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Fibroids

In April 2007, our guest experts in Le Club's Ask the Expert was Dr. Grace Liu, MD.

Grace is an Obstetrician and Gynaecologist with the Perinatal & Gynaecology Program of Sunnybrook Health Sciences Centre, which is currently housed at Women's College Hospital. Grace specializes in obstetrics, infertility, minimally invasive surgery and uterine fibroid surgery.

Here are Grace’s answers to your questions about Fibroids.

 

Q:  How does a uterine fibroid occur in the uterus?  How is it treated or does it require surgery?  What are the dangers to fibroid tissues?  Is a fibroid benign or malignant?


A: Unfortunately, we do not know what causes a uterine fibroid to grow in the uterus.  We do know that it might be genetic, and that race also plays a factor (Blacks > Caucasians > Asians).  Most of the time, fibroids do not need to be treated, 50 percent of the time, they are asymptomatic.  When they become symptomatic, then options include medical, radiological, and surgical interventions.

There are no specific “dangers” to fibroid tissues alone, but their symptoms may cause discomfort and health issues (eg. bleeding, pain, infertility, obstruction or pressure on other structures).  Fibroids are 99.9 percent of the time completely benign.  Rarely, they are cancerous.

 


Q: I have five large uterine fibroids. The largest one measures 15 cm. I recently had a baby. The fibroids did cause some complications during pregnancy. I do want to have another baby however I am concerned about the fibroids. I have already had three previous surgeries for ulcerative colitis. I have a pelvic pouch to which I am concerned that three surgeries plus a c-section will cause further scar tissue. What are my options for removing or shrinking fibroids without complicating my chances of pregnancy and adding further scar tissue?

A: Unfortunately, you are in a bit of a difficult situation.  Your fibroids as they stand right now would probably affect fertility or at least cause complications again in another pregnancy.  You might try to shrink them with lupron, and then try to get pregnant quickly after stopping (keeping in mind that the fibroids will probably grow and may again complicate your pregnancy).

Any surgery to remove fibroids may result in further scar tissue (i.e. myomectomy).

A uterine fibroid embolization would shrink your fibroids, but may affect pregnancy as it impacts blood supply to the uterus (risk include miscarriage, threatened preterm labor, etc.)

 



Q: Do fibroids affect a woman's ability to conceive?


A: Yes, fibroids can affect a woman’s ability to conceive, depending on their location in the uterus, and depending on their size.  Fibroids which come close to, or encroach upon the cavity of the uterus can affect implantation.  Larger fibroids (greater than 5 cm), may also affect fertility.

 


Q:  I am 32 years old with no kids. I have not tried to get pregnant either.

A couple of months ago I was diagnosed with a uterine fibroid. My uterus is anteroverted, enlarged, myomatous measuring 169mm X114mm X124mmm. The fibroid measured as 115 X 78 X 109 mm. The endometrium is 8 mm in thickness.  The uterus has also been pushed anteriorly to a concave shape. The ovaries appear to be normal.  My doctor has put me on Lupron 11.25mg Depot and has advised me to go for a myomectomy. I am afraid of this major surgery. Do I have any other options? I really want to have a child. I am a pharmacist.  Please advise. Thank you.

A: I am assuming that you only have one single fibroid which is measuring 11.5 cm x 7.8 cm, x 10.8 cm.  Unfortunately, if you really want a child, I think that the myomectomy is probably your best option, even though I know that the prospect of major surgery is scary.

Medications that can be offered to you (such as birth control pills, cyklokapron, Mirena IUD) may help with symptoms, but they will either prevent pregnancy, or not help.  Your fibroid is quite large and is distorting your endometrial cavity.  This might theoretically make it difficult for you to achieve pregnancy.  If you did, you would be at increased risk for both an early or a late miscarriage.  As well, you would be at risk during pregnancy of a growing fibroid which might cause pain and might cause threatened preterm labor (unfortunately, it is hard to give a percentage chance of this happening).

The uterine fibroid embolization is not recommended in women trying to get pregnant.

Good luck. I hope your surgery is a success and that you get pregnant.

 


Q:  When does a women need to be concerned about a uterine fibroid?

A: A woman needs to be concerned about a uterine fibroid if it is causing any symptoms affecting her quality of life or activities of daily living (e.g. missed days of work or activities secondary to bleeding or pain).  As well, she should be concerned if a fibroid is growing rapidly.

 



Q: Hello.

Are you aware of dietary changes that would reduce heavy bleeding and fibroids? I am 48 years old and I have been experiencing heavy bleeding along with a fibroid. No discomfort just the heaviness. Are there any natural remedies that may work such as wild yam root cream? Any thoughts would be appreciated. Thank you.

A: Hello.
There is some evidence to suggest that decreasing dairy intake, or at least switching to organic dairy products help with fibroids (growth) and menorrhagia (heavy bleeding with periods).

There is some endometriosis/pelvic pain data to suggest that decreasing dairy products also helps with cramping associated with periods.

Other dietary changes include what is called a “macrobiotic” diet… in other words, limiting sugar intake, wheat intake, and processed foods.  With this diet, you also only eat what is in season locally (i.e. organic, no pesticides).

Unfortunately, however, none of these dietary changes will decrease the size of your fibroids… they may just help with your symptoms. With regards to naturopathic remedies (eg. wild yam root, etc), I am just not sure, as I do not prescribe these medications.

I hope this helps.

 


Q: I have fibroids and would like to know if they cause heavy periods and clots. I have been passing fairly large clots during my period.


A: Yes, fibroids can cause very heavy periods and clots.  The fibroids which typically cause heavy periods are ones which are “submucosal”, “subendothelial” or “intracavitary”.  These terms refer to fibroids which come close to your uterine cavityA pelvic/transvaginal ultrasound should help delineate which kinds of fibroids you have.

 



Q:
 I am 48 & I have one son. I have a fibroid of size about 12cm x 15cm, which is very big. It has caused anemia & I have to take iron pills. I would like to know what kind of treatment will be suitable for me. Will I be a suitable candidate for laparoscopic surgery or UFE? Also, how can I get an appointment to see a specialist in Toronto as soon as possible? Thanks so much.


A: Hello.
Your fibroid is quite large.  You would be a candidate for medical therapy and UFE.  Medical therapy would include cyklokapron (which is an antifibrinolytic and delays clots from being broken down) and lupron (which is a GnRH agonist that causes a “medical menopause”) and the Mirena IUD.  Cyklokapron is sometimes not as effective with a large fibroid present.  Lupron is effective and may also shrink your fibroid, but after six months you will either need to stop or go on hormone replacement therapy to prevent osteoporosis.  If you stop it completely, eventually your fibroids will grow again.  The Mirena IUD is best if your uterine cavity is normal in shape and configuration.

UFE is a good option given what you have told me about your history.  It may shrink your fibroid up to 50 percent in volume, and it is good for heavy periods. As for whether or not you are a candidate for laparoscopic surgery, it really depends on your clinical examination, which is hard for me to get an idea of.  If your fibroid is too large, then you would have to have an abdominal incision in order to remove your fiboid/uterus.

To get an appointment to see a specialist in Toronto, your family doctor would have to refer you to a gynecologist or an interventional radiologist (for the UFE).

 



Q: My specialist recently suggested the Mirena IUD to help with my heavy menstrual cycle.  I have numerous fibroids, some quite large, and recently prior to having the IUD inserted, I had my period for 10 weeks straight.  The first couple of months after having the IUD inserted, my cycle seemed OK, however, this month it was quite heavy and painful again. I was told basically my only other option is hysterectomy, which I am very reluctant to have done.

Where can I find information to see if possibly there could be any other options for me? I had a friend who also had numerous fibroids, and she had a procedure where the fibroids were I believe, tied, so that they would be cut-off from the blood supply, thereby reducing their size.


A: The Mirena IUD is an excellent medical intervention.  It can, however, be not as effective in women where their fibroids change the shape of their uterine cavity. You are also a candidate for cyklokapron, and lupron (please see above question and response).

I am not sure what your friend had done, but she may have had a UFE (uterine fibroid embolization).  You might be a candidate for that as well, although you haven’t told me your age, and I am not sure if you are desirous of future fertility.  Traditionally, UFE is not recommended in women who are still considering pregnancy, as it affects the blood supply to your uterus (which, if you were to get pregnant, would in turn supply blood to your placenta and fetus).

You would still also be a candidate for myomectomy (be it laparoscopic or abdominal), depending on how many fibroids you have.  Again, traditionally hysterectomy was only offered, especially if a women had finished child-bearing.

Current trends, however, are to offer a women a myomectomy (removing only the fibroids and leaving the uterus). These women must understand, however, that there is a greater blood loss with this surgery, and that some of the fibroids may be left behind.

 



Q: Would a large posterior fibroid interfere with pregnancy? My gynaecologist has put me on Lupron 11.25mg and later on 22.5mg to shrink it. He will then send me for an ultrasound to see if it has shrunk and will later advise me to get pregnant. My fibroid is highly vascular and is 10 X 10 X 8cm in size.
Please help.


A: Yes, there is data to suggest that a large posterior fibroid might interfere with pregnancy.  Before, there was a lot of data to suggest that the only fibroids which caused infertility were ones which came close to the cavity of the uterus (where an embryo would implant).  These fibroids are called “submucosal”, “subendothelial”, or “intracavitary”.  Now, however, there is more data to suggest that fibroids which are larger than 5cm may also affect fertility.

While you are on lupron, you will not be able to get pregnant, as it makes you menopausal.  Hopefully, it will help to shrink your fibroid to the point where you can achieve pregnancy.  It is, however, hard to say how long you have before your fibroid will grow again.  Remember, too, that your fibroid may grow during pregnancy and cause complications (miscarriage, pain, threatened preterm labour).

 



Q:  I am a 45-year-old Asian-descent Canadian.  I have two children (nine and 11 years) and had taken the contraceptive pill in the past (before my pregnancies) for a number of years. But I have been off these pills now for 12 years.

I was diagnosed with Myomas (fibroids) in my uterus about five years ago.  The fibroids were very small at the time but already I had started to get heavier periods.  However, there were no further issues or annoying symptoms.  Two years ago, I had further ultrasounds revealing five fibroids ranging in size from 1.1cm X 1.2cm to 3.3cm X 2.7cm (the largest).  Again, most of these were small and no cause for concern according to my gynecologist.  I continued to have heavy menstruation, but no other issues.

Today, after two years, the fibroids range in size from 2.2cm X 2.1cm to 5.1cm X 3.0cm (the largest).  According to my gynocologist, the  fibroids have almost doubled in size in 2 years.  Menstrual bleeding is heavy including bleeding in between periods.  The result is that my red blood cell count is low and I need medication for anemia.  My uterus volume 2 years ago was 127 m3 and today it is 163.1 m3 with the result that I feel quite bloated all the time in my lower abdomen.

According to my current gynecologist there are two options:  1) hormone therapy or 2) hysterectomy.  She doesn't want to prescribe hormone treatments since she thinks this will create risks for my fibrocystic breasts.  She is recommending instead a hysterectomy!!

I am shocked since after doing some research on the internet I have seen other treatments being recommended which are less invasive.  I also don't want hormone therapy, but a hysterectomy is very invasive and for me the last resort.  The other treatments I have read about include:

  1.  Natural progesterone oils/creams applied to the skin/abdomen (brand names "Progest" or "Projestelle").  Would these be absorbed into my blood stream like ingesting progesterone with potential impact on my breasts too?  If yes, then this might not be an option for me.  Here's were I found out about it:http://www.fibroid101.com/
  2.  Enzymes nattokinase and serrapeptase to break down fibroids and lignans to put estrogen hormones in balance.  The chemical names are Natto SEB and Peptzyme SP (brand name "Neprinol" and "Brevail" combo pills). The results on the following website look incredible: http://www.fibromedica.com/uterine_fibroids
  3. Myomectomy: uterine artery embolization to cut off blood supply to fibroids
  4.  Myolysis: electric currents to cut off blood supply to fibroids
  5. Focused ultrasound: a new outpatient procedure using MRI to locate fibroids and then directing high intensity ultrasound energy to heat and destroy the fibroids.  This looks like a procedure that could be the least invasive:http://www.uterine-fibroids.org/mr_guided.html

My gynecologist did not tell me about any of these options.  Would you recommend any of these treatments to me?   I like option 2 the best (Neprinol and Brevail) and it appears to be an over-the-counter drug but there's no mention of side effects.  However, it appears to have worked for many women and is absolutely not invasive.

After option 2, I like option 5, the use of ultrasound energy guided by MRI, but this also appears to be fairly new and maybe not yet available in Canada?

I am desperate to avoid undergoing a hysterectomy and would really appreciate a second opinion and advice from someone who might have experience with these alternative treatments.


A:  Hello.
Let me answer your questions in turn so that I can be sure that I cover them all. Natural progesterone creams are not absorbed like pills.  They are absorbed transdermally, thereby bypassing the liver.  That is not to say, however, that they do not have effects on other areas of your body, and they may impact your breasts.  With regards to your fibroids, they will probably not shrink them or decrease their rate of growth.

Neprinol and Brevail are medications that some of my other patients have mentioned to me.  I have never prescribed nor endorsed them, but I have taken a look at these websites.  They are basically trying to “break down” excess collagen/fibrin in the body.  There are no studies that have actually looked at the use of neprinol in patients with fibroids vs. a placebo.  Fibroids, remember are mostly muscle tissue.  I agree with you that the claims the website makes are amazing.  I would caution you as to their use, however, as I just do not know enough about them.  You would be taking them at your own risk.

Myomectomy is not the same thing as Uterine Fibroid Embolization (UFE).  I am not sure if you already know this, or if it is the way the two were typed out in your question.  Myomectomy is the surgical removal of uterine fibroids, leaving the uterus behind.  This is done by the gynecologist.  A UFE is where the blood supply to the uterus/fibroid is mapped out by the interventional radiologist and then cut off by injecting nonabsorbable pellets into these vessels.  The fibroid is still present, but may shrink and decrease symptoms.  Both are well studied procedures.

Myolysis requires surgery, and was performed earlier in the 90’s for treatment of fibroids (without myomectomy).  The idea was to use electrical current to “pierce” the fibroid in multiple areas and ablate the blood supply to the fibroid that way.  It did not remove the fibroid, but would hopefully shrink it.  It is not as popular an option these days, as it was associated with more adhesion formation and also with increased risk of uterine rupture (if these patients went on to have a pregnancy).

Focused MRI guided ultrasound treatment of uterine fibroids is a very exciting area.  Unfortunately, it is not offered yet in Canada.  It is still on an experimental/trial basis in Boston, London (UK that is), Israel, and Germany.  Boston (Brigham Women’s Hospital) actually will offer it to you (they have a payment plan !! -- I think it is in excess of $15,000 US) if you are really interested.  Hopefully it will be offered to our women in Toronto in the next few years… I am eagerly encouraging our interventional radiologists (who would be performing this procedure).

One last new method that you haven’t mentioned, but that is being trialed here in Canada is the “Flostat” system.  This is an experimental procedure being performed in London, Ontario, and is not being offered routinely to women yet.  It involves a clamp that is placed on the uterine arteries (thereby affecting the blood supply to the uterus and the fibroids) through the vagina.  By clamping the uterine arteries for a set period of time, eventually the fibroids would shrink.

I hope this information of newer (and older) alternatives is helpful.  I cannot say what is best for you… this is a decision you and your physician will have to come to, but your options include medication (mentioned in the other questions), myomectomy, uterine fibroid embolization, and ultimately, hysterectomy.  Again, with regards to the other medication such as neprinol, that is something I cannot comment on.

 

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