Treating Uterine Fibroids: Key Questions Answered

Are uterine fibroids cancerous? Do they affect fertility? Which treatment is right for you? Read on as experts answer your top questions… Your period is so heavy, you avoid leaving the house a few days each month. Sex is painful. And you’re spotting regularly. The likely diagnosis – uterine tumors called uterine fibroids – is scary. But it’s common: As many as 80% of women develop a uterine fibroid tumor in their lifetimes, says Michele Curtis, M.D., a professor of obstetrics and gynecology at the University of Texas in Houston. Symptoms vary: Some women have excessive bleeding, pelvic pressure and pain. Others notice nothing. Only 25% of women have tumors that require treatment, which can range from simple birth control pills to a life-altering hysterectomy to remove the uterus. To find out how fibroids affect your body and the best ways to treat them, we asked gynecologists these key questions: 1. How did I get uterine fibroids? Doctors don’t know what causes these tumors – sometimes called leiomyomas or myomas – but there’s a strong genetic link. You’re three times more likely to develop fibroids if your mother had one, according to the National Women’s Health Information Center (NWHIC). They’re also more common among obese and/or African-American women. Research suggests the hormones estrogen and progesterone, which stimulate the uterine lining in preparation for pregnancy, also play a role in fibroid growth. Fibroid tissue contains more estrogen than normal uterine cells, and fibroids seem to be fueled by the presence of these hormones. When a woman enters menopause, and her estrogen levels decrease, fibroids shrink. Estrogen doesn’t cause fibroids, but it does feed them. 2. Can they become cancerous? It’s extremely rare – less than one in 1,000 fibroids is cancerous, according to the NWHIC. If they begin to grow rapidly, they’re more likely to be cancerous. Your gynecologist will track them through a routine manual pelvic exam or by ordering an annual ultrasound. Questionable tumors will be removed and tested for malignancy. 3. What other factors determine severity? Depending on its location, a small tumor can cause more problems than a larger one. For example, a 1-centimeter fibroid in the uterine cavity that’s causing profuse menstrual bleeding would require treatment, says Serene Srouji, M.D., of Boston’s Brigham and Women’s Hospital. But a 7-centimeter tumor in the outer wall that isn’t causing discomfort wouldn’t. 4. Do all fibroids need treatment? “There are no specific treatment guidelines in terms of size, location or number of fibroids,” Dr. Srouji says. “These decisions depend on symptoms.” If you don’t have any symptoms – such as heavy menstrual bleeding, pain during sex, frequent urination, constipation and abdominal bloating – fibroids don’t require treatment. If your fibroids are asymptomatic, they won’t cause other health problems, Dr. Curtis says. 5. Why do fibroids make my periods heavier? If the fibroid is inside the uterus, it increases growth of endometrial tissue that’s normally shed during menstruation, says Pasquale Patrizio, M.D., director of the Yale Fertility Center. 6. Can heavy bleeding cause other problems? Sometimes it can lead to iron loss and anemia. Iron makes hemoglobin, the protein that turns blood red and allows it to carry oxygen throughout your body. With a deficiency, you can feel weak, cold, dizzy and irritable. If iron-deficiency anemia is suspected, your doctor should check iron levels in your blood. Low levels are treated with iron supplements to improve strength. 7. Can fibroids affect my ability to have children? Fibroids alone rarely cause infertility, Dr. Curtis says. If they do, it’s often because of their location. A fibroid in the uterine wall can distort the uterus and prevent an embryo from implanting, resulting in first-trimester miscarriages. Or it can block or distort the fallopian tubes so the sperm and egg can’t get through. Removing the fibroid will fix both problems. 8. Do I need to have fibroids removed to become pregnant? Not necessarily. “If a woman [who wants to become pregnant] is diagnosed with a fibroid, we tell her to try getting pregnant,” Dr. Curtis says. “If she can’t, or if she has repeated miscarriages after a year, we may recommend removing the fibroid.” If you get pregnant and the fibroid is obstructing the cervix, your doctor may recommend a Cesarean delivery. 9. Do I need surgery to remove my fibroids? If your symptoms are limited to heavy bleeding, birth control pills or a progesterone intrauterine device (IUD) can reduce your flow. So can other less-invasive procedures, like endometrial ablation. But these aren’t recommended for women who want to get pregnant because they change the uterine lining: Uterine artery embolization (UAE). This procedure is commonly done when excessive menstrual bleeding (menorrhagia) is the primary symptom and the surgical risk is judged unacceptable or the patient declines surgery, Dr. Curtis says. A radiologist inserts a catheter tube through a small groin incision, then finds and catheterizes uterine arteries and inserts small, nonradioactive particles. These form a clot to stop blood flow to the fibroid, making it shrink. (There’s radiation from the imaging used to guide the radiologist during the procedure. It’s comparable to two chest CT scans.) Many women are hospitalized for 1-2 days after this procedure for pain, Dr. Curtis says. You may feel severe cramps lasting more than six hours at a time. While the procedure is considered safe, it’s not known if the radiation exposure causes any long-term effects. Endometrial ablation. This technique works for only fibroids in the uterine lining. Gynecologists use heat, cold or high-energy radiofrequencies to burn, scar or remove the uterine lining, destroying fibroids in that area and reducing menstrual bleeding. It’s usually done as an outpatient procedure, and women recover in 1-2 days. Some side effects, such as cramping, nausea and vaginal discharge, can last a week or two. 10. What are options to preserve my fertility? Your gynecologist can perform a myomectomy, an operation to remove the fibroids. This is often done through a minimally invasive abdominal incision, such as a laparoscopy, in which a thin instrument is inserted into the abdominal wall. In some cases, it’s possible to insert an instrument (known as a hysteroscope) through the vagina into the uterus to shave down the fibroid. This is an option when fibroids are just underneath the uterine lining and there aren’t many in the uterus’ muscle wall. Because the fibroid isn’t fully removed with this procedure, and they’re fueled by estrogen, it’s likely to grow back within 3-5 years if you’re still menstruating. 11. Will this get rid of severe symptoms? If symptoms are severe or the fibroid is large, your gynecologist may prescribe gonadotropin-releasing hormone (Gn-RH) agonists. These drugs mimic menopause, reducing the amount of estrogen in the body. “Estrogen is fibroid food,” Dr. Patrizio says. “They shrink in its absence.” That’s why fibroids shrink when women enter menopause naturally. This treatment can shrink large fibroids so they’re easier to remove. It will also stop bleeding so an anemic woman can gain back strength before surgery. Gn-RH agonists can’t be used alone for more than 6 months, however, because side effects include bone loss, which can lead to osteoporosis. Other side effects are similar to those of menopause, including hot flashes and vaginal dryness. 12. Is there a way to get rid of fibroids permanently? A hysterectomy – surgery to remove the uterus – is the only permanent solution. If you have persistent problems and don’t plan to get pregnant, ask your gynecologist whether it’s right for you. 13. What are my options for a hysterectomy? You have several choices, all of which are covered by most health insurance plans. Recovery time is 4-6 weeks: Vaginal hysterectomy: The uterus is removed through the vagina. This isn’t an option if your uterus is enlarged or there’s scarring from previous surgeries. If that’s the case, you’ll have to have one of the options below. Abdominal hysterectomy: An incision, either vertical or horizontal, is made in the abdominal wall. This option may be necessary if the uterus is large. Laparoscopic hysterectomy: A thin, lighted tube with a camera is inserted through small abdominal incisions. This surgery takes longer than abdominal surgery, requiring more time under general anesthesia, but you’re left with a smaller scar. 14. Are there new treatments being developed? Magnetic resonance-guided focused ultrasound ablation was approved by the Food and Drug Administration in 2004 and is available at some large teaching hospitals. This outpatient technique – with local anesthesia and a sedative – is typically used to treat uterine-wall fibroids that are larger than 3 centimeters. Because it’s expensive, not covered by insurance (the other treatments mentioned are) and isn’t suitable unless your fibroids are large, it’s not available at most hospitals. Single-treatment sessions last about three hours, and about 50% of women require a second-treatment session within 12 months, Dr. Curtis says. “But patients are able to return to normal daily activities the day after the procedure,” she adds. 15. How does this treatment work? A radiologist uses magnetic resonance imaging (MRI) to locate the tumor and a highly focused ultrasound heat beam to kill and remove fibroid cells. It can be painful, but most patients return to their regular activities the next day. Because this procedure destroys some uterine tissue, it could hurt fertility, so doctors don’t recommend it for women who want to become pregnant. Although the beam is targeted, it also can damage nearby tissue, so it’s not recommended for fibroids near other organs, such as the bowel. Because this procedure is so new, there aren’t any long-term studies of risks and benefits. 16. If I have my fibroids surgically removed, are they gone for good? Those fibroids won’t grow back – but new ones can. Within five years of fibroid removal, about 50% of women develop new tumors, Dr. Srouji says. But because they differ in size and location, they might not require the same treatment. Consult your doctor if you think you’re experiencing fibroids.