What are fibroid tumors?
Fibroids are benign (non-cancerous) tumors, or growths, within the muscle wall of the uterus. Each fibroid is thought to arise from a single cell which grows into a mass. Both estrogen and progesterone hormones (products of the ovaries) are thought to promote the growth of fibroids. Some fibroids will remain stable in size over many years while others will appear suddenly and grow quite rapidly. Whether or not treatment is needed depends on the size, location, and rate of growth of the fibroids. Symptoms are caused by the size of the fibroids themselves (heaviness or pressure in the pelvis), or by pressure on surrounding organs such as the bladder or large intestine. Very rarely, about 1 in 10,000 cases, a fibroid may develop into a sarcoma, or very aggressive cancer.Many fibroids produce no symptoms at all, and are simply noted during the course of routine annual examinations and Pap smears. Others will cause heavy and prolonged periods. In still other situations, the size and position of the fibroid(s) may cause pain during intercourse, increased menstrual cramps, or decreased bladder capacity.
Are there medical treatments for fibroids?
Hormonal treatments have relatively little effect on fibroids. In fact, birth control pills can sometimes make them grow. An exception to this seems to be the progesterone-containing IUD, Mirena, which reduces menstrual flow, and in one recent study, has been shown to shrink fibroids slightly. Once in place, this IUD is effective contraception for seven years.Fibroids are mostly dependent on estrogen to stimulate their growth. For this reason, they often grow until menopause, then shrink, and can grow again if Hormone Replacement Therapy (HRT) is used after menopause. Shutting off ovarian function by the use of Lupron can result in a 30-60% decrease in fibroid size over two to three months, but they will re-grow within a few months after stopping the drug. For this reason, Lupron has its best role as a medication to shrink fibroids in order to make a planned surgery easier.
What surgical treatments are there for fibroids?
The uterus can be preserved when fibroids can be removed and the uterine muscle itself repaired. This procedure is called a myomectomy.
A myomectomy can be performed through an open incision, or in some cases, laparoscopically. Most experts believe that about 9-10 centimeters (about 4 inches) diameter is the largest size fibroid that should be removed laparoscopically. A few important points to remember about myomectomy:
- If four or fewer fibroids are present, the chance of regrowth of fibroids over the subsequent 5 years after myomectomy is about 10 %.
- If more than four fibroids are present when they are removed, the chance of regrowth after myomectomy is more than doubled.
- Tests such as ultrasounds and MRI scans cannot accurately count fibroids when more than four or five are present.
- For this reason, the exact number of fibroids present (and therefore the chances of regrowth after myomectomy) many times cannot be determined until the myomectomy surgery is begun.
- Adhesions, or scar tissue, commonly forms after myomectomy, and can cause fertility problems and pain.
When symptoms are severe enough, when fibroids are growing particularly quickly, when there are so many that myomectomy is impractical, or when a person wants to be certain that the fibroids will not grow back, then removal of the uterus and fibroids together makes sense. When the uterus and cervix are removed together, it is called a complete hysterectomy. In most cases the ovaries can be left in place.The types of hysterectomy that are possible in an individual situation depends on the size of the uterus and fibroids, how much previous surgery has been done, and whether or not you have had a vaginal delivery in the past. Laparoscopic hysterectomy can be performed to remove a uterus as large as a five month pregnancy (about up to the navel) or larger in some cases. Vaginal hysterectomy can be done if there is enough room in the pelvis and there are not too many adhesions of bowels to the uterus. Sometimes, we will do laparoscopy to remove adhesions, then do the rest of the surgery vaginally. If either the laparoscopic or vaginal approach will not work, then an abdominal incision is made (traditional laparotomy), although in our experience this is necessary in only 5-10% of cases.In many cases, we will remove the uterus, but leave the cervix (mouth of the uterus) in place. Click on supracervical hysterectomy to learn more.
What about uterine artery embolization (UAE)?
This procedure is done by interventional radiologists. It involves introducing a catheter into the artery and the top of the leg, threading it into the arteries supplying the fibroid or fibroids, then injecting some plastic granules that plug off the blood vessels, essentially starving the fibroid of its blood supply.Typically, this procedure takes 1-2 hours, requires an overnight stay in the hospital for pain control, and has a recovery period of 1-2 weeks. The larger the fibroids treated, the greater the pain and the longer the recovery period. Fibroids shrink between 30-60 %. The rate of recurrence of fibroids over many years is uncertain, as the procedure is relatively new. Patients are usually advised that they should not plan to become pregnant after this procedure, as it is not certain that the uterine wall will be strong enough after this procedure to carry a pregnancy. There is also a 5-10% chance that one or both ovaries will stop functioning after this procedure.We have seen a number of women who have had UAE, and then, when their symptoms were not cured, went on to have laparoscopic hysterectomy. There has not been a scientific study to directly compare the two methods, but these patients have told us that the pain after the procedure was less after hysterectomy than it was after UAE.