Deborah, a 54 year old woman from the Midwest, called stating that her uterus had multiple fibroids which have grown over the last two years, and she wanted to avoid a hysterectomy for personal reasons. She was having regular menstrual periods and lab work (FSH) showed that she was not yet menopausal, and was quite uncomfortable from the pressure of her huge uterus and heavy menstrual bleeding. An MRI was ordered, in which over 30 fibroids were identified. (Sticky post) Read the rest of this entry »
by Paul Indman, MD
March 09, 2010 was the first time I met Dr. Paul Indman for a second opinion on fibroid treatment. I’d been searching for the specialist in this field in Bay Area since September 2009, when I was told by my general OB/GN doctor my fibroid was so big (11cm by ultrasound and my tummy as big as 16~18 weeks pregnant ) that I need to consider surgery. She talked about the rapid growth of my fibroid (in January 2009 it was 8cm) that would possibly be sarcoma (cancerous) that I would need to remove the whole uterus. I was not comfortable by this conversation and just replied that I need to find a second opinion before I make a decision (I don’t blame my general OB/GN doctor in any means, in fact she’s helped me all the time for woman issue and helped me on my childbirth with a C-section in 2006). Luckily in the beginning of this year, I found Dr. Indman’s website and read all the articles there and found they all make sense. So I made a phone call to his office for the appointment.
I was already very anemic at the time Dr. Indman first saw me. My hemoglobin was only 5 (normally 12 ~16). And he diagnosed me with ultrasound and confirmed the big fibroid. So he treated me in two steps: first, heal my anemia first by controlling my blood loss during menstrual period and second, do the surgery to remove the fibroid. When the second time I saw Dr. Indman in about a month, my hemoglobin has increased to 11.3. The first step treatment seems very encouraging so we scheduled the surgery. May 10, 2010, I had my abdominal myomectomy surgery by Dr. Indman and I stayed in hospital for two days. Now I’m home and it’s the fifth day after my surgery.
When I’m looking back what has happened in the last two months, my heart is filled with gratitude to Dr Indman and his staff team. I’m very satisfied to the outcome of the treatment and convinced with his expertise and skills, his truly caring to patients. I know surgery is not an easy decision to everyone. From my experience, my piece of advice would be to find the doctor that you think you’re really comfortable to work with.
When I first saw Dr. Indman in October 2009, I was seeking a second opinion. The gynecologist I had been seeing for about 10 years, and who had originally diagnosed my fibroid, told me that in her opinion I should have my uterus removed. She had been monitoring my fibroid by doing ultrasound exams every six months for about six years. The ultrasound images showed the fibroid had been growing slowing during that period.
So she was alarmed when she compared the ultrasound she did in March 2009 to the one she did in September 2009; she saw that my fibroid had been growing quickly during that six months. At her direction, I had an MRI. When she received the results of the MRI, she felt she couldn’t “rule out cancer.” That’s when she called me to recommend a hysterectomy. I immediately phoned my husband. I was still in shock, and my husband asked if I wanted to get a second opinion. Indeed I did!
The idea of having my uterus surgically removed did not sit well with me for many reasons. Although having children was no longer an issue, I recoiled at the idea of having surgery that might not be necessary. From what I knew of fibroids, I didn’t think it was very likely that this was cancer. I felt extremely healthy and had no pain or other symptoms. I also wanted to prevent the trauma to my body and to my sense of self that I knew would come with a hysterectomy. And lastly, I am self employed, so if I don’t work I don’t make money. The recovery time would have been a period of zero income for me.
The day I was told I needed a hysterectomy, I hopped on the Internet and learned as much as I could about fibroids, treatment, the aftermath of a hysterectomy and the possibility that what I had could be cancer. I learned a great deal from one site, www.myomectomy.net. What I read there educated me and also validated some of the things I was already thinking.
That web site provided information about Dr. Indman, and I was surprised and happy to find out that his office is only a half-hour drive from my house. I called his office the next morning and made an appointment to see him that same week. I was told to bring the recent MRI results, radiologist’s report, and ultrasound results with me. At that first appointment, Dr. Indman talked to me; conducted a thorough physical examination, including an ultrasound; and studied the MRI results, radiologist’s report, and previous ultrasound results. He explained that based on statistics, the chance of my fibroid being cancerous was quite slim. We agreed that I would come back for another ultrasound a month later. The results of that exam showed no growth of the fibroid.
In a follow-up ultrasound with Dr. Indman six months later, he found that the fibroid was actually a little smaller than it had been. I was delighted when he finished the exam and said, cheerfully, “Another hysterectomy bites the dust!”
One last thing about Dr. Indman. In addition to his professional abilities and his many years of experience, he has a very pleasant manner with patients. I greatly appreciate the respect with which he treats me. He wants me to be involved in my own care, and he listens—really listens—to what I have to say. And he answers my questions thoroughly. I’m very glad I went to him for my second opinion.
In October, 2009 I saw Kate, a 50 year old woman who was told that she needed a hysterectomy. In March 2009 a 3.5 cm (about 1 1/2 inch) uterine fibroid was found by her gynecologist. She was on low dose birth control pills at the time.
On Sept 23, 2009 she was told that the fibroid was 7.2 x 6 cm. She had no symptoms at all. No pain, no pressure, no abnormal bleeding. Her gynecologist told her that the fibroid was growing rapidly, and could be cancer, so she needed an immediate hysterectomy.
I first saw Kate on October 1, 2009. At that time I could feel a small fibroid next to her uterus. I did an ultrasound during which I saw a pedunculated myoma (a fibroid on a stalk) measuring 6.9 x 4.6 cm. Knowing that the risk of cancer is extremely low, we decided to monitor the size of the fibroid closely rather than rushing into surgery.
November 1, 2009. I rechecked the fibroid with ultrasound and it measured 6.5 x 5.1 cm. Essentially the same size.
April 5, 2010: Her fibroid measured 6.3 x 4.7 cm. (a slight decrease in size). As she was 51, we decided to stop the birth control pills and will do lab work (FSH) to determine if she has reached menopause.
Dr. Indman’s Comment: This situation is something I commonly see — a woman has a fibroid detected and told that she needs surgery because it is rapidly growing. In Kate’s situation she had an ultrasound that showed that it really was growing, although frequently these “new” fibroids” have been there for a long time and have just been missed on exams.
The risk of cancer in rapidly growing fibroids is approximately 1 in 400. Understanding that there is a very small risk of cancer, we decided that close monitoring was reasonable. As Kate’s fibroid has actually decreased in size, it is extremely unlikely that she will need surgery.
Economics: Kate would have only had to pay 20% of her insurance company’s “preferred provider’s” contracted rate for the unnecessary hysterectomy. She also would have lost 6 weeks salary off of work, and had an operation that she did not need. The cost of an expert evaluation was far less than 20% of a discounted operation she did not need!
A 47 year old woman with “rapidly growing uterine fibroid”. P.D.M. contacted us because she was told she had a rapidly growing fibroid. She wanted to avoid a hysterectomy, but in her home state of Wyoming was only offered hysterectomy with removal of both ovaries because of the possibility of cancer. Several years ago she was noted to have a small myoma on ultrasound, but it appears to have grown rapidly in the last year. She noticed some pelvic pressure but no abnormal bleeding.
When she contacted my office we suggested that she get an MRI, which showed a 10 cm. (4 inch) mass in the uterus will cystic (fluid filled) areas (which are white), suggesting a degenerating fibroid. (This is a fibroid that has outgrown it’s blood supply.) Her MRI is shown to the left.
We discussed options, and the very low risk that this could be cancer. With that knowledge, she chose to come for a myomectomy.
P.D.M.’s myomectomy is shown in the photographs. An incision was made that was smaller than the fibroid, but it was possible to remove the fibroid through this incision.
Here is the removed fibroid, which has been cut open to show the fluid filled areas.
The pathology report showed a benign degenerating uterine fibroid.
She left the hospital on the second day after surgery, and was able to return to Wyoming the following week.
Dr. Indman’s Comment: P.D.M. was advised to have a hysterectomy because of concern that she may have had Leiomyosarcoma, or malignant fibroid. A sarcoma is serious, but fortunately they are uncommon. There is no evidence that benign fibroids can become malignant. One large study has shown the risk of cancer in rapidly growing fibroids to be 0.26%, or about 1 in 400. As 70-80% of women have fibroids (although many are too small to notice), and malignant fibroids are rare, it is hard to justify removing most fibroids or doing a hysterectomy because of the possibility of cancer. In my patient’s situation the fibroid was growing rapidly and causing symptoms, so she chose to have it removed.
The decision to remove the fibroid or do a hysterectomy in a 47 year old woman who is not planning to have children is personal, and there are advantages and disadvantages to each approach. In the very unlikely chance that a malignancy is found, a hysterectomy would of course be necessary. On the other hand, we would be doing hundreds of hysterectomies for benign fibroids to find one that had cancer. In addition, I would strongly recommend against taking out her ovaries, as the increased risk of heart disease, osteoporosis, and other problems outweigh the risk of later developing ovarian cancer.
I feel that my role is to explain all of the reasonable options available to women, and help them make the best decision for their own lifestyle. As P.D.M. felt emotionally that she wanted to keep her uterus, and there was no medical need for a hysterectomy. The fibroid was easily removed while leaving her uterus.
What are Uterine Fibroids?
The walls of the uterus are made of smooth muscle called myometrium, and the inside lining, with glandular tissue, is called endometrium. “Uterine fibroid” is a slang term for leiomyoma, or often simply myoma. Fibroids are benign tumors made of smooth muscle cells.
Fibroids are extremely common. It is often stated that 30% of women have uterine fibroids, but this is an underestimate. Most women have fibroids, but many are too small to be detected and do not cause any problems. They are more common in women of African descent, with one study showing an incidence of 60% by the age of 35 and 80% by the age of 50. In Caucasian women the incidence has been found to be 40% by age 35 and 70% by age 50.
What Causes Uterine Fibroids?
There are a number of factors that cause fibroids. There is a genetic factor, as the DNA in fibroids frequently show abnormalities. Likely there is an abnormality in which the cells in fibroid handle estrogen and progesterone. Fibroids are not caused by too much estrogen any more than fire is caused by too much air!
Can Fibroids turn to Cancer?
There is no evidence that benign fibroids can turn into cancer. One study looked at 371 study in women with rapidly growing myomas and found only one sarcoma (cancer) or 0.26%, in the group. Although women are often advised to have surgery because of fear of cancer developing in a fibroid, the actual risk is very low. Although Leiomyosarcomas are serious malignancy, the actual risk of a seemingly benign fibroid being malignant is extremely low.
What Causes Fibroids to Grow?
Fibroids are sensitive to both estrogen and progesterone. Without these hormones most fibroids will shrink but not go away. Do not interpret this to mean that fibroids are caused by too much estrogen. That would be the same as saying that too much air causes fires because fires go out without air! Changes in fibroid cells cause fibroids to be more sensitive to normal levels of estrogen and progesterone.
Do Birth Control Pills Cause Fibroids to Grow?
There is no evidence that birth control pills increase the risk of developing fibroids or causes new fibroids to grow. There is some evidence, in fact, that certain birth control pills may slow the growth of fibroids.