Fibroids, also known as leiomyomas or myomas are growths of muscle tissue throughout the wall of the uterus. The exact cause of fibroids is unknown but they are affected by hormones and genetics. It is estimated up to 80% of women have fibroids, although only a minority of women will have symptoms.
In general, symptoms of fibroids include:
Fibroids can be diagnosed with a physical exam and pelvic ultrasound (similar to that used in pregnancy). Often an MRI (magnetic resonance imaging) is performed to delineate the exact locations, number, and size of fibroids.
Fibroids can be located in many locations in the uterus. The most common location is in the wall or muscle of the uterus. These are called intramural (inside the wall) fibroids. They can also be located inside the cavity of the uterus. These are called submucosal fibroids. Finally they can be located outside of the wall of the uterus underneath the outside lining of the uterus - the serosa. These fibroids are called subserosal. One type of subserosal fibroid commonly seen is a pedunculated fibroid. This type of fibroid sits outside the uterus on a stalk.
There are some specific types of patients who may be at higher risk for developing fibroids than others. Please understand, the majority of fibroids - especially smaller fibroids - tend to not cause any symptoms. So, in our discussion about fibroids I will refer to patients who have symptoms from fibroids.
The lifetime risk (cumulative incidence) of fibroids varies among ethnic groups. For example, black women tend to have a lifetime cumulative incidence of developing fibroids, around 80%. This means that at some point from birth to death a black woman has an 80% chance of having a fibroid. This includes both symptomatic and asymptomatic fibroids. For white non-hispanic woman, that cumulative incidence number falls to around 60-70% and for Asian woman it is even lower. Although the true cumulative incidence of fibroids among Asian women is not well known.
Other than genetic / ethnic factors, which are likely to be responsible for fibroid growth than they are for presence of fibroids, there are a few controllable factors that may be associated with the growth of fibroids that are already present. Several studies have reports that any of several factors may be related to a lower incidence of increasing myomas. Those factors may include:
Clearly, these factors are going to be different in everyone and have a different level of impact in everyone but these are the general factors that may be associated with a lower risk of growing / enlarging fibroids. This may be more important factors in older women than in younger women.
Other risk factors may include:
Interestingly, high use of soy products has NOT been shown to be associated with fibroid growth.
In general fibroids in black women grow larger and faster than they do in white women and further when white women get older that growth tends to slow down. This effect is not seen in premenopausal black women.
Many women with fibroids are told that the only possible option is a hysterectomy. This is clearly not true in the vast majority of cases and is likely on overused treatment by many gynecologists.
There are several medical options for managing fibroids.
The most commonly used option for decreasing the size of fibroids and decreasing bleeding at the same time is a class of medications called gonadotropin releasing hormone agonists (GnRHa). This class of medications after a few weeks of use ultimately tells the brain to stop telling the ovaries to produce estrogen. The problem with this is that it mimics the biochemistry of menopause. So, the major side effect of this class of medications is feeling like you are in menopause. Those side effects include but are not limited to:
Fortunately, the side effects can be easily counter balanced and essentially eliminated with very low dose hormone replacement. So, this sounds like a nice treatment. Yes? Not really. It really depends on a woman's stage in life and reproductive goals. The problem with this treatment is that once the medication is stopped (it can really only be used for up to 1 year - and some sources say safely for only 6 months) the fibroids will predictably regrow. So, it is a poor long term solution for younger women. It may be an acceptable solution for a woman closer to menopause who wants to decrease some of the pressure of bulk symptoms of fibroids and create a symptom free "bridge" until she goes into natural menopause.
The levonorgestrel containing intrauterine device (Mirena) may be effective in managing bleeding in women with fibroids. It may also be effective is decreasing the volume of smaller fibroids. While this sounds promising (and it is) the issue is that the fibroids do not disappear with this treatment and while the bleeding is lower than with no treatment it is certainly not eliminated. The other drawback to using the Mirena in women with fibroids is that there is a higher rate of expulsion versus women without fibroids. Expulsion is when the device comes out on its own. If your goal of treatment is simply to decrease bleeding and not decrease pain or pressure symptoms, in selected situations this may be an effective therapy for you.
Another class of medications that may have showed promise in the treatment of fibroids in the selective estrogen receptor modulators (SERMs). It makes sense that decreasing the action of estrogen at the cellular level will decrease the growth of fibroids. This did not work out so well in 3 different clinical trials.
In the future, we will likely start using a class of medication called selective progesterone receptor modulators (SPRMs). The sperms may be helpful because they decrease the action of progesterone at the level of the fibroid and may in the long term also decrease the action of estrogen (which clearly makes fibroids grow). One problem with these medications in experiments has been that a side effect may be overgrowth of the lining of the uterus (endometrium) and possibly a subsequently higher risk for developing endometrial cancer.
There are several different surgical approaches to managing fibroids. The decision to have surgery versus having medical therapy depends on many factors. Our job is to educate you and let you decide. Factors that may be associated with a decision for medical versus surgical therapy include:
In general, in our practice we do our bets to avoid counseling a patient to perform a hysterectomy unless it is absolutely necessary because of some other medical issue or simply because the patient wants it.
There are 2 main surgical procedures that can be performed to remove fibroids. They are myomectomy and hysterectomy. In addition there is a class of procedures that can be performed to decrease or eliminate the severe bleeding associated with fibroids. Those procedures are called global endometrial ablation (GEA).
Global endometrial ablation (GEA) procedures are very simple and very effective procedures. There are many ways to perform a GEA. One can use heat, electrical energy, or cold. We prefer to use the hot water (Thermachoice) or electrical energy (Novasure) techniques. We feel these techniques are the most effective and the best tolerated by patients. We have performed thousands of these procedures with excellent results.
There are several advantages to having a GEA
Myomectomy is a procedure during which fibroids are removed. There are several ways to perform myomectomy and the technique depends mainly on the location and size of the fibroids.
Hysteroscopy with myomectomy is when we place a camera inside the uterus. We can then using a very small cutting device to remove the fibroid from the cavity of the uterus very carefully without causing damage to the remainder of the lining of the uterus. This is a big advantage over older methods of hysteroscopic myomectomy which were done with electrical energy and may have caused damage to the lining of the uterus. Most of the time hysteroscopy with myomectomy is being performed in women who are planning to have children. Thus, using our technique of directed cutting without electrical energy there is minimal damage to the endometrium, which works very well for this group of patients.
Laparoscopic / robotically assisted (daVinci) myomectomy is a procedure in which multiple small incisions are made in the abdomen and the fibroids (even very large ones) are then removed. There are a lot of benefits to this procedure. In particular, for women who are planning to maintain their fertility and desire a minimally invasive approach this is a very good option. Some of the benefits to this procedure include:
Dr. Levey serves as a proctor at NYU's Robotic Surgery Center and frequently has visitors from around the United States come to NYU to learn from his surgical technique. You can view a video of Dr. Levey performing this surgery.
Dr. Levey was the first surgeon to perform robotic myomectomy at NYU Langone Medical Center.
Abdominal (open) myomectomy is a procedure during which fibroids are removed from a fairly large incision in the lower abdomen. The vast majority of the time we are able to perform a robotic / daVinci myomectomy. We are experts in doing so. If an open myomectomy is indicated, we are able to minimize the size of your incisions (we almost never have to make large vertical incisions) and often patients are able to go home the next day.
Hysterectomy is a procedure in which the uterus is removed. This can be done without removing the cervix. Many women prefer to leave the cervix in. Although, there is no evidence of any medical or sexual function benefit to doing this. I often see patients who are confused about the definition of a hysterectomy. please remember, a hysterectomy is the removal of the uterus only. Removing the uterus DOES NOT mean the ovaries will be removed as well. The vast majority (>95%) of our patients do not require removal of the ovaries at the time of hysterectomy. The ovaries are where important hormones are made. Thus, leaving the ovaries inside means you will not go into menopause immediately after your surgery.
As I indicated above we do our best to avoid having to do a hysterectomy. But the simple fact of this is that sometimes a hysterecomy is required for optimal outcomes and sometimes patients request a hysterectomy. Reasons patients request a hysterectomy, in my experience are as follows:
Hysterectomy is the only procedure that can guarantee fibroids will never return.
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