Fibroids are non-cancerous tumors that grow in the fibroconnective tissue of the uterus, but there’s nothing benign about the emotions their treatment evokes. At stake are a woman’s fertility and, some argue, her femininity.

Even the United States government is taking an interest in fibroids. Three United States Senators co-sponsored legislation last spring that asks for $10 million a year for four years in research funding through the National Institutes of Health, plus an educational campaign.

Fibroids are common, affecting between 25 percent and 50 percent of women over age 35. Although it’s been widely reported that African-American women have a greater incidence of fibroids, the current data may not support that belief, says Dr. Gerson Weiss, professor and chair of obstetrics, gynecology and women’s health at New Jersey Medical School. “What we do know is that African-American women have more sizable fibroids and are more likely to have surgery.”

For many women with fibroids, the benign tumors are not a problem. They have no symptoms, and the fibroids frequently are first discovered by the doctor during a routine pelvic examination. A follow-up ultrasound indicates their size and location. These estrogen-fed tumors will naturally shrink in size during menopause, so if the woman is not experiencing symptoms, the course of treatment is to leave the fibroids alone.
Fibroids typically develop on the outside of the uterus (subserous), the inside (submucous), or within the uterine wall (intramural). Their location is one factor that influences which treatment is recommended. Click on image to enlarge.
Then there’s the flip side. The size, location, and number of fibroids can make a woman’s life sheer agony. She can have heavy, lengthy menstrual periods, so severe that the blood loss can lead to anemia and hemorrhage. Other symptoms include pelvic pain or pressure, frequent urination, and constipation. Fibroids can make it difficult for a woman to become pregnant by interfering with implantation of the egg in the uterine lining. They can also contribute to premature birth.

Fibroids typically develop on the outside of the uterus (subserous), the inside (submucous), or within the uterine wall (intramural). Their location is one factor that influences which treatment is recommended.

New Choices for an Old Problem

Many years ago, the standard treatment for symptomatic fibroids was hysterectomy, the surgical removal of the uterus. Even today, fibroids are the number one reason for hysterectomy; in 2001, more than 200,000 fibroid-related hysterectomies were performed. Hysterectomy offers a permanent solution-no more uterus, no more fibroids-that is sometimes a good choice for women whose families are complete or who are past the childbearing years. Still, hysterectomy is a major surgery that carries risks, such as post-operative bleeding and fever, and has a recovery period of about eight weeks. Some women who have had a hysterectomy report a decrease in sexual function; others state no difference.

“There are strong feelings on either side of hysterectomy,” says Dr. Weiss. “For some women, it’s a non-issue. Their mothers had a hysterectomy and did well, and they don’t have a problem with it. Others say, ‘I was born with a uterus, and I want to keep it.’”

For women seeking alternatives to hysterectomy, several uterine-conserving treatments have emerged or become more commonly offered over the past few years.

A group of synthetic hormones, GnRH agonists, such as Lupron, suppress the production of estrogen, thus reducing the fibroids’ size. “This treatment is useful when surgery needs to be delayed; for example, a teacher wants to have her surgery in the summer, but she is experiencing debilitating symptoms in spring. A smaller-sized fibroid typically produces fewer symptoms and can be easier to remove,” says Dr. Weiss. However, once the medication is stopped, the fibroids grow back. GnRH agonists shouldn’t be used for an extended time, he cautions, as they can produce hot flashes and cause thinning of the bones.

Gynecologists can perform a myomectomy, a surgery in which the fibroids are removed and the uterus stays intact. “The 50-year-old woman who’s completed her family might be an ideal candidate for a hysterectomy, but because she wants to keep her uterus, she has a myomectomy,” says Dr. Weiss. Although myomectomy preserves the uterus, fibroids can reoccur, and fertility might be impacted by scar tissue that forms within the uterus. Fibroids return in up to half the women who have myomectomy, Dr. Weiss says, with 15 percent needing a repeat procedure.

There are three ways to gain access to the fibroids via myomectomy, and the choice ultimately is determined by the tumors’ location and size. If the fibroids protrude into the uterus, the doctor can insert a hysteroscope (a flexible, thin instrument with special attachments) through the woman’s vagina and cervix to remove the growth. The hysteroscopic myomectomy is usually an outpatient procedure.

When fibroids are no bigger than 5 centimeters and located on the outside of the uterus, a laparoscopic myomectomy can be considered, says Dr. Weiss. A thin, telescope-like instrument with a tiny camera is inserted through a small incision near the navel, enabling the doctor to view the area on a screen in the operating room. The laparoscope also has surgical tools attached to facilitate the removal of the fibroids. Laparoscopic myomectomy is less invasive than the traditional “open” procedure and has a shorter recovery time, which can be attractive to the patient. But the availability of the procedure doesn’t mean it is always necessary, believes Dr. Weiss. “It raises a major question: If the fibroids are that size, are the symptoms bad enough to warrant treatment?”

Abdominal myomectomy, the “open” procedure, is a major surgery that can be complex and sometimes result in significant blood loss. “Hysterectomy is a straightforward procedure. Myomectomy is more of a puzzle with a lot of variables, and the pieces are put together during the surgery,” says Dr. Weiss.

Traditionally, myomectomy has a blood transfusion rate between 3 percent and 20 percent, but there are techniques doctors can use to minimize blood loss. “Before surgery, whether a myomectomy or a hysterectomy, if the patient is anemic due to heavy vaginal bleeding, we need to build up her blood count. GnRH agonists stop menstrual cycles in most women, enabling the blood count to be built up with iron supplementation,” says Dr. Winsome Parchment, an obstetrician/gynecologist at University Hospital and an assistant professor of obstetrics, gynecology and women’s health at New Jersey Medical School. “The limiting factors are cost and the side effects. Depo Provera injections are cheaper but can cause breakthrough bleeding.”

At University Hospital, whose bloodless program enrolls about 500 patients each year, there’s a belief that the techniques used to minimize blood loss are also good medical practice. There are several blood-conserving tactics that can be used with myomectomy, says Dr. Parchment. A vasoconstricting substance, vasopressin, can be injected into the uterus, and a tourniquet can be placed at the lower uterine segment to occlude the uterine arteries. The patient’s own blood can be returned to her through cell-saver technology, and if there is severe hemorrhaging, the utero-ovarian ligament can be clamped. One possibility that Dr. Parchment discusses with her patients before surgery, however remote, is hysterectomy in the event of a life-threatening loss of blood.

When Radiologists Intervene

Often in medicine, an established technique gets applied in a new way. That’s the case with uterine fibroid embolization (UFE), a variation of uterine artery embolization, a technique used by interventional radiologists to curtail excessive bleeding after childbirth or following trauma.
UFE is a non-surgical, uterus-preserving treatment that blocks the blood supply to fibroids, causing them to shrink. Before consulting with an interventional radiologist, the patient undergoes tests and is examined by her gynecologist to ensure that fibroids are the source of her problems. “The woman must meet an established criteria regarding the fibroids’ size and other factors before she is considered as a candidate for UFE,” says Dr. Phillip Bahramipour, chief of interventional radiology at University Hospital and assistant professor of radiology at New Jersey Medical School.

During UFE, a catheter is inserted in the woman’s groin and threaded through her femoral artery and to her uterine artery. Once the catheter is in place, the interventional radiologist releases tiny, polyvinyl alcohol particles to the vessels leading to the fibroid. The particles cut off the blood supply to the fibroids. UFE typically takes between 1 and 2 hours to complete, with an overnight hospital stay.

UFE is not major surgery, the uterus is preserved, and abnormal bleeding from the fibroids is reduced significantly. However, UFE is relatively new, with only about 8,600 procedures done in the United States; it has been performed for about five years at University Hospital, one of the few hospitals in northern New Jersey to offer the procedure. The FDA and other major health organizations generally describe UFE as promising, but more studies need to be done on its safety, efficacy, and effect on fertility. Some risks of the procedure include infection, injury to the uterus that might require a hysterectomy, passage of fibroid tissue, and death; these complications are rare, researchers say, occurring about 4 percent of the time.

There’s also the question of UFE’s effect on fertility. “Whether or not UFE affects a woman’s fertility is a source of debate,” says Dr. Bahramipour. “It can, however, cause periods to temporarily stop, or, for a woman who is nearing menopause, send her into an early menopause.” This suggests ovarian damage, which clearly can decrease fertility. It is hypothesized that a decrease in blood supply to the ovaries following UFE could contribute to the cessation of menstrual periods. However, women have had babies following UFE, also.

Making the Right Choice

With expanded options for fibroid patients, decision-making can be more complicated than before. The standard advice applies--research the options, find out how experienced the doctor is with a certain procedure, and seek a second opinion, if needed. But when fertility and femininity come into the picture, the issues are deeper and might take some soul searching.

“There’s no one-size-fits-all approach to fibroid treatment,” says Dr. Weiss. “It’s a very personal decision.”

For more information about treatment for fibroids, call (973) 972-2700.