Obstetrics & Gynecology
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Fibroids are so common that women with them are part of my practice every day. Fibroids are benign tumors of the uterus that usually do not appear, or at least do not present problems for women until after the age of 30. Rarely are they a cause of infertility. If you have been told you have fibroids, and you are not experiencing problems, such as heavy cycles, then chances are, there is no need to remove them. Any menstrual flow that lasts more than seven days is not normal. Passing clots, especially for more than the first two days of a cycle is abnormal. Heavy bleeding can lead to anemia which may indicate a need to remove the fibroids. Usually, fibroids do not cause pain, but sometimes fibroids can cause a uterus to push on nerves or the bladder or rectum, causing discomfort, constipation, urinary incontinence or frequency, or dyspareunia (painful sex).
Fibroids usually appear at the top of the uterus, known as the fundus, but they can occur anywhere on or near the uterus. Fibroids are described as being pedunculated, if they are attached to the uterus by a stalk. They can be subserosal if they are just below the outer surface of the uterus. Intramural fibroids, or fibroids in the muscular wall of the uterus, are the most common, and often do not cause problems, although they can get quite large. Occasionally a fibroid will penetrate or even grow into the cavity of the uterus. These are called submucosal and are the most likely to effect your bleeding, regardless of the size. Intracavitary fibroids are similar to pedunculated fibroids, but they are located on the inside of the uterus rather than the outside. These almost always cause bleeding abnormalities.
There are several different procedures to manage uterine fibroids, but the definitive treatment is hysterectomy. A hysterectomy is removal of the uterus via an abdominal incision, with the laparoscope, or through the vagina. It is important to know that your ovaries do not necessarily have to be removed with a hysterectomy. Ovaries provide you with your natural hormones, so if you can keep them, that is usually best.
Other less invasive procedures are possible depending on the location, size, and number of fibroids. With all other procedures other than hysterectomy, the woman may still have menstrual bleeding and the possibility that fibroids will return. Endometrial ablation involves destruction of the endometrium. The endometrium is the lining of the uterus that is shed each month. Ablation is an attractive option when the fibroids are small, as it does not require an incision or weeks off from work. There are four types of ablation. First is called the roller ball. In this procedure, a hysteroscope is used along with a small electrode that is used to burn the lining of the uterus. Compared to other procedures, it is time consuming, and I dare say that new physicians today probably are not trained in this method. I have done quite a few, but not in years.
Two other procedures burn the lining of the uterus. One is called balloon ablation and the other is Novasure. Balloon ablation is a technique in which a small balloon is inserted into the uterine cavity through the vagina and filled with water. The water is then heated to a temperature that will cause thermal destruction of the uterine lining. Another technique, that is faster, is Novasure. This procedure involves inserting a device into the uterine cavity, that then fans out to fill the cavity. This procedure is fast and effective if the fibroids are small. It may work better if the fibroid or fibroids are inside the cavity. Finally, there is cryoablation. This involves freezing the lining of the uterus. Cryoablation is most easily done in the physicians office compared to the other methods. All of these procedures only require a couple of days off work.
Ablation may completely prevent menstrual bleeding, but more often than not, a woman will still have cycles, although lighter, or she may have a return to menstruation months to years later. One other concern with ablation techniques is that it may hide a developing endometrial cancer. Endometrial cancer usually presents with abnormal or post menopausal bleeding. Scarring of the uterine lining by ablation may prevent this warning sign from occurring.
A procedure performed by some radiologists called uterine artery embolization can be highly effective for women who have only one or two large fibroids. The radiologists locates the fibroids and passes a catheter through an artery supplying blood flow to a particular fibroid, then blocks the flow of blood to the fibroid causing the fibroid to deteriorate over time.
Myomectomy is a surgical procedure where the fibroids are removed and the uterus is repaired. This can be done with a laparoscope, hysteroscope, or an abdominal incision depending on the location, size and number of fibroids. Myomectomy is the best option for women who still want to conceive.
There is one medication available that will shrink fibroids called leuprolide acetate. Lupron is a GnRH agonist that shuts down ovarian production of estrogen, essentially putting a woman into temporary menopause. Lupron can cause significant bone loss after a few months, and after the medication is stopped, the fibroids quickly return to their previous size. Lupron is a one month or three month injection that costs several hundred dollars per injection. I sometimes will use Lupron for a short period of time to shrink really large fibroids, before performing a hysterectomy or myomectomy. Menopause in and of itself will cause a reduction in size and symptoms of fibroids.