Uterine Fibroids Blog — An Expert Speaks Out

Medical Journal Article

Levonorgestrel-releasing intrauterine device insertion ameliorates leiomyoma-dependent menorrhagia among women of reproductive age without a significant regression in the uterine and leiomyoma volumes.

A progesterone containing IUD (or “Lng-IUS”), marketed in the USA as Mirena®, has be shown to decrease or eliminate menorrhagia (heavy menstrual bleeding) in many women, and is proving for some to be a viable alternative to surgery.  Read the rest of this entry »

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 »

Read about and see photos of Jan’s abdominal myomectomy

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.

Sincerely,

Jan F.

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

My successful adventure in finding Dr. Indman was an interesting journey.  In June of 2008, I realized I had a problem when I was unable to empty my bladder.  After going to the emergency room and having a catheter inserted in order to empty my very full bladder, I visited a urologist who thought I might have had too much water to drink after hiking the day before.  When a second similar incident happened later in the summer, the urologist was again at a loss as to what might be going on.  He recommended I see a neurologist and get an MRI.  Finally, it was determined that I had a large uterine fibroid.  In September, I visited the gynecologist to determine what my options might be.  Before this doctor had even examined me, he told me I would need a hysterectomy in the next month. Read the rest of this entry »

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.

If you’re reading this, you’re probably suffering with issues related to uterine fibroids (heavy bleeding, cramping, Anemia, fertility issues, etc.). I’m writing this because I used to struggle with those same health issues. Today, I’m back to living a normal life, even though I never thought it would be possible again.

Read the rest of this entry »

Medical Journal Article Review

This is a study in which human uterine fibroid tissue was implanted into mice, and the effects of progesterone, estrogen, and anti-progesterone compounds were observed.  The authors found that estrogen plus progesterone stimulated growth of fibroid cells, and this growth was blocked with anti-progesterones. Withdrawal of progestrone caused fibroid tissue to shrink.  Interestingly, estradiol (estrogen) without progesterone had no effect in this study.

Comment: This study confirms others in showing that progesterone is needed for fibroid growth. For those tempted to use over-the-counter progesterone creams to treat fibroids, this study shows that extra progesterone may cause more harm than good. Do not interpret this study to mean that you shouldn’t take birth control pills if you have fibroids.  Certain low dose birth controls do not cause fibroid growth, and may actually slow growth! — Paul Indman, M.D.

In order to evaluate uterine fibroids, we need to know what is on the inside of the uterus.  Many times ultrasound (or saline enhanced ultrasound) or MRI will provide the information we need.  Many women are subjected to endometrial biopsy which is good to rule out cancer, but useless in diagnosing submucous fibroids and polyps.  Fortunately it is easy to look directly into the uterus using a thin telescope called a hysteroscope.

With today’s tiny instruments, it usually only takes a few minutes to do office hysteroscopy using local anesthesia, and most women report little discomfort.  First I numb the cervix, which is hardly noticeable.  Saline is used to fill the uterus so we can see, and a thin flexible or regular hysteroscope is inserted through the cervix under direct vision.  I encourage my patients to watch on the video monitor so they will have a better understanding of what is going on inside her own uterus.  If someone is extremely anxious she can have something to help her relax during the procedure, but the vast majority of women do not need this and can go about their normal activities for the rest of the day.

Hysteroscopy compliments other diagnostic studies, so that when we decide on a treatment plan we know exactly what we are treating, and don’t wind up with any surprises.

The photo below shows an actual view from an office hysteroscopy.  You can clearly see the submucous fibroids on the back wall of the uterus.  This type of fibroid can easily be removed (by an gynecologist experienced in this type of surgery) in an outpatient procedure called hysteroscopic resection of fibroids.

The next photo shows a large submucous fibroid at the beginning of hysteroscopic resection of the fibroid.  The loop seen is what will be used to remove (resect) the fibroids.

Comment: I feel that for a gynecologist, doing hysteroscopy in the office is as basic as an ear doctor being able to look into an ear in the office.   What would you do if you saw a doctor for an earache and he or she wanted to schedule you for surgery so they could look in your ear?  Yet only 10% of gynecologists in the U.S. (who are supposedly specialists in treating the uterus)  do office hysteroscopy.  I see too many women taken to the operating room whose surgery is abandoned because submucous myomas had not been diagnosed by surgeons not prepared to treat them.  And many of these women are told that they need a hysterectomy because the gynecologist is not experienced in hysteroscopic treatment of submucous fibroids.  I’ll have much more in detail about hysteroscopic treatment of submucous fibroids in upcoming posts!

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!

Read about Kate’s Case