About 20 percent to 80 percent of women develop fibroids by the time they reach age 50, according to the Office on Women's Health. What are they and how can they be treated?
Dr. Michael Moore, who is a minimally invasive gynecologic surgeon, sat down with us to answer some of the most common questions.
QUESTION: What are fibroids?
Dr. Moore: Fibroids are tumors of uterine muscle cells. The uterus is a big muscle and inside is the cavity where the baby implants. The labor contractions of the muscle deliver the baby. For reasons we do not understand a uterine muscle cell mutates into a tumor and it grows.
A woman can have several fibroids and each one is a separate mutation. They are almost always benign. They can become quite large. The fruit scale is the easiest way to understand size and we talk about oranges, grapefruits and watermelons.
QUESTION: How do you know if you have them?
Dr. Moore: Fibroids commonly cause bleeding problems. The woman notices an increase in flow. The flow can last longer, and cramps frequently get worse. When they get large a mass can be felt. Mass effect symptoms include urinary frequency, pelvic pressure and pain with intercourse. Ultrasound is the most cost-effective imaging exam to diagnose fibroids. In my opinion, CT scans and MRI are generally not necessary.
There is a simple classification for fibroids, submucosal, interstitial and subserosal. Submucosal fibroids arise in the inner third of the muscle wall closest to the cavity, interstitial fibroids arise in the middle third and subserosal fibroids develop in the outer third of the wall.
Submucosal fibroids generally cause bleeding and cramping problems. Because they arise close to the cavity the uterus is frequently normal size on exam. If only an exam is done, the doctor may blame the bleeding on age. An ultrasound is necessary to determine if bleeding is due to a fibroid. I have seen many patients over the years who had been told to live with it because it was just age by more than one provider until they came in and an ultrasound revealed the cause.
Subserosal fibroids arise closer to the outside of the uterus and frequently don’t cause bleeding problems. They are generally found on exam as a mass. The woman may have noticed urinary frequency. Interstitial fibroids can cause both mass and or bleeding problems. Not all masses are fibroids. I have seen a lot of ovarian cysts causing a mass. I can think of a few patients who went to more than one doctor and were told they had fibroids but had not had an ultrasound.
QUESTION: Are there certain age groups/ethnicities that are more susceptible?
Dr. Moore: Fibroids are very common, approximately 40% of women by age 40 have fibroids. The lifetime incidence in Asian, Hispanic and Caucasian women is 70%. Women of African heritage have an 80% lifetime occurrence. The average age at hysterectomy and myomectomy(take the fibroid out and not do a hysterectomy) is younger for black women. Fibroids are the single most common reason for hysterectomy.
QUESTION: Can fibroids be deadly?
Dr. Moore: Leiomyosarcoma is when a fibroid is cancer. The Department of Health and Human Services published the largest ever review on fibroid care in December 2017. The conclusion of that report is the risk of an unexpected leiomyosarcoma at the time of hysterectomy is 0 to 13 per 10,000 cases. The average was 8 to 9 per 10,000, meaning 1 per 1,000. When a woman is diagnosed with a fibroid the chances are 99.9% it is benign.
Unfortunately, leiomyosarcoma survival is low. The estimated 5-year survival when a woman has stage I leiomyosarcoma is 60 to 65%. The majority of women who develop leiomyosarcoma are postmenopausal. Many studies report the average age for leiomyosarcoma at around 60 years.
Fibroids do not convert from benign to cancer. The tumor starts as benign, or it starts as cancer. A postmenopausal woman who developed fibroids before menopause should be treated as if they are benign.
QUESTION: What do you do if you find out you have fibroids?
Dr. Moore: Educate yourself. The internet contains a lot of factual information, as well as a lot of fibroid science fiction. The best place to get scientific information, based on medical research, is a website that contains NIH and .gov. That information is published by the National Institute of Health. As a governmental agency, all information is reviewed by recognized experts. AdvancedGYN.com is dedicated to sharing that information in an easy to understand format.
I have seen many patients who have tried hot castor oil packs, Chinese herbs and numerous other homeopathic cures. I am unaware of scientific controlled studies showing benefit.
General teaching is about half of women with fibroids do not need surgery. Small fibroids in women with no or minimal symptoms should be followed. Larger fibroids should be evaluated more frequently so a grapefruit does not become a watermelon and increase the risk of surgery.
QUESTION: What are the treatment options?
Dr. Moore: There is no pill you can take for years to shrink fibroids. Medications for fibroids are meant to shrink them in preparation for surgery. There are companies trying to develop medications for long term use. Women with fibroids who are trying to avoid or delay surgery may want to consider an FDA supervised clinical trial. All exams and medications are at no cost. You have to keep a diary of symptoms and be prepared to get a placebo pill. Usually, a placebo is only for 6 months and then you will get the actual medication.
When a woman’s fibroids become problematic surgery is the next step. There are two options, hysterectomy or not. Non-hysterectomy options include Myomectomy(take the fibroids out), Uterine Artery Embolization(under Xray the blood supply to the uterus is blocked) and Radio Frequency Ablation(a needle is inserted by ultrasound into the fibroid that causes it to shrink in the next few months).
Myomectomy can be performed by hysteroscopy. A small scope is inserted through the cervix and a small submucosal fibroid is removed. No abdominal incisions are made and recovery is 2 to 4 days.
Laparoscopic myomectomy is possible in most(98-99%) women. The small incisions allow part-time return to work in as little as 4 to 5 days and fulltime in 10 to 14 days in office-based patients, including physician patients.
Uterine artery embolization is an alternative to hysterectomy. The radiology approach is highly successful. Fibroids shrink and symptoms improve. It is not recommended if seeking pregnancy. The procedure failure rate in one study at 3 years was 30% versus 3% for myomectomy. Larger fibroids may not always shrink and are still bothersome in some. The benefit of myomectomy is removal of the tumor.
Radiofrequency ablation(RFA) is newer. It has been used in other areas with success and has been available by a laparoscopic application for several years.
The most exciting advance in fibroid treatment technology in the last 20 years occurred last August when the FDA approved the SONATA platform for ultrasound-guided trans cervical RFA of fibroids. An ultrasound probe inside the uterine cavity and then a needle is inserted into the fibroid and it is treated with RFA. In laparoscopic and hysteroscopic surgery there are often small interstitial fibroids that cannot be taken care of. That means the woman will need something else later. The SONATA procedure allows us to take care of all the fibroids. Sometimes it will be combined with laparoscopic or hysteroscopic surgery, but it can be done by itself in certain cases. It depends on the size and location of the fibroids.
Hysterectomy is the more common choice of women who have completed their family, no more bleeding and no more fibroids. Minimally invasive hysterectomy is possible over 99% of the time. Non-robotic laparoscopic hysterectomy has less pain and a faster recovery while costing less to perform.
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