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The Painful Facts About Fibroids


Fibroids (also called leiomyomas) are the most common solid pelvic tumors in women, with some studies finding fibroids in up to 70% of white women and more than 80% of African-American women by age 50 years. Many women do not have symptoms and do not require medical or surgical treatment. On the other hand, fibroids can grow to fill the abdomen making women look 9 months pregnant and cause abnormal uterine bleeding and pelvic pressure.


The most common type of bleeding is heavy or prolonged menstrual bleeding, which can lead to anemia (low blood count) requiring blood transfusion and even admission to the hospital. The pelvic discomfort and heavy flow can disrupt a woman's daily activities and cause problems at work, home, and in relationships. Frequent doctor's visits and fatigue from anemia can lead to missed days from work, decreased productivity, and even depression. Large fibroids compress the other pelvic organs and can cause difficulty defecating, urinary incontinence, and even pain during sexual intercourse.


Diagnosing fibroids is done by asking women questions about their menstrual cycle and symptoms, a physical exam, and most often an ultrasound. Ultrasound uses sound waves to create a picture of the pelvic organs and does not expose women to radiation. Other scans such as MRI and CT scans can sometimes be used to see the pelvic organs, but usually ultrasound is adequate. Fibroids deep in the womb often require a quick outpatient procedure called hysteroscopy in which a slender camera (much smaller than a pencil) is inserted through the cervix and the lining of the womb is visualized. If required, visualized fibroids can by excised during this procedure.


Fibroids are the number one reason why women undergo hysterectomy (removal of the uterus or womb). For women with severe symptoms, hysterectomy is the only permanent treatment that prevents fibroids and symptoms from recurring.


Women who wish to preserve their ability to have more children or who desire to retain their womb even after completion of childbearing often seek alternative medical and surgical treatments. The treatment is usually individualized based on the number, size, and locations of the fibroids. Currently, as OB/GYNs we lack simple, inexpensive, and safe long-term medical treatments and ultimately patients often require surgery. When considering an alternative to hysterectomy, both patient safety and the effectiveness of the alternative need to be considered. All medical and surgical alternatives to hysterectomy allow the possibility for new fibroids to form, and undetected small fibroids may grow rapidly, requiring another treatment. The risk of new or undetected fibroids forming must be weighed against potential complications of alternative treatments, and it must be noted that procedural complications can lead to unanticipated hysterectomy in rare cases.


This article is meant to introduce you to the medical and surgical management options, not to be a complete review. I hope it helps you better understand your treatment options.



1. Common medication treatments: Birth control pills and NSAIDs


Birth control pills are widely used to control menstrual abnormalities in women with and without fibroids. These medications are often the first treatments attempted in controlling abnormal bleeding and painful periods. However, studies suggest that medications tend to give only short-term relief, and that they are frequently followed by surgical management.


NSAIDs (Nonsteroidal antiinflammatory drugs) are effective in decreasing the pain experienced during periods in women who don't have fibroids, but there are no studies showing an improvement in women with fibroids.


2. Medication for HUGE fibroids: GnRH Agonists


Occasionally, women develop massive fibroids that can fill the abdomen and make them look 9 months pregnant. Medication called gonadotropin-releasing hormone (GnRH) agonists may used before surgery to shrink fibroids. These medications can have undesirable side effects and are generally used in severe cases.


3. Myomectomy


This surgical procedure involves removing the fibroids while the womb is kept in place. This option maintains a woman's ability to become pregnant after surgery. Depending on the number, size, and locations of fibroids a myomectomy can be performed by:


Hysteroscopy - a slender camera (much smaller than a pencil) is inserted through the cervix and the lining of the womb is visualized. Fibroids are then excised. No abdominal incisions are made and the patient is discharged from the hospital the same day as the surgery.


Laparotomy - surgery through an open abdominal incision. This surgery usually results in a larger incision, more post-operative pain, increased risk of bleeding, and a longer hospital stay when compared to the following methods.


Laparoscopy - surgery through small abdominal incisions using a thin, lighted tube. When compared to the large abdominal incision of laparotomy, this type of surgery generally results in less bleeding, less post-operative pain, faster recovery, a quicker return to work, and in many cases the patient can be discharged from the hospital the same day as the surgery.


Robot-Assisted - this is a form of laparoscopic surgery in which the surgeon's visualization is enhanced with 3D camera and surgical precision is improved. Similar to laparoscopy, the patient is often discharged home the same day as the surgery.



4. Hysterectomy


This surgical procedure involves removing the uterus (womb) along with the fibroids. This may be done via laparotomy, laparoscopy, robotic surgery, or through the vagina. Hysterectomy is the only method of providing complete assurance that fibroids do not re-grow or that new fibroids form.


5. Uterine Artery Embolization


This is a procedure in which a radiologist blocks the blood flow to the fibroids in attempts to stop their growth. This method is used in patients who at at high risk of complications during surgery. Side effects include pain, bleeding, vaginal discharge, delayed infection, possible passage of a fibroid through the vagina, potential damage to the ovaries and womb, and it has an unpredictable effect of future fertility. It is not a cure, and women frequently require another procedure or even hysterectomy.



My Take Away Message


I hope that this blog has provided you with an overview of what fibroids are and the many treatment options. If you or someone you know is suffering from the heavy bleeding, pain, pressure, or chronic fatigue caused by fibroids, please know that treatment options exist. In my experience, patients often struggle with managing the side effects of their fibroids for years before they take the leap towards curing the condition permanently. I encourage everyone to become informed, ask your doctor(s) many questions, and choose the medical or surgical treatment that is best suited for your individual circumstances. As always, I look forward to your thoughts and welcome your messages.


-A. Juusela, MD, MPH




And now with the boring (but unfortunately necessary) disclaimer:

The information I provide is intended for general knowledge only and is not intended for use in diagnosing or treating a health problem or disease without consultation with a qualified healthcare provider. My blogs are not a substitute for professional medical advice, or treatment for specific medical conditions. For any medical issues or emergencies, please consult a qualified healthcare provider in person.



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References:

Day Baird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188:100–7


Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database of Systematic Reviews 2006, Issue 2


Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol 2004;104:393–406


Friedman AJ, Daly M, Juneau-Norcross M, Fine C, Rein MS. Recurrence of myomas after myomectomy in women pretreated with leuprolide acetate depot or placebo. Fertil Steril 1992;58:205–8.


Wise LA, Palmer JR, Harlow BL, Spiegelman D, Stewart EA, Adams-Campbell LL, et al. Reproductive factors, hormonal contraception, and risk of uterine leiomyomata in African-American women: a prospective study. Am J Epidemiol 2004;159:113–23.




Dr. Juusela holds a uterus filled with fibroids.




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