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.

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

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.

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

Dear Dr.Parker:

I have just turned forty and I have recently had a pelvic ultrasound , which revealed four uterine fibroids, the largest being 8.6 cm in diameter (my uterus measuring 16 x 14 x 8cm).

I have never had children and have chosen not to in the future, my gynecologist suggested a hysterectomy based on that fact.  I am really scared about this, as I was only in the hospital the first time ever in my life in 2009 to have my gall bladder removed. I have a conctraceptive implant Implanon, heavy bleeding only two days a month, but this has improved while taking iron tablets and vit B12 injections as perscribed for anaemia.

After reading your  informative website, should I seek a second opinion?  As I am not keen on the idea of making such a rash decision, I wish to make the right one.

I thank you for your kind attention.

There should be many options available to you , as outlined on my website, including the option of no treatment since the fibroids do not sound like they are bothering you.   Hysterectomy should not be necessary and you should seek a second opinion from a gynecologist who can offer you the other options in order to see what is right for you.

See these webpages: http://www.fibroidsecondopinion.com/treatment-for-fibroids/

http://www.fibroidsecondopinion.com/laparoscopic-myomectomy/

http://www.fibroidsecondopinion.com/uterine-artery-embolization/

I hope you find this information helpful,

Bill Parker, MD

Dr. Parker,

I am 49 yrs. old in good physical health. I walk or run several times a week, and am slim(5ft.115 lbs) and look youthful. However, I have a lot of stress-6 children, 2 with drug addictions, a difficult marriage, etc. I have a 10 cm fibroid that is putting pressure on my rectum. I had bleeding and huge clots but taking progesterone 10 days of my cycle has alleviated that. My gyn recommends hysterectomy. I am scheduled for this Thursday, Dec.16, but have a lot of anxiety about it, because I am depressed and worried about how it will affect my emotional state which is already terrible. When I called my gyn he was in his other office further away, and could not call me back. He told his office manager that he already went over everything with me, and to tell me a hysterectomy was the best course of action. He said a myomectomy would thin the lining of my uterus too much. He never mentioned UFE. He seems perturbed that I did go to another gyn for a second opinion. The other gyn said hysterectomy also, not mentioning UFE. I called an interventional radiologist and they said they could see me. Have I broken the doctor-patient trust factor? Will he treat me differently now?

L,

Doctors should welcome a second opinion. You need to do what is best for you and getting a second opinion when surgery is recommended is always a good idea. UAE works very well for heavy bleeding and shrinks fibroids about 40%, so if this would help you, you should see the interventional radiologist to see what they recommend. Myomectomy is always possible and it will not thin the uterine lining no matter what the size of your fibroid. A 10 cm fibroid can be removed laparoscopically as an outpatient by a skilled laparoscopic surgeon.

If the doctor does treat you badly because you got a second opinion, you should consider getting another doctor.

Bill Parker, MD

Authors: Stout MJ, Odibo AO, Graseck AS, Macones GA, Crane JP, Cahill AG.

Study from: Washington University, St Louis, Missouri

Problem: Numerous studies have been conducted to see if the presence of fibroids during pregnancy affects the outcome of the pregnancy or the health of the baby. Most of these studies have been poorly designed and have failed to answer these important questions.

Study: Between 1990 and 2007, 64,047 consecutive pregnant women had a routine second-trimester ultrasound and the presence or absence of fibroids was routinely noted. The outcomes of the pregnancies in women with fibroids were compared to pregnancies in women without fibroids.

Results: Fibroids were seen on ultrasound in 3.2% of all pregnant women. The following findings were noted.

• Babies were breech in 5.3% of women with fibroids compared with 3.1% of women with no fibroids.
• Placenta previa (placenta partially or completely blocking the cervix) was found in 1.4% (fibroids) compared with 0.5% (no fibroids).
• Placental abruption (placenta separating from the uterine wall, causing bleeding) was found in 1.4% (fibroids) compared with 0.7% (no fibroids).
• Preterm rupture of membranes was found in 3.3% (fibroids) compared with 2.4% (no fibroids).
• Preterm birth less than 37 weeks was found in 15.1% (fibroids) compared with 10.5% (no fibroids) and at less than 34 weeks was 3.9% (fibroids) compared with 2.8% (no fibroids).
• Intrauterine fetal death in women with a baby with growth restriction (small baby) was found in 3.9% (fibroids) compared with 1.5% (no fibroids).
• Cesarean delivery was performed in 33% (fibroids) compared with 24% (no fibroids).

Authors’ Conclusions: Women with fibroids are at low risk for obstetric complications compared with women without fibroids.

Dr. Parker’s Comments: Two other excellent studies have been published previously on this topic: one showed absolutely no increased risk of complications for women who became pregnant with fibroids; the other showed very minimal increased risks.

This new study shows very minimal increased risks: a 0.9% increased risk of the placenta blocking the cervix; a 0.7% increased risk of placental separation; a 0.9% increased risk of early ruptured membranes; a 4.6% increased risk of delivery before 37 weeks (where the babies usually do extremely well) and a 1.1% increased risk of delivery before 34 weeks (most babies also do well, but need neonatal ICU care); and, a 1.4% increased risk of fetal death in babies who were very small at birth. The new study was conducted at an urban referral hospital and the women had a high rate of alcohol use, smoking and high blood pressure, so the results might be even better in a healthier group of women.

The findings of the three well-performed studies show an extremely small increased risk, which ought to be reassuring for women with fibroids who wish to become pregnant. It should also be noted that, based on a review of the literature I did for a chapter on fibroids to be published in Berek and Novak’s Gynecology textbook, in the past 30 years there have been only four babies born in the world who have been reported to have birth defects related to the presence of fibroids during pregnancy. This is also very reassuring news.

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: 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.

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.