Although it is often frightening to learn about the presence of “a tumor” in our uterus, the good news is that fibroids are simply smooth muscle tumors, made up of the same cells that form our uterus to begin with. The cells get disoriented and form growths. They are neither dangerous nor cancerous. In many cases they are noted on otherwise normal annual exams and merit no more than a passing reference to their presence, that is, they may simply be observed. 30% of all women have fibroids in their lifetime. Only a few require treatment. Fibroids seem to be related to our reproductive cycling and circulating estrogens. They do not seem to be related to the taking of birth control pills. They grow during our menstrual life and stop growing at menopause. They can even shrink after menopause. The majority of fibroids do not cause any symptoms at all. The diagnosis of fibroids on a check up where nothing else is bothering you should not necessitate any treatment whatsoever. We can live happy lives coexisting with small to moderate sized fibroids.
Symptoms from fibroids are usually related to where in the uterus the fibroid is located. If there is a growth inside the uterine cavity (Submucosal fibroid) it can cause very heavy menstrual periods, dangerously heavy. In fact this can lead to a serious anemia or low blood count. This results in fatigue and possibly even dizziness. These same fibroids can interfere with fertility because the implantation site of the embryo may be compromised. If the fibroid is in the uterine wall (Intramural fibroid) it can enlarge the uterus anywhere from a little bit to a great deal. The largest fibroid I have ever removed was the size of a term pregnancy, almost a foot in diameter. After this was removed, the uterus returned to normal size. These can also cause heavy bleeding. If the fibroid forms on the outside of the uterus (Subserosal or pedunculated fibroid) it rarely causes problems with bleeding and does not interfere with the uterine function much at all. However, it can be confused with an ovarian mass, or can grow to be large enough to cause symptoms on this basis alone. Of course it is possible for there to be several fibroids in several locations.
So when is it recommended to treat fibroids?
As I mentioned before, fibroids located inside the uterine cavity, submucosal fibroids, interfere with the normal menstrual period and can cause very heavy bleeding with periods or between periods. The periods can be unusually long as well. When this occurs, it is time to consider treatment. First we must be certain it is the fibroids that are causing the bleeding. An ultrasound of the pelvis can help distinguish between conditions such as fibroids, polyps, or hormonal conditions leading to a thickened uterine lining. It is also important to be aware of other conditions that cause bleeding, such as a blood clotting abnormality like hemophilia or Von Willebrand’s Diseases. These are rare conditions that are treatable medically. Once the diagnosis is confirmed, treatment can be recommended.
As previously described, fibroids can be microscopic or quite large. If the fibroid is small and causing no symptoms, we can and should ignore it. No treatment is needed for small fibroids or asymptomatic fibroids. But once they grow into a tumor that presses on other vital organs like our rectum or our bladder we can experience serious symptoms that interfere with our quality of life. These may be either intramural or subserosal fibroids. Fibroids can grow to almost any size but when they reach the size of a cannon ball they tend to become annoying. We may experience an urge to urinate frequently if the fibroid presses on the bladder or difficulty with bowel movements if the fibroid may be pressing on our rectum. This tends to get worse in time as the mass grows. Even though it is a benign mass, (not cancer), it may need treatment. There has been misinformation in the past that if a fibroid grows rapidly it might be cancer. This is true less than a tenth of one percent of the time or very, very rarely. Rapidly growing fibroids should be treated the same as any similar size fibroid.
There are times when usually non-painful fibroids can actually become very tender causing considerable pain. If a fibroid outgrows its blood supply, this causes some of the muscle tissue to “die” or degenerate. When smooth muscle dies, it can be painful, like when heart muscle dies causing a heart attack. The difference is that while every part of our heart muscle is important to the overall function of our heart, and a heart attack is an emergency, the same is not so for the uterus. When this process occurs in the uterus, it may be very painful, but since we really do not depend on the fibroid tissue for any function, there is no emergency, just pain. This pain is usually self limited, will stop eventually on its own and can be treated conservatively with pain medicine until the process is over. This can take several weeks. Other causes of pain are from the pressure of the fibroid pressing on other organs. If the pain does not completely resolve, removal of the fibroid may be considered.
If treatment is needed for heavy bleeding the options include birth control pills, which reduce menstrual flow in most women, or the use of the long cycle pills where periods occur only every 3 months. If this is not adequate, and it may not be, there is Lupron, which is a monthly or every three-month injection given at the doctor’s office. This causes temporary reversible menopause, stops the bleeding, and allows us to replenish our blood supply enough to withstand a surgical procedure that would be more definitive. Low doses of hormones may be given to reduce any menopausal symptoms that might occur. This is only a short-term solution for 3 – 6 months. BUT it effectively stops the growth of fibroids and any accompanying bleeding. This allows for safer surgery, emotional preparation and the possibility that if menopause is near, the avoidance of surgery entirely.
There are three ways to approach a myomectomy, the removal of the fibroids and reconstruction of the uterus.
The simplest is in the case of the isolated submucosal fibroid in the uterine cavity. This can be removed with a resectoscope myomectomy, which is very much like a sophisticated D & C. This procedure is performed with an anesthesia in a hospital or surgicenter. The cervix is opened and a telescope, called a hysteroscope, is inserted into the uterus with a cutting wire attached. The fibroid in the cavity is removed piece by piece with the cautery wire. This removes the fibroid entirely if it is completely in the cavity. If it is partially in the wall of the uterus as well, the portion in the wall will be left behind, as it is not safe to dig into the wall to remove more than that which is visible in the telescope. Usually this is all that is necessary to stop the bleeding. Normal activity is resumed the very next day. There may be light bleeding for up to a couple of weeks. The only limitations are that nothing should be in the vagina, no intercourse, tampons, swimming, or baths for 2 weeks while healing occurs (showers are fine). Otherwise you may resume normal exercise and activity.
If the fibroid is in the wall of the uterus or protruding into the abdomen it may be removed through a “bikini” type incision. This is about an inch above the pubic bone and about 6 inches in length. The fibroids are then cut from the uterus and the uterus is reconstructed with several rows of stitches. This resembles a cesarean section type surgery and the recovery is similar, a few days in the hospital followed by 2 weeks at home and a full month to six weeks before all normal activity may be resumed. We have many techniques to reduce surgical pain. At the time of surgery, long acting local anesthesia is injected into the incision, which lasts at least 8 – 12 hours. There are local anesthesia pumps that continuously pump more local anesthesia into the incision for 3 – 4 days. We can also add an anti-inflammatory pain medication, Toradol, which reduces the need for narcotic pain medication. We can add a small amount of narcotic with a PCA, patient controlled analgesia. This is a button attached to a pump the patient pushes to release a small dose of pain medicine directly into the IV line. The advantage of this system is that the small doses have fewer side effects and may be given every few minutes if necessary. It is ideal when the patient is in control of the flow of pain medication as it reduces stress and improves healing when the patient is not worried about pain medication. This is a good choice especially if the fibroid is quite large or there are several of them. Many women have been told by their physician that their fibroids are too large for a myomectomy, that only a hysterectomy will be possible, that the risks of bleeding or the surgical difficulty is too great. This has not been shown in the scientific literature. There are many techniques to manage the blood loss of surgery. Of interest is the cell saver. This is technology where any blood loss is recaptured and returned to the patient in the form of an auto-transfusion. It is a very effective way to avoid hysterectomy or blood transfusions. Even the largest fibroids have been successfully removed, as I mentioned before, the largest I have removed was about 25 cm or almost a foot in diameter. If there are several fibroids, this method will succeed as well. I have removed as many as 25 fibroids from one woman. Even with these seemingly extreme circumstances, three months after surgery, the pelvic exam was normal and the symptoms were gone!
Whenever possible it is best to avoid the abdominal “bikini” incision with a minimally invasive procedure. Laparoscopic myomectomy involves the placement of a small telescope, the laparoscope, through a half-inch incision in the umbilicus and 2 – 3 other quarter to half-inch incisions in the lower part of the abdomen. The fibroid is cut away from the uterus and in a fashion similar to the abdominal myomectomy, stitches are placed in multiple layers to close the uterine incision. The fibroid tissue is then removed with an instrument known as a morcellator. This technology cuts fibroid tissue into long strips that can be removed through a half-inch incision. A laparoscopic myomectomy may require more evaluation including an ultrasound and possibly an MRI. The benefits are that it can be done as an outpatient and that normal activity can be resumed in a few weeks.
The Da Vinci surgical robot is now available at our hospital, and we have done the preliminary training in San Jose and case observations in San Diego. It is possible to remove fibroids with the laparoscope and the robot. We are beginning to schedule robotic cases at this time. I have personally assisted in these cases and look forward to continuing this interesting new technology.
Uterine artery embolization is performed by a radiologist in an outpatient setting with sedation. General anesthesia is not required. A small tube (a catheter) is threaded through the arteries to the uterine artery. Through this catheter, pellets are injected to temporarily block the artery and stop the blood flow to the fibroid. This halts the growth of the fibroid and the associated bleeding. It encourages shrinkage of the fibroid to approximately half its original size. This is a reasonable option for women with heavy bleeding and a dominant fibroid who want to avoid surgery. The vessels reopen after a while and new fibroids may form or untreated fibroids may grow. Pedunculated fibroids are not treatable by embolization.
As always, hysterectomy should be a last resort. If myomectomy is not possible without an incision, sometimes a supracervical laparoscopic hysterectomy remains an option. It may actually be logistically simpler to remove the uterus than to perform a laparoscopic myomectomy if there are several fibroids, or if the location of the fibroids is difficult to approach laparoscopically. If myomectomy has been performed before, it would be reasonable to discuss hysterectomy although sometimes a second myomectomy is possible. I have performed as many as 3 myomectomies on some patients. Since fibroids can continue to form, there comes a time that a woman might prefer the certainty of a hysterectomy. If a woman knows she wants to take estrogen replacement, it is simpler to take without a uterus and will never cause bleeding. As long as there is not an issue of future fertility hysterectomy is reasonable. If future pregnancy is desired, all efforts should be made to save the uterus.
It is most important to collaborate with your physician. Get a second opinion, ask questions until you educate yourself about your options and feel comfortable with your decision. Ask about your doctor’s philosophy about myomectomy and hysterectomy. If uterine preservation is important to you, make sure the surgeon is on board and has the same philosophy. Do not be afraid to ask specific questions about options and the procedures themselves. Ask about recovery details as well as pain management.
Remember, if your fibroids are not too large, and not symptomatic simple observation may be all that is required. Most fibroids do not require treatment, but in those cases when treatment is needed, be an educated consumer. As a physician, I always appreciate it when the patient participates in the treatment plan. A collaboration is much more satisfying for both the patient and the physician and leads to better outcomes.