Uterine Fibroids Blog — An Expert Speaks Out

Michelle with her sons

I first saw Michelle when she was 35 in 2005.  She had her first myomectomy at the age of 26 and her second at the age of 33.  She was sent to me by her Ob-Gyn after an ER visit for severe bleeding.

I did an ultrasound on the first visit, and there was fluid in the uterus which outlined a large submucous fibroid. The bulk of the fibroid was in the wall rather than inside the cavity of the uterus.  Because of the location I felt hysteroscopic treatment was inadviseable.  Although we were concerned because she already had two abdominal myomectomies (elsewhere), I did her third myomectomy.

I did an ultrasound in September, 2006 showing a healthy 10 week prgnancy.  Michelle delivered her first son by cesarean in 2007. Her OB noticed some scar tissue inside her uterus at the time.  I later did an office hysteroscopy to clear this and a small amount of retained placental tissue and treat the scar tissue.  In October, 2010, she returned with another healthy early pregnancy.

Comment:  Michelle came in today with her 4 year old son, her 4 month old baby, and a picture of them taken when he was just born.  Even if you have had prior surgery don’t give up hope without seeing an expert in the treatment of fibroids.

At the time I was starting this blog two patients with similar fibroids came to see me. Both were severely anemic, and one was hemorrhaging and in shock.
Before any procedure was done I received both patients’ permission to share their stories.  At the time of the initial writing one had treatment 6 weeks ago and one 3 weeks ago.  Neither of their experiences to date are necessarily typical, but I am following through on my commitment to share their stories.

Comment:   (Updated 6-17-2010)

Yesterday was a difficult day. We did surgery on my first patient (who had the embolization) and found a high-grade sarcoma (cancer) which had spread throughout the abdomen. I talked to her about deleting her story, but she was comfortable with leaving it in.  Uterine sarcoma is very uncommon, being seen in fewer than 1 in 500 rapidly growing fibroids. The risk of cancer is much lower for fibroids that are not rapidly growing. Benign fibroids have never been shown to undergo malignant change.

Could this have been diagnosed earlier, and if so would it have made a difference? Probably not.  There is a single study in which a blood test coupled with a special MRI done with IV contrast rapidly infused differentiated between sarcoma and fibroids.  To my knowledge this has not been confirmed by other studies, and by the time the tumor can be diagnosed there is a high probability that it would have already spread.

It is easy to overreact and be overly aggressive in removing fibroids because of the fear of cancer, which is in fact rare. We would be doing hundreds of unnecessary surgeries to find a single sarcoma.  Yes, had she chosen myomectomy or hysterectomy, we would have diagnosed her sarcoma two months earlier, but it is unlikely that the outcome would be different.  I was tempted to remove this story for fear that it would frighten women into surgery that is not needed.  But I promised to tell the story as it is.  Please understand that this is very unusual, and most women do well when embolization is done in appropriate situations.  — Paul Indman, M.D

Should I have my fibroids removed before I try to get pregnant?  That is one of the most difficult questions I have to answer!  Here is what we know:

1. Submucous fibroids, or intramural fibroids that indent the endometrial cavity (inside of the uterus) significantly decrease the chances of conception, and increase the miscarriage rate. Large intramural fibroids (in the wall of the uterus) can have a submucous portion that distorts the cavity and should be considered included in this group.  Fibroids that are mostly in the endometrial cavity can usually be removed by outpatient hysteroscopic myomectomy (hysteroscopic resection).  This should only be done by a gynecologist with extensive experience in hysteroscopic surgery to reduce the risk of  scar tissue formation.  Although it may be possible to remove some submucous fibroids that are mostly in the wall hysteroscopically, if they are large they should be removed by abdominal, laparoscopic, or robotic myomectomy.
2. Intramural fibroids that do not indent the cavity appear to decrease fertility and increase miscarriage rates, but studies are inconclusive. Even if this is the case, studies are lacking to show that removing these fibroids increases the chance of successful pregnancy.
3. There is no evidence that subserous fibroids interfere with conception or increase the miscarriage rate.

Fibroids in Pregnancy

Although we used to think that pregnancy causes fibroids to increase in size, ultrasound studies show that they usually do not grow.  They often feel larger because the whole uterus is larger.

Some of the problems fibroids can cause are:

1. Pain, which can be severe enough to require hospitalization.  Sometimes a fibroid may infarct or cause pain because of decreased blood flow.
2. Increased risk of placenta problems such as abruption (premature separation of the placenta).
3. Increased risk of prematurity.
4. Increased risk of cesarean section.
5. Increased risk for post-partum hemorrhage.

The risks of serious complication are low.  Most women with fibroids go through pregnancy without any problems.

Treatment recommendation for fibroids before attempting pregnancy

There is no way I or any other physician can make specific recommendations without evaluating you individually!  These are general recommendations, and should not be followed without advice from your own physician.

If fibroids are causing symptoms such as heavy bleeding, pain or pressure it is usually reasonable to remove them.  If the fibroids are not causing symptoms, the following are general recommendations.

1.  Most submucous fibroids should be removed.  Hysteroscopic myomectomy, when done by an expert, is the treatment of choice in most situations.

2. Intramural fibroids that distort the endometrial cavity should usually be removed before attempting pregnancy.

3.  Intramural myomas that do not distort the endometrial cavity and are not causing symptoms usually do not need to be removed before attempting pregnancy.  There is no evidence that removing them improves pregnancy outcomes.

4.  Subserous myomas, unless large enough to cause symptoms, do not need to be removed prior to pregnancy.

Is myomectomy risky? This obviously depends on the skill of the surgeon.  The risk of needing to do a hysterectomy at the time should be less than 1 in 100.  I have never had to do an unplanned hysterectomy in a woman of reproductive age when I had planned to do a myomectomy.  While adhesions can develop, there are a techniques to minimize them.  All in all, myomectomy should not lower, and in many cases will improve the chances for a successful pregnancy.  Be aware that if many or deep fibroids are removed (except by hysteroscopic myomectomy) a cesarean delivery will often be recommended.

What about other treatments, such as embolization (UAE or UFE)?  Embolization blocks the blood vessels to the fibroids and/or uterus.  Although new blood vessels my take over to supply the uterus, the effect on pregnancy is unknown.  While there have been successful pregnancies after embolization, it also can decrease ovarian reserve or menopause as well as causing intrauterine adhesions (Asherman’s syndrome).  Therefore I, and most experts in fertility, would only recommend embolization as a last resort in women desiring pregnancy.

Medical Journal Article Review

Tulandi, T and Salamah K.  Obstetrics & Gynecology. 2010, 115:857

This is an article that presents a case of premature ovarian failure in a 37 year old infertility patient after a uterine artery embolization (UAE).  It goes on to discuss the current literature about UAE and fertility.

In reviewing evidenced based studies (versus “opinion” articles) the authors make the following points:

1. Women with fibroids in or partially in the cavity (submucous fibroids) undergoing IVF were less likely to conceive and more likely to miscarry than women without fibroids.
2. Women in whom fibroids distort the uterine cavity are more likely to conceive if these fibroids are removed.
3. Women with fibroids that do not distort the cavity and do not have symptoms do not require intervention before pregnancy.

The authors looked at studies on pregnancy after UAE and after myomectomy and found:

1. By measuring FSH (follicle stimulating hormone) levels one study showed UAE decreases ovarian reserve in all women.  This may not result in menopause but may impair fertility.
2. The safety of pregnancy after UAE is unclear.  They cited studies showing that the risks of miscarriage and premature delivery are higher after UAE than after myomectomy.

Comment: There are very few studies comparing pregnancy with and without treatment of fibroids.  Most studies are retrospective, meaning that records of women treated by different methods are reviewed.  The best type of study would require taking women planning treatment and randomly assigning them to a no-treatment group, a UAE group, and a myomectomy group.  One study by Mara et al, and cited in the above article, did in fact randomize women to have either myomectomy or UAE, with the finding of more pregnancies in the myomectomy group.  I will be watching for further research in this area and posting the results of any new studies.