Fibroids

Fibroids

Taking Action
Isn't Always Necessary

You feel bloated, your back aches, and you have a period that won't quit. You drag yourself into your doctor, who finds that your heart's okay, your lungs are fine, and your blood pressure's terrific.

Then she does a pelvic exam.

"Bingo," you hear from the other end of the stirrups. She presses down on your uterus, up from the vagina, then renders her verdict. "Yep--it's a fibroid. Not too big. It has your uterus pushed out to about the size of a nine-week pregnancy."

She strips off her gloves. "Sit up, and we'll talk about what we're going to do."

It's a common scenario. At some point in their lives, 60 percent of American women will have fibroids, which are benign tumors. Fibroids begin as tiny clumps of muscle cells that grow from inside, outside or within the uterine wall.

The problem is that fibroids can make us old before our time. They can tear up the lining of the uterus and can grow big enough to put pressure on the bowel, the bladder and the tubes that lead from the kidneys to the bladder--all which can lead to infertility, incontinence, kidney damage, constipation, chronic pain and hemorrhoids.

Watch and Wait

What causes fibroids is still something of a mystery, doctors say.

Fibroids usually occur during a woman's fertile years, after her first period and before menopause, because they thrive on her supply of estrogen. They're most common in pregnant and overweight women and in those who take the types of birth control or hormone replacement pills that expose women to higher levels of estrogen.

But aside from the observation that they seem to run in families, nobody has a clue as to their cause.

"They're always benign," says Alvin F. Goldfarb, M.D., director of education for obstetrics and gynecology at Jefferson Medical College of Thomas Jefferson University in Philadelphia. "They may undergo malignant changes, but the development of a malignant tumor is rare. So in most instances, if the fibroids don't cause symptoms, nothing need be done."

What kinds of symptoms require action? "Backaches, constipation, pressure on the bladder causing frequency and urgency of urination or a uterus larger than a 10- to 12-week pregnancy," replies Dr. Goldfarb. All may indicate the onset of bladder, bowel and kidney problems spurred by the fibroids.

Fibroids also require action if you begin to bleed excessively during your period, if you bleed between periods, if your gynecologist detects a sudden growth spurt in the fibroids between routine exams or if they affect reproduction either by preventing implantation of a fertilized egg or by causing repeated miscarriages, says Dr. Goldfarb.

Weighing Your Options

Fortunately, only half of women who get fibroids experience any symptoms severe enough to require treatment. Here's what doctors recommend when women do.

Starve them. Your doctor can prescribe gonadotropin-releasing hormone (GnRH), which may decrease the size of fibroids by 50 percent. It shuts down production of the ovaries' estrogen, thus depriving the fibroids of what for them is a steady supply of Miracle-Gro.

But women who take GnRH must understand that when the hormone therapy stops, the fibroids will grow back, cautions Mary Lake Polan, M.D., Ph.D., professor and chairman of the Department of Gynecology and Obstetrics at Stanford University School of Medicine in California. And no one should take the hormone alone for more than six months, because it can cause osteoporosis. There are other therapies that combine GnRH initiators with estrogen and/or progestin, a synthetic form of the hormone progesterone. This allows women to use GnRH therapy for years, says Dr. Polan.

One appropriate time to use GnRH is when a woman is close to menopause, says Dr. Polan. It can shrink the fibroids and keep them small until they naturally disappear at menopause.

Consider removal. If you want to protect your fertility, you may need to have the tumors removed. The operation is called a myomectomy and is done two ways, Dr. Goldfarb says.

In a laparoscopic procedure, a couple of tiny incisions are made in the abdomen. In one incision, a laparoscope, a tiny instrument used to view the inside of the body, is inserted; in the other, a laser is inserted. The doctor locates the fibroids and zaps them with the laser. Another surgical instrument removes the debris.

This is the procedure that younger doctors are inclined to use, because it's more modern, adds Dr. Goldfarb. It's less invasive than other options, and it does a great job as long as the fibroids aren't large.

Dr. Goldfarb suggests that women considering this procedure make sure their doctors are well versed in it. He says you should ask your doctor how many laparoscopies she performs annually. Aim for a doctor who does at least 50 a year, Dr. Goldfarb says.

The second procedure is an operation in which the entire abdomen is opened up and the fibroids are surgically removed. The surgery is more invasive and requires a longer recovery time.

Dr. Goldfarb advises that whether the fibroids are removed by laser surgery or by an open operation, you should always discuss with your doctor the possible complications of either procedure.

Discuss the possibility of hysterectomy. If your tumors are very large, you may have to have a hysterectomy. And often a doctor won't know you need that until a myomectomy is under way, Dr. Goldfarb says.

"I've done many myomectomies where I've taken off as much as four to seven pounds of tumor and saved the uterus, and the women have gone on to have babies," Dr. Goldfarb says. "But you can never guarantee anything until you're in there. If you're my patient, I'll tell you up front: If you have huge tumors and I can't take them off, I want permission to do a hysterectomy."

Before a myomectomy, ask your doctor about the possibility of a hysterectomy and the repercussions of this surgery. Tell her whether or not you would want this procedure.