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

Study from: Georgetown University Hospital Department of Radiology, Washington, DC

Problem: Despite the very common occurrence of fibroids, very few studies have evaluated the severity of symptoms caused by uterine fibroids, their effect on health-related quality-of-life, or the changes in symptoms after treatment compared with women who do not have fibroids.

Study: Groups of women with fibroids who were scheduled for hysterectomy, myomectomy, or uterine artery embolization, as well as women without fibroids were assessed using questionnaires designed to measure quality of life and symptoms, including physical functioning, pain, sexual function, vitality, energy/mood, social functioning and mental health. Questionnaires were completed before treatment and again at 6 and 12 months after treatment.

Results: A total of 375 women Participated in the study: 101 without fibroids, 107 who had embolization, 61 who had a myomectomy, and 106 who had a hysterectomy. Before treatment women with fibroids had more severe symptoms than women without fibroids. At both 6 and 12 months after treatment, women having treatment for their fibroids had as few symptoms as women who did not have fibroids. One year after treatment, the women who had a hysterectomy reported less symptoms and better health-related quality of life than women who had embolization or myomectomies. However, the majority of the benefit of hysterectomy was attributed to the absence of menstrual periods.

Authors’ Conclusions: At 12 months after treatment, all three leiomyoma therapies resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy due to the absence of menstrual periods.

Dr. Parker’s Comments: Since myomectomy, embolization and hysterectomy all reduce symptoms to the levels seen with women without fibroids, all three treatments should be very effective for women who have bothersome symptoms related to fibroids. Therefore, a woman’s choice for treatment should depend on other individual factors including the desire for fertility, the desire to preserve her uterus, willingness to undergo surgery and anesthesia, willingness to undergo embolization, etc. The other point here is that the women choosing to have treatment had significant symptoms; most women with minor symptoms will often choose watchful waiting and wait for menopause when fibroids shrink and bleeding stops.

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/