Treatment of symptomatic fibroids is the #1 reason why women have a hysterectomy in the United States today.
Uterine fibroids are benign (noncancerous) tumors that grow on or within the muscle tissue of the uterus. Approximately 20-40% of women 35 years and older have fibroid tumors. Fibroids are more common among women of African-American descent. Some statistics indicate that up to 80% of African-American women will develop uterine fibroids. While some women do not experience any of the symptoms of fibroids, the location and size of fibroid tumors can cause symptoms that can affect a woman's quality of life.
Fibroids are hormonally sensitive so symptoms are likely to be cyclical, like menstruation. As estrogen levels tend to increase prior to the onset of menopause, this may cause the size of many uterine fibroids to increase. This may cause an increase in the symptoms of fibroids as well. During menopause the levels of estrogen decrease dramatically, causing fibroids to shrink. However, women taking hormone replacement therapy (HRT) during menopause may not experience any symptom relief because the estrogen contained in this regime may cause fibroid tumors to enlarge and symptoms to return.
The size of fibroids range from very small (walnut size) to as large as a cantaloupe or even larger. Typically, physicians measure uterine fibroids in terms of the size of the uterus during pregnancy; for example, a very large fibroid can cause the uterus to become the size of a six- or seven-month pregnancy (24-28 weeks). Additionally, there can either be one dominant fibroid or a cluster of many small fibroid tumors.
Who Gets Fibroids?
Uterine fibroids are the most common tumors within the female reproductive system, so all women are at possible risk of developing them. During your annual internal gynecological examination, or if you schedule a special visit to investigate possible symptoms, your doctor will check the size of your uterus. If it feels enlarged, your doctor may prescribe an abdominal or transvaginal ultrasound, which can confirm the presence, location and size of fibroid tumors. Other methods can be used to confirm uterine fibroids including magnetic resonance imaging (MRI) or ultrasound. After identifying the size and location of your fibroid(s), and also after other diagnostic tests, your doctor may recommend ruling out other, potentially more serious, conditions, and advise you of your options and a recommended course of uterine fibroid treatment.
Furthermore, many clinical papers cite African-American women as especially susceptible to developing uterine fibroids. It is believed that African-American women develop symptoms quicker and in greater magnitude than other women. It is estimated that between 50% and 80% of African-American women in the United States will develop fibroids. Due to the prevalence of this condition, it is essential for all women to understand fibroids, possible symptoms, and the choices available for uterine fibroid treatment.
Most clinicians believe that instances of fibroids shrinking occur when a woman goes through menopause. Consequently, the majority of uterine fibroids are diagnosed and treated in women between the ages of 35 and 54. However, fibroids can and do occur in women under the age of 35, even as young as the early 20's. In the United States, there are approximately 42 million women between these ages. In clinical literature, it is estimated that between 20-40% of all women have fibroid tumors. This means that 10 million to 21 million women have fibroids in the United States alone. From this group about 5.5 million will seek treatment each year. Between 200,000 and 300,000 hysterectomies performed every year are for symptomatic uterine fibroid.
Symptoms of Fibroids
Many women live with fibroid tumors and still maintain a good quality of life. Some women may experience some symptoms of fibroids, but can still manage to perform their daily activities. Many women who suffer from symptomatic fibroids underestimate the severity of their symptoms as they have become accustomed to excessive bleeding, pain, and the pressure fibroids can cause. However, if the symptoms of uterine fibroids are so severe that they affect your ability to maintain your day to day activities, it is a good time to discuss with your physician all of the alternatives available to help you manage these symptoms.
Common symptoms of fibroids include:
- Very heavy menstrual bleeding and prolonged monthly periods, sometimes with clots
- Frequent occurrence of soiling events due to excessive menstrual bleeding
- Anemia (excessive fatigue due to low red blood count)
- Pelvic pain or pressure
- Pressure on the bladder which leads to a constant need to urinate or incontinence
- Pain in the back of the legs
- Pain during sexual intercourse
- Pressure on the bowel which can lead to constipation and/or bloating
- An enlarged abdomen which may be mistaken for weight gain or pregnancy
If you are experiencing any of these symptoms, you should go to your doctor to confirm the cause of them. These may be symptoms of other problems that need to be diagnosed by a medical professional.
Excessive Menstrual Bleeding
One of the most common symptoms of fibroids is prolonged and excessive menstrual bleeding. The passage of clots is also another symptom commonly related to heavy menstrual bleeding, which in many cases can cause frequent soiling events. Prolonged bleeding over a long period of time can cause anemia and fatigue, which may result in the need for transfusions.
Pelvic Pain and Pressure
As fibroid tumors grow in size, they may put pressure on surrounding organs; causing pain and discomfort. In other instances, fibroids may be accompanied by other conditions, such as adenomyosis (components normally in the endometrium are within the myometrium) and endometriosis (endometrial tissue is generally found outside of the uterus), which can cause pain and other complications. It is important to ensure that you have a complete gynecological evaluation to properly diagnose all of the conditions causing symptoms.
Urinary Incontinence and Frequency
In conjunction with pelvic pain and pressure, growth of fibroid tumors can put pressure on surrounding organs, such as the bladder. This pressure can cause urinary incontinence or more frequent urination. It is very common for women with fibroids to feel the need to urinate many times throughout the day and night.
Once you have been diagnosed with fibroids, your doctor will discuss with you the various fibroid tumor treatments available. These fibroid treatments range from "watchful waiting" to pharmaceutical therapy for fibroids that may have recently been diagnosed or may have some associated symptoms, but do not interfere with daily living.
However, many patients may require additional fibroid treatment options to manage more severe symptoms. Your physician may advise you of minimally invasive, uterus-sparing therapy, such as UFE, to surgical interventions, such as hysterectomy and myomectomy. It is important to be sure to discuss all of these fibroid treatment options with your physician to see what is the best option for you.
Diagnosis and Watchful Waiting
If your fibroids do not cause symptoms, there is no need to treat them. Your doctor may want to watch them and monitor for any fibroid growth at each of your annual examinations. Some women may have fibroids, but not experience symptoms.
If you begin to experience, of have been experiencing, some or many of the symptoms of fibroids previously indicated, there are several other fibroid treatment options that may be available to you. These include drug therapies; minimally invasive non-surgical options; and surgical options. Your doctor should discuss all the alternatives with you based on your condition.
Pharmaceutical Fibroid Tumor Treatments
Birth control pills - many physicians will prescribe birth control pills as a means of controlling excessive menstrual bleeding caused by fibroids. Other non-steroidal anti-inflammatory agents (NSAIDs) may be prescribed for pain relief. Birth control pills effectively trick your body into thinking it is pregnant. There are several potential side effects of the use of birth control pills, including risk of high blood pressure, development of blood clots, increased risk of heart disease, and/or liver disease. Data suggests that fibroids may re-grow after this treatment ends.
GnRH Agonists - can be prescribed by physicians when the symptoms of fibroids are not controlled by birth control pills, or can be prescribed as a first attempt in controlling fibroid symptoms. GnRH agonists are used to decrease the production of estrogen in the ovaries, which may reduce the size of fibroids and help manage the associated symptoms. Because of the decrease in estrogen production, there may be some side effects, such as hot flashes or mood swings. Furthermore, there may be some bone loss associated with prolonged use of GnRH agonists. In addition, data suggests that fibroids may re-grow after this treatment ends.
Non-surgical Option: Alternatives to Hysterectomy
Uterine fibroid embolization, also known as artery embolization, is a procedure where an interventional radiologist uses a catheter to deliver Embosphere® Microspheres that block the blood supply to the fibroids. This is a minimally-invasive, non-surgical therapy that treats all fibroids. This fibroid treatment usually takes less than one hour. Clinical data suggests that patients treated with Embosphere Microspheres return to work and daily activities on average within 11 days. Patients treated with other embolic agents return to work and daily activities between 13 and 16 days. Potential benefits of UFE include:
- Preservation of the uterus
- Decrease in menstrual bleeding from symptomatic fibroids
- Decrease in urinary dysfunction
- Decrease in pelvic pain and/or pressure
- No surgical removal of the uterus and possible need of hormone replacement therapy (HRT)
- Virtually no blood loss
- Covered by most insurance companies
- Out-patient procedure (generally 10 to 23 hours)
- More confidence with less chance of soiling events
- Overall significant improvement in patient's physical and emotional well-being
Overall, UFE is a safe procedure for treating symptomatic fibroids with minimal risk. Overall, 96% of patients indicated they were happy with their twelve month outcome, and would recommend UFE to a friend. Most reported risk factors and complications associated with UFE are transient amenorrhea, common short term allergic reaction/rash, vaginal discharge/infection, possible fibroid passage, and "post-embolization syndrome." For more comprehensive information see possible risks and complications associated with UFE.
Hysterectomy is defined as the "surgical removal of the uterus" (womb). It is one of the most common of all surgical procedures and can also involve the removal of the fallopian tubes, ovaries and cervix. Following this operation you will no longer have periods, nor will you be fertile or be able to have any more children.
There are two main ways to perform a hysterectomy. The most common way is to remove the uterus through an incision in the lower abdomen. The second and less common way, is to remove the uterus through a cut in the top of the vagina, where the top of the vagina is stitched. Each operation lasts between one to two hours and is performed in the hospital under a general anesthesia
There are different types of hysterectomy:
A "total hysterectomy" removes the complete uterus including the cervix. This is the operation most commonly performed.
A "subtotal hysterectomy" removes the uterus leaving the cervix in place. If you have this operation you will need to continue to have Pap smear tests.
A "total hysterectomy with a bilateral or unilateral oopherectomy" removes the uterus, cervix, fallopian tubes and both or one of the ovaries. If you you have not had your ovaries removed and you have not gone through menopause before your operation, there is a 50% chance that you will go through menopause within 5 years of having this operation.
Physically there are a number of issues that are common to all women having a hysterectomy. You will not have any more periods and you will not be able to have any more children. If you have had your ovaries removed you will go through menopause regardless of your age. Menopause is not related to age, it is related to the production of the female sex hormone, estrogen. Your physician should discuss Hormone Replacement Therapy (HRT) with you to help you understand the pros and cons of HRT.
Myomectomy - is the surgical removal of the fibroids. While this procedure keeps your uterus in-tact, it can be a surgically challenging procedure and is not performed by all physicians. In addition, only certain fibroids may be treated with this therapy. An abdominal myomectomy is performed through a horizontal incision through the abdomen, similar to a "bikini cut" used in a cesarean section. Most types of fibroids, even very large ones, can be removed in an abdominal myomectomy. The recovery time varies with each patient, but typically is 4-6 weeks in length. Pedunculated and subserosal fibroids can be removed via a laproscopic myomectomy, which is performed through three small incisions. When a resectoscope is used to remove submucousfibroids, this is called a hysteroscopic resection. The use of a resectoscope requires proper training by the physician prior to use.
Frequently Asked Questions:
What is Uterine Fibroid Embolization (UFE)?
- UFE blocks the flow of blood to the fibroids, causing them to shrink.
- Blood flow is blocked using tiny particles called embospheres. The material used for the embospheres are well tolerated by the body.
How do I know if this is the right procedure for me?
- Patients who are ideal for UFE include women who:
- Have symptomatic fibroids
- Do not intend to get pregnant
- Want to keep their uterus
- Do not want surgery
How do I know if my fibroids are symptomatic?
- Fibroid symptoms may include:
- Heavy, prolonged monthly periods
- Lower abdominal or lower back pain
- Frequent urination
- Pain during sexual intercourse
Is it a surgery?
- UFE is a procedure
- It is minimally invasive:
What kind of doctor does the procedure?
- UFE is performed by an interventional radiologist, a doctor who uses x-rays to see inside the body and treat conditions without surgery.
How long does the procedure take?
- Typically, less than an hour.
- Requires an overnight stay
Will I be put completely to sleep?
- During UFE, you are sedated but remain awake. Most people do not remember being awake for the procedure. You do not feel pain during the procedure.
How will I feel after the procedure?
- Some women experience moderate to severe pain and cramping in the first several hours following the procedure.
- Symptoms can be controlled with appropriate medications.Some experience nausea and fever
- Some experience nausea and fever
How successful is the UFE procedure?
- Studies have shown that up to 90% of women will experience significant or total relief of heavy bleeding, pain and other symptoms.
- The procedure is effective for multiple fibroids.
- Recurrence of treated fibroids is rare.
How long am I off of work?
- Patients return to work in an average of 11 days.
Will my health insurance cover this procedure?
- Most Health plans are currently covering this procedure.
How do I get an appointment?
- HMO plans will need a referral from your physician.
- PPO or Medicare may be self referred