Fibroids are benign tumors in the uterus. They are very common and studies have noted that they are present in 3 out of every 4 women. They do not cause a medical problem for a lot of women. However, if they are large or located in certain locations in the uterus, they can become problematic.
The most common problem is heavy vaginal bleeding. This bleeding can be painful and can make women anemic (low blood levels). Fibroids can also cause pressure and fullness in the abdomen and pelvis. Additionally, they can impact fertility and pregnancy outcomes.
Fibroids tend to grow during a women's reproductive lifetime. In other words, they start to grow when women start having periods and tend to shrink in menopause when hormone levels are much lower. Most fibroids grow slowly over time.
While we do not yet know why, fibroids are found more frequently in African-American women than in Caucasian women. Women can also be at higher risk of developing fibroids if they have a family history. Additional factors that may increase risks include obesity, high blood pressure and a diet rich in red meats or ham.
Many fibroids do not cause symptoms and do not require any intervention. Watchful waiting is a reasonable option for these patients.
There are multiple options for medical treatment:
- Birth control pills can can control bleeding symptoms, but will not shrink fibroid size.
- Progesterone medications can also control bleeding symptoms and may be associated with a decreased risk of fibroid formation.
- Lupron is a medication that causes temporary menopause. It can improve bleeding and decrease the size of fibroids by 30-50%. It can be used for up to a year, but fibroids may start to slowly regrow after stopping medication.
- Ulipristal (progesterone modulator) and mifepristone (antiprogestin) are medications that have been shown to improve bleeding and shrink fibroids temporarily. However, neither is FDA approved for fibroid management but may be made by compounding pharmacies, although this can be expensive and difficult.
- Tranxenamic acid (Lysteda) can be used to treat the bleeding symptoms associated with fibroids. This is typically used to increase blood levels prior to a surgical intervention.
- NSAIDS (Motrin) can improve pain with heavy bleeding, but have not been shown to reduce blood loss due to fibroids.
These include surgical or minimally invasive techniques. These are broken down into which are appropriate for women wishing to maintain fertility or not.
Not interested in fertility
- Uterine artery embolization – this option permanently shrinks fibroids by 30-50%. It is performed by interventional radiologists by selectively cutting off the major blood supply to the fibroids through a small incision in the groin.
- Hysterectomy – frequently the uterus and all fibroids can be removed through minimally invasive surgical techniques. The ovaries are typically retained preventing menopause and associated symptoms. This method is the most definitive management of fibroids.
- Magnetic resonance guided focused ultrasound – uses ultrasound energy to cause thermal destruction of fibroids. This technology is still time consuming and costly (most major insurance companies do not cover).
Desires future fertility
- Myomectomy – this is a surgical procedure that removes just the uterine fibroids and repairs the uterus so that it can carry a pregnancy in the future. In expert hands, many of these procedures can be done through small, Band-Aid-sized incisions.
Most fibroids are benign conditions. Rarely, a fibroid can be something called a leiomyosarcoma (LMS) or a cancerous process. In 2013, there was one case in Boston where a women underwent a hysterectomy for presumed benign fibroids and as part of the surgery electromechanical morcellation (EMM) was performed. EMM has been a standard part of minimally invasive gynecologic surgeries for about 20 years. Unfortunately, in this case, the uterus had LMS disease. The patient and her husband were very upset and started a movement to end EMM for fear that it can spread the disease process.
Part of this movement was a request for the FDA to review the use of EMM for hysterectomies and myomectomies. The FDA complied and issued a safety communication stating that LMS can occur in 1 out of every 458 women undergoing fibroid surgery (although the methodology of this review has been questioned by the Society of Gynecologic Oncologists). In November 2014, the FDA issued an updated communication which states that only women that meet specific guidelines are candidates for EMM. These guidelines state that EMM is contraindicated in perimenopausal or menopausal women, women whom have known cancer of the uterus or cervix, or women in whom the tissue can be removed enbloc (without cutting up) through a small incision.
This controversy has brought important attention to the need to find better ways to identify LMS versus fibroid tissue prior to surgery. Additionally, this case has highlighted the importance to appropriately inform patients of risks, and to develop newer techniques for fibroid removal. However, the benefits of minimally invasive surgery (band-aid surgery) must be balanced against the risk of EMM when it is necessary. Recent evidence suggests that when appropriately used, EMM actually saves lives as compared with open or big incisions.
Additionally, a recently published article in the premier Ob/Gyn national journal reviewed all the appropriate studies concerning fibroids and LMS. The article found that 1 in every 1,550 patients could have LMS, however that is the highest estimate and the actual rate is probably even less frequent. We do note that LMS diagnosis is much more common in older patients (the average age of diagnosis of LMS is 60 years), so the risk for young women is likely even lower.
All the major medical associations continue to support EMM when used for appropriate patients and with the informed consent of the patient. These organizations include American College of Obstetricians and Gynecologists (ACOG), American Association of Gynecologic Laparoscopists (AAGL) and the Society of Gynecologic Oncology (SGO).
After careful consideration and evaluation of all the literature, our physicians continue to offer EMM for appropriate patients that fall within appropriate FDA guidelines. We have a very complete consent process and respect that all patients will have different desires. If a patient does not want EMM we will honor that request and perform the surgery per the patient preference.
We have instituted an additional measure in response to LMS concern by offering contained EMM. In contained EMM, This the fibroids into a specimen bag inside the abdomen for the portion of EMM.[MC1] This contains the disease process and limits the spread. While the technique is being perfected, the studies demonstrating ideal containment are still being studied.