UTERINE FIBROIDS (MYOMAS)
What are fibroids?
A fibroid, also called myoma, or leiomyoma, is a benign (non-cancerous) tumor arising from the smooth muscle of the uterus. Because a fibroid consists of smooth muscle tissue as well as fibrous tissue, the preferred term is myoma.
• It is the most common pelvic tumor, occurring in 70% of women.• It is extremely rare that it turns malignant (cancerous).
Myomas are usually multiple, but each one starts from a single muscle cell.
Although they are most often seen in the uterus, they may also grow in the cervix and the fallopian tubes.
Uterine myomas are classified according to location:Intramural Myomas within the muscle wall of the uterusSubserosalThe myoma extends to the outer wall of the uterus.PedunculatedA subserosal myoma can grow on a stalk from the outer wall.SubmucosalThe myoma grows into the uterine cavity.
Myomas start as small as a pea but can grow to fill the pelvis and they are often small and asymptomatic. Symptomatic fibroids occur in 25% of white women and 50% of black women. Their growth is variable and not predictable.
Fibroid locations
The names of fibroids reflect their orientation to the uterine wall. Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids project to the outside of the uterus, and pedunculated fibroids hang from a stalk inside or outside the uterus.
http://www.mayoclinic.com/health/medical/IM01586
What causes myomas?
The cause is unknown as yet.
• It is usually an inherited condition.• For some reason, it is more common in black women.
Risk factors include:
• Race• Obesity and overweight
Myomas are estrogen-dependent tumors.
• Growth is associated with exposure to circulating estrogen, the main female hormone.• Thus, maximum growth is during the reproductive years, when a woman produces high concentrations of estrogen regularly. There is a growth spurt in the decade before
menopause.• They can grow in pregnancy, not just because of high estrogen, but because of increased blood flow to the - uterus.• Predictably, they decrease in size after menopause, or other conditions of low estrogen.
Risk factors
There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Other factors include:
Heredity. If your mother or sister had fibroids, you're at increased risk of also developing them.
Race. Black women are more likely to have fibroids than are women of other racial groups. In addition, black women have fibroids at younger ages, and they're also likely to have more or larger fibroids.
Areas of researchResearch examining other potential risk factors continues in these areas:
Obesity. Some studies have suggested that obese women are at higher risk of fibroids, but other studies have not shown a link.
Oral contraceptives. So far, strong data exist showing that women who take oral contraceptives have a lower risk of fibroids. This is generally true for all women, except those who start oral contraceptives between ages 13 and 16.
Pregnancy and childbirth. Researchers have also looked at whether pregnancy and giving birth may have a protective effect, and so far pregnancy and childbirth seem to have a protective effect.
http://www.mayoclinic.com/health/uterine-fibroids/DS00078/DSECTION=risk-factors
How do I know I have myomas?
Most myomas produce no symptoms. Therefore, most women learn about it when they are examined by a gynecologist manually or through ultrasound.
When symptoms occur, they usually correlate with –
• The location of the myomas• Their size• Any degeneration in the myomas
The most common signs of symptomatic myomas are:
• Menstrual changes – heavy bleeding, more frequent periods, cramping• Pain in the abdomen and lower back, and during sex • Pressure symptoms such as• Frequent urination, or difficulty in urinating• Constipation, rectal pain, or difficult bowel movement
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Do I need treatment for myomas?
Symptomatic myomas require medical attention.
If you have no symptoms, but are seeking fertility care, your infertility specialist will tell you whether treatment of the myoma is necessary before to proceed to fertility treatment.
Not all myomas necessarily interfere with fertility.
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Signs and Symptoms of Myomas
The most common signs of symptomatic myomas, all requiring medical attention, are:
• Menstrual changes – heavy bleeding, more frequent periods, cramping• Pain in the abdomen and lower back, and during sex• Pressure symptoms such as - Frequent urination, or difficulty in urinating - Constipation, rectal pain, or difficult bowel movement
If the myoma(s) grow big enough, your belly will grow. Doctors often describe the size of a myomatous uterus in terms of comparison to a pregnant uterus. Example: A 6-week uterus or a 12-week uterus.
Excessive menstrual bleeding is often the only symptom. This is due to several factors:
• Increased blood supply to the myomas also brings increased blood supply to the uterine lining (endometrium) which is shed at menses.• Fibroids usually increase the size of the uterine cavity, therefore , there is an increased surface area of the lining.• Bleeding could also be aggravated by endometritis (inflammation of the lining) which is frequently observed in the endometrial tissue overlying submucosal tumors.• Degeneration of the myoma
Degeneration results because of infection or when the myoma loses its blood supply. The muscle cells and connective tissues are replaced by fat, cysts, calcification, and/or granular, hyaline or mucoid material characteristic of necrotic (dying) cells. This often leads to excessive menstrual bleeding.
Excessive bleeding can lead to anemia, usually manifested in fatigue, headaches and lightheadedness.
It can also affect your quality of life, if the bleeding interferes with your regular activities.
Pain as a symptom is infrequent. It is usually associated with:
• Twisting(tortion) of a fibroid stalk• Cervical dilatation, if a myoma protrudes through the lower uterine segment• Carneous degeneration, often associated with pregnancy.• Adenomyosis (presence of endometrial glands in the uterine muscle) is usually associated with myomas, and may also cause pain.
Myomas can cause acute severe pain, due to torsion of the stalk or degeneration.
• In such cases, the pain will be localized to the specific area that is affected.• This can usually improve with pain relievers and go away after two-three weeks.
Obviously, if the pain is unbearable, it is best to see a doctor right away.
Chronic pelvic pain, which is mild but persistent, can also occur. Again, this is generally localized to a specific area.
Low back pain may be experienced, when the fibroids can press against the nerves of the lower back.
Pain or discomfort during sexual intercourse (dyspareunia) may also be experienced. This may be associated only with certain positions, or with the beginning or middle (around ovulation) of your menstrual cycle.
In any case, the doctor must rule out other possible causes of pain that may not be due to the myomas. For example;
• Acute pelvic inflammatory disease (PID)• Endometriosis• An ectopic pregnancy• A ruptured ovarian cyst
A "big belly" when you are not pregnant or particularly overweight can be a sign. Some
patients find it difficult to bend over or exercise because of this. Most will feel a continuous sense of heaviness or discomfort in the lower abdominal region.
Pressure symptoms are more bothersome. As myomas grow, pressure is exerted on adjacent pelvic organs, especially the bladder and the rectum.
Pressure on the bladder can cause:
• Frequent urination, because the bladder cannot hold as much as it can; or• Inability to urinate despite a ‘full’ bladder, because the pressure blocks the outflow passage for urine.
Pressure on the rectum can result in:
• Constipation• Difficulty or pain during bowel movement• A sense of fullness in the rectum• Sometimes, hemorrhoids
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Possible complications from myomas:
Although uterine fibroids usually aren't dangerous, they can cause discomfort and may lead to complications such as anemia from heavy blood loss. In rare instances, fibroid tumors can grow out of your uterus on a stalk-like projection. If the fibroid twists on this stalk, you may develop a sudden, sharp, severe pain in your lower abdomen. If so, seek medical care right away. You may need surgery.
Pregnancy and fibroidsBecause uterine fibroids typically develop during the childbearing years, women with fibroids are often concerned about their chances of a successful pregnancy.
Fibroids usually don't interfere with conception and pregnancy. However, they can rarely distort or block your fallopian tubes, or interfere with the passage of sperm from your cervix to your fallopian tubes. Submucosal fibroids may prevent implantation and growth of an embryo.
Research indicates that pregnant women with fibroids are at slightly increased risk of miscarriage, premature labor and delivery, abnormal fetal position, and separation of the placenta from the uterine wall. But not all studies confirm these associations. Furthermore, complications vary based on the number, size and location of fibroids. Multiple fibroids and large submucosal fibroids that distort the uterine cavity are the type most likely to cause problems. A more common complication of fibroids in pregnancy is
localized pain, typically between the first and second trimesters. This is usually easily treated with pain relievers.
In most cases, fibroids don't interfere with pregnancy, and treatment isn't necessary. It was once believed that fibroids grew faster during pregnancy, but multiple studies suggest otherwise. Most fibroids remain stable in size, although some may increase or decrease slightly, usually in the first trimester.
If you have fibroids and you've experienced repeated pregnancy losses, your doctor may recommend removing one or more fibroids to improve your chances of carrying a baby to term, especially if no other causes of miscarriage can be found and if your fibroids distort the shape of your uterine cavity.
Doctors usually don't remove fibroids in conjunction with a cesarean section because of the greater risk of excessive bleeding.
Myomas can cause infertility through
• A submucosal myoma, which interferes with implantation.• A markedly distorted, enlarged uterine cavity that can also interfere with implantation or with normal sperm transport.• Myomas can also cause severe displacement of the cervix, which interferes with the deposition of sperm at the cervical opening• Some intramural myomas may cause obstuction or dysfunction of the tubal ostia (the point at which the tube joins the uterus)
In IVF patients, distortion of the endometrial cavity by myomas is associated with;
• Decreased pregnancy rate• Spontaneous abortion rate up to 50%.• Recurrent pregnancy loss.
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Myomas very rarely become malignant (cancerous)
It is thought that cancerous uterine growths (leiomyosarcomas) arise by themselves and are not related to benign myomas.
However, rapid growth (for example, an increase in uterine size equivalent to a 6-week pregnant uterus in less than year) must raise a suspicion of malignancy, especially in
• Post-menopausal patients or• Younger patients who are not pregnant
Surgery to remove the myoma(s) and obtain a biopsy is indicated.
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Diagnosing Myomas (Fibroids)
Tests and diagnosisBy Mayo Clinic staff
Uterine fibroids are frequently found incidentally during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus through your abdomen, suggesting the presence of fibroids.
UltrasoundIf confirmation is needed, your doctor may obtain an ultrasound — a painless exam that uses sound waves to obtain a picture of your uterus — to confirm the diagnosis and to map and measure fibroids. A doctor or technician moves the ultrasound device (transducer) over your abdomen (transabdominal) or places it inside your vagina (transvaginal) to obtain images of your uterus.
Transvaginal ultrasound provides more detail because the probe is closer to the uterus. Transabdominal ultrasound visualizes a larger anatomic area. Sometimes, fibroids are discovered during an ultrasound conducted for a different purpose, such as during a prenatal ultrasound.
Other imaging testsIf traditional ultrasound doesn't provide enough information, your doctor may order other imaging studies, such as:
Hysterosonography. This ultrasound variation uses sterile saline to expand the uterine cavity, making it easier to obtain interior images of the uterus. This test may be useful if you have heavy menstrual bleeding despite normal results from traditional ultrasound.
Hysterosalpingography. This technique uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Your doctor may recommend it if infertility is a concern. In addition to revealing fibroids, it can help your doctor determine if your fallopian tubes are open.
Hysteroscopy. Your doctor inserts a small, lighted telescope called a hysteroscope through your cervix into your uterus. Your doctor injects (instills) saline into your uterus expanding the uterine cavity and allowing your doctor to examine the walls of your uterus and the openings of your fallopian tubes. A hysteroscopy can be performed in your doctor's office.
Imaging techniques that may occasionally be necessary include computerized tomography (CT) and magnetic resonance imaging (MRI).
Other testsIf you're experiencing abnormal vaginal bleeding, your doctor may want to conduct other tests to investigate potential causes. He or she may order a complete blood count (CBC) to determine if you have iron deficiency anemia because of chronic blood loss. Your doctor may also order blood tests to rule out bleeding disorders and to determine the levels of reproductive hormones produced by your ovaries.
Treatment of Myomas (Fibroids)
Asymptomatic fibroids must be evaluated periodically.
A woman found to have myomas but who remains asymptomatic will be evaluated periodically during her routine gynecological check-ups.
The concern is to assess the size of the uterus and whether symptoms have manifested.
Generally, fibroids will continue to grow until menopause, but the growth is variable and unpredictable.
Only a rapid change in size over a one-year interval may cause concern.
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What treatments are currently available for symptomatic fibroids (myomas)?
Treatment choices include: Treatments and drugsBy Mayo Clinic staff
There's no single best approach to uterine fibroid treatment. Many treatment options exist. In most cases, the best action to take after discovering fibroids is simply to be aware they are there.
Watchful waitingIf you're like most women with uterine fibroids, you have no signs or symptoms. In your case, watchful waiting (expectant management) could be the best course. Fibroids aren't cancerous. They rarely interfere with pregnancy. They usually grow slowly and tend to shrink after menopause when levels of reproductive hormones drop. This is the best treatment option for a large majority of women with uterine fibroids.
MedicationsMedications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don't eliminate fibroids, but may shrink them. Medications include:
Gonadotropin-releasing hormone (Gn-RH) agonists. To trigger a new menstrual cycle, a control center in your brain called the hypothalamus manufactures gonadotropin-releasing hormone (Gn-RH). The substance travels to your pituitary gland, a tiny gland also located at the base of your brain, and sets in motion events that stimulate your ovaries to produce estrogen and progesterone.
Medications called Gn-RH agonists (Lupron, Synarel, others) act at the same sites that Gn-RH does. But when taken as therapy, a Gn-RH agonist produces the
opposite effect to that of your natural hormone. Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves.
Progestin-releasing intrauterine device (IUD). If you have fibroids that don't distort your inner uterus, a progestin-releasing IUD can relieve heavy bleeding and pain caused by the fibroids. A progestin-releasing IUD provides symptom relief only and doesn't shrink fibroids or make them disappear.
Androgens. Your ovaries and your adrenal glands, located above your kidneys, produce androgens, the so-called male hormones. Given as medical therapy, androgens can relieve fibroid symptoms.
Danazol, a synthetic drug similar to testosterone, may effectively stop menstruation, correct anemia and even shrink fibroid tumors and reduce uterine size. However, occasional unpleasant side effects, such as weight gain, dysphoria (feeling depressed, anxious or uneasy), acne, headaches, unwanted hair growth and a deeper voice, make many women reluctant to take this drug.
Other medications. Oral contraceptives or progestins can help control menstrual bleeding, but they don't reduce fibroid size. Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, are effective for heavy vaginal bleeding unrelated to fibroids, but they don't reduce bleeding caused by fibroids.
HysterectomyThis operation — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. It ends your ability to bear children, and if you elect to have your ovaries removed also, it brings on menopause and the question of whether you'll take hormone replacement therapy. Most women with uterine fibroids can choose to keep their ovaries.
MyomectomyIn this surgical procedure, your surgeon removes the fibroids, leaving the uterus in place. If you want to bear children, you might choose this option. With myomectomy, as opposed to a hysterectomy, there is a risk of fibroid recurrence. There are several ways a myomectomy can be done:
Abdominal myomectomy. If you have multiple fibroids, very large or very deep fibroids, your doctor may use an open abdominal surgical procedure to remove the fibroids.
Laparoscopic myomectomy. If the fibroids are small and few in number, you and your doctor may opt for a laparoscopic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. Your doctor views your abdominal area on a remote monitor via a small camera attached to one of the instruments. Use of a surgical robot now allows for removal of more fibroids or larger fibroids.
Hysteroscopic myomectomy. This procedure may be an option if the fibroids are contained inside the uterus (submucosal). A long, slender scope (hysteroscope) is
passed through your vagina and cervix and into your uterus. Your doctor can see and remove the fibroids through the scope. This procedure is best performed by a doctor experienced in this technique.
Other procedures to shrink or destroy fibroidsCertain procedures can destroy uterine fibroids without actually removing them through surgery. They include:
Myolysis. In this laparoscopic procedure, an electric current or laser destroys the fibroids and shrinks the blood vessels that feed them. A similar procedure called cryomyolysis uses liquid nitrogen to freeze the fibroids. The safety, effectiveness and associated risk of fibroid recurrence of myolysis and cryomyolysis have yet to be determined.
Endometrial ablation. This treatment, performed with a specialized instrument inserted into your uterus uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow. Endometrial ablation is effective in stopping abnormal bleeding, but doesn't affect fibroids outside the interior lining of the uterus.
Uterine artery embolization. Small particles (embolic agents) injected into the arteries supplying the uterus cut off blood flow to fibroids, causing them to shrink. This technique, performed by an interventional radiologist, is proving effective in shrinking fibroids and relieving the symptoms they can cause. Advantages over surgery include no incision and a shorter recovery time. Complications may occur if the blood supply to your ovaries or other organs is compromised.
Focused ultrasound surgeryMRI-guided focused ultrasound surgery (FUS) is a noninvasive treatment option for uterine fibroids that preserves your uterus.
This procedure is performed while you're inside of a specially crafted MRI scanner that allows doctors to visualize your anatomy, and then locate and destroy (ablate) fibroids inside your uterus without making an incision. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids. A single treatment session is done in an on- and off-again fashion, sometimes spanning several hours. Initial results with this technology are promising, but its long-term effectiveness is not yet known.
Before you decideBecause fibroids aren't cancerous and usually grow slowly, you have time to gather information before making a decision about if and how to proceed with treatment. The option that's right for you depends on a number of factors, including the severity of your signs and symptoms, your plans for childbearing, how close you are to menopause, and your feelings about surgery.
Before making a decision, consider the pros and cons of all available treatment options in relation to your particular situation. Remember, most women don't need any treatment for uterine fibroids.
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Medical therapy for myomas
Medical options are sub-optimal and limited. • They are used to control bleeding and/or to shrink some myomas• They have no effect beyond the time they are being used.
There is no medical treatment for pressure symptoms from large myomas.
The basis of medical therapy is to decrease circulating estrogen and thus ‘starve’ the myomas. Several drug types are used for this.
• Exogenous progestins, taken orally, are often used to reduce bleeding but have no effect on fibroid size. - Medroxy-progesterone acetate (Provera) 5-10 mg once a day, or - Megestrol acetate 10-20 mg daily Either one is prescribed the first 10-14 days of the menstrual cycle. Usually, bleeding is regulated after 1-2 cycles.• NB: Provera can also be administered as a single injection (150 mg intramuscular) once every 3 months. - It is recommended to see first whether the patient does not show adverse side effects (weight gain, depression, and even irregular bleeding) to the oral dose before trying the injection, because the effects of one shot will last three months.• Birth control pill by continuous therapy (daily during the whole month) reduces bleeding and provides contraception.• Danazol is an androgenic agent that can suppress fibroid growth but it has fallen out of favor because of a high rate of adverse effects (weight gain, acne, hirsutism or hair loss, edema, deepening of the voice, vaginal dryness).• Lupron (generic name: leuprolide acetate), which is familiar to women undergoing IVF, is currently the preferred medication to stop heavy bleeding and shrink myomas until surgery can be done. - Acts by blocking the production of estrogen. - Generally prescribed 3-6 months before surgery to minimize blood loss at surgery and facilitate removal of large tumors that have been shrunk. - Also used 3-6 months after a Myomectomy to control the growth of any seedling fibroids not seen at surgery. - Administered as a one-a-month injection (depo-Lupron, 3.75 mg intramuscular)
- Not advisable if surgery is not planned, because myomas will re-grow after it is discontinued. However, since Lupron decreases estrogen production, it may also cause menopausal symptoms such as hot flushes. - Use for longer than 6 months at a time is not recommended because it may result in bone loss. - Women younger than 35 will recover the loss after they stop treatment, but women 35 years or older will not.
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Surgical removal of myomas (myomectomy)
When is surgery advisable?
Myomectomy is advised in case of
• Rapidly growing myoma• Heavy bleeding which does not respond to medical therapy• Persistent or intolerable pain/pressure• Urinary or abdominal symptoms• Necessity prior to infertility treatment
The first three symptoms in post-menopausal women particularly require immediate attention.
Myomectomy is very effective because it removes the myoma(s), but these can re-grow.
• Re-growth or even new growth post-myomectomy is more likely for younger women.• Women close to menopause are much less likely to be troubled about myomas again.
Myomectomy is also the best option for women who have symptomatic fibroids and desire to bear children.
Removal of the myomas necessitates repair of the uterine wall with stitches at surgery ~ Therefore, such patients are usually warned that they may require a Caesarean section to deliver to avoid rupturing the uterine wall due to the strong muscle contractions during natural childbirth.
The type of Myomectomy depends on the number, size, and location of the myomas.
Abdominal Myomectomy is the treatment of choice when
• Multiple myomas are present, particularly if most are intramural (within the muscle of the uterus).
• The uterus is significantly enlarged (myomas larger than 5 cm, or uterine volume greater than 16 weeks size)
Abdominal Myomectomy is a major surgical procedure, generally called a laparotomy (open abdominal surgery).
• It involves general anesthesia, at least two nights in the hospital, and 4-6 weeks of home rest after surgery.• At surgery, a 4-inch cut is made at the ‘bikini line’ of the lower abdomen.• The uterus is exposed, the fibroids are dissected out, and the uterine wall is repaired in layers with absorbable surgical stitches.• The cut across the abdomen is sutured. (This will leave a 4-inch scar, but good sutures which do not get infected usually result in smoothly healed scars.)• Blood loss during surgery may require a blood transfusion. The patient will usually be asked to bank her own blood before the operation.• Antibiotic treatment during and after surgery will minimize risk of wound infection.• If the patient is planning to have children, she will be warned about the possible risks of natural childbirth, and that a Caesarean delivery may be necessary.
Myomas can and do recur. Studies show that
• Five years after myomectomy, 50-60% of patients will have new myomas detected on ultrasound.• 10-25% will require a second major surgery.
Laparoscopic myomectomy is a less complicated but also major surgical procedure that may be done if:
• The uterus is small enough to be seen in entirety through an operating telescope instead of through an open abdominal cavity. Usually it should be less than 17 weeks size; and• Only a small number of myomas, and none greater than 5 cm, are present.
Laparoscopic myomectomy;
• Does not require ‘opening up’ your belly, but it is also done under general anesthesia.• Requires 3-4 small cuts – about 1 cm each - in the abdominal region: one just below the belly button, one just above the public hairline, and one near the hip (sometimes one near each hip).• The laparoscope- a thin lighted telescope with a mini-camera set-up – is introduced through the cut below the belly button. This enables the doctor to see the pelvic organs.• The other cuts are used to introduce micro-instruments to grasp the uterus and to perform the cutting and dissection needed to remove the myomas; and to sew back the layers of the uterine wall after removal of the myomas.• After the surgery, only Band-Aids are usually needed for the cuts, which will heal in a few days.
• You may go home a few hours after surgery but you will be advised to spend 2-4 weeks of home rest.• Sometimes, during the laparoscopy, the doctor may decide it is necessary to switch to an abdominal procedure. This possibility is included in the pre-surgery consent form you are required to sign.
Hysteroscopic Myomectomy is a procedure to take out submucosal myomas those that protrude into the uterine cavity.
• It may be done by itself, if the patient has no intramural or subserosa lmyomas that require surgery; or• Just before a laparoscopic or abdominal Myomectomy.
Hysteroscopic Myomectomy is also best done under general anesthesia.
• It does not involve any skin cuts. The whole procedure is done though the vaginal canal.• First, a suitable solution is instilled into the uterus through the cervix to distend the cavity so that its internal walls can be clearly seen.• A thin lighted telescope (hysteroscope) is then inserted through the cervix in order to look directly inside the uterine cavity.• The scope has an operating channel through which the surgeon can pass micro-instruments or a laser fiber to scrape away or cut through the myoma and any other abnormal growths that he may see inside the cavity.• If hysteroscopy is the only procedure done, the patient stays in Recovery for a few hours. Some cramping and light bleeding may be experienced. Home rest of 2-4 days is advised.• If laparoscopy is to be performed to remove subserosal and intramural myomas, then it can be performed right after the hysteroscopy
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Hysterectomy (Removal of the uterus)
Myomas are the most common indication for a hysterectomy.
• Removing the uterus simply eliminates all symptoms as well as the possibility of any recurrence.• It is generally an attractive option for women who have completed childbearing.• A recent two-year follow-up study of 1,299 women who had a hysterectomy for myomas and other benign conditions showed that more than 90% found significant reductions in depression and anxiety levels, and an improvement in quality of life.
Many women, even if they are past child-bearing age, may have psychological resistance to the idea of having their womb taken out.
In any case, the decision to have a hysterectomy when it is advisable to do so is obviously something that every patient has to weigh carefully.
Statistically, increased incidence of myomas in black women compared to Caucasian women is reflected in hysterectomy statistics:
• 30% of hysterectomies in Caucasians are for myomas, compared to >50% for black women.• For women between 25-45 years , the cumulative risk for a hysterectomy is 7%, compared to 20% for black women.
A hysterectomy can be performed in three ways:
• Vaginal by taking out the uterus through a cut in the vaginal wall.• Laparoscopic as in laparoscopic myomectomy.• Abdominal by cutting open the belly as in abdominal myomectomy.
Vaginal hysterectomy is possible if the uterus is not too enlarged.
It is usually best done in conjunction with laparoscopy (laparoscopy-assisted vaginal hysterectomy , LAVH).
LAVH is recommended over laparoscopic hysterectomy alone, because
• It allows the use of conventional instruments that are more efficient than miniature instruments manipulated through the laparoscope.• Control of bleeding and suturing the stump (where the uterus is cut off) is much easier, and in the case of the sutures, more robust.
Laparoscopic hysterectomy, like laparoscopic myomectomy, demands great surgical skill.
Abdominal hysterectomy may be
• Total (TAH, total abdominal hysterectomy): in which the entire uterus including the cervix is taken out. - Women who have had abnormal pap smears are encouraged to have TAH.• Supra-cervical hysterectomy if the cervix is left in. - The patient may have less bladder leakage and vaginal relaxation later in life but there are no conclusive studies to prove this. - Moreover, she will continue to need pap smears.
Are the ovaries also taken out at hysterectomy?
The ovaries and the tubes are both attached to the uterus, but they are not necessarily taken out during hysterectomy.
Some guidelines on whether it is advisable to take them out include:
• If the ovaries look abnormal• If the patient wants to eliminate the risk of developing ovarian cancer later in life.• If the woman is already in menopause or close to menopause. - Removing the ovaries of a pre-menopausal woman will bring on premature menopause and all its symptoms.
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UTERINE ARTERY EMBOLIZATION (UAE)
This is a relatively new technique that is a non-surgical alternative for the treatment of symptomatic myomas.
Embolization means blocking blood flow to the myoma. This will cause its cells to die, so the myoma shrinks.
It has been shown to decrease menstrual bleeding, and relieve pain and pressure symptoms including urinary frequency and constipation.
UAE is performed by a qualified interventional radiologist in a hospital radiology department.
• The procedure is similar to having an angiogram done.• It requires 8 hours of fasting (no food or drink) before the procedure.• Painkillers or blood-thinning medicine should not be taken starting 5 days before the procedure.• First, the doctor will start an I-V line in one of your arms through which medication and other agents used for embolization will be passed.• You will be sedated lightly for the procedure so that you are awake but not actively so.• A needle is placed in a suitable artery on one of your legs or in the crease of the groin.• A very thin catheter will then be passed through the needle, and dye will be injected.• As the dye reaches the blood vessels leading to the uterus, X-rays will be taken to take images of the blood vessels leading to the fibroid.
The catheter is now directed to these arteries, and polyvinyl particles the size of a sand grain are injected in order to block them.
• The course of the dye is watched carefully to make sure that the particle goes to the fibroid only.• Both the right and the left uterine arteries are embolized. The procedure can take several minutes.• A repeat arteriogram is done afterwards to confirm that embolization was successful: - The catheter is removed and pressure is held over this area for approximately 15 minutes. - After the exam you must be on bed rest for six hours lying flat with your leg straight.
Some pain may be felt during this time, but the experience varies with each patient.
• Some report no pain at all.• Those who do say it is similar to menstrual cramps.• The most significant pain usually occurs immediately following the procedure and over the next 6 hours.• Patients stay in the hospital overnight so that the arterial-access site can be monitored, and adequate pain control given if necessary.• Most patients can resume full normal activity after a week.
What happens after UAE?
Blocking the blood flow to the fibroid also cuts off oxygen to its cells, and they will begin to die. This will take several weeks.
• 80-90% of patients report improvement of symptoms.• Fibroids shrink to about half the size, and so does the uterus.
Serious complications may occur in <4% of patients. These include :
• Injury to a blood vessel during the procedure• Blood clots which may block other vessels• Injury to the ovaries• Uterine infection
These are unlikely to happen if the physician performing the UAE is a qualified and experienced interventional radiologist.
http://www.newyorkfertility.com/uterine-fibroids.htmlphotos: http://www.sfwomenshealthcare.com/graphics/procedures/fibroids/6.html
"Magnetic Resonance Imaging" - better known as MRI - is the best way to see the changes in fibroids after embolization. Using MRI, a radiologist creates a "slice" of a woman's pelvis (without X-Rays) which gives the most accurate picture of what is happening inside. Though reading these films is quite technical, yet with some help a layperson can still understand it well enough to get useful information. What follows is a brief demonstration of "reading an MRI". Its purpose is to help the layperson to make sense of the unique animated GIF image we have developed.
Here is an actual MRI of a uterus markedly enlarged by multiple fibroids.
This MRI slices through the body lengthwise. For orientation, the front of the abdomen is to the left, and the spine (which appears as a pile of blocks (A)) is to the right.
We outlined the uterus and its fibroids with a black line for better definition. (B)
Notice that within the uterus, there are a number of grey circles. (C) These are the fibroids. They develop as small
spheres which - by pressing against each other - stretch and elongate the uterus making it larger, and its outer surface irregular.
At the left of the picture is a thick black line - the muscle of the abdominal wall.(D) The hockey-stick curve at the top, is the navel (or umbilicus). Notice how the large fibroid uterus (equivalent to the size of a 17-18 week pregnancy) curves these muscles outward.
At 14 weeks after embolization, the fibroids (B) can still be seen, but they are no longer grey. Instead they are black. The MRI principle demonstrated is that when a tissue loses moisture (such as its blood supply after embolization), it appears black on the film. Notice how the line of abdominal wall muscles straightened. (D) Because of the dramatic decrease in uterine size, it no longer distorts the outer surface of the abdomen.
At 27 weeks after embolization, the uterine size has decreased still further. For comparison we have drawn a line where the top of the uterus was before the procedure. The dramatic change is quite obvious.
To view the entire sequence of changes in an unusual animated GIF,
.)
http://www.fibroiduae.com/fibro3a.html#index
Preparing for your appointmentBy Mayo Clinic staff
Your first appointment will likely be with either your primary care provider or a gynecologist.
Because appointments can be brief, and it can be difficult to remember everything you want to discuss, it's a good idea to prepare in advance of your appointment.
What you can do
Write down any symptoms you're experiencing. Include all of your symptoms, even if you don't think they're related.
Make a list of any medications and vitamin supplements you take. Write down doses and how often you take them.
Have a family member or close friend accompany you, if possible. You may be given a lot of information at your visit, and it can be difficult to remember everything.
Take a notebook or notepad with you. Use it to write down important information during your visit.
Prepare a list of questions to ask your doctor. List your most important questions first, in case time runs out.
For uterine fibroids, some basic questions to ask include:
How many fibroids do I have? How big are they? Are the fibroids located on the inside or outside of my uterus? Will they keep getting bigger? What kinds of tests might I need? How much experience do you have in diagnosing and treating uterine fibroids? What medications are available to treat uterine fibroids? Is there a certain
medication that can improve my symptoms? What side effects can I expect from medication use? Under what circumstances do you recommend surgery? Will I need a medication before or after surgery? What kind of problems can fibroids cause? Will uterine fibroids affect my ability to become pregnant? Can treatment of uterine fibroids improve my fertility? Can you recommend any alternative treatments I might try?
Make sure that you understand completely everything that your doctor tells you. Don't hesitate to ask your doctor to repeat information or to ask follow-up questions for clarification.
What to expect from your doctorSome potential questions your doctor might ask include:
How often do you experience these symptoms? How long have you been experiencing symptoms? How severe are your symptoms? Do your symptoms seem to be related to your menstrual cycle? Does anything improve your symptoms? Does anything make your symptoms worse? Do you have a family history of uterine fibroids?
http://www.mayoclinic.com/health/uterine-fibroids/DS00078/DSECTION=preparing-for-your-appointment
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