New ideas for a common problem in women’s health
Smooth muscle tumors occur in 30% of women by the age of 30. By pelvic exam, they are detected as an enlarged or irregular uterus. They can be one or many, tiny or larger than a watermelon. I removed 63 from one patient and have seen them weigh several pounds. We aren’t really sure what causes fibroids, but they do “run” in families, are more common in women of African descent, and appear to grow faster and more often in women with “estrogen dominance”. Progesterone seems to have a beneficial effect, so low dose birth control pills and other contraceptives may actually help. Most often, fibroids cause no noticeable problems, but
many women have enough trouble with pain, bleeding or other symptoms that they want some relief.
Fibroids are a common cause of abnormal menstrual bleeding, bleeding between periods, pelvic pressure, bladder frequency, pain with sex, and sometimes infertility. If a fibroid outgrows its blood supply, it undergoes “degeneration’ and can become very painful. Fibroids typically grow little by little every year until menopause. At that time, they usually stabilize and sometimes even shrink a little. They rarely cause significant problems after menopause, even in women using bio-identical hormone therapy.
Once fibroids are detected, they should be monitored by a gynecologist at regular intervals. Ideally, ultrasound should be used to help count and measure fibroids. Ultrasound can also be used to look for more serious problems that mimic fibroids, such as “atypical fibroids”, malignant tumors and tumors in the ovary. At Swor Women’s Care, we offer physician-performed clinical vaginal ultrasound. With the gynecologist looking “real-time” at the pelvic organs using sonography, an immediate and accurate assessment can be made. Although rarely cancerous, if fibroids appear to be growing rapidly or “look” abnormal to a trained eye on an ultrasound, then they should be removed surgically.
Deciding when and how to treat fibroids is usually based on the severity of symptoms, the fertility wishes of a patient, her age and the number and size of the fibroids. When they are relatively small and causing little difficulty, then close monitoring is adequate with the use of
Aleve® or Advil® and sometimes hormone balance or progesterone therapy. We have had great success with natural progesterone cream therapy for a number of women’s health concerns, including abnormal bleeding and fibroids. There are also strong drugs such as Lupron®, that can shrink fibroids at least temporarily, and this may be a good idea close to menopause or before surgery to make removal easier.
If a woman desires future pregnancy, then myomectomy is an excellent option. This is typically done with either laparoscopy or an “open” incision, laparotomy. Gyn specialists, with skill at laparoscopic surgery, can remove most fibroids with this minimally-invasive technique. In our practice, we rarely use an “open” technique, as almost all common gyn surgical problems are amenable to less invasive techniques. We now have additional special tools such as
robotic-assisted laparoscopy available. The DaVinci robotic technology became available at Sarasota Memorial for advanced gyn surgery in Spring 2007. This technique provides even better visibility, access and healing time for complex laparoscopic procedures, including fibroid surgery.
If future pregnancy is NOT planned, then several options are available. Surgical options range from the most minimal, endometrial ablation to the most aggressive, hysterectomy. Ablation involves “heat treating” the uterine lining to reduce or take away menstrual bleeding completely.
Recovery is a matter of days and risks are minimal. This procedure doesn’t remove fibroids, but only decreases bleeding. Laparoscopic or open myomectomy is also an option to conserve the uterus. Myolysis is a choice, where heat or freezing are used during laparoscopy to shrink fibroids. This is relatively new and misses the opportunity to remove and test the fibroids.
Another excellent surgical option is LASH or laparoscopic supracervical hysterectomy. This is a minimally invasive procedure with a 1-2 week recovery that removes the part of the uterus that contains fibroids. The result is no menstrual period or any bleeding at all in 95% of patients and fibroids are removed and tested in the lab. Other problems that are commonly associated with fibroids, such as endometriosis, are also treated at the same time. For women with “bad periods” who want a less invasive approach and permanent “birth control”, this is a common choice. The cervix is preserved and this is thought by many experts to help with pelvic support and possibly better sexual function.
LARGE FIBROID UTERUS
Non-surgical treatments are also available, including uterine artery embolization and MRI-guided high frequency ultrasound. These techniques will often shrink fibroids, but have various disadvantages, including leaving fibroids in place.
New drug therapies are currently under investigation in FDA-approved clinical trials. We have one upcoming at Physician Care Clinical Research, an affiliate of USF in Sarasota. The study involves a new pill that may work well and have fewer side effects, if preliminary testing is any indication.
Many women will have to deal with the issue of fibroids, and fortunately, there are many options for those who want or need therapy. From simple natural progesterone cream to DaVinci robotic surgery, the options vary widely. It is important to seek advanced gynecology care when getting advice and making decisions.
