Fibroids:

A Gynecologist's Second Opinion

By William H. Parker, MD

Table of Contents

1. If You Have Uterine Fibroids

2. About Uterine Fibroids

3. Symptoms of Uterine Fibroids

4. Fibroids, Fertility and Pregnancy

5. Conservative Treatment for Fibroids

6. Do You Need Surgery for Fibroids?

7. Fibroids and Cancer

8. Laparoscopic and Robotic Myomectomy

9. Abdominal Myomectomy

10. Hysteroscopic Myomectomy for Bleeding

11. Questions Everyone Should Ask Their Doctor Before Surgery

12. Caring for Yourself After Surgery

13. Can New Fibroids Grow After Myomectomy?

14. Do You Need a Hysterectomy for Fibroids?

15. Uterine Artery Embolization and Focused Ultrasound

16. Fibroid Treatment Options Based on your Symptoms

17. Adenomyosis

18. Resources

19. Getting a Second Opinion

20. About the Author

Chapter 1

If You Have Uterine Fibroids

If you are reading this eBoook, based off my popular website http://www.fibroidsecondopinion.com/, it is likely that you or someone close to you has uterine fibroids…

Recent developments in gynecology have expanded the treatment alternatives now available to women with fibroids. I wrote and designed this download to provide women with comprehensive and easy-to-understand information about fibroids and state-of-the-art treatments available.

I am a practicing gynecologist in Santa Monica, California, Clinical Professor of the Department of Obstetrics and Gynecology at the UCLA School of Medicine, former President of an international minimally invasive gynecological organization (AAGL) and former Chair of the Gynecology and Obstetrics Department of St. John’s Health Center in Santa Monica. Most importantly, I have been performing and teaching all the available surgical techniques covered in this download for many years, and this experience has allowed me to stay in the forefront of the field.

The medical information available to women regarding fibroids in books, on the internet or from doctors is often contradictory and confusing. In my own efforts to understand all the issues related to fibroids, I undertook a year-long review of more than 300 papers from the medical literature. As a result of that review, I published a two-part article in the internationally renowned journal Fertility and Sterility. For those who wish to see the original articles, they may be accessed here: Etiology, Symptomatology and Diagnosis of Uterine Myomas and Uterine Myomas: Management. Much of the information on this website is adapted from those articles and it is information you will want to know before choosing the path to take for any fibroid-associated problems.

The present pressures in healthcare leave many doctors little time or incentive to learn new medical developments, and they have even less time to explain treatment alternatives to patients.   For women who need treatment, many treatment options exist and you need to search out a doctor who both understands all the available options and who is also skilled at performing these treatments (or the rare doctor who will refer you to another physician who does have the necessary skill and experience).

I have many years of experience in performing laparoscopic myomectomy, abdominal myomectomy for large fibroids and hysteroscopic myomectomy. I hope that this download will have the answers you’ve been looking for and will provide you with a trusted reference to turn to. And, I wish you good health.

Chapter 2

About Uterine Fibroids

Introduction

Fibroids are an enormous healthcare problem because they are the primary reason given for surgery in 199,000 hysterectomies and 30,000 myomectomies performed yearly in the US. The cost of inpatient surgery for fibroids is about $2 billion a year. Time taken away from work or family make this condition very costly for women and their families. And, presently there are many options other than hysterectomy available for women with bothersome fibroid symptoms.

Women and their gynecologists need better information on which to base decisions regarding possible treatments. Hopefully, this website will provide you with that information. Much of the information on this website is adapted from two articles I recently published in the prestigious international journal Fertility and Sterility: Etiology, symptomatology, and diagnosis of uterine myomas and Uterine myomas: management. These two articles are the result of reading more than 300 research papers about fibroids. This is information you will want to know before choosing the path to take for any fibroid-associated problems.

What Are Fibroids?

Fibroids are non-cancerous (benign) growths of the muscle wall of the uterus. They are probably responsible for more unnecessary gynecologic surgery than any other condition. Every year a staggering 600,000 American women have a hysterectomy. And about 30 percent of those hysterectomies, 199,000 in all, are performed because of fibroids. Many of these surgeries are not necessary.

Fibroids are extremely common. More than 75 percent of women can be found to have small fibroids using MRI, a very sensitive imaging technique. However, only about 30 percent of all women will have fibroids large enough to be noted during a pelvic exam, and the vast majority of even these women, more than 80 percent, will never have symptoms and will never require treatment. And for the rare woman who does have problems, there are a number of sound and effective options available. Hysterectomy should be the solution of last resort.

What Causes Fibroids?

While there is much we don’t know about fibroids, we do know that each individual fibroid starts from a single cell growing abnormally (mutation). These cells overproduce large amounts of collagen and other proteins. Recently, other gene mutations have been discovered in fibroid cells that alter the cell’s growth. There may also be environmental causes, as yet undetermined, that stimulate fibroid growth. It is important to realize that there is no evidence that fibroids turn into cancer. Fibroids are benign from the beginning and remain benign.

We do know that the female hormones estrogen and progesterone are necessary for fibroids to grow, but growth of a fibroid requires a complex interaction of estrogen, progesterone, and cell growth factors. Fibroids do not occur before puberty when estrogen and progesterone production begins, and fibroids shrink after menopause when hormone production drastically decreases. Studies are now under way to try to determine how fibroids start and what influences their growth.

Fibroids usually do not develop until between ages twenty-five and thirty-five. You might expect that women with fibroids are making too much estrogen or progesterone, however the levels of these hormones in the blood are absolutely normal. But, fibroids have enzymes that convert androgens (male hormones made by the ovary and the adrenal gland) into estrogens within the fibroid cells, so the fibroid cells actually contain higher levels of estrogen than the the rest of the body. Fibroids are also very sensitive to progesterone and appear to thrive during the time of the menstrual cycle when progesterone levels are highest.

Special proteins found in the bloodstream, called growth factors, are produced by cells in the body and stimulate fibroid growth. Some of the identified fibroid-related growth factors (which sound like a virtual alphabet soup) are transforming growth factor-B (TGF-B), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF) and prolactin (PRL). Some of these growth factors encourage cell growth and others encourage blood vessel growth to feed the fibroids. Unfortunately, we still do not understand which of these proteins are important.

Importantly, women with fibroids are not more prone to fibrocystic changes in the breast, a totally unrelated condition and they are not more prone to develop any other benign or cancerous conditions.

How Common are Fibroids?

Fibroids are extremely common. One study found fibroids, some as small as ¼ inch, in 77% of women. Because ultrasound cannot see these small fibroids we often underestimate how common this condition is. Small fibroids, however, are almost never bothersome. By age 35 fibroids can be found using ultrasound in 60% of African-American women and 40% of Caucasian women. By age 50, fibroids can be found in 80% of African-American women and 70% of Caucasian women.

What Increases Your Risk for Developing Fibroids?

Studies that evaluate “risk factors” are very hard to do, so we don’t really know how important these factors are.

- If you have a mother or sister with fibroids, you have an increased risk.

- African-American women have a higher risk than Caucasian women.

- Using birth control pills does not appear to increase risk, except very rarely.

- Pregnancy and childbirth decrease the risk.

- Smoking decreases the risk (but, not a reason to smoke!)

- Hormone therapy after menopause usually does not make fibroids grow.

What Are the Different Types of Fibroids?

All fibroids begin as a growth somewhere within the uterine muscular wall. The symptoms caused by fibroids depend on where they grow in the wall and how big they are. Fibroids that grow and bulge toward the outside of the uterus, called subserosal fibroids, can press on (but not injure) the organs surrounding the uterus such as the bladder or rectum. Sometimes, they may grow large enough to push outward and cause a noticeable swelling in the abdomen.

Fibroids that grow and bulge toward the inside of the uterus are called submucosal fibroids. These grow directly below the lining cells of the uterus and may lead to heavy or irregular bleeding. Fibroids that stay mostly embedded within the middle of the wall of the uterus are called intramural fibroids. Some fibroids may form on stalks that connect them to the uterus. These are called pedunculated fibroids and can be either submucosal or subserosal in location.

What is the Best Way to Make the Diagnosis of Fibroids?

Fibroids are most commonly diagnosed during a pelvic examination. Fibroids are benign tumors of the uterine muscle wall and, as such, cause the uterus to feel larger than normal and irregular. If the size of the uterus is hard to determine or the diagnosis is uncertain, a pelvic ultrasound can be helpful. An ultrasound exam is fairly accurate at determining the sizes and positions of fibroids within the uterine wall. However, sometimes the exact position of the fibroids is hard to accurately determine with ultrasound.

The best test to tell size and position of fibroids is an MRI. Fibroids contain more collagen than normal uterine muscle and, as a result, the fibroids appear distinct and darker on the MRI. Getting an MRI may be a good idea if the ultrasound is not clear or it is important to know exactly where the fibroids are. I also use this test if a laparoscopic myomectomy is being considered. MRI gives me a good idea as to whether it will be possible to get all the fibroids out with the laparoscopic instruments. If ultrasound is not clear, MRI can also be used to see if submucous fibroids are present. This can be helpful if unexplained heavy bleeding is present or fertility is a concern.

Chapter 3:

Symptoms of Uterine Fibroids

Most women with uterine fibroids have no symptoms or just mild symptoms and do not need treatment. In one study, almost 80% of women who chose “watchful waiting” for their fibroids had no major changes in their bleeding, pain, bothersome symptoms, mental health, general health or activity after one year. After menopause, bleeding stops, fibroids decrease in size and the rate of surgery for fibroids decreases dramatically. So, for some women with fibroids “watchful waiting” will allow treatment to be avoided, perhaps indefinitely.

Treatment will be necessary for women with heavy bleeding that causes severe anemia or, very rarely, for blockage of the ureters (tubes that pass urine from the kidneys to the bladder) by very large fibroids. Some women may also chose treatment for heavy bleeding, pelvic pain or pressure, urinary frequency or incontinence that interferes with their quality of life. But, this decision is for each woman to make based on her own sense of her quality of life. Of interest, one study found that women who chose to have a hysterectomy because of fibroid-related symptoms had worse scores on quality-of-life questionnaires than women diagnosed with hig blood pressure, heart disease, emphysema or arthritis.

However, if women are offered a hysterectomy as a first and sometimes only treatment option, they may choose to adapt to their symptoms and stop seeking treatment. If this has happened to you, get a second opinion from a gynecologist who regularly takes care of women with fibroids. Otherwise your symptoms (such as bleeding or pain) may slowly get worse (“symptom creep”) and can lead to fatigue from anemia, increasing discomfort and mental fatigue from concern about your situation.

At present, medications, a progesterone-releasing IUD, endometrial ablation, hysteroscopic myomectomy, laparoscopic myomectomy, abdominal myomectomy, uterine artery embolization and focused ultrasound are all available in addition to hysterectomy for treatment.

Can Fibroids Cause Bleeding Problems?

Women with fibroids may have an increased amount of menstrual bleeding, although many women with fibroids do not have this problem. There are a number of theories as to why heavy bleeding might happen. At the time of the menstrual period, when the uterine lining is shed, the inside of the uterus is raw and bleeding. The uterus has two basic ways to stop itself from bleeding. The first is the normal blood-clotting mechanism that works throughout the body by forming plugs in the blood vessels. However, because the uterus is a muscle, it also has the unique ability to contract and squeeze the bleeding vessels of the uterus, much like stepping on a hose. These contractions are what you may feel as menstrual cramps. One theory suggests that the fibroids don’t allow the uterus to squeeze down properly, so the blood vessels in the uterus stay open longer, and you lose more blood. Also, fibroids produce proteins that make blood vessels grow nearby and other proteins that make the blood vessels expand, so that more blood is lost after menstrual bleeding starts.

Other medical conditions may also cause heavy bleeding or bleeding in between periods. Hormonal changes, polyps, overgrowth of the uterine lining, or, rarely, even precancer or cancer of the uterus can all result in abnormal bleeding. Von Willebrandt’s Disease, a not uncommon subtle abnormality of the blood clotting mechanism can also cause heavy bleeding. Therefore, any abnormal bleeding should be reported to your physician, and you should get a thorough evaluation.

When heavy menstrual bleeding persists over time, your body may not be able to make new blood cells fast enough to replace those that have been lost. Some women with fibroids find that the bleeding is so severe that even iron pills (taken with 1,000 mg of vitamin C to help the iron get absorbed into the bloodstream) cannot correct the problem, and anemia develops. Anemia can result in weakness, fatigue, fuzzy thinking and, if severe, light-headedness. If you have any of these symptoms, treatment beyond iron pills should be considered.

Can Fibroids Cause Pain or Pressure?

A normal size uterus lies below the pubic bone, well down in the pelvis. It is just under the bladder, just above the rectum, and surrounded by the intestines. Since it is so near to these other organs, growth of the uterus from fibroids may cause pressure or, rarely, pain in the pelvis. The uterus is normally about the size of a small pear and weighs less than one-quarter of a pound. But with fibroids, the uterus will enlarge and can cause an awareness of fullness or pressure. If the fibroids grow toward your back, pressure on the rectum can cause constipation. You may also feel pressure or pain in the lower back or discomfort with activity or intercourse. If the fibroids grow towards the front of the uterus, they can press on the bladder and cause frequent urination. However, fibroids do not cause any permanent damage to any of the organs.

If the uterus gets to be as large as a cantaloupe, it may be seen as a noticeable swelling in the lower abdomen, perhaps even making a woman appear pregnant. While not dangerous, the enlarged uterus may cause enough discomfort or enough visible change for you to want to seek treatment.

Can Fibroids Cause Sudden Pain?

Fibroids are living tissue, and need blood and oxygen to survive. If a fibroid grows quickly, blood vessels feeding the fibroid may not be able to grow fast enough to supply the new tissue with enough blood and oxygen. If this happens, the fibroid undergoes a process called degeneration, or cell death. As the cells in the fibroid die, chemical substances are released that cause pain and swelling in the uterus. This pain may be severe but is not usually associated with any serious problems. If these chemical substances from a degenerating fibroid reach the bloodstream, they may cause a low fever. As some of the fibroid dies, the blood supply to the rest of the fibroid will be enough to keep it alive and healthy. At this point, the pain will go away. This process may take a few weeks. When pain develops in a woman with fibroids, examination by a physician is important to help figure out the source of the problem.

If you have a degenerating fibroid, a heating pad on your abdomen will be comforting, and pain medication should provide relief for a few days or weeks until the pain begins to subside. In rare instances, a fibroid on a stalk (pedunculated fibroid) can twist around on the stalk so that no blood can get through the stalk to the fibroid. If that happens, the entire fibroid begins to die, and the pain becomes very severe and surgery is usually necessary to remove the dying fibroid.

Can Fibroids Cause Urinary Problems?

The uterus lies directly beneath the bladder, and the uterus and bladder are partially attached at one point. If a fibroid begins to grow forward, it may squeeze the bladder so that it cannot fill properly with urine and you may feel the need to urinate more often. Also, when you laugh, cough, or sneeze, the fibroid may push against the bladder and cause you to lose urine. This is called stress incontinence. While this may only be a minor inconvenience for some women with fibroids, others may be so bothered by the incontinence that they limit their activity to avoid embarrassment. There are also other causes of incontinence, so you should get a careful examination. There are now a number of treatments available other than surgery for many of the causes of incontinence. Stress incontinence is not something you “just have to live with”.

Chapter 4

Fibroids, Fertility and Pregnancy

Can Fibroids Cause Fertility Problems?

Fibroids that change the shape of the uterine cavity (submucous) or are within the cavity (intracavitary) decrease fertility by about 70% and removal of these fibroids increases fertility by 70%. Other types of fibroids, those that are within the wall (intramural) but do not change the shape of the cavity, or those that bulge outside the wall (subserosal) do not decrease fertility, and removal of these types of fibroids does not increase fertility. (see: Hysteroscopic Myomectomy)

Regular ultrasound is not the best way to determine exactly where fibroids are. For this information, MRI is best, but most expensive. Hysteroscopy (looking in the cavity with a small telescope) and saline-infusion sonography (ultrasound after sterile water is placed into the uterine cavity) are also very good.

Can Fibroids Cause Miscarriage?

Fibroids that bulge into the uterine cavity (submucous) or are within the cavity (intracavitary) may sometimes cause miscarriages. The fertilized egg comes down the fallopian tube and takes hold in the lining of the uterus. If a submucosal fibroid happens to be nearby, it can thin out the lining and decreases the blood supply to the developing embryo. The fibroid may also cause some inflammation in the lining directly above it. The fetus cannot develop properly, and miscarriage may result. However, with the next pregnancy, it is possible that the egg will settle in another location, and pregnancy may proceed without problems. However, if you do have a miscarriage and a fibroid is found bulging into the uterine cavity, it is advisable to have it removed. (see: Hysteroscopic Myomectomy)

I am including the following journal abstract regarding fibroids and fertility:

Fibroids and infertility: a systematic review of the evidence.

Author: Pritts EA.
Obstetrical and Gynecological Survey.2001;56:483-91.

A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13–0.70) and implantation rates (RR 0.28; 95% CI 0.10–0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13–2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45–2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.

Does Pregnancy Make Fibroids Grow?

Pregnancy has an unpredictable effect on fibroids, but most fibroids do not increase in size during pregnancy. The effect of pregnancy on fibroid growth probably depends on individual differences in the genetic changes in each fibroid and the type and amount of growth factors that are present in the blood. An ultrasound study of pregnant women with fibroids found that 69% of the women had no increase in the size of fibroids throughout the pregnancy. In the 31% of women who had an increase in size, it usually happened before the third month. Almost always, fibroids shrink after delivery.

Can Fibroids Cause Problems During Pregnancy?

Although many women will have fibroids during their lifetime, the fibroids most often occur in women in their late thirties and forties, a time in life many women have already completed their families. Only 2% of pregnant women are found to have fibroids when examined with ultrasound. Also, the vast majority of women who are pregnant and do have fibroids encounter no problems. They go on to have full-term, healthy babies without difficulty. Most studies show no differences in the risk of premature delivery, fetal growth problems, fetal abnormalities, placental problems, or heavy bleeding after delivery. The need for caesarean section, however, is more common among women who have fibroids (see below).

During pregnancy, the placenta makes large amounts of female hormones which may rarely cause fibroids already present to grow. Very rarely, if the fibroids grow too quickly the blood vessels supplying them may not be able to get enough oxygen to the tissue and degeneration of the fibroid cells can then occur. This process of degeneration can cause pain, but usually resolves in a short time without treatment and without harm to the baby. Some women may have mild contractions during this time, but it is extremely rare for premature labor to actually begin. However, it is crucial that a pregnant woman with fibroids see her physician if she experiences pain or contractions. Bed rest, heat, and pain medication will usually be prescribed, and medications to inhibit premature labor may sometimes be needed.

Can Fibroids Hurt the Developing Baby?

Fibroids almost never cause injury to a baby. Review of the entire world’s medical literature for the past 25 years discovered only four babies affected by a fibroid.

Do Fibroids Mean You Need a Caesarean Section?

Rarely, a fibroid may grow near the cervix during pregnancy. If it is large enough, it may prevent the baby from coming through the birth canal. This is not dangerous and can often be diagnosed by a sonogram before labor begins. Sometimes this problem is discovered during labor because the baby does not come down the birth canal. A caesarean section is then performed. However, most women with fibroids deliver their babies without any problems.

Chapter 5

Conservative Treatment for Fibroids

What Are the Treatment Options for Fibroids?

If you need treatment for fibroids, there are many options available to you. Your choices should be guided by the medical problems the fibroids are causing, your desire to have children, and your feelings and thoughts about your body, surgery or about other options. I think it is important for you to know all the options available. Even if some treatments do not apply at the current time, your condition or symptoms may change. If you understand the potential for future symptoms and problems, as well as the alternative means of treatment available, much of the mystery of fibroids will disappear.

Can “Watchful Waiting” Be Used to Keep an Eye on My Fibroids?

Although most women will have fibroids during their lifetime, only a small number of them will ever need treatment. The vast majority of women with fibroids are unaware of them until their doctor feels them at the time of a routine pelvic exam. Some women have very minor symptoms, which are not bothersome at all. If that is the case for you, then no treatment is necessary and then I consider “watchful waiting” to be the primary option.

It is not possible for either you or your doctor to predict whether your fibroids will grow in the future or whether you will go on to develop new symptoms. A study of women with fibroids 2 months pregnancy size or larger, found that 77% of women choosing “watchful waiting” had no significant changes in bleeding, pain or bothersome symptoms at the end of a year. Also, they had no changes in their mental health, general health or ability to do physical activity. However, 23% of the women were bothered by symptoms to the point that they chose to have a hysterectomy during the course of the year.

Based on this study, women with fibroids that cause only mild or moderate problems “watchful waiting” may enable surgery to be postponed or entirely avoided. Women who are close to menopause might choose “watchful waiting” because there is less time to develop new symptoms and after menopause bleeding will stop and fibroids shrink about 50%.

The cause of the growth of fibroids is not well understood, and the rate of growth is unpredictable. Most fibroids never grow; others grow gradually over the course of many years; and some seem to go through growth spurts and then may stop growing entirely. The only way to know what is happening is to have a pelvic examination on a regular basis. I usually examine women with fibroids every three to six months. If the fibroid grows during that time period, the growth will be discovered early, and a number of options short of hysterectomy, should still be available. If the fibroid continues growing, I usually do exams more frequently, generally every month until the growth stops. Ultrasound, a simple test that uses sound waves to make a picture, can also be used to determine the size of the fibroids.

What if Fibroids Cause Bothersome Symptoms?

Fibroids may sometimes grow large enough to cause frequent urination, constant discomfort, pressure, and even pain. And, while not dangerous, the discomfort may lead you to choose surgery as treatment for fibroids. Two added notes: very large fibroids may partially block blood flowing from the legs back to the heart. This can lead to swelling of the legs and some discomfort. Very rarely, it can also lead to formation of blood clots in the legs that can be dangerous and this can be a good reason to get treatment. If you have very large fibroids, it is important that you not sit for prolonged periods of time so that clots have less chance to form. Also, very rarely large fibroids may block the flow of urine out of the kidneys and, even more rarely, this can cause kidney damage. If your doctor thinks the fibroids are close to the ureters on pelvic examination then this can easily be evaluated with either ultrasound or X-ray of the ureters.

What If You Have Large Fibroids?

Doctors have been taught that if a woman has fibroids the size of a large grapefruit (a three month pregnant uterus) or larger, she would be at risk for other health problems. This reason-the future possibility of problems-simply does not make sense to me. If you have a large fibroid and you are feeling fine, I can’t see the need for you to undergo surgery. It is actually unlikely that your large fibroid will ever go on to cause you any bothersome symptoms.

Doctors also feel that large fibroids make it very difficult to perform a thorough pelvic examination and fear that a less than optimum pelvic examination can result in missing an early diagnosis of ovarian cancer. Unfortunately, ovarian cancer is extremely difficult to diagnose in the early stages, with or without fibroids, even with the most sophisticated and expensive testing.

This is a frustrating and difficult reality for us all. Usually, by the time a gynecologist can feel an abnormality of the ovary during the pelvic exam, the disease has already spread. It is also common for gynecologists to not be able to feel every patient’s ovaries because of the size of the ovaries, the position of the ovaries, or the weight of the patient. It would make no sense to recommend a hysterectomy to every woman whose ovaries were unable to be felt by her gynecologist. And no study has ever shown that removal of a uterus enlarged with fibroids will make any difference in the early detection of ovarian cancer.

Another argument for aggressive surgery relates to the belief that the risks and complications of surgery are greater if the surgery is delayed and the uterus grows larger. As shown in a study at the University of Iowa College of Medicine, the complication rate for women who have hysterectomies for large fibroids is no different from that for women with small fibroids.

Also, a myomectomy may be safely performed on a woman with large fibroids. Drs. Stanley West , Reginald Ruiz and I published an article in the August, 2005 issue of Obstetrics and Gynecology reviewing the results of 91 women with uterine fibroids larger than a four month sized pregnant uterus operated on by Dr. West. The results compare very favorably to other studies of women who had a hysterectomy for large fibroids.

Many patients with uterine fibroids need no treatment. Surgery is only reasonable if you have symptoms that truly warrant the risk, time, stress, and money that an operation entails. But, if you need surgery it can be performed safely by a gynecologist experienced in fibroid surgery.

Can You Take Medication for Fibroids?

Unfortunately, there are no medications currently available that are able to prevent the formation of fibroids or permanently shrink them once they are present. Medicines are often used to buy time or reduce symptoms. For some women, medication allows a more relaxed time period to prepare emotionally and physically before treatment. Medications may also temporarily reduce the size of the fibroids enough to allow for a less invasive surgery with a quicker recovery. For some women who are approaching menopause, the “bought time” may lead them right into menopause, when the natural loss of estrogen and progesterone shrinks the fibroids.

Lupron (injectable) and Synarel (nasal spray) are two of the medications that work by temporarily shutting off the ovaries’ ability to make estrogen and progesterone, and menstrual periods temporarily cease. Since estrogen and progesterone are some of the substances necessary for fibroids to grow, the lack of hormones causes fibroids to shrink. These medications take about two weeks to begin shrinking the fibroids, and the full effect is seen after three months. At that time, most fibroids will decrease in size by about 35% of their volume. The shrinking effect is maintained for as long as you use the medication, but there is rarely any further shrinkage after the third month of treatment.

Heavy bleeding goes away in almost all women by about 6 months. However, if the medication is stopped, the ovaries begin to produce hormones again and the fibroids return to their original size and bleeding returns within 3-6 months. Therefore, the medication has no permanent effect and is primarily used to reduce symptoms and allow time to bring your blood count back to normal and plan treatment. In addition, long-term use of these medications is limited by their side effects and the risk of osteoporosis. Side-effects occur in 95% of women treated with Lupron; 78% have hot flushes, 32% have vaginal dryness and 55% have headaches on and off for a few weeks. Muscle or joint pain, trouble sleeping, fluid retention, fragile emotions, depression and decreased libido can also happen but are less common. Importantly, significant bone loss can occur if treatment continues for 6 months or more.

The FDA has approved the use of Lupron for 6 months or less. Use for any longer time is considered “off-label use” and the risks should be discussed with your doctor.

After the first three months of therapy, low doses of estrogen and progestins (called add-back therapy) may be taken with Lupron in order to decrease side-effects and bone loss. However, a study of Lupron used for 6 years found a wide range of bone loss among different women, so the effects of this treatment for individual women is not predictable and should be monitored closely.

Can Lupron Be Used Before Surgery?

Because Lupron stops heavy bleeding, women who are treated for 3 to 4 months before surgery will have higher blood counts but still have a similar risk of needing a blood transfusion. Some surgeons use Lupron before a hysterectomy to shrink the uterus so that the hysterectomy might possibly be performed through a vaginal incision rather than an abdominal incision.

Can Lupron Be Used as Temporary Treatment for Women Approaching Menopause?

A woman with symptoms from fibroids who is approaching menopause can use Lupron or Synarel until menopause begins. Then the natural supply of estrogen will cease, and the fibroids will remain small without any medication. After the first three months, low doses of estrogen and progestins may be taken to reduce side-effects, but it is important to measure bone density. However, because the exact age of natural menopause is unpredictable and we have no way to test when it will occur, long-term Lupron can turn into an expensive proposition-$2,000 per year-and is usually not covered by medical insurance. But, for some women, this treatment plan may be useful.

Can Progesterone-Blocking Medication Treat Fibroids?

Contrary to what many women have heard, progesterone can make fibroids grow. Under the microscope, fibroid cells seem to be growing the fastest during the part of the menstrual cycle when progesterone levels are naturally highest. Treatment with the progesterone-blocking drugs Mefipristone (RU-486) or Asoprisnil shrinks fibroids and stops heavy bleeding in most women. However, Mefipristone can cause over-growth of the uterine lining cells (endometrial hyperplasia) in about one quarter of women. There is some concern that this over-growth could lead to pre-cancer or cancer of the lining cells, although this has not been seen in preliminary studies. Asoprisnil is currently undergoing FDA review following its recent clinical trials.

I am including the abstracts:

Low-dose mifepristone for uterine leiomyomata.

Authors: Eisinger SH, Meldrum S, Fiscella K, le Roux HD, Guzick DS.
Obstet Gynecol. 2003 Feb;101(2):243-50

OBJECTIVE: To compare the effect of 5 and 10 mg of mifepristone on uterine leiomyoma size and symptoms, and to measure side effects.

METHODS: Forty premenopausal women with large, symptomatic leiomyomata were randomized to receive either 5 or 10 mg of mifepristone daily for 6 months in an open-label study. Uterine volume was measured at bimonthly intervals by sonography. Serum concentrations of hemoglobin levels, follicle-stimulating hormone, and liver enzymes were obtained, and endometrial samples, symptoms, and menstrual bleeding were also assessed.

RESULTS: Nineteen of 20 subjects taking 5 mg and all 20 subjects taking 10 mg completed all 6 months of the study. Mean uterine volume shrank by 48% (P <.001) in the 5-mg group and 49% (P <.001) in the 10-mg group, a nonsignificant difference. Leiomyoma-related symptoms were comparably reduced in both groups. Amenorrhea occurred in 60-65% of both groups. Hemoglobin levels increased by 2.5 g/dL in anemic subjects. The incidence of hot flashes increased significantly over baseline in the 10-mg group but not in the 5-mg group. Simple endometrial hyperplasia occurred in 28% of all subjects, with no difference between groups. No atypical hyperplasia was noted.

CONCLUSION: Mifepristone in doses of 5 mg or 10 mg results in comparable leiomyoma regression, improvement in symptoms, and few side effects. Further study is needed to assess the long-term safety and efficacy of low-dose mifepristone.

-

Asoprisnil (J867): a selective progesterone receptor modulator for gynecological therapy.

Authors: DeManno D, Elger W, Garg R, Lee R, Schneider B, Hess-Stumpp H, Schubert G, Chwalisz K.
Steroids. 2003 Nov;68(10-13):1019-32.

TAP Pharmaceutical Products Inc., 675 N. Field Drive , 600452, Lake Forest , IL , USA

Asoprisnil is a novel selective steroid receptor modulator that shows unique pharmacodynamic effects in animal models and humans. Asoprisnil, its major metabolite J912, and structurally related compounds represent a new class of progesterone receptor (PR) ligands that exhibit partial agonist and antagonist activities in vivo. Asoprisnil demonstrates a high degree of receptor and tissue selectivity, with high-binding affinity for PR, moderate affinity for glucocorticoid receptor (GR), low affinity for androgen receptor (AR), and no binding affinity for estrogen or mineralocorticoid receptors. In the rabbit endometrium, both asoprisnil and J912 induce partial agonist and antagonist effects. Asoprisnil induces mucification of the guinea pig vagina and has pronounced anti-uterotrophic effects in normal and ovariectomized guinea pigs. Unlike antiprogestins, asoprisnil shows only marginal labor-inducing activity during mid-pregnancy and is completely ineffective in inducing preterm parturition in the guinea pig. Asoprisnil exhibits only marginal antiglucocorticoid activity in transactivation in vitro assays and animal models. In male rats, asoprisnil showed weak androgenic and anti-androgenic properties. In toxicological studies in female cynomolgus monkeys, asoprisnil treatment abolished menstrual cyclicity and endometrial atrophy. Early clinical studies of asoprisnil in normal volunteers demonstrated a dose-dependent suppression of menstruation irrespective of the effects on ovulation, with no change in basal estrogen concentrations and no antiglucocorticoid effects. Unlike progestins, asoprisnil does not induce breakthrough bleeding. With favorable safety and tolerability profiles thus far, asoprisnil appears promising as a novel treatment of gynecological disorders, such as uterine fibroids and endometriosis.

Can a Progestin-Releasing IUD Treat Heavy Bleeding from Fibroids?

Women who have a uterus with fibroids smaller than 12 weeks size and a normal size uterine cavity may get relief from heavy bleeding by using a progestin-releasing intra-uterine device (Mirena). The progesterone in the IUD thins the uterine lining cells, so the cells bleed less. One study showed that by 3 months, 85% of women returned to normal bleeding, and heavy bleeding and anemia were cured in virtually all women at the end of one year.

Can Alternative Medicine Be Used to Treat Fibroids?

Unfortunately, there are few studies of alternative treatments for fibroids. However, one very small study compared fibroid growth in women treated with Chinese Medicine, body therapy and guided imagery with women treated with non-steroidal anti-inflammatory medications (NSAIDs), progestins, or oral contraceptive pills. After 6 months, ultrasounds showed that fibroids stopped growing or shrank in 59% of the women treated with the combination of alternative medicines, but in only 8% of the other women. Another study reported treatment of 110 women with fibroids smaller than 10 cm. (4.5 inches) with the Chinese herbal medicine Kuei-chih-fu-ling-wan. Fifteen of the 110 (14%) women requested and had a hysterectomy during the study. However, fibroids went away in 19% of the other women, got smaller in 43%, did not change in 34% and grew in 4%. Heavy bleeding improved in 95% and severe cramping improved in 94%. The Chinese Medicine doctor with whom I work tells me that he has success with small fibroids (less than 2 inches), but not with fibroids larger than that. So, this treatment may work for women with small fibroids who wish to prevent the fibroids from growing and causing more symptoms. In any case, it is important to work with a reputable alternative medicine practitioner who can direct your care.

Are There Any Other Promising Medications on the Horizon?

Pirfenidone is a new, not yet available, medication that blocks the growth of existing fibroids and may stop the formation of new fibroids. Although the exact mechanism of action is not known, pirfenidone affects the production of collagen, a major component of fibroids. Other effects of pirfenidone on cell growth factors may also be important. Studies are now under way to evaluate how fibroids respond to this new drug and to evaluate its side effects. In the future, women with small fibroids may be able to take pirfenidone, or a medication like it, to prevent fibroid growth and avoid any other need for treatment.

Chapter 6

Do You Need Surgery for Fibroids?

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 Hysteroscopic Myomectomy) 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.

Chapter 7

Fibroids and Cancer

Do Growing Fibroids Mean Cancer?

Fibroids are benign uterine growths. Furthermore, fibroids do not turn into cancer. Genetic studies of fibroids and uterine muscle cancer (sarcoma) show that they have very different genetic mutations and that sarcomas do not develop from fibroids. However, a leiomyosarcoma, an extremely rare malignant tumor of the uterine muscle, also causes enlargement of the uterus. But only 1 out of every 1,000 women admitted to the hospital for surgery because of problems thought to be from fibroids will be found to have a sarcoma. And since 80 percent of women with fibroids are never admitted to a hospital for surgery, the incidence of sarcoma in all women with fibroids is extraordinarily low. The average age of women who develop fibroids is 38. Although sarcoma can rarely occur in young women, the average age of a woman who develops a sarcoma is 63. So, if you have fibroids, there is not much reason to worry about sarcoma.

Most gynecologic textbooks teach physicians that if a woman has a rapidly growing uterus, she should have surgery to see if she has a uterine sarcoma. Surgery would be needed to remove tissue for microscopic analysis. However, during the course of my training and years in practice, I have never seen a “rapidly growing fibroid” actually turn out to be a sarcoma.

To study this issue, I did a clinical study at the hospitals where I practice and reviewed the charts of 1,332 women admitted for surgery because of fibroids. Only three women (two tenths of 1%) were found to have a sarcoma. Of the 371 patients admitted because of rapidly growing fibroids, only one (three tenths of 1%) had a sarcoma. This study showed that the risk of developing a sarcoma is extremely low, even if your fibroids are rapidly growing.

I am including the abstract from our article:

Uterine sarcoma in patients operated on for presumed leiomyomas and rapidly growing leiomyomas.

Authors: Parker W, Berek J, Fu YS.
Obstetrics and Gynecology 1994; 83:414-8

Objective: To determine the incidence of uterine sarcoma in patients operated on for symptomatic uterine leiomyomas or “rapidly growing” leiomyomas.

Methods: Medical records of 1332 women admitted to either of two community hospitals between 1988-1992 for hysterectomy or myomectomy for uterine leiomyomas were reviewed. The incidence of leiomyosarcoma, endometrial stromal sarcoma and mixed mesodermal tumor was calculated. Patient ages, admitting symptoms, operative and pathologic findings were analyzed. Included in the study were 371 women (28%) operated on for “rapidly growing” leiomyomas. All patients operated on during the same interval and found to have a uterine sarcoma were reviewed.

Results: One of 1332 patients (.07%) operated on for presumed leiomyoma was found to have a leiomyosarcoma This woman was the only patient found to have a sarcoma among 371 (0.27%) women operated on for “rapid growth” of the uterus. None of 198 patients who met a published definition of rapid growth had a uterine sarcoma. Two women (0.15%) were found to have endometrial stromal sarcoma and none was found to have a mixed mesodermal tumor. During the same interval, nine additional patients were found to have uterine sarcomas, and for these the preoperative diagnosis was sarcoma in four, endometrial cancer in three, ovarian cancer in one, and prolapsed uterus in one.

Conclusions: The total incidence of uterine sarcoma (leiomyosarcoma, endometrial stromal sarcoma, and mixed mesodermal tumor) among patients operated on for uterine leiomyoma is extremely low (0.23%). The incidence of sarcoma among patients operated on for “rapidly growing” leiomyoma (0.27%), or those who met published criteria for rapid growth (0%) does not substantiate the concept of increased risk of sarcoma in these women.

Can the Diagnosis of Sarcoma be Made Without Surgery?

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.

What Should You Do if You have a Growing Fibroid?

If you have a growing fibroid, it is perfectly reasonable to be followed by having a pelvic examination every one to three months. If the fibroid begins to cause bothersome symptoms, then surgery may be considered. If the fibroid continues to grow very rapidly, doubling in size in a few weeks or months, then surgery may be indicated. However, because of the rarity of sarcomas (especially in women younger than fifty), we found no justification for assuming that growth in a fibroid means that cancer is developing. And, as stated before, there is no evidence to suggest that fibroids turn into cancer. Therefore, surgery is not usually indicated.

If you are a woman in her fifties or sixties, the issue of growth of fibroids is different. Published reports show that sarcomas may occur in women in their fifties and sixties. If you are postmenopausal and not on estrogen replacement therapy, any growth in your uterus may be cause for concern. Until there is further confirmation of the MRI/LDH tests, surgery may be needed to remove the growing fibroid. A pathologist performs an examination of the tissue under a microscope to conclusively show if cancer is present.

Do Birth Control Pills Cause Fibroids to Grow?

Birth control pills do not appear to cause the growth of fibroids. Three studies have tried to answer this question; one study found a slightly increased risk of fibroids, another study found no increased risk and the third study found a slightly decreased risk. However, these studies are retrospective and may contain selection bias.

Does Menopausal Hormone Therapy Cause Fibroids to Grow?

Postmenopausal hormone therapy does not normally cause fibroid growth. A few studies have tried to answer this question. After three years, only 8% of postmenopausal women with fibroids who were taking hormones had any increase in fibroid size. If any increase in uterine size is noted, it is likely related to the dose of progestins. A study found that for women taking oral estrogen plus a low dose of synthetic progesterone for one year, 23% had a slight increase in size (about 1 inch in diameter) while 50% of the women taking a higher dose had an increase in size. Estrogen patches or skin creams (with synthetic progesterone) may cause slight (1/4 inch) increase in the diameter of fibroids while oral estrogen (with synthetic progesterone) caused no increase in size.

In our fibroid study, we found that in the small number of postmenopausal women (7 women) who were taking estrogen and were noted to have growing fibroids, none was found to have a sarcoma during surgery. Therefore, a reasonable option for these women might be to discontinue the estrogen and see if the uterus shrinks back to its previous size. If the fibroids do shrink (because the estrogen and progestin is no longer present), then you could stay off the hormones and avoid surgery. Or, if the hormones are necessary for bothersome menopausal symptoms, you can restart them with the knowledge that surgery will probably be necessary if the fibroids grow again. If you stop taking hormones and your uterus does not shrink, or especially if it continues to grow, then surgery should be performed because of the possibility of uterine sarcoma.

Chapter 8

Laparoscopic and Robotic Myomectomy

What Is a Laparoscopic Myomectomy?

Laparoscopic surgery is usually performed as out-patient surgery under general anesthesia and has absolutely revolutionized gynecologic surgery because of the short hospital stay and quick recovery. The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Two or three small, half-inch incisions are made below the pubic hairline and instruments are passed through these small incisions to perform the surgery. Because the incisions are smaller, patients can enjoy faster recovery times and smaller scars.

Laparoscopic surgery differs from traditional surgery in a few key ways: during laparoscopic surgery, the surgeon is not looking into the abdomen directly through a large incision across the abdomen, but performs the surgery while looking at a large video monitor suspended over the patient’s abdomen.  The surgery, and especially the suturing of the uterus that is necessary during a laparoscopic myomectomy, requires a great deal of hand-eye coordination and dexterity, as well as knowledge of pelvic anatomy in order to be successful.

The procedure is very safe an effective when performed by a properly trained physician and the technique continues to evolve as new instruments are developed. However, many physicians today still lack the skills necessary to perform myomectomies through the laparoscope and therefore do not offer them to patients. Because of the small size of the incisions and the level of skill needed to correctly perform the surgery, this procedure is actually harder for a physician to perform without the proper experience and takes more skill and training than abdominal surgery.

I began performing operative laparoscopic procedures in 1987 and have been performing laparoscopic myomectomies for nearly 20 years. I have been teaching these techniques to other gynecologists since 1990.  As a result, I am able to perform laparoscopic myomectomy surgery with minimal blood loss, a short time under anesthesia for the patient, and with consistently good outcomes.

For laparoscopic myomectomy, a small scissors-like instrument is used to open the thin covering of the uterus. The fibroid is found underneath this covering, grasped, and freed from its attachments to the normal uterine muscle.

After the fibroid is removed from the uterus, it must be brought out of abdominal cavity. The fibroid is cut into small pieces with a special instrument called a morcellator, and the pieces are removed through one of the small incisions. New morcellators allow the easy removal of even large fibroids. The openings in the uterus are then sutured closed using specially designed laparoscopic suture holders and grasping instruments. Laparoscopic suturing with small instruments, in particular, requires special training and expertise. The entire procedure can take one to three hours, depending on the number, size, and position of the fibroids.

Myomectomy should be performed only if appropriate indications exist. And since it is a technically difficult surgery, your physician should have the extra training and experience that it requires. When talking to your doctor or interviewing a gynecologic surgeon, it is your right to ask about qualifications:

- How were you trained to do this surgery?

- How many of these operations have you performed for women with a situation like mine?

- Have you had any complications?

Many gynecologists have not been trained to suture with laparoscopic instruments, and some may even say that laparoscopic surgery is not possible. It is often a good idea to get a second opinion from a gynecologist who performs laparoscopic myomectomies on a regular basis to see if this procedure is feasible for you (see below).

Following laparoscopic myomectomy, most women are able to leave the hospital the same day as surgery. For more extensive surgery, a one-day stay may be a good idea. Because the incisions are small, recuperation is usually associated with minimal discomfort. Since the abdominal cavity is not opened to air, bacteria are less likely to reach the area of surgery, and the risk of infection is very low. The intestines are not exposed to the drying effect of air, or the irritating effects of the sterile gauze sponges used to hold the bowel out of the way during abdominal surgery. As a result, the intestines usually begin to work normally again immediately after laparoscopic surgery. This avoids the one- or two-day delay before a person is able to eat following regular abdominal surgery. After laparoscopic myomectomy, women usually can walk the day of surgery, drive in about 1 week and return to normal activity, work, and exercise within two weeks.

Can Laparoscopic Myomectomy be Performed if You Want to Have Children?

The use of laparoscopic myomectomy for women who desire to have children is controversial. The concern is how well the uterus will be able to withstand the stress of labor after having been cut and repaired with laparoscopic techniques. Fewer women have gone through labor and delivery after having a laparoscopic myomectomy than the numbers of women going on to have children after an abdominal myomectomy. The uterine scar, however, appears to heal as securely with a laparoscopic myomectomy as with myomectomy done by laparotomy. While many women have gotten pregnant and delivered safely, some physicians may recommend Caesarean section for delivery to avoid the stress of labor on the uterus. There are now a number of studies showing the safety and success of laparoscopic myomectomy for women who wish to get pregnant. However, a study comparing laparoscopic myomectomy and standard myomectomy with regard to fertility, labor, and delivery has not yet been performed by the research community. Further study will be needed to clarify this issue.

How Can We Remove a Big Fibroid Through a Small Laparoscopic Incision?

Less than a decade ago, removing fibroids after laparoscopic myomectomy was a difficult and time-consuming task. However, a few years ago an electrically powered device, called a morcellator, was invented and now allows us to quickly cut up the fibroid and easily remove it from the abdomen. The device is a hollow tube with a sharp circular blade at the end that rotates quickly and takes small slices off the fibroid in a few seconds. A large fibroid can now be removed in about fifteen minutes. Therefore, we are now able to perform laparoscopic myomectomy on women with even large fibroids. This device has allowed a major advance in our laparoscopic technique.

Which Fibroids Can Be Removed Laparoscopically?

The limits to laparoscopic myomectomy depend on a number of factors -- the size(s), number and position of the fibroids, whether future fertility is desired, and the experience of the surgeon. Some of the issues are:

1. How safe will the surgery be in terms of blood loss, time of anesthesia, and risk of injury to other organs,

2. Strength of the repair of the uterus if fertility desired.

Size: Many experienced laparoscopic surgeons are comfortable removing fibroids less than 8 cm (3.5 inches) in diameter. Depending on the position of the fibroid, I have removed fibroids as large as 15 cm, and the largest reported in the literature is 16 cm.

Number: It is actually easier to remove 1 large fibroid than 10 small ones, because each fibroid may require a separate incision which then needs to be sutured. Suturing laparoscopically is more tedious than through an abdominal incision and is a skill that takes many years to perfect. Many experienced laparoscopic surgeons are comfortable removing up to 5 fibroids, but more may be reasonable in some situations.

Position: The easiest fibroids to remove are those that are outside the uterus on a stalk (subserosal pedunculated). Once the stalk is cut, the fibroid can be cut up into small pieces with a specially designed instrument called a morcellator and brought out of the abdomen through a small incision. The deeper the fibroid is into the uterine muscle wall, the more difficult it is to remove, and the more suturing needs to be done to repair the muscle wall. Other considerations regarding position include how close the fibroids are to the fallopian tubes (if fertility is desired) or to the uterine blood vessels, and whether there is any risk of damage to these areas. Skill, experience and judgment of the surgeon all come together here.

Fertility: If future fertility is desired, then the strength of the uterine wall repair is important. While this issue has not been fully studied, my feeling is that if there is going to be a large area of the wall that needs to be repaired and it is right up against the uterine cavity, then the repair is probably stronger if done through an abdominal incision with standard surgical instruments. If the fibroid is not large or not near the cavity, then laparoscopic surgery can be performed. Or, if future fertility is not desired, then the size of the fibroid and proximity to the cavity is not important and laparoscopic surgery can almost always be performed. MRI is a very helpful test that allows me to see the exact size, number and position of all the fibroids, so I always get an MRI before laparoscopic surgery. I like to show the MRI to the patient so that she can appreciate what the issues are and so we can discuss what is in her best interest.

These are the reasons why different gynecologists will give different opinions about whether laparoscopic myomectomy is feasible and appropriate -- it is complicated. And, to a large degree, opinions will be based on the surgeon’s experience, skill and comfort doing laparoscopic myomectomy.

Can Myomectomy Lead to Scar Tissue?

Any surgery can cause scar tissue to form. Your body makes new tissue as part of the healing process to help connect things back together. This new tissue is called scar tissue or adhesions. Unfortunately, this natural defense can work against us when it occurs internally after surgery, because scar tissue may stick to and pull the normal tissue around it, sometimes causing pain. Scar tissue near the fallopian tubes or ovaries may decrease fertility by making it difficult for the egg to travel to the fallopian tube.

One of the major benefits of laparoscopic surgery is the principle that it causes fewer adhesions than abdominal surgery. A group of Italian doctors recently performed laparoscopy on a group of women a few months after they had fibroids removed by either laparoscopy or traditional abdominal surgery. The number of women studied was small (thirty-two), but the doctors found fewer and thinner adhesions in the women who had laparoscopic surgery. Further studies need to be performed, but this information is encouraging for women wishing laparoscopic surgery.

Can Adhesion Barriers Prevent Scar Tissue?

Another new advance in surgery has been the use of special substances, called adhesion barriers, which help prevent the formation of scar tissue after surgery. Small sheets of cloth-like material can be wrapped around the raw areas from surgery and the material prevents nearby tissue such as the intestines from sticking to the surgery sites. After a few weeks, the material dissolves, leaving the newly healed surgery sites fairly free of adhesions. While the barriers are not perfect, they have been shown to help reduce the formation of adhesions.

This adhesion barrier looks and feels like a silky piece of gauze.

When placed over the uterus and sprinkled with sterile water, the adhesion barrier sticks to the uterus and prevents other organs from sticking to the sutured area.

I am including an abstract of an article about one adhesion barrier, called Seprafilm:

Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a blinded, prospective, randomized, multicenter clinical study. Seprafilm Adhesion Study Group.

Author: Diamond MP.
Fertil Steril. 1996 Dec;66(6):904-10.

OBJECTIVE: To assess the safety and efficacy of Seprafilm (HAL-F), Bioresorbable Membrane, (Genzyme Corporation, Cambridge , MA ) in reducing the incidence, severity, extent, and area of uterine adhesions after myomectomy.

DESIGN: Prospective, randomized, blinded, multicenter study. Adhesion reduction was assessed by an independent, blinded, gynecologic surgeon who reviewed videotapes of each patient’s second-look laparoscopy.

SETTING: Nineteen institutions across the United States .

PATIENT(s): One hundred twenty-seven women undergoing uterine myomectomy with at least one posterior uterine incision > or = 1 cm in length.

INTERVENTION(s): Patients were randomized to treatment with Seprafilm or to no treatment at the completion of the myomectomy.

MAIN OUTCOME MEASURE(s): The incidence, severity, extent, and area of uterine adhesions at second-look laparoscopy.

RESULT(s): The incidence, measured as the mean number of sites adherent to the uterine surface, was significantly less in treated patients (4.98 +/- 0.52 [mean +/- SEM] sites) than in no treatment patients (7.88 +/- 0.48 sites) as were the mean uterine adhesion severity scores (1.94 +/- 0.14 versus 2.43 +/- 0.10; treatment versus no treatment, respectively), mean extent scores (1.23 +/- 0.12 versus 1.68 +/- 0.10), and mean area of adhesions (13.2 +/- 1.67 versus 18.7 +/- 1.66 cm2). No adverse events occurred that were judged to be related to the use of Seprafilm.

CONCLUSION(s): In this multicenter study, treatment of patients after myomectomy with Seprafilm significantly reduced the incidence, severity, extent, and area of postoperative uterine adhesions. Additionally, Seprafilm treatment was not associated with an increase in postoperative complications.

Should You Have a Robotic Myomectomy?

Both laparoscopic myomectomy and robotic myomectomy are considered minimally invasive surgery; they are performed through small (1/2 inch) incisions, and are outpatient procedures with a short recovery (about 14 days). During laparoscopic myomectomy the surgeon uses laparoscopic instruments to remove the fibroids and suture the uterus. The robotic uses similar instruments that are controlled by the surgeon sitting in a console a few feet away from the operating table (see photo).

After 15 years of experience performing and teaching laparoscopic myomectomies, I have now been trained and have started performing robotic myomectomies as well. To date, the only real benefit I see to using the robot is for women who wish to maintain their fertility and who have a fibroid that takes up the entire wall of the uterus. In these women, a slightly more precise suture repair of the wall may be (although not proven) beneficial to keep the wall strong during the later months of pregnancy.

In almost all other women, laparoscopic myomectomy is straight-forward and saves both time and money (the robot costs $1.5 million and requires $100,000 a year maintenance fee). Many gynecologists recently started using the robot because they have not been trained, or do not have the skill, to perform laparoscopic myomectomies and the robot does make suturing easier for them. So, up until now, these gynecologists were only able to offer their patients abdominal myomectomies. But, other than allowing the doctor to do an operation they could not do with laparoscopic instruments, there does not appear to be any benefit to the patient over laparoscopic myomectomy.

However, the recent infatuation with robotic surgery, both among doctors and women, as the “new thing on the block” concerns me. Unfortunately, gynecologists with little or no laparoscopic surgical expertise are using the robot as a marketing tool and using women as their guinea pigs. I recently heard about a few robotic surgeries that took 7 hours and the patients had scalp damage and hair loss from being tilted head-down on the operating table for so long. Another surgery took 5 hours, the surgeon left in smaller fibroids and the woman needed a blood transfusion. These situations seem irresponsible.

Women should be asking the same questions about robotics as they should be asking any surgeon -- how many cases of robotic surgery have you done? How many for women with fibroids like mine? How long will this take? How many complications have you had and what were they? How many of your patients have required blood transfusions? Would this surgery be possible laparoscopically by someone with more experience? Would I be better served by someone else with more robotic experience?

As someone who teaches laparoscopic surgery to residents, fellows and other gynecologists on a regular basis, I fully understand the problem of doctors needing to get more experience and improve their skills. But, they should be starting with very easy cases and patient safety should be the primary (only) concern. Unfortunately, the robot company is pushing the robot very hard to gynecologists and hospitals, as well as marketing directly to women. Some of the cases described on message boards and elsewhere make it apparent that some physicians are getting in over their heads. So, make sure you are getting good care.

Chapter 9

Abdominal Myomectomy

What Is a Myomectomy?

Myomectomy means the surgical removal of just the fibroid, with reconstruction and repair of the uterus. There are now a number of techniques used to perform myomectomy: through an abdominal incision, vaginal incision, with a laparoscope, or with a hysteroscope. Myomectomy relieves symptoms in more than 75% of women. “The restoration and maintenance of physiologic (normal) function is, or should be, the ultimate goal of surgical treatment”, said Victor Bonney, an early advocate of abdominal myomectomy, in 1931. However, women are often told that myomectomy is not appropriate for them because hysterectomy is safer, is associated with less bleeding or that uterine muscle cancer (sarcoma) may be present. However, recent studies dispute all of those claims.

Studies show there may actually be less risk of complications during myomectomy than during hysterectomy. One study of women who had myomectomies and women who had hysterectomies for fibroids of the same sizes (about 4 months pregnancy size) found surgery took slightly longer in the myomectomy group (200 v. 175 min), but there was more blood loss in the hysterectomy group. The risks of bleeding, fever, life-threatening complications, need for another surgical procedure or re-admission to the hospital were not different. The authors of the study concluded that there was no difference in complications and with an experienced surgeon myomectomy is a safe alternative to hysterectomy.

What Is an Abdominal Myomectomy?

The most common method of removing fibroids is by making a four- to six-inch “bikini” incision on the abdomen just below the pubic hairline.

After inspecting the uterus to determine the number and position of the fibroids, the uterus is injected with pitressin, a solution that limits bleeding during the surgery. Then the covering of the uterus overlying the fibroid is cut (illustration 1), and the fibroids are separated and removed from the normal uterine muscle (illustration 2). In that fibroids push away normal uterine muscle as they grow (and do not destroy it), the normal uterine muscle can be sewn back together (illustration 3). This procedure takes about one to two hours, depending on the number, sizes and positions of the fibroids. Following surgery, a woman having an abdominal myomectomy may need to stay in the hospital for two to three days.

For information about recovery (and other issues) from women with fibroids, see:
http://health.groups.yahoo.com/group/uterinefibroids/

Can Adhesion Barriers Prevent Scar Tissue?

Another new advance in surgery has been the use of special substances, called adhesion barriers, which help prevent the formation of scar tissue after surgery. For abdominal myomectomy, small sheets of thin transparent material can be wrapped around the raw areas from surgery and the material prevents nearby tissue such as the intestines from sticking to the surgery sites. After a few weeks, the material dissolves, leaving the newly healed surgery sites fairly free of adhesions. While the barriers are not perfect, they have been shown to help reduce the formation of adhesions.

The adhesion barrier Seprafilm is teased out of its paper protection onto the incision in the uterus. The Seprafilm will dissolve within 2 weeks, after the uterine incision has started to heal.

New Pain Management Techniques Used Following Surgery

The first few days after surgery are the hardest, and research is always being done in an effort to ease postoperative discomfort. I use an innovative device to relive post-operative pain called “ON-Q”. As we are finishing surgery two tiny plastic tubes are inserted underneath the incision. The tubes are connected to a tennis ball sized device that slowly and evenly pushes local anesthetic contained in the ball into the incision – exactly where you need it. The device is used for 3 days and then easily, and absolutely painlessly, removed. This device greatly reduces the need for injected pain medication which travels throughout the entire body and brain and causes the grogginess that often accompanies narcotics.

I also commonly prescribe another effective innovation called “Patient Controlled Analgesia” (PCA). With this method, a small bedside pump drips pain medication into your IV at a very controlled, slow, and steady rate. With this steady low level of medication, you should not develop significant pain and the total amount of medication necessary per day is much smaller than with shots. Therefore, you will not feel as groggy, and the pain relief is much better.

The ON-Q catheter is left under the incision and the pump is carried in a belt pack.

The catheter has small holes that allow the local anesthetic to be sprinkled under the incision area

Are Some Fibroids Too Big for an Abdominal Myomectomy?

The short answer is NO. Some doctors and some managed-care organizations have policies stating that an abdominal myomectomy cannot be attempted if the uterus is bigger than a certain size (usually a three-month pregnancy size). Hysterectomy is the only option that they will offer. However, gynecologists who are skilled and experienced at myomectomy surgery can perform an abdominal myomectomy on just about any size uterus (see photo gallery below). One of the risks of a myomectomy is bleeding from the uterus during surgery. However, there are a number of techniques that can be used to reduce bleeding. A medication can be injected into the uterus that causes the blood vessels in the muscle to constrict, and less blood will seep out of the incisions in the uterine wall. Or the doctor can place an elastic tourniquet around the lower portion of the uterus to decrease the blood flow to the uterus.

Pre-op view of patient's abdomen

Uterus with fibroids prior to removal

Fibroids after surgical removal by myomectomy

Uterus after myomectomy

Post-op view of patient's abdomen after fibroids were removed

The placement and depth of the incisions on the uterus are also important. Making the incisions down to the area between the fibroid and normal muscle, where there are very few blood vessels, will reduce bleeding. Closing every incision quickly and tightly will promptly stop bleeding.

A cell saver is a surgical machine that suctions blood from the surgery site, washes it with sterile salt water, filters it and then gives the patient their own blood through her IV. Therefore, there is less need to give your own blood before surgery and less need for a blood transfusion, avoiding the risk of infection or transfusion reaction. Although I rarely need to use the cell-saver, I have it available outside the room for every myomectomy surgery. If needed, it takes only a few minutes to set up. For women who have very numerous, large fibroids, I set the cell-saver up right at the beginning of the surgery. If I need it, it is ready to go.

In a study of 91 women with fibroids larger than 16 weeks (ranging from 16 to 36 weeks), no one needed to have the surgery changed to a hysterectomy. Complications were very rare and, by using a cell-saver, very few women (7) required a blood transfusion. Many gynecologic surgeons don’t have training in these techniques and so don’t offer them. Ask your doctor and get some clarification on these issue and their experience with myomectomy surgery.

The abdominal incision is stretched (muscles are NOT cut) to allow the entire uterus with fibroids to be easily seen.

Largest fibroid (12 cm) is removed from uterus.

23 fibroids were removed from this woman's uterus

The uterus reconstructed after removal of the fibroids

Avoiding the Need for Blood Transfusion

Donated blood, even if you donate your own blood, decreases in quality every day it sits in the blood bank. The blood cells become more fragile and when they are transfused they clog up capillaries and block blood flow and oxygen delivery to the body’s cells.

Studies show that ill patients in an ICU who were transfused had more problems than patients with similar levels of anemia who did not get transfused. Although serious problems are less of a risk for young, healthy women who are having myomectomies (compared to 80 year-olds in an ICU!), the best strategy is for you to get your blood count up before surgery and the use of a cell-saver during surgery.

If your blood count is very low (hemoglobin levels below 9), I usually use Procrit to stimulate red blood cell production for about 3 weeks before surgery. This medication is exactly like the protein made by the kidney that tells the bone marrow to make more red blood cells. It is important to also take high doses of iron to provide your body with the building blocks to make red blood cells. Vitamin C (1000 mg/day) should also taken, which helps you absorb more iron through the intestines. There is no magic number, but it is safer to have the hemoglobin 10 or higher before surgery. In some women, very heavy menstrual bleeding does not allow us to get the blood counts up even with Procrit and Vitamin C (very rare), but this usually works well.

A number of surgical techniques can be used to reduce the risk of blood loss during surgery. I use Pitressin, a medication that makes blood vessels constrict and which has been shown to effectively decrease blood loss during myomectomy. It is important to find the exact area where the fibroid starts and the normal uterine muscle ends – this is the area where the fewest blood vessels are found and where the least amount of bleeding occurs when removing the fibroid. After each fibroid is removed, it is important to suture closed the hole in the normal uterine muscle so that bleeding is stopped immediately.

An additional strategy is the use of the cell saver, which allows me to replace blood loss, if necessary, immediately during surgery with the patient’s own fresh blood before the blood has a chance to deteriorate. In addition, with the cell-saver, since you get your own blood there is no risk of HIV, hepatitis or mismatched blood.

And lastly, the current recommendation is to not get a blood transfusion unless it is really necessary: if you are very dizzy or weak when you stand up, or if your hemoglobin is below 7 (normal is 12). Since the transfused blood doesn’t work very well, it is better and safer to take lots of iron and let your body to build up your own blood count slowly during the recovery period.

What are the risks of abdominal myomectomy?

Some studies suggest that there may be less risk of intraoperative injury with abdominal myomectomy compared to abdominal hysterectomy. One study of women having surgery for fibroids showed that operating times were slightly longer in the myomectomy group, but blood loss was slightly more in women who had a hysterectomy. The risks of severe complications such as severe bleeding, fever, life-threatening problems or need for readmission to the hospital were the same for both groups of women. However, 13% of women in the abdominal hysterectomy group had a complication, including 1 bladder injury, 1 ureteral injury, 3 bowel injuries, 8 women who had nausea, vomiting and slow return of bowel movements, and 6 women with pelvic infections. In contrast, complications occurred in only 5% of the abdominal myomectomy patients, including 1 bladder injury, 2 women who needed another operation for a bowel obstruction and 6 women who had nausea, vomiting and slow return of bowel movements. The authors concluded that myomectomy should be considered a safe alternative to hysterectomy.

What Does the Incision for an Abdominal Myomectomy Look Like?

I am often asked what the incision will look like after an abdominal myomectomy. I always make a bikini incision (medical name is Pfannensteil incision after the doctor who developed it). The incision is about 1 inch above the pubic bone and 4-6 inches long, depending on the size of the fibroids. The tissue underneath the skin called the fascia is then cut to allow access to the abdominal cavity. I do not cut the muscles, but stretch them apart (they have a natural separation) in order to get to the uterus and fibroids. The incision heals nicely as can be seen in the photos.

Picture of the abdomen prior to surgery

Picture of the incision

Picture of the incision 2 weeks after surgery

Can a Myomectomy Be Performed During a Cesarean Section?

Experienced surgeons can safely perform a myomectomy in carefully chosen women during a Cesarean section. One study of twenty-five women who had myomectomies performed for fibroids between 2 and 10 cm, showed that although five women needed a blood transfusion, no one needed to have a hysterectomy. Another study found that less than 1% of women needed a transfusion and none required hysterectomy. The authors concluded that, in experienced hands, myomectomy may be safely performed in some women during Cesarean section.

Chapter 10

Hysteroscopic Myomectomy for Bleeding

Can Fibroids Cause Problems with Bleeding and Fertility?

Fibroids bulging into the uterine cavity or within the cavity (submucous fibroids) can sometimes cause heavy menstrual bleeding or infertility. Submucous fibroids can often be removed with a hysteroscope, a telescope placed through the cervix and into the uterus. A study that combined results from many small studies found that submucous fibroids that change the shape of the uterine cavity decreased pregnancy rates by 70%. And, when these fibroids were removed there was an increase in the pregnancy rates by 70%.

The reason submucous fibroids can lead to infertility is not clear, but current theories are that the fibroids change blood supply to a developing embryo, or block passage of the embryo through the fallopian tube, or cause inflammation in the uterine lining, or produce proteins that interfere with the embryo’s journey through the tube, its attachment to the uterine lining or its development.

The way submucous fibroids cause heavy bleeding is also not clear, but most studies show removing these fibroids cures heavy bleeding. One study of women with very heavy bleeding found that, after removal of fibroids by hysteroscopy, additional surgery was needed by only about 10% of the women within 2 years, by 11% after 5 years and by 27% after 8 years.

What Is a Hysteroscopic Myomectomy?

Hysteroscopic myomectomy is a technique that can be performed only if fibroids are within or bulging into the uterine cavity (submucosal). This procedure is performed as outpatient surgery without any incisions and virtually no postoperative discomfort. Anesthesia is needed because the surgery may take one to two hours and would otherwise be uncomfortable. A small telescope, the hysteroscope, is passed through the cervix and the inside of the uterine cavity can be seen. A small camera is attached to the telescope and the view is projected on a video monitor. This magnifies the picture and also allows the physician to perform the surgery while sitting in a comfortable position.

Electricity passes through the thin wire attachment at the end of the hysteroscope, allowing the instrument to cut through the fibroid like a hot knife cutting through butter. As the fibroid is shaved out, the heat from the instrument sears blood vessels and the blood loss is usually minimal. Women go home the same day, and recovery is remarkably fast, with most patients able to go back to normal activity, work and exercise in one or two days.

When fibroids are the cause of infertility, pregnancy rates following hysreroscopic myomectomy have been about 50%. And when performed for heavy bleeding, nearly 90% of women have a return of normal menstrual flow.

Only a few years ago, treatment for fibroids in the cavity of the uterus involved major surgery-an abdominal incision and either cutting open the entire uterus to remove the fibroid or performing a hysterectomy. Hysteroscopic myomectomy has been a major advance in the treatment of women who have submucous fibroids.

What is Endometrial Ablation?

Endometrial ablation is an outpatient procedure used to stop or decrease bleeding from the uterus. The traditional method of performing endometrial ablation uses electrical energy passed into the uterine cavity at the end of a telescope in order to cauterize and destroy the lining of the uterus. This technique is very effective, but does require special training and skill on the part of the doctor. As a result, many doctors never learned how to perform endometrial ablation and do not offer the procedure to their patients as an alternative to hysterectomy.

Other methods of ablation have recently been developed. One procedure, called Hydrothermal Ablation (HTA), uses hot water circulated inside the uterus to destroy the lining cells. This device is specially engineered to keep the water at a low pressure so that it cannot escape through the tubes. If the device senses a leak, it automatically shuts off. Because the water circulates freely throughout the entire uterine cavity, the shape of the cavity does not affect the results. As a result, the device is very effective for women with fibroids or enlarged uterine cavities. Hydrothermal Ablation takes about 10 minutes and results are excellent.

Both types of procedures are offered in our practice depending on which is appropriate for the individual situation. With either procedure all the lining cells get destroyed in about 50% percent of patients and these women never have another menstrual period again. An additional 40% percent of women only experience a light flow for a few days each month because a few lining cells have been left behind. About 10% of women have no improvement noted. Thus, 90% of the women who have this procedure, all of whom have had severe and debilitating monthly bleeding, are extremely happy with this outpatient procedure. It is important to note that after endometrial ablation the ovaries continue to make normal amounts of hormone for the rest of your body, but without uterine lining cells, bleeding cannot occur. After surgery, women are able to return to normal activity in two or three days and look forward to life unencumbered by the fatigue and inconvenience associated with heavy bleeding.

Endometrial ablation should only be performed for women who do not wish to have any, or any more, children. Because the lining cells of the uterus are destroyed, there is no place for a developing fetus to attach within the uterus. Despite this, it is best to use some form of contraception after the procedure because there still exists the very rare possibility of pregnancy.

Chapter 11

Questions Everyone Should Ask Their Doctor Before Surgery

If you decide that surgery is right for your situation, you will need to choose the right doctor to perform your surgery. There are a number of factors that should influence your decision. You need to find a doctor who can perform the surgery that your condition requires. In most cases, there is more than one treatment option for medical problems. If your doctor states there is really only one surgical path to take, it is likely that this procedure is the only one he or she feels comfortable doing or is trained to do. Determining the skill of the surgeon is vital information for you to have. These are some questions you should ask any doctor you are considering for your surgery:

1) How many surgical procedures does the doctor perform a month?

2) How many of the surgical procedures you are requesting does this doctor do every month?

3) How many of these procedures has he or she performed on women with conditions or problems like yours?

4) How many complications from those surgeries performed have occurred with this doctor, and what kind of complications were they?

Some women are uncomfortable about asking these questions, but it is your body and your health. You have a right to get the best care possible. Finding a skilled surgeon is essential, and it is something you can do. Studies show that experience makes a surgeon better. Surgeons who frequently perform procedures have lower rates of complications. Surveys also show that many gynecologists perform less than one major operation a month. Choose your surgeon carefully.

Chapter 12

Caring for Yourself After Surgery

New Research on the Myths Regarding Instructions Doctors Give Following Surgery

A recent study from National Institutes of Health recommends that doctors change many of the current restrictions on activities following gynecologic surgery. After reviewing information 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, they found that the available studies do not support many of the recommendations currently provided by doctors. Resumption of usual activities after gynecologic surgery helps integrate women back into normal life and, although more study is needed, they suggested the following after abdominal surgery (restrictions are less after laparoscopic surgery):

Resumption of Normal Activity: Prolonged bed rest increases the risk of pneumonia and blood clots in the legs. A quick return to normal activity after gynecologic surgery should decrease the likelihood of these problems. For most women, normal activity includes walking, lifting, and climbing stairs. Many of the previous restrictions were intended to avoid straining the abdominal incision in a way that might cause it to open. But, as seen below, these fears are not justified.

Lifting: Patients have usually been instructed to not lift more than 10 pounds. However, normal events like forceful coughing (which we often encourage you to do) , or getting up from a lying down position (which you have to do to get out of bed every morning) place more stress on the incision than lifting. In fact, the force needed to tear open a surgical incision is much greater than the force generated by any kind of daily activity.

Poor nutrition, infection, obesity, anemia, and diabetes, as well as the type of suture material and the surgeon’s technique are more likely causes of the incision opening after surgery.

Climbing Stairs: Climbing stairs is a common and normal activity. There is no evidence that climbing stairs increases the risk of the incision opening.

Bathing and Swimming: Baths have usually not been permitted for 2 to 6 weeks after surgery in order to prevent wound infection. However, if the incision is closed and not already infected, there is no evidence that a tub bath is harmful once the bandage has been removed.

Driving a Car: The concerns have been that the physical activity associated with driving might cause the wound to open or that post-operative pain might cause you to hesitate to step on the brakes quickly in an emergency. However, there is no evidence that these things are true. It is a good idea to first try the pedals and hand controls in a stationery car. If this feels comfortable, then take the car for a short ride accompanied by another adult who could drive the car if you feel unable to continue driving.

More important is the possibility that narcotic pain medication may cause drowsiness or slow your reflexes while driving. Therefore, you should not drive until you no longer need narcotic pain medication.

Sex Following Hysterectomy: Sex can probably be initiated once you are comfortable and both partners are ready. If your cervix has been removed with the uterus (total hysterectomy), there is a small risk of infection around the sutures left in the vagina and a small risk of these sutures coming undone during intercourse. If you are menopausal, had prior pelvic radiation therapy, or have diabetes your risk is higher.

The cervix is a major source of normal lubrication, so if your cervix has been removed it is best to use vaginal lubricants during sex and try sexual positions with the woman on top so penetration can be controlled. This puts less pressure on the sutures at the top of the vagina.

If your cervix was left in place (supracervical hysterectomy) the risk of infection is even less and there are no sutures at the top of the vagina to worry about coming apart.

Returning to Work After Gynecologic Surgery: Advice on when to return to work varies greatly. In the United Kingdom, a survey found that doctors recommended returning to work anywhere from 1 to 10 weeks after surgery. It appears that a gradual return to work is better than an abrupt return to full-time work.

These new recommendations need to 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.

Chapter 13

Can New Fibroids Grow After Myomectomy?

Once fibroids are removed they do not grow back. Therefore, the term “recurrence” is technically incorrect. Although new fibroids may grow after a myomectomy, most women will not require any additional treatment. If the first surgery is performed for a single fibroid, only 11% of women will have another surgery within the next 10 years. If multiple fibroids are removed, about 26% will have subsequent surgery. And the risks are lower for women as they get close to menopause, when new fibroids do not form. It would be extremely unusual for a woman to need another operation or procedure if she had a myomectomy after age 40.

Fibroids may be found after a myomectomy because the surgeon was not careful about removing all the fibroids during surgery. One ultrasound study found that 29% of women had fibroids left behind after myomectomy. There are very rare instances when so many (more than 100) very small fibroids are present and it becomes extremely difficult to remove them all. I have personally seen this situation only once.

While ultrasound can reliably find fibroids, many of them are very small and will not cause any symptoms. One ultrasound study, often quoted by gynecologists to encourage women to have a hysterectomy rather than a myomectomy, found fibroids ½ inch or larger in 51% of women 5 years after myomectomy. So, you may see this 50% number, but remember that it is not a meaningful statistic because very, very few of these women will need any further treatment.

What Can Increase or Decrease Your Risk of Getting New Fibroids After Myomectomy?

One study found that childbirth was the only factor that decreased the new appearance of fibroids after myomectomy: after 10-years, new fibroids were found in 16% of women who had given birth after surgery, but were found in 28% of women who had not given birth. The risk of new fibroids appearing increases with the number of fibroids removed, representing either fibroids left behind because the surgeon did not remove them all or, rarely, the result of a strong genetic tendency to form new fibroids.

Treatment with Lupron before surgery makes the fibroids smaller and may make them harder to identify and remove during surgery. One study found that after surgery 63% of the women treated with Lupron had small fibroids found with ultrasound, but only 13% of women who did not get Lupron had similar fibroids.

Chapter 14

Do You Need a Hysterectomy for Fibroids?

About Hysterectomy

While bothersome symptoms such as very heavy bleeding or pain often respond to medications or other non-surgical treatment, sometimes the symptoms do not get better. For some women, other minimally invasive surgical techniques may have failed hysterectomy may be appropriate. A recent American study done by a woman doctor at Harvard found that many women who had a hysterectomy performed because of moderate or severe symptoms were “very satisfied” with the results of surgery, and they noted an improvement in their quality of life.

One of the most important factors in helping you choose appropriate medical care is your full understanding of the reasons for treatment, the risks, and the potential benefits for you. If hysterectomy has been suggested to you as an option, you should carefully weigh the potential benefits and risks so that you are able to make a comfortable and informed decision about whether hysterectomy is right for you. Hopefully, the information presented here will help you with this decision.

Myomectomy as a Surgical Alternative to Hysterectomy

“The restoration and maintenance of physiologic (normal) function is, or should be, the ultimate goal of surgical treatment”, said Victor Bonney, an early advocate of abdominal myomectomy, in 1931. Myomectomy means the surgical removal of just the fibroid, with reconstruction and repair of the uterus. However, women are often told that myomectomy is not appropriate for them because hysterectomy is safer, is associated with less bleeding or that uterine muscle cancer (sarcoma) may be present. Recent studies dispute all of those claims.

There may actually be less risk of complications during myomectomy than during hysterectomy. One study of women who had myomectomies and women who had hysterectomies for fibroids of the same sizes (about 4 months pregnancy size) found surgery took slightly longer in the myomectomy group (additional 25 min), but there was more blood loss in the hysterectomy group. The risks of fever, life-threatening complications, need for another surgical procedure or re-admission to the hospital were not any higher for the women having a myomectomy. The authors of the study concluded that with an experienced surgeon myomectomy is a safe alternative to hysterectomy.

There are two main types of myomectomy: laparoscopic myomectomy and abdominal myomectomy.

What Are the Different Types of Hysterectomy?

Hysterectomy, removal of the uterus, can be performed through an abdominal incision, an incision at the top of the vagina, or laparoscopically through a few small (1/2 inch) incisions in the abdomen.

Total hysterectomy removes the entire uterus, including the cervix.

Removal of the ovaries and tubes, which is rarely a good idea, is called bilateral salpingo-oophorectomy.

Supra-cervical hysterectomy

Supra-cervical hysterectomy removes only the upper body of the uterus and the cervix is left in place, attached to the top of the vagina. Unless you have cancer or have had recurrent problems with pre-cancer of the cervix you can have a choice as to whether the cervix will be removed or not. Some women feel that if the cervix is removed they will have diminished sexual pleasure or will develop bladder problems. This issue is discussed in detail below.

For patients who have known or suspected pelvic scar tissue or endometriosis, laparoscopic surgery allows the surgeon to remove the diseased tissue with the laparoscope before performing the hysterectomy. For patients who have large fibroids that might otherwise be difficult to remove by vaginal hysterectomy, laparoscopic hysterectomy allows the surgeon to detach the blood vessels to the uterus while viewing them through the laparoscope and skilled laparoscopic surgeons can remove even very large fibroid uteri laparoscopically and thus avoid a large abdominal incision. Laparoscopic hysterectomy does require extra training and considerable skill and experience on the part of the surgeon.

Laparoscopic hysterectomy and laparoscopic subtotal hysterectomy will be described here. Abdominal and vaginal hysterectomies are more fully discussed at: http://www.gynsecondopinion.com/.

Laparoscopic Hysterectomy

Laparoscopic hysterectomy, either total or supracervical, is often possible for women with fibroids, with the benefits of less postoperative pain, shorter hospital stay and faster recover

Laparoscopic Supracervical Hysterectomy

We pride ourselves in performing hysterectomies usually as a last resort to gynecologic problems, but the operation is sometimes necessary and appropriate. Dr. Parker has a superb reputation for gynecologic surgery in general and laparoscopic surgery specifically. He has been performing operative laparoscopic surgery since 1987 and laparoscopic hysterectomies since 1993.

One advantage of laparoscopic hysterectomy is that the incisions are smaller (1/2 inch) and much less uncomfortable than that of abdominal hysterectomy. Also, the hospital stay of 0-1 day and the ability to resume normal activity in about 2 weeks are substantially shorter than for abdominal hysterectomy (3 days in the hospital and 6 weeks recovery) and slightly shorter than for vaginal hysterectomy (1-2 days, 3-4 weeks).

Laparoscopic supracervical hysterectomy allows the uterus to be detached from inside the body using laparoscopic instruments while the doctor is viewing the uterus, tubes, and ovaries on a flat screen monitor using a camera attached to a telescope. This procedure differs from standard hysterectomies in that the cervix is retained in the woman’s body, while the main portion of the uterus is detached and removed through small (one inch) incisions in the lower abdomen. One of the instruments making this surgery feasible is called an electronic morcellator, which cuts the uterus into small pieces so that the tissue can be removed through the small incisions.

Is There Any Benefit to Leaving the Cervix in Place?

There is much debate as to whether there is any benefit to not removing the cervix. The proponents of supracervical hysterectomy suggest that bladder and sexual function are better preserved with this operation. These potential benefits have not been borne out by statistical analysis of two recent large studies, but some women may still note changes in sexual satisfaction, or bowel or bladder function if their cervix is removed and may benefit from keeping it. So, this is something you should think about and ask your doctor about. Also, it does appear that healing and recovery are somewhat faster because there is no surgery performed inside the vagina and no stitches at the top of vagina that need to heal. Since the cervix is still in place after supracervical hysterectomy, it is important to continue to have Pap smears regularly.

Dr. Parker has extensive experience performing both laparoscopic supracervical hysterectomies and total laparoscopic hysterectomies for many years and his patients’ experience has been extremely favorable. There are indications and reasons for each procedure, and before surgery he discusses these issues with each patient who is considering a hysterectomy.

What Is a Total Laparoscopic Hysterectomy?

Total laparoscopic hysterectomy is a surgical procedure that allows both the uterus and cervix to be detached from inside the body by laparoscopic instruments and then they are removed through a small incision at the top of the vagina. For women who have cervical conditions that require removal of the cervix (persistent abnormal pap smears, etc), this procedure allows removal of the cervix.

Will Hysterectomy Become a Less Common Operation?

New treatments for fibroids and abnormal bleeding, two of the most common reasons for hysterectomy, should decrease the need for hysterectomy. Myomectomy performed by hysteroscopy, laparoscopy, or abdominal surgery can usually be used to remove fibroids and alleviate symptoms without needing to remove the uterus.

Abnormal bleeding may often be treated by the progesterone IUD OR endometrial ablation with 90% of women reporting excellent results, which allows these women to avoid hysterectomy. Endometriosis, the third most common reason for hysterectomy, may be treated by medical therapy although the side-effects and expense of the medications limit its use. However, laparoscopic surgery to remove just the areas of endometriosis may also be used to alleviate pelvic pain associated with endometriosis. Hysterectomy, for most of these conditions, should be a last resort, not the first one.

What Questions Should You Ask Your Doctor if it is Recommended that you have a Hysterectomy?

It is important for you to understand the reasons that your doctor has suggested a hysterectomy as treatment for your gynecologic problem. The most common reasons for surgery are pain, bleeding, or symptoms from fibroids. The first question that you should ask is what is specifically causing your problem. You should also ask if there are other tests that can be done to make the diagnosis more certain.

Once a probable diagnosis has been established, you should also ask what the consequences to your health will be if you do not have surgery, either at all, or at this time. For every condition, there are usually alternatives of varying degrees of effectiveness. For problems that are not life-threatening, one option may be to do nothing. The next question to ask the doctor is “are there non-surgical or minimally-invasive therapies available to treat my condition?”

It is important to ask about your doctor’s experience doing any operation that has been proposed. You should feel comfortable with the number of procedures he or she has performed for problems like yours. For some of the newer procedures, such as endometrial ablation, laparoscopic surgery, or laparoscopic hysterectomy, additional training and experience must be acquired before the procedures can be safely performed. Regular, ongoing performance of these procedures is needed to keep surgical skills at a high level. Therefore, it is important for you to ask about surgical training and experience.

Should You Get a Second Opinion?

If surgery is recommended, often the answer is yes. Most doctors will welcome the idea of a second opinion. If they have done a complete job on the diagnosis and on the explanation of the problem to you, then they should feel confident about the range of options they have discussed with you. In addition, no doctor knows everything, and your doctor may welcome any other new ideas about your problem. This is your body and your life and you deserve to know everything you can about all the options available.

Laparoscopic Hysterectomy Compared to Abdominal Hysterectomy

A prospective, randomized, multi-centered study concluded that laparoscopic-assisted hysterectomy offered the benefits of less invasive surgery without increased risk. Estimated blood loss, postoperative day 1 hemoglobin, postoperative pain (as measured by a visual analog scale), and postoperative hospital stay were all significantly better for the laparoscopy-assisted hysterectomy group. The abdominal hysterectomy group had 7 postoperative complications; 1 woman with a cuff hematoma who required transfusion, 1 with delayed bleeding requiring reoperation and transfusion, and 5 other women with fevers. The only complications in the laparoscopic group were postoperative fevers in 2 women.

A retrospective cohort study compared laparoscopic hysterectomy in 34 women with uterine weights greater than 500 gms (range 500-1230 gms) to 68 women with uterine weights less than 300 gms. 101 The authors found no difference in complications rates, blood loss, hospital stay or postoperative recovery, but operating times were significantly shorter in the women with smaller uteri. No patient required conversion to laparotomy. Therefore, in experienced hands the benefits of laparoscopic hysterectomy may also be extended to women who have large myomas.

What are the Risks and Possible Complications of Hysterectomy

Major complications from a hysterectomy are rare. The risks include injury to the bladder, bowel, and ureters. While these injuries can be serious, if they are detected early they can usually be corrected. The Maine Women’s Study recently reported that only 1% of the 400 women in their study who had a hysterectomy had a bleeding complication, 5% had a treatable wound or bladder infection, and no woman had a serious complication or died. For all women in the United Sates ages 35 to 44 who have a hysterectomy (not for cancer) the risk of dying is about 3 per 10,000 women.

The largest study (about 4,000 surgeries) to measure complications from laparoscopic hysterectomy found that about 2% of women had a major complication, including one woman (0.002%) who died from a pulmonary embolus after surgery. Another study compared complications in 3112 laparoscopically assisted hysterectomies, 1618 abdominal hysterectomies. Injury to the bladder, ureter, and bowel was slightly more common with laparoscopic than abdominal procedures.

In studies of abdominal and vaginal hysterectomies, injury to the bladder has been reported in 1 out of 200 surgeries, and injury to the ureter in 1 out of 1,000 vaginal hysterectomies and in 1 out of 200 abdominal hysterectomies. In the Finnish study of laparoscopic hysterectomies, injury to the bladder was seen in 7 out of 1,000 surgeries, injury to the ureter in 1 out of 100, and injury to the intestine in 1 out of 250 women.

One study of women with fibroids reported 13% of women in the abdominal hysterectomy group had a complication including 1 bladder injury, 1 ureteral injury, 3 bowel injuries, 8 women who had nausea, vomiting and slow return of bowel movements, and 6 women with pelvic infections.

I have performed more than 500 laparoscopic hysterectomies and have never had an injury to the ureter or bowel or have a pelvic infection after surgery. Two women with multiple cesarean sections had a lot of scar tissue near their bladders from those surgeries and small holes made were made in the bladder. Laparoscopic suturing of these small injuries was done and the patients went home the next morning and had normal recoveries. In 29 years of an active gynecological surgery practice I have never had one patient die as a result of surgery.

If you need a hysterectomy, should you also have your ovaries removed?

A few years ago I changed my view about this controversial subject and I now believe that, unless there is cancer present or a strong family history of cancer, the ovaries should almost never be removed at the time of hysterectomy.

First, the risk of ovarian cancer goes down if the ovaries remain after removal of the uterus. The reason for this is not clear, but it may be that the path for potential carcinogens from the vagina to the ovaries is interrupted when the uterus is removed. Thus, the risk of a woman developing ovarian cancer after hysterectomy is probably closer to 1 in 200 (0.5%) by the time you are 90 years old, rather than 1 in 80 (1.2%) for women who have not had a hysterectomy. This fact is not known by most women or even their physicians.

Significantly, the ovaries produce hormones long after menopause. Estrogen continues to be produced in small amounts, about 25 percent of normal pre-menopausal levels. Studies show lower rates of heart disease (the major killer of women today), less bone loss and less dementia in women who keep their ovaries than in women who have had their ovaries removed.

Testosterone one of the hormones normally produced by the ovary and it is produced daily for at least 30 years after menopause. Muscle, skin and fat cells change testosterone into estrogen, so the ovary continues to make estrogen this way for many years. This source of estrogen appears to be responsible for the lower risks of heart disease and osteoporosis found in women who still have their ovaries.

We recently published an article in the renowned journal Obstetrics and Gynecology that showed a lower risk of dying before age 80 if you choose to keep your ovaries at the time you have a hysterectomy. By performing a computer analysis of the risks for heart disease, stroke, osteoporosis, ovarian cancer and breast cancer for women who have had their ovaries removed and comparing the risks of dying from these conditions for women who still have their ovaries, we found an advantage to leaving your ovaries in until age 65. And, based on our analysis, there is no real advantage to removing the ovaries at any age unless, of course, you are at high risk of developing ovarian cancer based on family history or genetic testing.

Here is the abstract from our article:

Ovarian Conservation at the Time of Hysterectomy for Benign Disease

William Parker, MD, Michael Broder, MD MPH, Zhimei Liu PhD, Donna Shoupe, MD, Cindy Farquhar, MD, Jonathan Berek, MD
Obstetrics and Gynecology 2005; 106:219-26

Objective: Prophylactic oophorectomy is often recommended concurrently with hysterectomy for benign disease. The appropriate age for this recommendation has not been determined.

Methods: Using published age-specific data for absolute and relative risk, both with and without oophorectomy, for ovarian cancer, coronary heart disease (CHD), hip fracture, breast cancer, and stroke, a Markov decision analysis model was used to determine the optimal strategy to maximize survival. For each 5-year age group from 40-80, four strategies were compared: ovarian conservation or oophorectomy; and use of ERT or non-use. Outcomes as proportion of women alive at age 80 were measured. Sensitivity analyses were performed varying both relative and absolute risk estimates across the range of reported values.

Results: Ovarian conservation benefits long-term survival for women before age 65; women with oophorectomy before age 55 have 8.38% excess mortality by age 80 and before age 59 have 3.92% excess mortality. There is sustained, but decreasing, benefit until the age of 75, when excess mortality for oophorectomy is less than 1%. These results were unchanged following multiple sensitivity analyses and were most sensitive to the risk of coronary heart disease.

Conclusion: Ovarian conservation before age 65 benefits long-term survival and may have some benefit for older women.

For more information about this important topic, please visit http://www.ovaryresearch.com/

Testosterone also influences sexual feelings, desire, arousal and mood. Women with hormones from their own ovaries have a lower rate of depression than women who have had them removed, even if estrogen therapy (ET) is taken. These issues are harder to measure and, for that reason, were not included in our study.

Are There Reasons Some Women May Wish to Have Their Ovaries Removed?

However, there are a few situations where women may wish to have their ovaries removed at the time of hysterectomy. If the ovaries are affected by endometriosis or a woman has severe endometriosis and pelvic pain, studies show that removing the ovaries is associated with better long-term relief of pain than if the ovaries are not removed. Severe adhesions, or scar tissue, around the ovaries may also cause continued pelvic pain.

Some women have a family history of ovarian cancer. A genetic counselor can help evaluate your risk and may suggest BRCA (breast/ovarian cancer) gene testing to determine if you have inherited this gene that increases your risk. If you have an increased risk, you should strongly consider having your ovaries removed. In this case, the benefits of removing your ovaries and preventing ovarian cancer should far outweigh the benefits of keeping your own ovarian hormones.

Each woman needs to weigh the risks and benefits of having the ovaries removed at the time of surgery. Women tend to make very different decisions based on their particular circumstances. However, it is always best to make these decisions based on accurate and current medical information. This decision is yours to make and should be discussed in detail with your doctor. As always, if there are unanswered questions or concern, get a second opinion.

Chapter 15

Uterine Artery Embolization and Focused Ultrasound

What Is Uterine Fibroid Embolization?

Uterine fibroid embolization (UFE) is a non-surgical technique that shrinks fibroids without removing them. The procedure is performed by an interventional radiologist, an M.D. with basic certification in radiology and special education and certification in interventional radiology. You do not need to be put to sleep, but sedating medications are given in the vein to help you relax during the one to two hours the procedure takes. A small (one-inch) incision is made in the groin directly over the artery carrying blood to the leg. The interventional radiologist guides a long thin catheter (tube) into the blood vessels that supply the uterus while monitoring the process under X-ray. Small plastic particles are pushed through the catheter until they form a blockade to the blood flowing to the uterus. Fibroids have a limited supply of blood vessels, and with the blood flow blocked, the fibroid cells start to die off. The surrounding normal uterine muscle has a better blood supply and is able to survive. Deprived of blood, nutrition, and oxygen, fibroids shrink like prunes for the three to six months following embolization, and the symptoms from the fibroids often lessen as well.

It has now been performed in about 30,000 women in the United States and another 20,000 women worldwide.

Uterine Fibroid Embolization - placing catheter into uterine artery

What Is Recovery Like After UFE?

After embolization blocks the blood supply to the fibroids, the cells of the fibroid start to die off immediately. The dying cells release toxins that irritate the surrounding tissue and cause pain and inflammation. Almost all women have moderate to severe pain for the first day or so after uterine artery embolization and are kept in the hospital for one day so that they can be given narcotic pain medication. Anti-inflammatory medications, like Anaprox or ibuprofen, are also given to keep the inflammation down in the uterus. Tylenol is given for the fever that commonly follows the procedure.

However, most women are able to go home the next morning and only need to take oral pain and anti-inflammatory medications for the next few days. As with all medical procedures, the recovery varies from woman to woman. Many women feel back to normal within a few days and return to regular activity within a week or so. Other women have pain or discomfort for weeks and may not get back to normal activity for a few weeks or, rarely, even months.

How Effective and Safe Is UFE?

Many women will notice a relief of fibroid symptoms within six weeks after the procedure. However, it takes a few months for the fibroids to fully shrink and the full effect of the procedure to be evident. Three to six months following UFE, the uterus and fibroids will have decreased about 40 percent in size. About 90 percent of women who were bothered by symptoms related to the size of their fibroids will have a significant improvement and be satisfied with the results. Likewise, about 85 percent of women who had heavy bleeding from their fibroids will have lighter and shorter periods and be satisfied with the results. About 10 to 15 percent of women who have UFE will continue to have bothersome symptoms and usually require other treatment. Many of the initial women who had UFE have now been followed for three years and are still symptom free. Because the procedure has only been widely available since 1997, we do not have longer follow-up on these women yet.

About 25,000 women worldwide have had UFE performed for uterine fibroids. To date, the procedure has been extremely safe. The Society of Interventional Radiology reports only four deaths from this procedure or 1 out of every 6,000 women who have had UFE. For comparison, the risk of dying from surgery or anesthesia for a hysterectomy is about 2 out of 6,000 women. Risks for an individual are related to your medical condition, your age, and the disease for which you are being treated. Comparing risks of UFE to hysterectomy for women of similar age and condition with fibroids, it appears that the serious risks may be slightly lower with UFE.

I am including an abstract of a recent and large UAE study:

The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids.

Authors: Pron G, Bennett J, Common A, Wall J, Asch M, Sniderman K; Ontario Uterine Fibroid Embolization Collaboration Group.

Fertil Steril. 2003 Jan;79(1):120-7.

OBJECTIVE: To evaluate fibroid uterine volume reduction, symptom relief, and patient satisfaction with uterine artery embolization (UAE) for symptomatic fibroids.

DESIGN: Multicenter, prospective, single-arm clinical treatment trial.

SETTING: Eight Ontario university and community hospitals.Five hundred thirty-eight patients undergoing bilateral UAE.

INTERVENTION(S): Bilateral UAE performed with polyvinyl alcohol particles sized 355-500 microm.

MAIN OUTCOME MEASURE(S): Three-month follow-up evaluations including fibroid uterine volume reductions, patient reported symptom improvement (7-point scale), symptom life-impact (10-point scale) reduction, and treatment satisfaction (6-point scale).

RESULT(S): Median uterine and dominant fibroid volume reductions were 35% and 42%, respectively. Significant improvements were reported for menorrhagia (83%), dysmenorrhea (77%), and urinary frequency/urgency (86%). Mean menstrual duration was significantly reduced after UAE (7.6 to 5.4 days). Improvements in menorrhagia were unrelated to pre-UAE uterine size or post-UAE uterine volume reduction. Amenorrhea occurring after the procedure was highly age dependent, ranging from 3% (1%-7%) in women under age 40 to 41% (26%-58%) in women age 50 or older. Median fibroid life-impact scores were significantly reduced after UAE (8.0 to 3.0). The majority (91%) expressed satisfaction with UAE treatment.

CONCLUSION(S): UAE reduced fibroid uterine volume and provided significant relief of menorrhagia that was unrelated to initial fibroid uterine size or volume reduction. Patient satisfaction with short-term UAE treatment outcomes was high.

Are You a Good Candidate for Embolization?

Embolization is still a relatively new procedure, and selecting the appropriate women who will clearly benefit from UFE is still a work in progress. There remains some difference of opinion among interventional radiologists, and even more differences between gynecologists and interventional radiologists, as to which women should have the procedure. If shrinking the fibroids to a little more than half their present size would relieve your symptoms, then UFE may be right for you.

However, UFE may not be very helpful for women with extremely large fibroids because they may not shrink enough to make a significant difference in the symptoms. Women with fibroids on a stalk outside the uterus, called pedunculated fibroids, should not have UFE. Embolization can cause the stalk to deteriorate and allow the fibroid to float around the abdominal cavity. The dead tissue causes an inflammation inside the abdomen resulting in pain and fever. Surgery may be required to remove the degenerating fibroid. Fibroids that mostly bulge inside the uterine cavity, submucus fibroids, may also detach and float inside the uterine cavity after embolization. The uterus will then cramp and contract to expel the fibroid. Discharge and blood may accompany this process, and sometimes infection develops. If the fibroid is not expelled, surgery may be needed to remove it.

What Is Post-embolization Syndrome?

Following UFE, some women may develop fever, increasing rather than decreasing pelvic pain, and a vaginal discharge. This combination of symptoms is called post-embolization syndrome. Many of these women will also experience nausea and exhaustion. The symptoms may last for days or even weeks and cause concern because of the possibility that serious infection is present in the uterus. If the symptoms get worse over time, rather than better as would be expected, then an examination and evaluation for infection is important. Post-embolization syndrome will resolve over time, even if it takes a few weeks. However, if infection is present in the uterus, hysterectomy is usually necessary to prevent the spread of a very serious infection throughout the body. This infection, called sepsis, has led to the deaths of 2 women (out of 25,000) following UFE. Good communication between the gynecologist and interventional radiologist will be helpful to differentiate between post-embolization syndrome and infection.

What Are the Long-Term Risks of UFE?

Uterine fibroid embolization was first performed to shrink fibroids in 1995 and has only been widely available since 1997. For that reason, there is presently no long-term follow-up information. However, since embolization has been used for a long time for other reasons, we do know that it is very safe. There have not been any allergic reactions to the particles. Also, there is no evidence, or even any reason to believe, that embolization could cause cancer of the uterus.

Some women worry that the particles will travel to other parts of the body during the procedure or at a later time. Misembolization, particles traveling during the procedure, is discussed below. After the procedure, the particles become embedded into the vessel wall by scar tissue and do not travel in the bloodstream. After about six weeks, the blood vessels open back up and start supplying blood to the uterus again. Since the fibroids have already died off, they do not grow back again.

Childbirth after embolization is now viewed with caution. We know that women who have had embolization of the uterus for hemorrhage following childbirth have been able to safely have more children. However, those women have not had embolization for fibroids, a somewhat different situation. Fibroids are an integral part of the uterine wall, and embolization destroys them. Therefore, the strength of the remaining tissue is uncertain. Hopefully, further study will clarify whether childbirth is safe after UFE.

What Is Misembolization?

The particles that are used for embolization are very small, about the size of a grain of sand. In a few instances, the particles have been noted to travel through blood vessels to areas other than where they were intended to go. We call particles ending up in the wrong place non-target embolization, or misembolization. We do not know how often this happens, but it appears to be uncommon.

In an attempt to avoid these complications, many interventional radiologists are paying close attention to the pattern of the blood vessels in the pelvis for every patient, noting that the path of the vessels can be different from woman to woman. An attempt is made to avoid vessels going anywhere other than the uterus. However, the vessels supplying one area may interconnect with the vessels of another area. If this is the case, it may be difficult to completely avoid particles going to other areas. In over 25,000 women having UFE to date, serious misembolization has only been reported in a very few.

Can UFE Affect Fertility?

The answer is maybe. Misembolization, or particles travelling to unintended areas as described above, may rarely block off blood flow to the ovaries and interfere with the function of the ovaries. In addition, in about 10 percent of women, the main blood vessels supplying the ovaries start as a branch from the uterine artery. If the uterine artery is blocked, the blood supply to the ovaries is also blocked, and the ovaries cease functioning. Following embolization, in about 5 percent of women, the ovaries stop functioning, and early menopause follows. While this is never a good thing at any age, it is devastating for a twenty-five-year-old woman who wishes to have children.

Another unanswered question is whether the age of menopause will be affected in women who have UFE. If misembolization allows particles to block blood flow to some eggs, those eggs may die. The ovaries have many eggs, and the surviving eggs may continue to produce some hormone even if lots of other eggs have been destroyed. Hormone tests during this time may appear normal. However, if fewer eggs than normal remain in the ovaries, both eggs and the hormones they produce may be depleted before normal menopause is expected, around age fifty-two. We do not know whether any women who have had UFEs are destined to enter earlier menopause. This question will take many years to answer.

The problem of early menopause has been seen after hysterectomy in some women. If the blood vessels supplying the uterus also have a branch as the main supply to the ovaries, then suturing the uterine arteries during the hysterectomy will destroy the ovaries. Myomectomy, which does not disturb the uterine or ovarian blood vessels, has not been found to cause this problem.

Pregnancies and healthy babies have been born to women who have had UFE. However, we do not know how many women tried to get pregnant and were unsuccessful. We do not know how many had a miscarriage. To date, no cases of rupture of the uterus during pregnancy or labor have been reported following UFE. However, since the number of women getting pregnant after UFE is very small, we do not know what the risk really is. As a result of all this uncertainty, most interventional radiologists recommend that women who wish to have children not use UFE as treatment for their fibroids.

Are There Surgical Techniques That Mimic UFE?

There has been a bit of discord between some gynecologists and interventional radiologists over UFE as treatment for fibroids. Some of this disagreement is medical-an honest debate about which women will benefit most from UFE instead of myomectomy or hysterectomy-and some of the disagreement is self-interest and economics. Gynecologists recently created a surgical technique to tie off the uterine arteries (rather than block them with particles) using the laparoscope. So far, the first two years of results in a small number of women have been as good as those achieved with UFE. There may be advantages to the surgical approach, called laparoscopic uterine artery ligation, and there are some clear disadvantages. The current surgical approach requires an anesthetic and is an invasive procedure with the risks of any laparoscopy. However, the surgical approach only ties off the uterine artery, and since no particles are used, there is no risk of misembolization to other areas.

Laparoscopic uterine artery ligation may, theoretically, decrease the small risk of premature menopause that accompanies UFE. If, however, some women have a branch of the uterine artery as the only blood supply to the ovaries, then surgical ligation of the uterine artery will cut off blood supply to the ovaries, and the result will be early menopause for these women. A variation of this surgical technique that is being developed blocks the uterine artery though a small vaginal incision and does not require general anesthesia, and thus avoids some risk. It is still too early to tell whether there will be any long-term differences between these techniques, so you will need to ask your doctor about new results as they are published.

How Do You Find a Doctor to Perform UFE?

Interventional radiologists, M.D. sub-specialists in the field of radiology, perform uterine artery embolization. Interventional radiologists are not only trained to interpret X-rays, but they take three years of special training and are certified to place catheters into blood vessels to deliver medications or, in these cases, particles to block blood flow. As is true for gynecologists and gynecologic surgery, some interventional radiologists have more experience with UFE than others. You need to ask the same questions you would ask of your surgeon: How many of these procedures have you performed? How many in cases similar to mine? How many complications have you had, and what was the extent of those complications?

The other important issue to consider is whether UFE is right for you in the first place. Unfortunately, interventional radiologists are not trained in gynecology, and there may be other less invasive treatments available to treat your symptoms. It might be best to get a second opinion from a gynecologist in addition to an opinion from an interventional radiologist before choosing treatment. UFE has been performed on women who were not appropriate candidates for the procedure and who would have been better off with another type of treatment. Hopefully, in the future, more gynecologists and interventional radiologists will work together to help guide women to treatment options that are right for them without regard to monetary gain or other self-interests.

Can Focused Ultrasound (MRgFUS) be Used to Treat Fibroids?

Ultrasound uses high-frequency energy in the form of sound waves. This energy can be focused on a single point inside a woman’s body (for instance on a fibroid) so that the heat created by the energy destroys fibroid cells. This is like focusing a lens to burn a hole in a leaf. And just as you can pass your hand above the leaf without feeling any heat because the energy is not focused there, the ultrasound energy can pass through the body without harming it until it gets to the focal point in the fibroid. MRI is used to focus the ultrasound waves, hence the term MRgFUS (Magnetic Resonance guided Focused Ultrasound).

Focused Ultrasound

Still in early development, focused ultrasound is a non-invasive alternative to treat some women with fibroids. The advantages of focused-ultrasound are very low risk and very rapid recovery, with return to normal activity in one day. Presently, the procedure is not recommended for women wishing future fertility because no women have become pregnant after the procedure and the safety of pregnancy after MRgFUS is not known.

In published studies, the FDA limited the area treated to about 10% of the fibroid size, and women had only a 15% reduction in fibroid size 6 months after treatment. Two years after treatment there was only a 4% reduction in fibroid size. Six months after treatment 71% of women had fewer symptoms, but at the end of a year only about 50% still had less bothersome symptoms and 23 of 82 women (28%) had chosen to have a hysterectomy, myomectomy or UAE. One woman had an injury to her sciatic nerve due to ultrasound energy and 5% of the women had minor skin burns. Once the FDA allows larger areas to be treated, we would expect to see greater success, but we will also need to see whether there will be increased risks. Hopefully, as the technology improves, MRgFUS will be another proven alternative for women with symptomatic fibroids.

Chapter 16

Fibroid Treatment Options Based on your Symptoms

Fibroid Treatment Options at a Glance

There is usually more than one type of treatment available for each fibroid problem. It is important for each woman to make a decision about which treatment is right for her.

Things to consider:

1. What symptoms do you have and, do the symptoms interfere with your quality of life?

2. What are your wishes about future childbearing?

3. What is the likelihood that a treatment will be successful FOR YOUR SPECIFIC SITUATION?

4. What are the possible risks, the expense, the recovery time including time away from work or family?

5. What are your opinions about each of the treatment options appropriate for you?

6. Are you able to find a doctor who can skillfully provide the treatment option you wish? If you are knowledgeable about the treatment options, either your present doctor has the skills to perform them, or should refer you to a gynecologist who has the necessary skills.

Depending on your symptoms and medical situation, the treatment options may include:

1. Watchful waiting

2. Medication, including the progesterone-IUD (Mirena)

3. Surgery

1. Endometrial ablation

2. Hysteroscopic myomectomy

3. Laparoscopic myomectomy

4. Robotic myomectomy

5. Abdominal myomectomy (bikini incision)

6. Hysterectomy (removal of uterus)

1. Laparoscopic hysterectomy (without or with removal of cervix)

2. Vaginal hysterectomy

3. Abdominal hysterectomy (bikini incision)

4. Uterine Artery Embolization (UAE)

5. Focused Ultrasound (MgFUS)

The following general guidelines should be discussed with your doctor.

For a woman with no bothersome symptoms and who wishes to maintain her fertility

The effect of fibroids on your fertility usually depends on whether or not the fibroids change the shape of the uterine cavity. Therefore, it is important to have a test to “examine” the cavity.

Any of these tests are considered accurate:

1. Ultrasound with fluid inserted inside the cavity (called saline-infusion-sonography or sonohysterogram).

2. Hysteroscopy (telescope to look inside the cavity), usually performed in the office.

3. Pelvic MRI. Studies show this to be the most accurate way to examine the uterine cavity, and it will accurately show other fibroids.

If the cavity is misshapen by the fibroids, removal of the fibroids by hysteroscopic myomectomy or abdominal myomectomy is usually necessary to improve fertility. Laparoscopic or robotic myomectomy can be offered by experienced laparoscopic surgeons.

If the uterine cavity is not misshapen by the fibroids, you usually would not need to be treated and you can try to get pregnant.

For a woman with no bothersome symptoms and who is not interested in future fertility

1. Watchful waiting should be considered. I usually like to see these women at least twice a year to evaluate any changes in their symptoms or change in the size of the fibroids.

For a woman with bothersome symptoms who desires future fertility

1. If your main symptom is abnormal bleeding,

1. A blood count (hemoglobin or hematocrit) is helpful to make sure anemia is not present.

2. If you have irregular bleeding, an endometrial biopsy or D&C can be performed to make sure there are no abnormal cells.

3. The shape of the uterine cavity can be checked with saline-infusion sonography, hysteroscopy or MRI (the most accurate method). This information can help determine the appropriate treatment options.

4. If the cavity is misshapen, myomectomy (hysteroscopic or abdominal) should be considered.

1. Laparoscopic or robotic myomectomy can be offered by an experienced laparoscopic surgeon.

2. If the main symptom is pain or pressure (called bulk symptoms)

1. If the uterine cavity is not misshapen:

1. Abdominal myomectomy can be considered.

2. Laparoscopic or robotic myomectomy can be offered by an experienced laparoscopic surgeon.

2. If the cavity is misshapen:

1. Abdominal myomectomy should be considered.

2. Laparoscopic or robotic myomectomy can be offered by an experienced laparoscopic surgeon.

For a woman with bothersome symptoms who is not interested in future fertility

1. Watchful waiting can be considered if you do not want treatment for symptoms now. If you are close to menopause (the average age is 52), then you can consider watchful waiting until menopause, when symptoms usually diminish.

2. If irregular bleeding is present, evaluation of the uterine lining cells with ultrasound or endometrial biopsy or D&C is a good idea to make sure no abnormal cells are present.

If the lining cells are normal, treatment options may include:

1. a progesterone-IUD (Mirena)

2. oral contraceptive pills

3. hysteroscopic myomectomy and/or

4. endometrial ablation.

5. Myomectomy

1. abdominal

2. laparoscopic

3. robotic

6. Hysterectomy

1. vaginal

2. abdominal

3. laparoscopic

7. Uterine Artery Embolization

8. Focused Ultrasound (MgFus)

If you have discomfort due to fibroids (bulk symptoms), treatment options may include:

1. Myomectomy

1. Laparoscopic

2. Abdominal

2. Hysterectomy

1. Laparoscopic

2. Vaginal

3. Abdominal

3. Uterine artery embolization

4. Focused ultrasound (may be limited by size and number of myomas)

If you do not have a family history of ovarian cancer and you choose hysterectomy, you should consider keeping your ovaries. Recent studies show that the beneficial effects of ovarian hormones, both before and after menopause, on the heart, brain and over-all health may outweigh the small risk of ovarian cancer for women without a family history of ovarian cancer.

Very, Very Unusual Situations

If there is concern that the uterus may be compromising the ureters, you can have a kidney ultrasound or x-ray (IVP) to make sure there is no damage to the kidneys. If there is very rapid growth of the uterus, you can have a special timed MRI with dye and a blood test for an enzyme called LDH. (link)

Chapter 17

Adenomyosis

Adenomyosis is a non-cancerous condition of the uterus that can mimic many of the signs and symptoms of fibroids. This condition results from the lining cells of the uterus growing directly into the muscle wall of the uterus. When the lining cells of the uterus bleed at the time of the menstrual period, these misplaced cells in the muscle bleed as well. And bleeding directly into the muscle causes pain. As the blood accumulates, the surrounding muscle swells and forms fibrous tissue in response to the irritation. This swollen area within the uterine muscle wall, called an adenomyoma, feels very much like a fibroid on examination and is often confused with a fibroid on a sonogram. Adenomyosis may be mild and cause no symptoms at all, or, in more severe forms, it may lead to heavy bleeding and severe cramping during menstrual periods. Adenomyosis is present in about 10 percent of women and, therefore, is less common than fibroids.

How Is the Diagnosis of Adenomyosis Made?

The diagnosis of adenomyosis is suspected if the uterus feels enlarged and tender to the touch during the pelvic examination. However, the diagnosis of adenomyosis based on these findings is often inaccurate, and other causes-fibroids, endometriosis, or polyps-are often found as the cause for the bleeding or discomfort. The diagnosis may be suggested by the appearance of the uterus on a sonogram, although it is often difficult to tell the difference between adenomyosis and fibroids using sonography. MRI is better at detecting adenomyosis, but the test is very expensive and rarely used for this purpose. Unfortunately, the only way to establish the diagnosis of adenomyosis with certainty is with surgery. Once removed, the tissue can be examined under the microscope, and the uterine lining cells can be seen within the muscle wall.

What Is the Treatment for Adenomyosis?

The medications Lupron or Synarel can cause cessation of the periods and associated menstrual cramping and even lead to shrinkage of the swelling associated with adenomyosis. However, the effect is temporary-when the medication is discontinued, the symptoms return. At the present time, the only treatment for adenomyosis is surgery. In situations where the adenomyosis is confined to isolated areas in the muscle wall, an attempt may be made to surgically remove these areas and repair the rest of the uterus. In situations where the majority of the uterus is affected, hysterectomy may be the only cure.

This woman’s uterus was enlarged as a result of adenomyosis.

Morcellation of the uterus shows glands and blood within the uterine muscle wall.

Can Uterine Artery Embolization Be Used to Treat Adenomyosis?

Only a small number of women with adenomyosis have been treated with uterine artery embolization (UAE), and the results so far have been disappointing. Symptoms appear to improve for a year or two, but most women then have recurrence of symptoms. Adenomyosis is defined as the presence of uterine lining cells within an otherwise normal uterine muscle wall. The blood supply to that muscle is normal, unlike fibroids, and should be resistant to the effects of embolization. Again, further research will be needed to see if better results can be obtained.

Treating Adenomyosis with the Progesterone IUD

Adenomyosis has been a frustrating disease to treat; medical treatment with oral progesterone or birth control pills often does not work and uterine artery embolization often fails. Hysterectomy is the only treatment known to be highly (100%) effective. According to a recent study, the progesterone-containing IUD (Mirena) can help with menstrual cramping in about 70% of women. The IUD probably works because it slowly gives off progesterone directly to the lining cells in the uterus and in the uterine muscle wall. Progesterone causes the cells to shrink and produce less prostaglandin, the protein that causes cramping. The most common side effects from the IUD were weight gain (29%), benign ovarian cysts (22%) and lower abdominal pain (12%).If you have pain from adenomyosis, this IUD is probably worth considering.

Chapter 18

Resources

National Uterine Fibroids Foundation

http://www.nuff.org
The National Uterine Fibroids Foundation (NUFF) is a not for profit public benefit corporation organized to engage in charitable, educational and scientific activities related to the care and treatment of women who have uterine fibroids or related conditions of the reproductive system.

Uterine Fibroids E-Group on Yahoo!

http://health.groups.yahoo.com/group/uterinefibroids/
The Uterine Fibroids eGroup is sponsored by the National Uterine Fibroids Foundation and is an email and web based discussion group for individuals interested in researching and discussing all methods of alternative treatments for uterine fibroids.

Hope For Fibroids Organization

http://www.hopeforfibroids.org/
The Hope For Fibroids Organization is a non-profit organization created by a uterine fibroid patient and volunteers. The web site is a subscriber to the Health On the Net Foundation. There are nine Contributing Doctors on the web site, Gynecologists and Interventional Radiologists, who review all the medical information on uterine fibroids and pelvic pain gynecological medical conditions. The web site contains the following: FAQs, Insurance, Legislation, Comment Section, Media, Other Sources, Research, Highlights of Fibroid Fighters, translated in five languages, and much more.

OvaryResearch.com

http://www.ovaryresearch.com
Many women are told they need to also have their ovaries removed if they must have a hysterectomy. This has been a controversial issue for many years, but until recently most doctors recommended removal of the ovaries after about age 45. The reason for this was that removal of the ovaries would prevent women from developing ovarian cancer. However, the ovaries continue to produce hormones for many years after menopause and these hormones have many long-term health benefits, as well as benefits for improved mood, prevention of vaginal dryness, preservation of skin tone and elasticity.

The ovaries continue to produce estrogen in small amounts, and testosterone in normal amounts for about 30 years after menopause. Muscle, skin and fat cells change testosterone into estrogen, and this source of estrogen appears to be responsible for the lower risks of heart disease and osteoporosis that have been found in studies of women who still have their ovaries.

We recently published an article in the renowned journal Obstetrics and Gynecology that showed a lower risk of dying before age 80 if you choose to keep your ovaries at the time you have a hysterectomy. You can find the information here.

Chapter 19

Getting a Second Opinion

Should you get a second opinion?

If surgery has been recommended to you, I think a second (or even a third) opinion is an excellent idea. Very few things in medicine are black or white, and there is a lot of room for differences of opinion. In the present managed care medical environment, many doctors will not take the time to discuss your situation with you. And many have not taken the time to be trained in the new minimally invasive treatments available. For most doctors, if they do not know how to perform a procedure, they will not discuss or recommend it to you.

When a new patient comes to see me for a second opinion, we ask them to bring all the notes from previous doctor’s appointments and any test results that are relevant to the problem. If an ultrasound or MRI has already been performed, I like to look at the films myself so that I can come to my own conclusions about the diagnosis.

After a complete examination, we go back to my office to discuss the issues and answer any questions you might have. I often use illustrations to demonstrate what those findings are. At this point I make a list of one or more possible diagnoses and outline the treatments available for each problem. To be complete with this list, I usually include even those treatments I would advise against or those the patient has eliminated. Together we then go through the list and come up with a short number of options that are both medically sound and personally acceptable to the patient.

Family members or friends are welcome to join you and this is sometimes helpful to make sure all your concerns are addressed and to help you remember what is said. I usually suggest that you not decide on any specific course at the time of the first visit. I think these decisions are usually best made in the comfort of home, when there is time to think. Women are welcome to call me with any additional questions they might have.

What if you decide that surgery is right for you?

If you decide that surgery is right for your situation, you will need to choose the doctor to perform your surgery. There are a number of factors that should influence your decision. The first is to choose a doctor who will perform a procedure that fits your particular situation and problem. In most cases, you should have more than one option from which to choose.

The next concern is the skill of the surgeon. How many procedures does the doctor perform a month? How many procedures like the one you are requesting? How many of these procedures have they performed in women with problems like your? How many complications has the doctor had and what kind of complications were they? Studies show that experience makes a surgeon better. Surgeons who perform procedures frequently have lower rates of complications. But surveys show that many gynecologists perform less than one or two major operation a month. Choose your surgeon carefully.

It is also important to feel comfortable with your doctor. Do you get an opportunity to ask questions and are they answered? Is the doctor available by phone?

If you decide to have surgery, another visit should be set up with the doctor you have chosen to go over the specific details of the procedure you are to have performed. Again, it is nice to have someone accompany you. Once a decision has been made, we go over a paper called the “Informed Consent”. Filling out this form, if properly done, encourages a frank discussion of what you should expect from surgery. It allows the doctor and patient to go over the details of the operation to be performed, the specific risks of the procedure, the alternatives to the surgery, and the possible consequences if the surgery is not performed.

About Dr. Parker

Dr. William H. Parker is a board-certified Fellow in the American College of Obstetricians and Gynecologists. Dr. Parker has a private practice in Santa Monica, California and is a Clinical Professor at the UCLA School of Medicine. He has been chosen for Best Doctors in America and Top Doctors since the late 90′s.

Dr. Parker is former Chair of the Department of Obstetrics and Gynecology at Saint John’s Health Center. Dr. Parker was President of the American Association of Gynecological Laparoscopists, an international association of over 5,000 gynecologists from 63 countries, after serving on its Board of Trustees for many years. He is certified by the Accreditation Council of Gynecologic Endoscopy for both laparoscopic and hysteroscopic surgery. Dr. Parker was an Editor of The Journal of Minimally Invasive Gynecology and is now on its editorial advisory board.

Dr. Parker is a frequent lecturer and teacher of advanced surgical techniques both in the United States and abroad. He has published over 40 articles on his research in the areas of laparoscopic myomectomy, abdominal myomectomy, laparoscopic hysterectomy, ovarian cyst surgery, ovarian conservation and the care and treatment of women with fibroids.

Dr. Parker is author of the highly-acclaimed and best-selling woman’s health book, A Gynecologist’s Second Opinion: the Questions and Answers You Need to Take Charge of Your Health (Penguin/Plume). Dr. Parker received Santa Monica-UCLA Medical Center’s Distinguished Physician of the Year for his surgical expertise and compassionate patient care.

Dr. Parker is a graduate of Rutgers University (BA) and earned his medical degree from SUNY Downstate Medical Center in Brooklyn, New York, and he completed an internship and residency in Obstetrics and Gynecology at the University of California, San Diego.

Specialized Services

Advanced Gynecologic Surgery

- Laparoscopic Myomectomy

- Robotic Myomectomy

- Abdominal Myomectomy

- Hysteroscopic Myomectomy

- Laparoscopic Supracervical Hysterectomy

- Laparoscopic Hysterectomy

- Endometrial Ablation

- Laparoscopic Ovarian Surgery

Awards and Honors

William H. Parker, MD

Certifications

- Fellow, American Board of Obstetricians and Gynecologists, 1982

- Accreditation Council of Gynecologic Endoscopy, 1996 For Laparoscopy and Hysteroscopy

Awards

- Best Doctors in America – 1997-2011

- Top Doctors Book – 1997-2011

- 1998 – Distinguished Physicians Award Santa Monica-UCLA Medical Center

- 1987 – Senior Resident’s Teaching Award Santa Monica Hospital Family Practice Residency Program

Positions

Clinical Professor, 1995-Present
UCLA School of Medicine
Los Angeles , California

Chairman, Obstetrics and Gynecology, 2004-2008
Saint John’s Hospital and Health Center
Santa Monica , California

Chairman, Obstetrics and Gynecology, 1992-1999
Santa Monica-UCLA Medical Center
Santa Monica , California

Board of Directors, 2000-present
National Uterine Fibroid Foundation

President, 2000
American Association of Gynecologic Laparoscopists

Editor, 1997-2003
Journal of American Association of Gynecologic Laparoscopists

Editor, 2006-2008
Journal of Minimally Invasive Gynecology

President, 2009
Los Angeles Obstetrical and Gynecological Society

Consultant

The Rand Corporation, January 1997
Women’s Health and Hysterectomy Project

NIH Expert Panel on Fibroid Classification, 2007-2008

Foundation for Informed Medical Decision Making, Boston, Mass
Fibroids, Abnormal Bleeding – Benign Uterine Conditions

National Women’s Health Resource Center Women’s Health Advisory Council

OBGYN.NET, Medical consultant for:
- Laparoscopy and Hysteroscopy
- Hysterectomy and Alternatives

Invited Chair

NIH International Congress on Uterine Leiomyoma Research – 2010

New Patients are Always Welcome

Dr. Parker looks forward to seeing new patients in his practice. The practice is always open to admit newcomers, especially those seeking the specific expertise he has to offer for evaluation and treatment of women with fibroids, and those seeking his expertise in laparoscopic, hysteroscopic and general gynecologic surgery. For information on making an appointment, please visit http://www.fibroidsecondopinion.com/ or call (310) 451-8144.