J. Glenn Bradley, M.D.
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UTERINE FIBROIDS- (What Every Woman Should Know)

Introduction

Uterine fibroids ( "fibroid tumors";" leiomyoma"; "myomas") are benign, (non- cancerous) growths present in about 30% of women over the age of 30. They are usually detected on pelvic examination, which may reveal the uterus to be enlarged and/or irregular in configuration. The vast majority of cases are absolutely silent and cause no symptoms. The size of a single fibroid may be smaller than a pea, or larger than a melon. In a given patient, there may be a single fibroid, or multiple fibroids of varying size. In the latter situation, the summation of the fibroids of varying sizes will lead to an aggregate size increase.

Do all fibroids need to be removed? For the vast majority of patients, the answer is definitely no. Silent stable fibroids may be observed and the patient followed conservatively. Occasionally, ultrasound evaluation may be helpful in confirming the diagnosis, measuring the size of the fibroids, evaluating size changes (i.e. is the fibroid continuing to grow??) and differentiating a fibroid from the ovary. This latter requirement is essential, as an ovarian tumor may be mistaken for a fibroid, and ovarian tumors have a much higher likelihood of being cancerous.

Indications for Treatment

a) Fibroids that are larger than a 12-14 week pregnancy(e.g. a large grapefruit). If allowed to become even larger, the associated risk of complications of surgery begins to increase, especially involving injury to the ureter or bladder. Additionally, large fibroids may predispose to greater blood loss at the time of surgery. Very large fibroids even if silent and asymptomatic, also are inclined to undergo a process called "degeneration", an event which occurs if the enlarging fibroid outgrows its blood supply. Not receiving sufficient oxygen, the cells of the fibroid die, causing abrupt, severe pain and tenderness. At this point, hysterectomy is the only option for treatment. In the case of very large silent fibroids ( cantaloupe size) there is a rare association with blood clots to the lung. (In my own career, I saw a patient who had been admitted for surgery. That very evening, in bed, as the resident doctors were discussing the planned surgeries for the next day, the patient was asked to lie flat so her large abdominal protuberance could be demonstrated. At that very instant, a large fatal "pulmonary embolism"( blood clot to the lung) occurred.)

Finally, rapidly growing large fibroids may be the only indication of underlying malignancy (" leiomyosarcoma" ). Unfortunately there is no absolute way to rule out fibroid malignancy other than microscopic analysis of the fibroid. Cancerous changes are often present only in the center of the tumor, and require special cell-counting techniques in order to determine truly the benign or malignant nature of a given case. This is an acknowledged risk the patient must face if the surgery performed is only the removal of the fibroid(s), ("myomectomy") as opposed to hysterectomy. In the latter situation, the fibroids are removed with the intact uterus, thus minimizing tumor spread. Removal of the fibroid alone in order to conserve the uterus, will allow malignant cells to persist. The overall risk of malignancy is reported to be approximately 1 in 750-1000 patients.

b) Excessive bleeding ( heavy and/or prolonged periods; intermittent or continuous bleeding). Fibroids are one of the most common causes of significant changes in the menstrual pattern, as described above. Paradoxically small fibroids, especially those that protrude into the uterine cavity, are frequently associated with profuse bleeding, whereas large grapefruit-sized fibroids are often totally silent. Rarely, a fibroid may be on a long stalk, and may actually be felt by the patient as a mass in the vagina. This type of "pedunculated" fibroid may be twisted off, but the physician needs to be prepared for possibly some vigorous bleeding. A more appropriate procedure is called "Hysteroscopy", a simple technique in which a telescope is passed through the cervix, and the inside of the uterus actually inspected. Protruding fibroids ( if present) may be visualized, and the exact source of the bleeding thus identified.

c) Pressure- As fibroids grow larger, they will obviously begin to press on adjacent structures, and as this slow process evolves, the patient may begin to become aware over time of an initial vague "heaviness", "pressure", or perhaps increasing protrusion of the lower abdomen. As the fibroid uterus becomes larger than a 12 week pregnancy, she may actually be able to feel this firm mass just above the bladder). Increasing pressure on the bladder may result in a need for urinary frequency, as the ability of the bladder to fill is compromised by the large mass pressing on it. A woman who has been pregnant will experience this change in her urinary pattern, as the growing pregnant uterus similarly presses on the bladder. Pressure on the rectum will contribute to constipation, a sensation of not having completely emptied the bowel. She may also experience discomfort with intercourse, describing a sensation as "my partner is hitting something". Large fibroids may also contribute to low back pain.

d) Pain- Fibroids are usually silent, as previously mentioned. Frank pain and tenderness, if caused by fibroids, is usually indicative of a process called "degeneration". As described earlier, if a rapidly growing or large fibroid outgrows its blood supply, the tissues cannot get enough oxygen, and may die ("a fibroid equivalent of a heart-attack!"). If left untreated, the body will slowly absorb this non-viable tissue, but the patient could be very uncomfortable for possibly weeks. Usually a large degenerating fibroid uterus is treated by hysterectomy. Fibroids themselves are not classically associated with typical "menstrual cramps".

e) Confusion in Diagnosis- If a fibroid, because of its location, impairs the physicians ability to differentiate a fibroid from an ovary, an erroneous diagnosis of a fibroid may be made, as opposed to an ovarian tumor. Malignant ovarian tumors are especially lethal, with only about 15-20% 5 year survival. The determination and differentiation between a fibroid and an ovarian growth is therefore critical. Physical examination, and ultrasound usually can provide an accurate diagnosis, but if not, special xray studies ("CT scan") or even laparoscopy may be necessary to settle the issue. If a given case requires operative intervention to confirm the diagnosis, it is reasonable to perform some procedure so that future evaluation will not be confusing.

TREATMENT OPTIONS:

a) Observation- If a fibroid uterus is "silent", and none of the above situations present, conservative observation is appropriate. Because fibroids may continue to grow, regular check-ups are necessary for ongoing evaluation.

b) Hormone therapy- Excessive bleeding may be controlled or modified by the monthly use of a progesterone -like drug called medroxyprogesterone acetate("Provera"). Fibroids that protrude into the uterine cavity( "submucous myoma") may especially not respond to this therapy, but it is simple and inexpensive and is worth a try. A long acting form("Depo-Provera) is an injection that lasts for more than 3 months, and may prevent any periods whatsoever. If successful, medical therapy must be continued indefinitely. A very special type of drug therapy ( called a GnRH agonist- Lupron, Synarel ) may be used for TEMPORARY control of bleeding or to shrink the size of a fibroid uterus prior to some surgical definitive procedure. Once stopped, the fibroid uterus will return to its pre-treatment status within 6 months ( in 85% of cases). Thus any advantage gained using this very expensive monthly drug therapy is only a temporary window for surgical intervention of some kind.

c) CONSERVATIVE SURGERY

1) "D&C"- A common age-worn procedure for bleeding problems, this entails the dilating or opening of the cervix and the introduction of a sharp spoon like instrument that ostensibly "cleans out' the uterine cavity. Because it is a blind procedure, most polyps or fibroids will be "missed". Fibroids are attached very securely to the uterine cavity by a stalk, or else they more commonly "bulge" into the cavity like boulders in a cave. Only a fibroid on a stalk ("pedunculated") may be removed by a "D&C", but stalked fibroids are the exception, not the rule. If the stalk is short, blind grasping for the pedunculated fibroid is similar to bobbing for apples BLINDFOLDED!! Practically speaking, a "D&C" should be used only for removing retained products of conception, after a miscarriage.

2) Hysteroscopic submucous resection- This procedure entails the introduction of a small telescope through the cervix, thus allowing the inside of the uterus to be seen visually! Bleeding protruding fibroids may then be shaved sufficiently to allow the configuration of the uterine cavity to be returned to normal. A significant portion of the protruding fibroid may be left behind. Exposed blood vessels are then sealed by electrical energy. This is appropriate for those patients who wish to maintain their fertility, and are having heavy or prolonged periods, as the possibility for conception and uterine implantation will still exist. If on the other hand, the patient is not concerned about maintenance of fertility, and is desirous of not having any periods ever again the entire uterine lining may be removed ("resection") and the uterine wall then sealed with electrical energy ("ablation"). Resection of the fibroid alone may solve the problem but there is no absolute assurance it will be successful, as heavy bleeding may be due to fibroids that are located in the wall of the uterus ("intramural") and these will not be amenable to hysteroscopic resection.

Endometrial resection and ablation is an excellent alternative to hysterectomy for those patients wishing control of heavy menses, on a permanent basis. As many as 85% may experience complete cessation of menstrual periods, and about 3-5% will fail the procedure.The procedure has no influence on the ovaries, thus there is no significant changes in hormones. (Coincidently, most patients who have an ablation performed also experience a decrease in their PMS symptoms) A failure by definition means that the menstrual pattern is not any better after the procedure compared to before the procedure. Performed in an outpatient setting, resection of the fibroid, with or without ablation is relatively simple and very safe (in experienced hands!!), much less costly than a hysterectomy, and recuperation is almost immediate. Of the approximate 250,000 hysterectomies performed each year in the United States because of excess bleeding, my personal experience and that of others who endorse endometrial resection and ablation would suggest that the vast majority could be successfully avoided. 3) Myomectomy- This is a uterine sparing procedure in which fibroid tumors are surgically removed from the uterus. It may be accomplished using minimally invasive technique ("operative laparoscopy" ; "laparoscopic myomectomy"; "pelviscopy") or through a standard conventional incision ("laparotomy") . The former approach, if possible and appropriate, is preferable in that post -operative recovery is extremely fast, and much less disfiguring. It's disadvantages are that operative time may be longer (adding significantly to cost), it technically is more difficult ( most gynecologists have little if any experience with laparoscopic myomectomy) , and the consensus of experienced opinion would suggest that large fibroids removed laparoscopically may develop significant post-operative adhesions thus impairing subsequent fertility. The approach to myomectomy, thus must be individualized. Fibroids that protrude on the out side of the uterus ("subserous myomas") may be relatively easily treated using minimally invasive techniques. The problem however, is that those cases in which the fibroids are in the wall of the uterus, (and not apparent because they do not "bulge' on the outside nor protrude on the inside, ) may be invisible to the eye, and thus not removed at the time of surgery. This would account for the high recurrence rate of up to 45%. Performing a conventional myomectomy through a standard laparotomy incision allows the surgeon to feel smaller inconspicuous fibroids that might otherwise be missed. Feeling a marble in your pocket is a good example of how the sensation of touch can play a very important role in some surgical procedures.

Often large fibroids may be shrunk by special medications ( GnRH analogs) alluded to earlier. Smaller fibroids mean smaller incisions, and this may result in smaller blood loss at the time of surgery. Further, smaller fibroids may also allow a laparoscopic approach as opposed to conventional incisions. Depending on the type and extent of the uterine incision performed at the time of the myomectomy, the patient may or may not be able to deliver a subsequent pregnancy, vaginally. If the incision extends through the entire thickness of the uterine wall and into the uterine cavity, subsequent delivery by cesarean section is customary in order to reduce the risk of uterine rupture during labor.

4) Myoma Coagulation- ( "myolysis"; "fibroid coagulation") As fibroids are dependent on an adequate blood supply in order to grow, reducing the blood supply in conjunction with destruction of some fibroid tissue, can result in fibroids not continuing to grow . In most cases in fact, the fibroids may shrink by as much as 50%. The procedure is carried out with a laparoscope in an outpatient setting. Various energy sources have been utilized-- laser, electrical, or freezing ("cryomyolysis") The latter is the newest modality, and while promising, clinical evaluations are still being performed prior to widespread availablity and acceptance. The YAG laser is excellent, but for those facilities that do not have this equipment available, special electrical needles may be used. The laser fiber , (or the electric needles) is passed in and out of the fibroid, much like repeatedly placing a toothpick in a ball of play-dough. The energy imparted to the uterine fibroid results in a reduction of the blood supply to the fibroid which will then shrink over several months . While the fibroid will not likely totally disappear, it more than likely will regress sufficiently to obviate pressure symptoms. Pre-treatment with a GnRH agonist for 2-3 months may reduce the fibroid volume by 50%, and this may be followed by a further 50% reduction consequent to the fibroid coagulation procedure.

5) Uterine Artery Embolization- This is a treatment for large uterine fibroids. This procedure is performed by an "interventional radiologist", not a gynecologist. The radiologist inserts a special catheter into a large artery in the groin, in a manner similar to a coronary angiogram. The uterine arteries are located using special x-ray equipment, and then particles of an inert substance called "polyvinyl alcohol" are injected. These particles permanently "clog" the blood vessels that nourish the uterine fibroids (like tea leaves in a strainer), and the fibroid undergoes degeneration. The description of " a fibroid equivalent of a heart attack" is appropriate, as the process is painful. Most patients need be kept hospitalized overnight for pain control, and then they can use oral pain medication for the next week to 10 days. Reportedly, following the embolization procedure, uterine fibroids may subsequently shrink from about 45% to 80%. The heavy bleeding often associated with uterine fibroids is "controlled" in about 90% of patients. ( ie a 10% failure rate) "Amenorrhea" is the medical term for a total absence of ANY bleeding. The amenorrhea rate for the embolization procedure is very low (as contrasted to a hysteroscopic resection and ablation procedure, with amenorrhea rates as high as 85%). Subsequent pregnancy is not recommended, as there is concern that the uterine wall may be weakened by the procedure, and thus be prone to rupture during pregnancy. Some patients in a European study however did become pregnant, and delivered uneventfully. Current cost estimates for embolization vary considerably, but may be as high as $30,000!!

6) Magnetic Resonance guided focused ultrsound is the newest treatment for fibroids. Developed in Israel, increasing numbers of facilities offering the procedure are becoming available in the United States. Focused high intensity ultrasound energy is used to destroy the fibroid
tissue. A comprehensive explanation of this new technology is easily accessed on the web. Look up "fibroids ExAblate" on Google. The equipment is very costly (approximately 1.5 million dollars) so the cost to a patient will likely be substantial

d) DEFINITIVE SURGERY

Hysterectomy- Most uterine fibroids are treated (if necessary) by removal of the uterus. A complete hysterectomy means that the body of the uterus and the cervix ( the opening to the uterine cavity) are removed . A "subtotal" or "supra-cervical" hysterectomy means that the body of the uterus only is removed, and the cervix is allowed to remain. Hysterectomy as a medical term does not refer to the removal or non-removal of the ovaries. There are advocates for both types of hysterectomy.

Those who champion "supra-cervical" hysterectomy claim that allowing the cervix to remain provides better pelvic support, lessens the likelihood of bladder dysfunction and incontinence, avoids the likelihood of post-operative pelvic infection ( the contaminated vagina is not entered surgically, thus avoiding the introduction of bacteria into the pelvis)and maintains sexual function better. If the supra-cervical hysterectomy is accomplished laparoscopically, the patient's recovery time is remarkable!!! Most patients are hospitalizd overnight, and go home the following morning. The average number of pain pills used after discharge is less than a dozen. The patients are out and about in a couple of days, return to work in a week, and resume intercourse in 5-10 days. The actual removal of the uterus may be accomplished through a) a conventional incision (laparotomy) , or b) the vaginal route , or c) the uterus may be removed laparoscopically. Abdominal hysterectomy is the least desirable as recovery is usually longer, more uncomfortable, hospitalization longer, and more disfiguring. Vaginal hysterectomy patients have no visible scars, and recuperation is faster. Laparoscopic hysterectomy provides very fast recovery as outlined above, minimal disfigurement ( the incisions are tiny), less pain, but most importantly, surgical treatment of other disease processes such as adhesions, or endometriosis.The availability of a special instrument called a morcellator facilitates the rapid safe removal of any sized fibroid(uterus) in a few minutes. Some surgeons have acquired extensive experience with this technique, and in experienced hands, patients do incredibly well. One must always remember however the old surgical adage that states "the belly is full of surprises".Once the pelvis is actually visualized, only then can your surgeon determine if you are a candidate for this operation. Patients should thoroughly discuss their options and experience with their physician.

The coincident removal of the ovaries at the time of hysterectomy is an issue totally separate from the fibroid problem, and thus needs to be individualized for a given patient.

SUMMARY:

The foregoing material reflects the views of this particular physician. A patient needs to avail herself of not only the essential information by which she can understand the nature of the problem, but also her options regarding treatment, if needed.

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