Fibroids

Fibroids

Growths You Can Live with--Or Without

Many of us have fibroids, and unless they're big enough to require removal, most of us don't even know it. Some experts say 50 percent of women of childbearing age have fibroids of one size or another.

Fibroids are benign growths that arise from the muscle tissue of the uterus. They sometimes grow within the uterine wall itself, causing a general enlargement of the uterus. They can also project into the uterine cavity or extend outward into the abdominal cavity. They may hug the wall of the uterus or grow on threadlike stalks. They may show no symptoms at all or cause severe pain, bleeding and permanent damage to other organs. Treatment of fibroids is the number one reason for hysterectomy in the United States today.

As far as medical science knows, absolutely nothing can be done to prevent fibroids, says Francis L. Hutchins, Jr., M.D., director of gynecology and women's services at Graduate Hospital and clinical associate professor of gynecology at Hahnemann University Hospital and Thomas Jefferson University Hospital, all in Philadelphia. Dr. Hutchins says numerous therapies--including diet and vitamin regimens and homeopathic and naturopathic remedies--have been tried, but so far none has been substantiated as a way to prevent fibroids.

The Estrogen Connection

There is no question that estrogen causes fibroids to grow, according to Dr. Hutchins. The estrogen connection means that women are most susceptible to fibroids during their reproductive years, when their systems are pumping estrogen. In addition, some fibroids grow faster and larger during pregnancy or when a woman takes birth control pills. African American women develop fibroids at a rate about three times that of other women--again, nobody knows why.

A few studies have linked fibroids to excess weight, although the exact relationship is unclear. Fatty tissue converts androgen hormones into estrogen, leading to higher-than-normal levels of estrogen in overweight women.

Even the rate of growth of fibroids is unpredictable. "In the women we're talking about--mostly between ages 19 and 50--fibroids appear to grow at varying rates. Nobody has successfully defined the normal rate of growth of fibroids," says Dr. Hutchins. What is certain is that fibroids do grow--little ones become big ones, and the potential for painful, debilitating symptoms increases.

The good news is that fewer than half of all women who have fibroids experience symptoms. When they do, the most common signs are abnormal menstrual flow and pain. Bleeding sometimes is so heavy and prolonged that anemia results. Pain can range from a feeling of pelvic pressure or heaviness to discomfort during intercourse. Sometimes fibroids grow so fast that they outstrip their blood supply and shrivel up, causing severe pain.

Other, less common complications occur when the fibroids put pressure on surrounding organs. "Even though they're benign, fibroids can get big enough to cause real problems, particularly if they compress the ureters, the tubes leading from the kidneys," according to Julia V. Johnson, M.D., assistant professor of obstetrics and gynecology at the University of Vermont in Burlington. The compression can do permanent damage. Dr. Johnson says a uterus enlarged by fibroids may also press on the bladder, causing frequent urination, or on the rectum and colon, resulting in constipation.

When Surgery May Help

When symptoms compromise quality of life or pose a danger to health, surgery is often the only solution. "If a woman is 25 years old and already has very large fibroids, it's unlikely she's going to make it through her reproductive years without having to have surgery," says Dr. Johnson. "On the other hand, if a woman is 49 years old and her uterus is not too large or she has mild symptoms but nothing else, she may want to wait, because the fibroids are going to shrink when she goes through menopause."

Surgical options include hysterectomy or myomectomy, a less drastic procedure in which only the fibroids--not the uterus--are removed. A myomectomy can be performed in a variety of ways, through an abdominal incision or using the newer techniques of hysteroscopy or laparoscopy. With hysteroscopy, the fibroids are removed with small instruments inserted into the uterus through the cervix. With laparoscopy, they are removed with tools inserted through a tiny slit in the abdomen. An even newer technique, laparoscopic myolysis, destroys the fibroid with electricity.

The disadvantage of myomectomy is that it requires more specialized training to perform than a hysterectomy. In addition, fibroids have a recurrence rate of about 15 to 30 percent. But it should be noted that the majority of women with recurrences won't require further surgery.

Key to the decision on which procedure to have is whether you wish to keep your uterus. If so, myomectomy would be the choice to discuss with your doctor.

Hysterectomy used to be the operation of choice for many doctors caring for patients with fibroids. In recent years, however, a growing number of doctors--perhaps spurred by greater health-care activism on the part of their women patients--have jumped off the hysterectomy bandwagon. Hysterectomy and oophorectomy--in which the uterus and ovaries are removed--plunge a woman into instant menopause, with all its symptoms and the need for estrogen replacement therapy. In addition, many women report depression, fatigue and decreased sexual desire after hysterectomy.

Dr. Hutchins believes doctors should not be so quick to advocate hysterectomy. "In every other area of medicine, we practice what is referred to as 'preservation of tissue,' so to sacrifice the organ when you could easily save it with no significant risk to the patient is inappropriate," he says.

Fibroids and Pregnancy

Pregnancy may be complicated by fibroids, says Ruth Schwartz, M.D., clinical professor of obstetrics and gynecology at the University of Rochester School of Medicine and Dentistry in New York. "If fibroids poke into the endometrial cavity, that can cause miscarriage. If they're in the lower portion of the uterus, they can get large and obstruct delivery of the baby; some may cause preterm labor." Occasionally, fibroids grow rapidly during pregnancy and deteriorate, becoming acutely tender and painful. "Some women need pain medication," says Dr. Schwartz, "but we try to wait it out until it quiets down--very few fibroids are operated on during pregnancy because of the potential for excessive bleeding."

Dr. Schwartz cautions that a woman who wants to get pregnant shouldn't necessarily have fibroids removed ahead of time. "Many women with fibroids successfully go through pregnancy, so we don't know if there's going to be a problem until she makes a try. With myomectomy, you often have to cut all the way through the uterus to remove the fibroid; that's a risk in later pregnancy because the uterus can rupture during labor."

Treating Fibroids

Although there are many situations in which surgery is the best answer, a woman has options. Here are the major ones.

Wait and watch. Less than half of all women with fibroids have symptoms. This means, says Dr. Hutchins, "the majority of fibroids can simply be observed." This is particularly true when symptoms are mild or nonexistent, the rate of growth of the fibroids is slow, or the woman is nearing menopause. Because growth of fibroids is related to levels of estrogen in the body, the fibroids stop growing and usually shrink as natural estrogen tapers off during menopause. And estrogen replacement therapy doesn't stimulate fibroids--the amount of hormone in these preparations is so minute that it rarely causes fibroids to grow.

In fact, if fibroids grow rapidly after menopause, it could be a tip-off to a more serious problem and should be investigated.

Try progesterone. Taking doses of this hormone inhibits the action of estrogen, says Dr. Hutchins. "It's very safe and effective in management of bleeding for fibroids and can be given as long as desired." Unfortunately, many women experience unpleasant side effects at higher doses--the most prominent being fluid retention, weight gain and mood fluctuation--after taking the drug for a while.

Ask about GnRH agonists. This group of compounds simulates the action of gonadotropin-releasing hormone (GnRH), a substance that occurs naturally in the body. At normal levels, GnRH stimulates production of estrogen, but at therapeutic levels, it desensitizes the pituitary, resulting in a dramatic drop in estrogen. The result is artificial, reversible menopause and a significant reduction in the size and symptoms of fibroids. Although GnRH agonists are still being investigated, Dr. Hutchins characterizes them as "the most exciting form of medicine for fibroids today." A GnRH agonist is given for three months, usually to shrink fibroids prior to surgery. After the treatment is discontinued, fibroids tend to grow to their former size, although symptoms may not be as severe.

The downside is that GnRH agonists are expensive and often not covered by medical insurance, points out Dr. Schwartz, because they haven't yet been approved by the Food and Drug Administration for treatment of fibroids.

Diagnose and treat together. If you experience heavy bleeding, it's possible for your doctor to view the inside of your uterus with a hysteroscope inserted vaginally to determine whether fibroids are the cause of the problem. "Diagnosing these problems with a blind D&C is no longer considered optimal," says Dr. Johnson, "but hysteroscopy is new and not all physicians offer it."

Hysteroscopy offers the benefits of both diagnosis and treatment with no more time or anesthetic risk than a standard D&C. "If fibroids are poking into the endometrial cavity," says Dr. Schwartz, "some of them can be removed with the hysteroscopy." No further surgery is necessary.

Ask about myomectomy. For a woman who needs surgery, "it's important she get the option of myomectomy, especially if there's any chance she might want a pregnancy in the future," says Dr. Schwartz. "It's certainly not fair to do a hysterectomy otherwise."

Sometimes myomectomy can be performed with a laparoscopic, or "belly-button," incision. This is particularly true for fibroids on the outside of the uterus. Sometimes a fibroid is so close to the ovaries that it's difficult to tell whether it's really a fibroid or a mass on the ovary. "The closer you get to menopause, the more you worry about ovarian cancer," says Dr. Schwartz. "In these cases, I do a laparoscopy just to look at the growth. When I'm assured it's not an ovarian tumor, I just leave it alone."

Laparoscopy is not always a good choice, however, because it's much more difficult to repair the wall of the uterus. "They can't all be removed through the laparoscope," says Dr. Johnson. "A few can be, and a few can be removed through the hysteroscope, but the majority are still going to have to be removed through open abdominal incision."

Know all about hysterectomy. The most dramatic solution to fibroids has a couple of advantages: The fibroids will never regrow, there's less risk of complications of surgery, and you won't have any withdrawal bleeding with hormone therapy during menopause, says Dr. Schwartz. In addition, there's some evidence that women who have a hysterectomy are less likely to develop ovarian cancer later in life.

One of the most common reasons given for hysterectomy for fibroids is that they're growing rapidly and could signal a more serious condition. "If it grows fast, that says it may not be a fibroid," says Dr. Johnson, "so that's clearly a reason for surgery." She wants women to understand that fibroids are not malignant and are not thought to "turn into" cancers. Growths that are thought to be fibroids, however, could be malignant tumors. While the risk of a malignant tumor is less than 1 percent, this is of particular concern for postmenopausal women--the group at greatest risk for uterine cancer.