Uterine Fibroids

More than half of all women have fibroids. They are a common, benign, uterine growth.

Fibroids are not a disease. Much like the genetic blueprint that determines the color of your eyes and hair, if fibroids are common in your family, you are more likely to develop them.

Fibroids often do not cause symptoms. Most women are unaware that they have them until a doctor mentions it during a routine pelvic exam.

Composed of smooth muscle cells and connective tissue, fibroids grow slowly until you reach menopause. They have two, predictable, rapid growth spurts that are natural and not a cause for concern. After menopause, fibroids shrink and become small and calcified.

The first rapid growth spurt usually occurs in the late 30’s to early 40’s, followed by a few years of slower growth. The second (and last) rapid growth spurt occurs just before menopause– when women experience the hormonal changes associated with the beginning of menopause. About a year after menopause, fibroids begin to slowly and gradually shrink to a negligible size.

Some women have large fibroids, while others have smaller fibroids. But for women in their late 30’s to early 40’s who have fibroids, the size of the uterus including the fibroids is, on average, about the size of a 10-12 week pregnancy–about 13cm in the largest dimension. In the middle 40’s, the uterus including fibroids is, on average, about the size of a 14-16 week pregnancy–about 17cm in the largest dimension. And for women in their late 40’s to early 50’s, the uterus including fibroids is, on average, the size of an 18-20 week pregnancy–about 21cm in the largest dimension.

By about age 40, women have all the fibroids they are ever going to have. Rarely will a new fibroid develop after about the age 40.

Both estrogen and progesterone stimulate fibroid growth. Some foods, such as eating large amounts of soy, can also stimulate excess estrogen production, which in turn makes fibroids grow. There is an abundance of advertising for vitamins and other products that promise to reduce the size of fibroids or eliminate them entirely, but many are ineffective, and others actually stimulate fibroid growth. For example, so-called “natural” progesterone yam creams are promoted as a way to shrink fibroids, but in fact they make them grow.

If you have symptoms such as extremely heavy menstrual bleeding with large blood clots or pressure on the bladder causing urinary frequency, it may be more of a nuisance than a true health problem. If you can live with the symptoms, you will avoid needless intervention of any kind. If you have symptoms that you cannot live with there are conservative treatment options.

The location of fibroids that cause heavy menstrual bleeding is submucosal. “Submucosal” fibroids are located in the inside layer of the uterus–in the endometrium. Even tiny submucosal fibroids can cause extremely heavy menstruation with large blood clots. Submucosal fibroids that are 4cm or smaller may cause heavy bleeding and large blood clots. They can by shelled out in a procedure called a hysteroscopic resection of the fibroid, which should not be confused with a hysteroscopic resection of the endometrium. You can avoid having a doctor think you want a hysteroscopic resection of the endometrium, which would make the bleeding worse, by referring to the procedure as the hysteroscopic shelling out of a submucosal fibroid.

Hysteroscopic resection is usually an outpatient surgery in which a long endoscope called a hysteroscope is inserted into the vagina, through the cervix, and into the uterus. A tool is attached to the scope, and the surgeon chips away at the fibroid until nothing remains but the shell. This may sound like a simple surgery, but shelling out the fibroid without perforating the uterus requires skill and experience.

Submucosal fibroids that are larger than 4cm cannot be shelled out hysteroscopically, but they can be removed with a myomectomy. Myomectomy is a conservative surgery to remove fibroids that leaves the uterus intact. Fibroids in other locations, such as intramural fibroids (in the middle wall of the uterus) and subserosal fibroids (in the outside wall of the uterus) and pedunculated fibroids (outside the uterus attached to a long stalk, which is the blood supply from the uterus to the fibroid) can also be removed with myomectomy.

Fibroids of any size, number, or location can be removed by a skilled surgeon. If a doctor tells you that a myomectomy cannot be performed because of the size, number, or location of your fibroids, you need another doctor. It is unlikely that a doctor will tell you that a myomectomy could be performed by a more skilled surgeon.

It is a major operation, but unlike hysterectomy, endometrial ablation, focused ultrasound, UAE (uterine fibroid embolization) and other destructive surgeries, myomectomy is a constructive surgery that preserves the uterus and its many lifelong functions.

Uterine Artery Embolization (UAE) is sometimes referred to as uterine fibroid embolization (UFE). It involves occluding (blocking) the blood flow in the uterine arteries. It is performed by an Interventional Radiologist who inserts an embolic material–such as tiny plastic polyvinyl alcohol particles, microspheres, embospheres, gel foam, or metal coils–into the femoral artery, and then into the uterine artery that supplies blood to the fibroid. UAE is considered successful if the fibroids shrink, even when there are serious complications.

One of the serious complications from UAE is misembolization. Misembolization occurs when the embolic material travels to distant parts of the vascular system. The reason this happens is that the blood supply to the fibroids is shared with other organs–such as the labia, vagina, clitoris, ovaries, bladder, and kidneys. In fact, the blood flowing through the uterine artery, where the embolic material is injected, is part of the same blood supply that provides blood flow to your legs and feet and back up through your vascular system to your heart and lungs. Adverse effects ranging from chronic pain and loss of ovarian function to a loss of sexual feeling have been reported as a result of misembolization, as well as several deaths.

The goal of UAE is to block the flow of blood. But when the blood supply to any part of your body is blocked, the tissue that depends on that blood supply may become necrotic–it might die. Necrosis of tissue as a result of impaired blood flow is common and may be lifethreatening.

The Food and Drug Administration (FDA) maintains an Adverse Events database with hundreds of reported complications of UAE. Although it receives only a small percentage of the actual number of adverse events that occur (reporting is voluntary, and the only complication that must be reported is death), it is a significant number. The Adverse Events database can be accessed online by going to “FDA Maude” on the FDA website, clicking on “Simple Search,” and entering the search term “uterine artery embolization.” A second search entering the term “uterine fibroid embolization” will provide additional adverse event reports.

The HERS Foundation has counseled many women with permanent, disabling problems from UAE. Some women experience necrosis of the uterus (leading to a hysterectomy that was not necessary before the UAE), as well as necrosis of the vagina, labia, buttocks, bladder, bowel, and kidney. And many women experience impairment, or even the total loss, of ovarian function. The medical term for the removal of ovaries is castration, and for the loss of ovarian function in intact ovaries, the term is de facto castration.

Although UAE does sometimes diminish heavy bleeding and shrink fibroids, the relief may be temporary. Fibroids often begin to grow again a few months after embolization and cause a recurrence or worsening of previous symptoms. The embolic material remains in a woman’s body the rest of her life, often causing future health problems. There is no remedy for these complications because the embolic material cannot be removed or flushed out of the vascular system once it is injected into it.

We will not know just how dangerous UAE is until the effects of longterm exposure to radiation (from fluoroscopy, which allows the doctor to see inside the artery during the procedure) and the effects of injecting plastic balls and metal coils into the human bloodstream plays itself out in the lives of millions of women.

Another destructive “alternative” treatment for heavy bleeding from fibroids is called endometrial ablation. Endometrial ablation is a surgery where the endometrium, the inside, endometrial layer of the uterus, is burned by heat or freezing. Whatever method of ablation is used, the purpose is to permanently scar the inside of the uterus so that the endometrium (the layer of the uterus that sheds during menstruation) cannot build up. The hypothesis is that if the endometrium is prevented from proliferating (building-up), there will be nothing to shed as it naturally does during menstruation.

Endometrial ablation is considered successful if menstrual bleeding stops. But the uterus continues to attempt to perform its natural functions as if it were not scarred. In preparation for menstruation, the natural engorgement of blood still occurs in the uterus and pelvis, but due to the scarring caused by ablation, there is no endometrial tissue to build up. With no endometrial lining to shed, there is no way for the blood to exit the uterus, so the uterus remains engorged with blood. This may initially only cause a feeling of fullness in the pelvis, but after a few months of the uterus being engorged with blood by a blockage of natural menstrual flow, many women experience constant, debilitating pelvic and vaginal pressure and pain.

Other risks of heat and freezing ablation include thermal perforation of the uterus, bowel, or bladder and infection and hemorrhage. Additional risks of heat ablation are fluid overload and death.

Intravenous fluid is given to replace the fluid lost during heat ablation. The amount of fluid must be closely monitored, and every woman is unique in terms of how much fluid her body will tolerate. The surgeon then applies heat or cryo (freezing) to the endometrium. This procedure causes an unknown quantity of the fluid to evaporate. Some of the fluid is absorbed into the woman’s body, but the amount of evaporation and absorption cannot be measured precisely. It is far from an exact science. Women have experienced serious complications, even death, as a result of fluid overload in the heart and lungs.

Damage to the uterus as a result of endometrial ablation often leads to a hysterectomy that was not necessary before the ablation. Although the exact number is not known, it is important to note that the incidence of hysterectomy after undergoing endometrial ablation or uterine artery embolization to treat fibroids is probably significant, because these procedures themselves often do irreparable damage to the uterus, ovaries, external genitalia and other internal organs.

If a doctor tells you that you need a hysterectomy for fibroids, you need a better doctor. You never need a hysterectomy for fibroids unless you have the wrong doctor. If you have symptoms that you feel you need to do something about, there are conservative treatment options.

Hysterectomy causes many well-documented, permanent, irreversible, and life-altering problems.

For more information, watch the short video “Female Anatomy: the Functions of the Female Organs.”