Fibroid Warnings: Are You Seeing Them?

Kathleen Di Mond, 39, a mother of two in Oakland, NJ, had always had normal periods. So when her flow suddenly became very heavy and lasted for two weeks, and she developed excruciating back pain during her periods, she consulted her gynecologist. The diagnosis: fibroids. And the recommended treatment: a hysterectomy to remove the six golf ball-size growths in her uterus.

But Di Mond didn’t want to lose her uterus. Although she and her husband didn’t plan to have any more children, she’d just had her gall bladder removed, and she didn’t want to go through major surgery again. But the alternative her doctor suggested–do nothing and at menopause, the fibroids and their symptoms would probably disappear–wasn’t an option either. She couldn’t endure ten more years of living with heavy bleeding and pain.

This is what fibroids look like (yuck).

This is what fibroids look like (yuck).

After consulting another gynecologist, Herbert A. Goldfarb, M.D., assistant clinical professor of obstetrics and gynecology at New York University School of Medicine in New York City, Di Mond discovered that she could be treated with a minimally invasive procedure. This would shrink the fibroids and remove part of the uterine lining to control the bleeding. The surgery was done on an outpatient basis, and Di Mond was back to normal within a week.

Of the 600,000 hysterectomies performed each year, about 200,000 are done to remove fibroids. But many of these hysterectomies are unnecessary. Indeed, in most cases, fibroids don’t need to be treated at all, says Steven R. Goldstein, M.D., professor of obstetrics and gynecology, also at N.Y.U. Medical School in New York City.

If you’re among the 20 to 25 percent of women over 35 who have fibroids, you need to understand what’s going on–medically and from a consumer point of view. That way, you can make sure you get the right treatment–no less than you need but also no more.

Just what are fibroids? Why do they form?

Fibroids are masses of tissue that grow either inside or outside the uterus or within the uterine wall. They can range from pea-size (in which case you probably wouldn’t even know you had them) to the size of a full-term pregnancy. Only a minuscule .02 percent are cancerous, and having fibroids doesn’t predispose you to cancer.

Nobody knows exactly why fibroids form, but once they do, their growth is fueled by estrogen. That’s why they’ll often enlarge during pregnancy, though usually not enough to interfere with the baby, says Maria Bustillo, M.D., a reproductive endocrinologist at South Florida Institute for Reproductive Medicine in Miami. Conversely, after menopause, when estrogen levels diminish, fibroids tend to shrink.

What are the symptoms?

Often none–many women only learn they have a fibroid during a routine checkup with their doctor. Sometimes, if fibroids become large, they can cause nongynecological symptoms, such as constipation (if the growths are pressing on the large intestine) or frequent urination (from putting pressure on the bladder). And some women, like Di Mond, suffer a heavier-than-normal menstrual flow, as well as killer cramps and bleeding between periods.

Will fibroids cause fertility problems?

Very rarely the growths can interfere with the implantation of the fertilized egg on the uterine wall. But if you are having trouble conceiving, you should rule out other causes first, advises Dr. Bustillo; then, if fibroids am the problem, consider whether to undergo surgery or other treatment. Surgery, she points out, may actually worsen problems, since it can leave scar tissue in the uterus.

When do fibroids need to be treated?

Often, it’s your call. If the growths aren’t bothering you, you only need to make sure you have regular checkups to monitor them, says Dr. Goldstein. Nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen, can relieve cramps. And if you’re bleeding heavily, your doctor may prescribe iron supplements to prevent anemia.

Are there any medications to treat fibroids?

Oral contraceptives, although they won’t cure fibroids, may be recommended to control excessive bleeding or bleeding between periods.

If you’re nearing menopause, which your doctor can check with a simple blood test of hormone levels, you might be a candidate for GnRH agonists (gonadotropin-releasing hormones). These drugs, synthetic versions of naturally occurring hormones, cause fibroids to shrink up to 50 percent. But they have many unpleasant and potentially serious side effects, including bone loss, hot flashes, and vaginal dryness. Also, GnRH agonists shouldn’t be used for more than six months, and once they’re discontinued, fibroids quickly grow back. This is why they’re usually recommended only during that brief “window” before menopause kicks in. The drugs may also be used for a few months before fibroid surgery, to reduce the size of the growths and facilitate their removal.

When is surgery the best option?

When the pain or bleeding is seriously interfering with your life, Dr. Bustillo says. There are several surgical procedures, but they essentially fall into two categories: hysterectomy, in which the uterus is removed, and myomectomy, where a doctor removes only the fibroids. Unfortunately, for about 25 percent of women who undergo myomectomy, the tumors will grow back, according to experts. (It could be that a woman who formed fibroids in the first place is likely to do so again.) Not all these women face further surgery, however. If the rate of regrowth is slow enough, a woman may enter menopause before the fibroids become large enough to cause problems.

Assuming you don’t want more children, should you ever consider having a hysterectomy?

If you have numerous fibroids throughout the uterus, it may be the safest operation, says Dr. Bustillo. Removing many growths can cause significant blood loss and carries a greater risk of infection. And a hysterectomy is the only procedure that guarantees the fibroids won’t grow back.

Hysterectomies can be performed without removing the hormone-producing ovaries, so women can continue to benefit from estrogen’s protective effects against bone loss and heart disease. If your doctor wants to take everything, try to argue, suggests Dr. Bustillo, especially if you’re a number of years from menopause. Or find another surgeon.

How do you know if you have the right doctor?

For a start, “your gynecologist should be able to give you the pros and cons of each treatment option and explain why he or she is leaning toward a specific procedure for you,” says Dr. Bustillo. Then, if you have decided on surgery, you need to make sure your doctor has enough experience in the particular procedure you’re considering. All ob/gyns are surgeons-and all have been trained to perform hysterectomies and abdominal myomectomies (see “New Ways to Treat Fibroids,” below). But some of the so-called minimally invasive procedures require special skills; you want tube sure that your doctor is performing these at least several times a month.

Finally, even if you have a lot of confidence in your gynecologist, it might be smart to consult someone at a different practice, especially if you’re considering one of the new procedures, says Bryan Cowan, M.D., professor and director of reproductive endocrinology at the University of Mississippi Medical Center in Jackson. Not all doctors are convinced these are as low-risk as promotions–or your own gynecologist’s endorsement–might have you believe.

New Ways to Treat Fibroids

Dealing with these benign growths is something of a growth industry itself. In the last decade and a half, hysterectomies have given way to myomectomies, which in turn are now done three different ways. In addition, several nonsurgical removal procedures have been developed in recent years.

Abdominal Myomectomy

Doctor removes fibroids through a bikini line or, occasionally, midline incision, leaving the uterus and ovaries intact. Surgery requires a two- to four-day hospital stay.

Who should consider? Women who want to have more children, Also, women with large fibroids, because these can be difficult to remove through the small incisions of less invasive procedures.

What you should know You may have scarring, which can interfere with conception.

Hysteroscopic Myomectomy

A tube is inserted vaginally, and fibroids are shaved off with a wire-loop or vaporized with an electrical current. Outpatient procedure.

Who should consider? Women with small or moderate-size fibroids that protrude into the cavity of the uterus and cause significant bleeding; also those who may want to become pregnant.

What you should know Some doctors may not be sufficiently skilled to safely perform these procedures.

Laparoscopic Myomectomy

Fibroids are removed through tiny incisions in the belly button and other sites on the abdomen. Requires an overnight stay in the hospital.

Who should consider? Women whose fibroids are not too large or too many, can be seen easily, and are in the wall or on an outer surface of the uterus.

What you should know A controversial procedure: If the surgeon is not highly skilled in laparoscopic techniques, there’s a chance of bleeding and infection and a rare chance of perforation of the bowel, intestine, or blood vessels.

Laparoscopic Myolysis/ Resection and Ablation

Electrically charged needles are inserted into the base of the fibroids to cut off their blood supply, which causes them to shrink (myolysis). Then the uterine lining is burned away with laser or electrocautery, to prevent excessive bleeding (resection and ablation). Outpatient procedure.

Who should consider? Women who have small to moderate-size fibroids and only those who’ve completed their families, because destroying the uterine lining causes infertility.

What you should know About 10 percent of women who undergo this procedure will require another procedure afterward.

Uterine Artery Embolization

Radiologists bombard the blood vessels supplying the fibroid and uterus with tiny, synthetic particles, thereby cutting off nourishment to the fibroid and causing it to shrink. Though a new technique for treating fibroids, it has been used for bleeding and trauma.

Who should consider? Women who don’t plan to become pregnant (because blood supply to the uterus is diminished) and, some say, patients who should not be anesthetized because of heart problems.

What you should know Though popularly touted as a “breakthrough” and promoted by some medical centers, many gynecologists worry that such enthusiasm is premature. Uterine artery embolization has been available for only about three years, so there are no long-term follow-up results yet.

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