnostic accuracy of conventional MRI and dynamic MRI with or without serum measurement of lactate dehydrogenase (LDH) levels. Two hundred ninety-eight consecutive patients were entered in this study. In eligible 227 patients, ten patients with LMS and 130 patients with uterine degenerated leiomyoma (DLM) were included for the present study. Precontrast T1, T2 weighted images were obtained in all patients. Serum LDH and its isozymes were also measured. Dynamic MRI by Gd-DTPA was obtained in all patients with LMS and 32 patients with DLM in whom elevated LDH levels were observed. The contrast enhancement at 60 s after administration of Gd-DTPA was detected in all LMS, but absent in 28 of 32 DLM patients. Concerning serum LDH isozymes, both total LDH and LDH isozyme type 3 were elevated in all 10 patients with LMS. The sensitivity for determination of LMS with MRI alone, dynamic MRI alone, and combined use of MRI (including dynamic MRI) and serum LDH levels was 100% in each group. The specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 93.1%, 52.6%, 100%, and 93.1% with MRI alone, and 93.8%, 83.3%, 100%, and 95.2% with dynamic MRI alone, and 100%, 100%, 100%, 100% with combined use of LDH and MRI, respectively. In conclusion, the combined use of dynamic MRI and serum measurement of LDH (isozymes) seems to be useful in making a differentiated diagnosis of LMS from DLM before treatment.
Although the study is very convincing, these tests will need to be confirmed in other studies before they should be given total acceptance.
By William H. Parker, MD
Clinical Professor, Obstetrics and Gynecology, UCLA School of Medicine
Director of Minimally Invasive Gynecologic Surgery, UCLA Medical Center, Santa Monica
Page last updated: October 11, 2009