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.

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.

Dear Dr Parker,

I am a forty year old female living in Australia and recently tests have shown that I have a very large fibroid growing on the Uterus Muscle. The fibroid is 17.5cm X 16.3cm X 6.8cm. I am worried that so far most have the notion that I would require a full hysterectomy in order to remove the mass. About four years ago I had GBS and now suffer from chronic fatigue and I am scared about having a hysterectomy. Have you removed fibroids this large from woman without the need of a full hysterectomy? I look forward to your reply…

Kind Regards

D.

D.

Yes, a fibroid this size can be removed by abdominal myomectomy with a bikini type incision. I have removed even larger fibroids this way. A hysterectomy is not necessary.

Bill Parker, MD

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.

Is it possible to build up hemoglobin enough to be able to just wait and watch fibroids. My hemoglobin was 6.6 and is now 7.5 from taking iron supplements. My uterus is 6 times normal size with one fibroid the size of a softball, and numerous others. My doctor is strongly recommending a laparoscopic hysterectomy. I just found your website today, and it is the most helpful and informative site I’ve found. Thank you for your help.

-Cynthia

You did not say, but I assume the anemia is from heavy menstrual bleeding due to the fibroids. If so, it is unlikely that you will be able to correct the anemia because you will be losing blood every month. However, there are many other ways to help you other than hysterectomy. Depending on the size, number and positions of the fibroids, hysteroscopic myomectomy, laparoscopic/robotic myomectomy, endometrial ablation, abdominal myomectomy, or uterine artery embolization are alternatives. Myomectomy is always possible and should work just fine. You should discuss these options with your doctor, or consider getting a second opinion. Also, take a look at these web pages regarding alternatives;
http://www.fibroidsecondopinion.com/laparoscopic-myomectomy/
http://www.fibroidsecondopinion.com/abdominal-myomectomy/
http://www.fibroidsecondopinion.com/hysteroscopic-myomectomy/

Bill Parker, MD

Dear Dr Parker

I found your site while researching the possible treatment for my fibroids.  Thank you for creating such an informative resource.

I am 50 this year and have had fibroids for some time which recently began to grow.  This week I had a uterine ultrasound and my doctor has told me I have about “a pound and a half” of fibroids in my uterus.  I’m afraid I don’t have specifics as he called me last night to just go through the test results.  He seems keen on surgery (hysterectomy) and I am not keen on that for the following reasons:

I have only recently started having minor discomfort in association with the fibroids, some heaviness and some changes in the need to urinate but nothing drastic.  My periods have become lighter recently with far less pain than in the past when the fibroids were probably smaller.

What would be an alternate choice of action to surgery at this point?   My doctor says they fibroids don’t seem to be interfering with urine flow but I would be happy to have my kidneys checked out to make sure all is well there.  I am worried that some doctors are just too prepared to perform major surgery when this may resolve itself after menopause.  Of course, if things get worse then I would reconsider the surgery option.Any advice?   Thanks so much again for offering your views on this issue to women who are looking for a balanced view.

T.S.

Hi T.S.,

It is very, very rare for fibroids to block the flow of urine from the kidneys to the bladder and the fibroids would have to huge to do this.  I cannot give medical advice over the internet, but since you are close to menopause you should ask your doctor about watchful waiting.  Myomectomy, removal of just the fibroids is always an option if the symptoms increase.  If the doctor persists with talk of a hysterectomy, then get a second opinion.  Thanks for the kind words about the website.

Bill Parker, MD

For more information about fibroids and surgery, please see:

http://www.fibroidsecondopinion.com/surgery-for-fibroids/

Although serious problems are less of a risk for young, healthy women who are having myomectomies (you are all really young and healthy compared to 80 year-olds in an ICU!), the best strategy is getting your blood counts up before surgery and using a cell-saver during surgery.

For women with very low hemoglobin levels (below 9), I usually use Procrit to stimulate red blood cell production for about 3 weeks before surgery. High doses of iron must also be given, so your body has the building blocks to make red blood cells, and vitamin C is also given to help you absorb more iron through the intestines. There is no magic number, but it is nice to have the hemoglobin 10 or higher before surgery, unless heavy menstrual bleeding does not allow us to get the blood counts up even with Procrit and Vitamin C (very rare).

The second strategy is the use of the cell saver, which allows us to replace blood loss, if necessary, immediately during surgery with the patient’s own blood, before it has a chance to deteriorate. Also, there is no risk of HIV, hepatitis or mismatched blood with the cell-saver.

Blood is suctioned from the incision and operative area, stored in the canister, and then filtered and returned to the patient through an IV

And lastly, the current recommendation is to not transfuse blood unless the patient is very dizzy when they stand up or very weak, or until the hemoglobin is below 7 (it used to be below 10). Since the blood doesn’t work very well anyway, it is better and safer to allow the patient to build up her own blood slowly during the recovery period.

There is a push to explain all this new information to doctors because it is different from what we were all taught. So, you will find differences of opinion based on a doctor’s knowledge of this new information.

More about myomectomy surgery can be found at this link: http://www.fibroidsecondopinion.com/abdominal-myomectomy/