1.WHAT ARE UTERINE FIBROID TUMORS?
Uterine fibroid tumors are benign (noncancerous) growths of the uterus and may also be called myomas, leiomyomas, fibromas, or just fibroids. They arise from the smooth muscle connective tissue that lines the uterus (myometrium) and can grow in any location in and around the uterus. Like other tumors, they have miraculous powers of survival because of their uncanny ability to create their own vascular networks or surreptitiously appropriate those of the uterus or other nearby organs. Some women only develop one fibroid or just a few, while others may have as many as 100 or more. Their size also varies tremendously; some are so small that a microscope is needed to visualize them, while others grow as large as a basketball. The worlds largest fibroid on record weighed in at over 140 pounds (63.5 kilograms).
Since not all fibroids cause symptoms, not all fibroids will be diagnosed, which means prevalence rates may be higher than current estimates. However, just because fibroids are common and not always symptomatic, dont let that mislead you into thinking that they cant cause medical mischief. In some cases severe symptoms may develop that require urgent medical attention. So, be sure to read the symptoms section below to learn when immediate medical care may be needed if more serious symptoms arise. The chance that fibroids will turn cancerous is quite rare. According to several studies cited by the American College of Obstetrics and Gynecologists (ACOG), only about .002 to .003 percent of cases of leiomyomas develop into cancer (ie, uterine leiomyosarcomas). According to the Sarcoma Foundation of America, only about 6 out of one million women will be diagnosed with this rare cancer in the U.S. annually.
There are 6 main types of fibroids:
- Submucosal fibroids Grow into the cavity of the uterus.
- Intramural fibroids Grow in the muscle wall of the uterus.
- Subserosal fibroids Grow on the outside lining of the uterus.
- Pedunculated fibroids Grow on a stalk off of the outside of the uterus.
- Interligamentous fibroids Grow between the uterine ligaments
- Parasitic fibroids Move and attach to other organs besides the uterus
2.HOW COMMON ARE FIBROIDS?
Fibroids are the most common type of non-cancerous tumors of the reproductive system. In fact, an estimated 3 out of 4 women will be diagnosed with fibroids at some point in their lives. Most of the time fibroids grow asymptomatically. However, when they are symptomatic, they can have a major impact on a womans quality of life. Theyre usually diagnosed during childbearing years, typically between the ages 30-40. One reason diagnoses occur more commonly in this age group may be because fibroids can increase in size during pregnancies and therefore finally begin causing symptoms. However, teenagers can and do develop fibroids that can be severely disruptive, both physically and socially. So, make sure to listen to your body and seek out medical care if youre experiencing symptoms, no matter what your age.
Although many surgical and non-surgical choices are now available, unfortunately fibroids are still among the most common reasons about 40% of the estimated 600,000 – hysterectomies are performed in the U.S. each year, at least based on national statistics (though this is not true for our Center!). Even so, weve come a long way from even just 20 years ago, when a painful,abdominal hysterectomy was essentially the only option on the table.
3.WHAT CAUSES FIBROIDS?
Fibroids occur when a single uterine smooth muscle connective tissue cell replicates until a cluster of cells form a mass that is distinct from the normal muscular tissues. Doctors and researchers are still investigating what triggers this disregulated growth; however no one really knows why fibroids develop.
Some possibilities are genetic factors (fibroids tend to run in families) or hormonal causes (fibroid tissue has more estrogen and progesterone receptors than normal uterine tissue and therefore are more sensitive to alteration of these two hormones during the menstrual cycle). Other observed tendencies include the fact that:
- fibroids do not develop before the onset of menstruation when hormonal changes occur
- fibroids will continue to grow and/or reoccur while estrogen is present
- fibroids often grow very quickly during pregnancy when the body is producing extra estrogen
- fibroids often shrink and/or disappear entirely after menopause when the body stops producing estrogen
- fibroids rarely develop after menopause.
4.WHAT ARE THE SIGNS AND SYMPTOMS OF FIBROIDS?
Changes in menstruation Fibroids distort the lining of the uterus and muscular wall of the uterus, which can lead to a variety of changes in your period, including:
- Periods lasting longer than 7 days
- More frequent periods
- Heavier than normal bleeding during your period (menorrhagia)
- Painful periods
- Irregular bleeding between periods
Pain As fibroids grow, they can exhaust their blood supply, causing intense pelvic pain and sometimes fever. The mass of the fibroids can also cause other painful symptoms including:
- Pelvic pain
- Abdominal pain
- Sudden or severe abdominal pain
- Pain with intercourse (dyspareunia)
- Pain during menstruation
- Lower back and thigh pain
Pressure Because the uterus is bordered above by the bladder and below by the rectum, larger or growing fibroids can cause pressure symptoms, including:
- Urinary frequency or difficulty with urination
- Bowel irregularities such as constipation, rectal pressure and difficulty with bowel movements
- Abdominal bloating and cramping
Pregnancy Miscarriages Fibroids can distort the uterus so a pregnancy cannot grow properly secondary to the mass of the fibroid. Also, the blood supply of the pregnancy can be diverted to a growing fibroid. In these cases, pregnancies can miscarry.
Infertility Fibroids can grow near the fallopian tubes and cervix blocking proper motility of sperm and egg through the uterus and tubes. Fibroids can also line the cavity of the uterus making it impossible for a pregnancy to properly implant in the uterus.
Anemia and other serious symptoms Some women with fibroids lose so much blood that they develop anemia (low blood cell count). The most common symptom of anemia is fatigue (feeling tired or weak). Other common symptoms include dizziness, shortness of breath, chest pain, syncope (passing out), headache, cold hands and feet, sweating, fast heart rate, irregular heart beat (arrhythmia), pale skin, and fluid imbalances (electrolyte imbalance, etc), just to name a few. These symptoms may arise because of iron deficiency and/or because your heart has to work harder to supply your body with the oxygen-rich blood that fibroids-related blood loss may have depleted. Even more serious symptoms: Although rare, if left untreated, anemia can even damage other organs like your kidneys because your blood cant deliver enough oxygen to them. And, again though rare, anemia-induced arrhythmias can damage your heart and potentially lead to heart failure. Other potentially serious symptoms that fibroids can cause are when they become twisted, which can cause very severe pain, infection, and internal bleeding that requires emergency medical care. This is particularly common with pedunculated fibroids. Other fibroids grow in such a peculiar way or so large that they lead to life-threatening obstructions to blood flow or otherwise interfere with the normal functioning of your organs or vascular system. For example, there have been reports of life-threatening bowel obstruction and/or bowel necrosis caused by fibroids.
As you can see, even though rare, fibroids can cause serious, system-wide health problems. So its always a good idea to get a second opinion if you think youre experiencing any of these severe symptoms or are having blood loss each month (or between periods) that you think may be abnormal.
To summarize, serious symptoms requiring immediate medical attention are sudden or severe abdominal pain, heavy menstrual bleeding causing anemia (low red blood cell count), any bladder or bowel symptoms, heart or kidney symptoms, recurrent miscarriages, and infertility.
5.HOW ARE FIBROIDS DIAGNOSED?
Fibroids can be diagnosed multiple ways. Most commonly, fibroids are diagnosed by pelvic exam by your doctor. Your gynecologist may be able to feel an enlargement or an irregular contour to the uterus.
A variety of imaging modalities are used to aid in the diagnosis of fibroids, including:
- Ultrasound A probe over the abdomen or inside the vagina that can visualize the uterus and any masses within it.
- Sonohysterogram Vaginal ultrasound is used after the uterus is distended with fluid. This allows visualization of the contour of the inside of the uterus. This makes it easier to diagnose submucosal fibroids that can often be missed by ultrasound alone.
- MRI (magnetic resonance imaging) This imaging technique is very sensitive in detecting the exact size and location of fibroids: however, it is very expensive.
6.WHEN SHOULD FIBROIDS BE TREATED?
If fibroids are causing any symptoms, a woman should seek treatment. Serious symptoms requiring immediate medical attention are sudden or severe abdominal pain, heavy menstrual bleeding causing anemia (low red blood cell count), any bladder or bowel symptoms, recurrent miscarriages and infertility.
7.IS THERE A TREATMENT FOR FIBROIDS?
There are a variety of treatment options for fibroids, ranging from medical management of symptoms to definitive surgical management. As with any medical intervention, there are always risks and benefits that must be carefully considered on a case-by-case basis before choosing a treatment plan. Therefore, make sure to consult with a gynecologic specialist to see which option is right for you.
8.ARE THERE MEDICATIONS I CAN TAKE FOR MY FIBROIDS?
Fibroids cannot be eliminated by medications but symptoms can be managed with certain medications:
- Combined oral contraceptive pills The birth control pill contains both estrogen and progesterone hormones, which can help decrease bleeding symptoms. Some studies show that they can slow the growth of fibroids, but cannot decrease the size of the fibroid
- Progesterone Releasing IUD (intrauterine device) This device is inserted into the uterus and contains a small amount of progesterone hormone. This can decrease bleeding symptoms. It has no effect on the fibroid itself.
- Progestin pills These pills contain progesterone hormone, which will decrease bleeding side effects. These pills have no effect on the fibroid itself.
- Gonadotropin Releasing Hormone (GnRH) agonists These medications (Lupron, Zoladex, Synarel, etc.) suppress the release of natural estrogen and progesterone production, which then causes shrinkage of fibroids and decrease in bleeding symptoms. These medications cause a temporary menopausal state and are often associated with hot flashes. Typically, your doctor will put you on this medication to correct anemia from heavy bleeding and shrink the size of the fibroid prior to surgical management. GnRH agonists are not a long-term management option.
- NSAIDs (nonsteroidal anti-inflammatory drugs) These are nonnarcotic pain medications that may help with the painful symptoms of fibroids but will not effect the fibroid or any bleeding symptoms.
9.WHAT SURGICAL OPTIONS DO I HAVE TO TREAT MY FIBROIDS?
There are a variety of surgical options. They range from minimally invasive procedures to open abdominal (laparotomy) surgeries. Some procedures are performed by a gynecologic surgeon and others are performed by an interventional radiologist.
HERE ARE THE DETAILS:
You can have an operation called a myomectomy where just the fibroids are removed from the uterine tissue. There are different types of myomectomies:
- Hysteroscopic myomectomy A camera with an electric loop attachment is placed inside the cavity of the uterus through the vagina and the fibroids are visualized and removed by shaving them off the wall of the uterus. Please note, this can only be done for submucosal fibroids that are protruding into the cavity of the uterus. This is an outpatient surgical procedure and patients can go home the same day of surgery with minimal side effects.
- Abdominal myomectomy A large incision is made on the abdomen to gain access to the uterus. The fibroids are removed by cutting into the uterus and taken out through the abdominal incision. The uterus is then sewn back together. Fibroids that are on the outside or in the wall of the uterus can be removed this way. Because of the large abdominal incision, patients are hospitalized for 2-4 days after surgery. Recovery can take up to six weeks.
- Video-assisted laparoscopic myomectomy A small camera is placed through the navel, 2-3 small 0.5-1.0cm incisions are made in the lower abdomen and the surgery is performed through these small incisions. Fibroids on the outside and in the walls of the uterus can be removed this way. They are cut into small pieces and pulled out through the small laparoscopic incisions. For larger fibroids (around 30-40 weeks gestational size), one of the small incisions is extended and the fibroid is pulled out in pieces through this extended incision. Patients typically go home the day of or day after their surgery. The American Congress of Obstetricians and Gynecologists stated in their 2009 Practice Bulletin, Laparoscopic myomectomy minimizes the size of the abdominal incision, resulting in a quicker postoperative recovery (compared to abdominal myomectomy). Because of the complex nature of laparoscopic dissection and suturing, special surgical expertise typically is required.
- Robotic-assisted laparoscopic myomectomy The incisions are similar to that of a video-assisted laparoscopic myomectomy, but instead of the surgeon standing over the patient operating the instruments, robotic arms are placed through the incisions and the surgeon sits at a consul operating the arms remotely. It aids the surgeon by allowing better visualization and handling of the fibroids. It also has similar recovery as a laparoscopic myomectomy and requires special surgical expertise.
10.CAN ALL FIBROIDS BE TREATED BY MINIMALLY INVASIVE SURGERY?
Minimally invasive surgery techniques, which include hysteroscopy, video-assisted laparoscopy and robotic-assisted laparoscopy, should be considered valid options for all patients seeking treatment for their symptomatic fibroids.
Removing fibroids minimally invasively requires advanced surgical skill
Its not well known, but removing fibroids minimally invasively actually calls for quite advanced surgical skills and experience. The fact that so many laparotomies and hysterectomies are performed each year merely for fibroids suggests that only a small minority of surgeons are able to treat this condition minimally invasively and while sparing the uterus. Although these hysterectomy statistics are disappointing, we really shouldnt condemn surgeons too much because fibroids can be, indeed, rather tricky to treat. This is because they are often what are called bleeders in surgical parlance, meaning that they usually bleed extensively due to their densely packed vascularization. Extensive bleeding during surgery is definitely not something any surgeon looks forward to. But, for those less experienced, its an especially dreaded possibility because, as you can imagine, uncontrolled hemorrhaging during surgery can be life-threatening. In some cases, for example, a surgeon only has a few minutes to control bleeding before more serious consequences ensue. This is particularly true for certain types of myomas, like interligamentous fibroids, which are especially difficult to remove without injuring other organs or vital blood vessels. Unusually large fibroids also present challenges because their vascular system can become intertwined with and therefore difficult to distinguish from the bodys major blood vessels. Such complex surgeries can be exacerbated when co-morbidities like endometriosis, excessive adhesions, and/or adenomyosis are present, all of which often co-exist with fibroids.
Its because of these potential difficulties and the inability to control intra-operative hemorrhaging that can cause less experienced surgeons to convert laparoscopic procedures to laparotomies; or simply avoid fibroid surgeries altogether and begin favoring hysterectomies instead.
However, in the hands of an expert minimally invasive surgeon, any size or type of fibroid can be treated with minimally invasive, organ-sparing techniques. Of course, the caveat is this: it takes a practically supernatural ability to remain sublimely calm under pressure, while delivering exquisitely deft and safe surgical skill that makes all the difference.
Why patients choose Dr. Camran Nezhat and colleagues
These very qualities are what make Dr. Camran Nezhat one of the worlds most respected surgeons. And, in terms of experience, he and his colleagues are among the most, if not the most, experienced surgeons in treating fibroids using advanced, minimally invasive techniques and were among the first to perform completely videolaparoscopic myomectomies. In fact, it was Dr. Camran, along with his equally preternaturally talented surgeon brothers, Drs. Farr Nezhat and Ceana Nezhat, who pioneered videoendoscopy and other techniques and instruments used in minimally invasive surgery.
11.WILL A MYOMECTOMY INCREASE MY CHANCES OF GETTING PREGNANT?
Pregnancy rates have been reported as high as 60% after myomectomy regardless of which type of myomectomy is performed.
12.WILL I HAVE TO HAVE A CESAREAN SECTION IF I GET PREGNANT AFTER A MYOMECTOMY?
The reason some patients are told they have to have a cesarean delivery if they have a myomectomy is because of the theoretical risk of uterine rupture during labor, which can cause fetal distress. No randomized trials have been performed on this subject. There are very few case reports of uterine rupture after myomectomy, particularly with hysteroscopic and laparoscopic myomectomies. With minimally invasive techniques, the risk of uterine rupture is low. However, you should discuss this with your doctor, as each patient has a unique health history that must be carefully evaluated.
13.WHAT IS THE ROLE OF UTERINE ARTERY EMBOLIZATION IN THE TREATMENT OF FIBROIDS?
Uterine artery embolization (UAE) is an outpatient procedure performed by an interventional radiologist. A catheter is placed through the groin into the uterine artery. Small coils or pellets are used to block the uterine artery, which gives its blood supply to the uterus and fibroids. Without adequate blood supply, the fibroids shrink and symptoms of pressure and heavy bleeding can also reside. UAE is recommended for a select group of patients who are premenopausal with symptomatic fibroids within the uterine wall and where future fertility is not a primary concern. UAE is also helpful for patients for whom surgery is too risky. Although it is a relatively safe procedure, there are some severe side effects, including fever, pain, infection, death (necrosis) to uterine tissue and vulva, premature ovarian failure, infertility, necrosis of buttock and thigh muscle, and increased risk of hospital readmission compared to other minimally invasive myomectomy procedures.
14.WHEN IS A HYSTERECTOMY INDICATED FOR THE TREATMENT FIBROIDS?
This is a difficult question to answer, since it depends on many factors, including some that have to do with the skill of the surgeon, rather than absolute medical indications. However, in general, many surgeons will suggest hysterectomy in postmenopausal patients whose health history may indicate a higher risk for reproductive cancers and whose fibroids are causing uncontrollable hemorrhaging and other severe symptoms which havent responded to more conservative treatments. For premenopausal women, the answer is more complicated. Firstly, if there appear to be precancerous signs or an otherwise heightened risk for reproductive cancers, your doctor may feel that hysterectomy is the right choice for you, especially if future fertility is not desired. Hysterectomy may also be recommended for severe cases of fibroids where the risk of myomectomy seems too great or when patients have other risk factors or co-morbidities, including bleeding disorders, diabetes, and adenomyosis.
However, in the past 30 years, Drs. Camran, Farr, and Ceana Nezhat have been able to save the uterus of any patient with fibroids who did not desire a hysterectomy. In other words, its essentially the skill and experience of the surgeon, more than any other factors that ultimately help determine whether a patient can choose alternatives to hysterectomy.
Please email us at firstname.lastname@example.org if you would like to receive additional medical articles about Fibroids treatment.
Drs. Nezhat have pioneered many of these techniques and instrumentations and are among the most, if not the most, experienced surgeons in treating fibroids.