* Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.
Uterine
Fibroids and Hysterectomy
WHAT
ARE UTERINE FIBROIDS?
A uterine fibroid
(known medically as a leiomyoma, or simply myoma)
is a benign (noncancerous) growth composed of smooth muscle and
connective tissue. The size of a fibroid varies from that of a pinhead
to larger than a melon. Fibroid weights of more than 20 pounds have
been reported.
Fibroids originate from the thick wall of the uterus and are categorized
by the direction in which they grow:
- Intramural
fibroids grow within the middle and thickest layer of the
uterus (called the myometrium). They are the most common
fibroids.
- Subserosal
fibroids grow out from the thin outer fibrous layer of
the uterus (called the serosa). Subserosal can be either
stalk-like ( pedunculated) or broad-based ( sessile).
These are the second most common fibroids.
- Submucous
fibroids grow from the uterine wall toward and into the
inner lining of the uterus (the endometrium). Submucous
fibroids can also be stalk-like or broad-based. Only about 5%
of fibroids are submucous.
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The Female Reproductive System
Reproductive Organs
-
The uterus is a pear-shaped organ located between
the bladder and lower intestine. It consists of two parts,
the body and the cervix.
-
When a woman is not pregnant the body of the uterus
is about the size of a fist, with its walls collapsed
and flattened against each other. During pregnancy the
walls of the uterus are pushed apart as the fetus grows.
-
The cervix is the lower third of the uterus. It
has a canal opening into the vagina with an opening called
the os, which allows menstrual blood to flow out
of the uterus into the vagina. Leading off each side of
the body of the uterus are two tubes known as the fallopian
tubes . Near the end of each tube is an ovary.
-
Ovaries are egg-producing organs that hold between 200,000
and 400,000 follicles (from folliculus, meaning
"sack" in Latin); these cellular sacks contain the materials
needed to produce ripened eggs, or ova.
-
The inner lining of the uterus is called the endometrium,
and during pregnancy it thickens and becomes enriched
with blood vessels to house and support the growing fetus.
If pregnancy does not occur, the endometrium is shed as
part of the menstrual flow. Menstrual flow also consists
of blood and mucus from the cervix and vagina.
Reproductive Hormones
The pituitary
gland is often referred to as the master gland because of
its important role in many vital functions, many of which
require hormones. In women, six key hormones serve as chemical
messengers that regulate the reproductive system.
-
The hypothalamus first releases the gonadotropin-releasing
hormone (GnRH) .
-
This chemical, in turn, stimulates the pituitary gland
to produce follicle-stimulating hormone (FSH)
and luteinizing hormone (LH) .
- Estrogen,
progesterone, and the male hormone testosterone
are secreted by the ovaries at the command of FSH and
LH and complete the hormonal group necessary for reproductive
health.
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WHAT
CAUSES UTERINE FIBROIDS?
Female
Hormones
Uterine fibroids
often grow during pregnancy and they degenerate after menopause.
From these observations and certain studies researchers are fairly
certain that the female hormones, both estrogen and progesterone,
play a role in their growth. Their contribution is not clear-cut
however, since pregnancy and oral contraceptive use appears to protect
against fibroids, and both conditions are associated with high hormone
levels.
Genetic
Factors
Inherited genetic
factors may be important in many cases of fibroids. Researchers
have identified chromosomes where genes may play a role in fibroid.
Some experts have observed that the estrogen patterns in fibroids
are similar to those in pregnancy. Fibroids are very sensitive to
estrogen, which keeps fibroid growth active and protects them from
natural self-destruction. Some evidence suggests that abnormal genetic
factors may produce smooth muscle cells in the uterus that undergo
changes that mimic pregnancy when the cells are exposed to female
hormones. These impaired cells, however, do not respond normally
to the signals that should make them self-destruct and return to
a nonpregnant state.
Response
to Injury
One theory is
that fibroids form in response to injury, essentially when the uterine
cells are deprived of oxygen during menstruation.
Growth
Factors
The formation
of fibroids may be attributable to abnormalities in substances called
growth factors. These are special proteins secreted by
different cell types and are responsible for cell to cell interaction.
Many of these substances regulate a process called angiogenesis,
which causes new blood vessels to sprout from pre-existing ones.
Researchers are investigating unique genetic factors that may be
responsible for some of the abnormalities leading to uterine muscle
overgrowth. Growth factors that have been studied for a role in
uterine fibroids include the following:
- Basic
fibroblast growth factor (BFGF). BFGF is normally suppressed
during the premenstrual phase, but in women who have fibroids,
it is not. This indicates that overactivity of BFGF may result
in excess production of blood vessel clusters and the growth
of fibroids.
- Insulinlike
growth factor (IGF)-I. Studies have observed increased levels
of this growth factor in uterine fibroids.
- Epidermal
growth factor (EGF). This factor may be decreased in fibroids.
Others being
studied include vascular endothelial growth factor (VEGF), platelet
derived growth factor, and transforming growth factor-alpha (TGF-Alpha).
WHAT
ARE THE SYMPTOMS OF UTERINE FIBROIDS?
Symptoms
of Uterine Fibroids
Less than 25%
of patients with fibroids experience symptoms. When they do, they
include the following:
- The most
common symptom is prolonged and heavy bleeding during menstruation.
This is caused by fibroid growth bordering the uterine cavity.
In severe cases, heavy bleeding may last as long as two weeks.
(Fibroids rarely bleed between periods, except in a few cases
of very large fibroids.)
- Large
fibroids can also cause pain in the abdomen or lower back that
sometimes feels like menstrual cramps.
- As the
fibroids grow larger, some women feel them as hard lumps in
the lower abdomen.
- Very large
fibroids may give the abdomen the appearance of pregnancy and
cause a feeling of heaviness and pressure. In fact, large fibroids
are defined by comparing the size of the uterus to the size
it would be at specific months during gestation.
- Unusually
large fibroids may press against the bladder and urinary tract
and cause frequent urination or the urge to urinate, particularly
during the night when a woman is lying down.
- Abnormal
pain during intercourse (called dyspareunia).
- If the
fibroids press on the ureters (the tubes going from the kidneys
to the bladder), obstruction or blockage of urine may result.
- Fibroid
pressure against the rectum can cause constipation.
WHO
GETS FIBROIDS?
Uterine fibroids
are the most common tumor found in female reproductive organs. One
study suggested that over 80% of women between the ages of 30 and
50 have fibroids, although they cause symptoms in only about 25%.
A number of possible risk factors have been identified, but very
little research exists to confirm or develop information on them.
Being
African American
Uterine fibroids
are particularly common in African American women, with an estimated
prevalence of 50% to 75%. These women are also more likely to have
severe pain, anemia, and larger and more numerous fibroids than
women in other population groups. Although genetics may play a role,
women of African descent who live in other countries do not appear
to have as high an incidence, an indication that diet or other environmental
factors are at work in the development of fibroids in African American
women.
High
Exposure to Estrogen
Fibroids can
start to grow soon after puberty, although usually they are detected
when a woman reaches young adulthood. Women with fibroids are at
risk for accelerated fibroid growth when estrogen levels are high
or when lifestyle behaviors keep estrogen levels high.
Some examples of risk factors for fibroids that are also associated
with high estrogen exposure include the following:
- Early
onset of menstrual period (before age 12).
- Being
overweight and sedentary.
- Never
being pregnant. The risk for fibroids decreases with more children.
(This risk factor, however, may be due to a greater risk for
infertility caused by fibroids in the first place.)
Oral
Contraceptives and Hormone Replacement Therapies
Oral Contraceptives
. The evidence on oral contraceptives (OCs) has been conflicting.
Early reports suggested they might be a risk factor for fibroids.
Most studies conducted more recently, however, have found no association
and some even suggest that OCs may be protective. Another indicated
that the only higher risk was in women who starting using oral contraceptives
before the age of 16 years.
Hormone Replacement Therapy. Hormone replacement therapies
(HRT) are agents that contain estrogen alone or estrogen plus progesterone
and which are used to prevent some of the complications occurring
after menopause. After menopause, fibroids usually shrink. Researchers,
then, are investigating whether the hormones used in HRT could cause
existing fibroids to persist or even grow. Some studies, but not
all, have found greater fibroid growth with the use of patch-administered
hormone agents. (In one of the studies taking oral estrogen however,
had no effect.) A 2001 systematic review of studies reported some
fibroid growth in women taking HRT, but usually without any significant
symptoms. In summary, if HRT has an effect on fibroid growth, it
is unlikely to be severe. Any increase in fibroid growth during
menopause must be evaluated surgically by a gynecologist since such
growth, even if a woman is on hormone replacement therapy, may mean
cancer.
Other
Risk Factors
Studies report
a higher incidence of fibroids in women with high blood pressure
and obesity. Both fibroids and hypertension are associated with
a thicker uterus, but it is not clear if or how these conditions
are related. There is also a weak association between fibroids and
diabetes.
HOW
SERIOUS ARE UTERINE FIBROIDS?
Effect
on Fertility and Pregnancy
Effect on
Fertility. Fibroids do not usually cause reproductive problems,
although evidence suggests that they may be more responsible for
infertility than previously thought. Infrequently, large fibroids
can cause infertility in the following way:
- By impairing
the uterine lining.
- By blocking
the fallopian tubes.
- By distorting
the shape of the uterine cavity.
- By altering
the position of the cervix and preventing sperm from reaching
the uterus.
Effect on
Pregnancy. Fibroids pose some risk to a pregnancy:
- A cesarean
section may be required in cases where multiple fibroids, particularly
those located in the lower part of the uterus, block the vagina
during pregnancy.
- Multiple
fibroids can also increase the risk for miscarriage. In one
2001 study the presence of intramural fibroids halved the chances
for a successful pregnancy. (The largest fibroid observed in
the study was less than an inch.)
- Fibroids
can degenerate during pregnancy causing pain and may cause premature
labor.
Anemia
Anemia from iron
deficiency can develop if fibroids cause excessively heavy bleeding.
Oddly enough, smaller fibroids, usually submucous, are more likely
to cause abnormally heavy bleeding than larger ones.
Most cases of anemia are mild, but even mild anemia can cause weakness
and fatigue. Moderate to severe anemia can also cause shortness
of breath, rapid heart rate, lightheadedness, headaches, ringing
in the ears (tinnitus), irritability, pale skin, restless legs syndrome,
and mental confusion. Heart problems can occur in prolonged and
severe anemia that is not treated. Pregnant women who are anemic,
particularly in the first trimester, have an increased risk for
a poor pregnancy outcome.
Urinary
Tract Infection
Large fibroids
that press against the bladder occasionally result in urinary tract
infections. Pressure on the ureters may cause urinary obstruction
and kidney damage.
Severe
Pain
Fibroids can
cause cramping during a period, which can be quite intense at times.
Pain can also develop if the blood supply is cut off from the fibroid
tissue. In such cases, the cells blacken and die (called necrosis)
from lack of oxygen and can result in pain. This event may occur
under the following circumstances:
- A very
large fibroid outgrows its own blood supply.
- A pedunculated
fibroid (one that grows on a stem from the uterine wall) becomes
twisted, thus cutting off its blood supply.
- Pregnancy
occurs, in which the risk for fibroid cell degeneration and
necrosis increases.
Leiomyomas
that Spread Outside the Organ
Rarely, a fibroid
breaks away from the uterus and develops in other locations. They
are typically one of the following:
- Benign
metastasizing leiomyoma or BML (which usually spreads to
the lung).
- Disseminated
peritoneal leiomyomatosis (which spreads to the abdominal
wall).
Neither are cancerous,
although there is some evidence that BML, which often occurs after
menopause, may represent a slow-growing variant of leiomyosarcoma.
Uterine
Cancer
Fibroids are
nearly always benign and noncancerous, even if they have abnormal
cell shapes. Cancer of the uterus nearly always develops in the
lining of the uterus (endometrial cancer). Only in rare cases (a
less than 0.1% incidence ) does cancer develop from a malignant
change in a fibroid (called leiomyosarcoma). Nevertheless,
rapidly enlarging fibroids in a premenopausal woman or even slowly
enlarging fibroids in a postmenopausal woman require surgical evaluation
to rule out cancer.
HOW
ARE UTERINE FIBROIDS DIAGNOSED?
Pelvic
Examination
A physician will
perform a pelvic examination to check for pregnancy-related conditions
and for signs of fibroids or other abnormalities, such as ovarian
cysts.
Medical
and Personal History
The physician
needs to have a complete history of any medical or personal conditions
that might be causing heavy bleeding. He or she may need the following
information:
- Any family
history of menstrual problems or bleeding disorders (which should
be suspected in teenage girls with heavy bleeding). It should
be noted that, in some cases, young women with heavy bleeding
from inherited conditions may not even report it if they grew
up in a family where such bleeding was considered normal.
- The presence
or history of any medical conditions that might be causing heavy
bleeding. Women who visit their gynecologist with menstrual
complaints, particularly heavy bleeding, pelvic pain, or both
may actually have an underlying medical disorder, which must
be ruled out.
- The pattern
of the menstrual bleeding. (If it occurs during regular menstruation,
nonhormonal treatments are tried first. If it is irregular,
occurs between periods, occurs after sex, is associated with
pelvic pain, or if it occurs with premenstrual pain, the physician
should look for specific conditions that may cause these problems.)
- Regular
use of any medications (including vitamins and over-the-counter
agents).
- Diet history,
including caffeine and alcohol intake.
- Past or
present contraceptive use.
- Any recent
stressful events.
- Sexual
history. (It is very important that the patient trust the physician
enough to describe any sexual activity that might be risky.)
Ruling
out Other Conditions that Cause Heavy Bleeding (Menorrhagia)
Almost all women,
at some time in their reproductive life, experience heavy bleeding
during a period (medically called menorrhagia). Being taller,
being older, and having a higher number of pregnancies increases
the chances for heavier than average bleeding. In some cases the
cause of heavy bleeding is unknown, but number of conditions can
cause menorrhagia or contribute to the risk, including the following:
- Miscarriage.
An isolated instance of heavy bleeding usually after the period
due date may be due to a miscarriage. If the bleeding occurs
at the usual time of menstruation, however, miscarriage is less
likely to be a cause.
- Having
late periods or approaching menopause. These events may cause
occasional menorrhagia.
- Uterine
polyps. (These are small benign growths in the uterus.)
- A retroverted
uterus, a condition in which the uterus is tilted backwards
(so-called tipped uterus).
- Certain
contraceptives. (Oral contraceptives or an intrauterine device,
an IUD.)
- An isolated
instance of heavy bleeding may be due to a miscarriage. If the
bleeding occurs at the usual time of menstruation, however,
miscarriage is less likely to be a cause.
- Bleeding
disorders. Bleeding disorders that impair blood clotting can
cause heavy menstrual bleeding and, according to different studies,
have been associated with between 10% and 17% of menorrhagia
cases. Von Willebrand disease, a genetic condition, is the most
common of these bleeding disorders. Most, but not all studies,
report this problem to be more common in African American than
Caucasian women. Other rare disorders that impair blood platelets
and clotting factors can also account for some cases of menorrhagia.
Most bleeding disorders have a genetic basis and should be suspected
in adolescent girls who experience heavy bleeding.
- Uterine
cancer.
- Pelvic
infections.
- Endometriosis.
(These are small implants of uterine tissue. They are more likely
to cause pain than bleeding.)
- Adenomyosis.
This condition occurs when glands from the uterine lining become
embedded in the uterine muscle. Its symptoms are nearly identical
to fibroids (heavy bleeding and pain), and in one study fibroids
were also present in 62% of cases. It is most likely to develop
in middle-aged women who have had many children.
- A number
of medical conditions: Eg, thyroid problems, systemic lupus
erythematosus, diabetes, certain cancers and chemotherapies,
and some uncommon blood disorder.
- Certain
drugs, including anticoagulants and anti-inflammatory medications.
- In many
cases the cause of heavy bleeding is unknown, and basic physiologic
factors may be responsible, although their mechanisms are not
fully clear. [For more information on heavy menstrual bleeding,
see the # 80 Report Menstruation: Heavy
Bleeding (Menorrhagia) ]
Hysteroscopy
Hysteroscopy
is a procedure that may be used to detect the presence of fibroids,
polyps, or other causes of bleeding. (It may miss cases of uterine
cancer, however, and is not a substitute for more invasive procedures,
such as D&C or endometrial biopsy, if cancer is suspected.)
It is done in the office setting and requires no incisions. The
procedure uses a long flexible or rigid tube called a hysteroscope,
which is inserted into the vagina and through the cervix to reach
the uterus. A fiber optic light source and a tiny camera in the
tube allow the physician to view the cavity. The uterus is filled
with saline or carbon dioxide to inflate the cavity and provide
better viewing. This can cause cramping.
Hysteroscopy is non-invasive, but 30% of women report severe pain
with the procedure. The use of an anesthetic spray such as lidocaine
may be highly effective in preventing pain from this procedure.
Other complications include excessive fluid absorption, infection,
and uterine perforation. Hysteroscopy is also employed as part of
surgical procedures. [ See Operative Hysteroscopy below].
Imaging
Techniques
Ultrasound
and Sonohysterography. Ultrasound is the standard imaging technique
for evaluating the uterus and ovaries, detecting fibroids, ovarian
cysts and tumors, and also obstructions in the urinary tract. It
uses sound waves to produce an image of the organs and entails no
risk and very little discomfort.
Transvaginal sonohysterography uses ultrasound along with saline
infused into the uterus, which enhances the visualization of the
uterus. This technique is proving to be more accurate than standard
ultrasound in identifying potential problems. Some experts believe
it should become a first line diagnostic tool for diagnosing heavy
bleeding.
Magnetic Resonance Imaging. Magnetic resonance imaging (MRI)
gives a better image of any fibroids that might be causing bleeding,
but it is expensive and not usually necessary.
Endometrial
Biopsy with or without Dilation and Curettage (D&C)
When heavy or
abnormal bleeding occurs, an endometrial (uterine) biopsy can be
performed in the office along with an ultrasound. It is usually
used with a procedure called dilation and curettage (D&C), which
is particularly important to rule out uterine (endometrial) cancer.
A D&C is a somewhat invasive procedure:
- A D&C
is usually done in an outpatient setting so that the patient
can return home the same day, but it sometimes requires a general
anesthetic. It may need to be performed in the operating room
to rule out serious conditions or treat some minor ones that
may be causing the bleeding.
- The cervix
(the neck of the uterus) is dilated (opened).
- The surgeon
scrapes the inside lining of the uterus and cervix.
The procedure
is used to take samples of the tissue and to relieve heavy bleeding
in some instances. D&C can also be effective in scraping off
small endometrial polyps, but it is not very useful for most fibroids,
which tend to be larger and more firmly attached.
WHAT
ARE THE LIFESTYLE MEASURES FOR MANAGING UTERINE FIBROIDS?
Because fibroids
are almost never life threatening, watchful waiting is a reasonable
option for many women, particularly if they are approaching menopause
(even if the fibroid is large).
Regular
Monitoring
Any woman who
chooses watchful waiting should be sure other causes of heavy bleeding
have been ruled out. She should also have regular pelvic examinations
and ultrasounds performed to monitor the growth of the fibroid.
Dietary
Factors
Foods for
Maintaining Healthy Iron Stores. The following are some suggestions
for increasing iron levels in the diet:
- The best
foods for increasing or maintaining healthy iron levels contain
absorbable iron, called heme iron . Such foods include
(in order of iron-richness) clams, oysters, organ meats, beef,
pork, poultry, and fish.
- About
60% of iron in meat is poorly absorbed; this is a form called
non-heme iron . Eggs, dairy products, and vegetables
that contain iron only have the non-heme form. Such plants
include dried beans and peas, iron-fortified cereals, bread,
and pasta products, dark green leafy vegetables (chard, spinach,
mustard greens, kale), dried fruits, nuts, and seeds. (One study
reported that even though non-heme iron is normally less easily
absorbed, people who were iron deficient absorbed 10 times the
amount of non-heme iron as people with normal iron levels.)
- Increasing
intake of vitamin-C rich foods can enhance absorption of non-heme
iron during a single meal, although regular intake of vitamin
C does not appear to have any significant effect on iron stores.
In any case, vitamin-C rich foods are healthful and include
broccoli, cabbage, citrus fruits, melon, tomatoes, and strawberries.
One orange or six ounces of orange juice can double the amount
of iron your body absorbs from plant foods.
- Foods
containing riboflavin (vitamin B2) may help enhance the response
of hemoglobin to iron. Sources include liver, dried fortified
cereals, and yogurt.
- Cooking
in cast iron pans and skillets is known to increase iron content
of food. According to one study, however, boiling, steaming,
or stir-frying many vegetables in utensils composed of any
material significantly increases the release of iron stored
in plants so it is available to the body.
- Certain
nutrients, such as tannin (found in tea) or phytic acid (found
in foods such as seeds and bran) impedes the body's absorption
of dietary iron. (It is commonly believed that fiber impeded
iron absorption, but researchers report that it most likely
has no effect.)
Sources of
Vitamins B12 and Folate. Vitamins B12 and folate are important
for prevention of anemia related to nutritional deficiencies. Although
this anemia is not necessarily related to fibroids, these vitamins
are very important for good health in general and for reproductive
health in women.
- The only
natural dietary sources of B12 are animal products, such as
meats, dairy products, eggs, and fish (clams and oily fish are
very high in B12); like other B vitamins, however, B12 is added
to commercial dried cereals. The recommended daily allowance
(RDA) is 2.4 mcg a day. Deficiencies are rare in young people,
although the elderly may have trouble absorbing natural vitamin
B12 and require synthetic forms from supplements and fortified
foods.
- Folate
is best found in avocado, bananas, orange juice, cold cereal,
asparagus, fruits, green, leafy vegetables, dried beans and
peas, and yeast. The synthetic form, folic acid, is now added
to commercial grain products. Vitamins are usually made from
folic acid, which is about twice as potent as folate. Many experts
now recommend that adults have 400 mcg of folic acid daily,
which is considerably higher than standard recommendations of
400 mcg of folate, which does not take into consideration
the possible benefits of folate on the heart. Low levels of
folate during pregnancy are common without supplements; deficiencies
at that time increase the risk of neural tube defects in newborns.
Women who are planning to get pregnant should take 400 mcg of
folic acid before conception as well as when they are pregnant
or breast feeding.
- Iron
Supplements. Iron supplements are the most effect agents
for restoring iron levels but they should be used only when
dietary measures have failed. Women should always discuss such
supplements with their physician. [
57, Anemia]
Nonsteroidal
Anti-Inflammatory Drugs (NSAIDs)
Although they
have not been studied for fibroids, nonsteroidal anti-inflammatory
drugs (NSAIDs) taken on a regular schedule reduce heavy menstrual
bleeding and pain from unknown causes. These drugs reduce inflammation,
in part by their action against prostaglandins, the chemicals that
stimulate uterine contractions and cause pain. Aspirin is the most
common NSAID, but there are dozens of others, including ibuprofen
(Advil, Motrin, Rufen) and naproxen (Aleve, Anaprox, Naprosyn);
both are recommended for menstrual pain. It should be noted, however,
that long-term use of any NSAID, can increase the risk for gastrointestinal
bleeding and ulcers. In fact, one 2001 study of women with iron
deficiency anemia reported that overuse of NSAIDs for menstrual
disorders contributed to the anemia.
Alternative
Treatments
Acupuncture.
Some women report relief from pelvic pain and heaviness after
acupuncture.
Yoga. Yoga exercises help some women relieve sensations of
heaviness and pressure.
Herbal Remedies. Herbal remedies used for fibroids include
ginseng or herbal combinations of rhubarb, cinnamon, and sargassum
seaweed. It is possible that some herbal medicines may be helpful,
but patients should always be wary of unproven claims for quick
cures. [See warning box.]
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Warnings on Alternative and So-Called Natural Remedies
It should
be strongly noted that alternative or natural remedies are
not regulated and their quality is not publicly controlled.
In addition, any substance that can affect the body's chemistry
can, like any drug, produce side effects that may be harmful.
There have been a number of reported cases of serious and
even lethal side effects from herbal products. In addition,
some so-called natural remedies were found to contain standard
prescription medication. Most problems reported occur in herbal
remedies imported from Asia. Even if studies report positive
benefits, most, to date, are very small. In addition, the
substances used in such studies are, in most cases, not what
are being marketed to the public.
The following website is building a database of natural remedy
brands that it tests and rates. Not all are available yet.
http://www.ConsumerLab.com/
The Food and Drug Administration has a program called MEDWATCH
for people to report adverse reactions to untested substances,
such as herbal remedies and vitamins (call 800-332-1088).
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WHAT
ARE THE MEDICATIONS USED FOR UTERINE FIBROIDS?
Hormone therapies
are the basis for medications used for fibroids. They block estrogen
and thus reduce bleeding and shrink fibroids.
GnRH
Agonists
Gonadotropin
releasing hormone (GnRH) block the release of the reproductive hormones
LH (luteinizing hormone) and FSH (follicular-stimulating hormone).
As a result, the ovaries stop ovulating and no longer produce estrogen.
These agents may be used in the following situations:
- To reduce
large submucous fibroids before uterine surgery.
- For women
with fibroids nearing menopause. (Such women only need them
for a short period.)
While GnRH agonists
can reduce fibroids by between 30% and 90% of original size , they
have certain limitations:
- They are
not permanent cures. Fibroids regrow after the drugs are discontinued.
- They can't
be taken orally.
- They are
expensive.
Before using
these drugs, the physician should be certain that no other complicating
conditions are present, particularly leiomyosarcoma (cancer). The
use of these drugs can delay treatment of the malignancy and cause
severe complications. [ See What Are the Surgical Procedures
for Uterine Fibroids?, below.]
Specific GnRH Agonists. GnRH agonists include goserelin (Zoladex),
buserelin, a monthly injection of leuprolide (depot Lupron), and
a nasal spray, Nafarelin (Synarel). Studies have reported that nafarelin
shrank all implants and significantly relieved symptoms in 85% of
patients, delayed recurrence of endometriosis after surgery, and
in comparison with leuprolide, was less expensive, had fewer side
effects, and a provided better quality of life.
Common Side Effects. Commonly reported side effects (which
can be severe in some women) include:
- Hot flashes
and night sweats.
- Reduced
sexual drive.
- Insomnia.
- Headache.
- Muscle
aches.
- Nausea
and vomiting.
- Memory
loss.
- Changes
in the skin and hair.
- Rapid
heartbeat.
- Vaginitis.
- Dryness
and/or burning sensations in the vaginal area.
- Weight
changes.
- Depression.
The side effects
vary in intensity depending on the GnRH agonist. They may be more
intense with leuprolide and persist after the drug has been stopped.
Risk for Osteoporosis. Estrogen loss from GnRH agonists
increases the risk for bone loss and osteoporosis. Women ordinarily
should not take them for more than six months. Certain other factors
intensify the risk:
- Smoking.
- A history
of polycystic ovarian syndrome (with infrequent periods).
- Alcohol
abuse.
- Long-term
use of corticosteroids, which also reduce bone density.
- A family
history of osteoporosis.
Certain approaches
may preserve enough estrogen to protect bones and still effectively
relieve endometriosis symptoms:
- Add-back
therapy, which provides doses of estrogen and progestin that
are high enough to maintain bone density, but are too low to
offset the beneficial effects of the GnRH agonist.
- Intermittent
leuprolide, which uses repeated six-month courses of GnRH agonists
followed by an average of nine months of symptom control only.
- Taking
GnRH agonists in very low doses is an alternate approach, but
is still largely untested.
- Adding
a bone-protective agent called a bisphosphonate (alendronate
or etidronate) may also be helpful.
- Other
agents are being tested in combination with a GnRH agonist to
preserve bone. They include parathyroid hormone or tibolone
(available in Europe). Tibolone is known as a selective estrogen-receptor
modulator (SERM), which means it has some, but not all, effects
of estrogen.
Effects on
Pregnancy. GnRH treatments used alone do not prevent pregnancy.
Furthermore, if a woman becomes pregnant during their use, there
is some risk for birth defects. Women who are taking GnRH agonists
should use non-hormonal birth control methods, such as the diaphragm,
cervical cap, or condoms while on the treatments.
Progestin
Other studies conclude that certain female contraceptives, like
the levonorgestrel implant system [
91, Female Contraception] containing progestin, may help shrink
fibroids.
Androgens
Danazol (Danocrine)
resembles a male hormone. It suppresses estrogen and is effective
for heavy menstrual bleeding caused by fibroids. In some women it
produces male characteristics, such as facial hair and voice change.
Exercise may help reduce the male-related side effects. Other side
effects include weight gain, acne, and dandruff. It may increase
the risk for unhealthy cholesterol levels. A few cases of blood
clots and stroke have been reported. At present there is no long-term
experience using danazol for fibroids.
Antiprogestins
Gestrinone.
Antiprogestins are promising agents for fibroids. Gestrinone
has been shown to reduce uterine volume and stop bleeding. In addition,
benefits appear to persist. In one study, 89% of the women maintained
a smaller uterine for at least 18 months after stopping the treatment.
In another study, bone density even increased slightly. Adverse
effects of gestrinone include male hormone symptoms, such as acne,
and possibly the development of unhealthy cholesterol levels. Adverse
effects of gestrinone include male hormone symptoms, such as acne,
and possibly the development of unhealthy cholesterol levels.
Mifepristone. Mifepristone (Mifeprex) is used for emergency
contraception, but is controversial because of its name: the abortion
pill. This agent is an anti-progestin that has reduced fibroid size
in some studies. In one study, it reduced fibroids as significantly
as GnRH agonists and the fibroids were less likely to recur.
Investigative
Agents
A number of agents
are under investigation for treating fibroids.
- Selective
estrogen-receptor modulators (SERMs) are agents that have some
of the effects of estrogen but do not produce some of its complications,
such as a higher risk for uterine cancer. Raloxifene (Evista)
is currently a well-researched SERM prescribed for prevention
of menopause-related disorders, such as bone loss. One study
suggested that it may reduce fibroid growth in postmenopausal
women. (The best-studied SERM, tamoxifen, does not appear to
have any benefit for reducing fibroids.)
- Agents
that block growth factors believed to play a role in fibroids
are also under investigation. Pirfenidone is one such agent,
which blocks fibroid cell reproduction. Another is interferon
alpha, substance that inhibits angiogenesis (the growth of new
blood vessels).
- Agents
derived from retinoids (vitamin A compounds) may inhibit cell
proliferation in fibroid tissue. One such agent LGD1069 (Targretin)
is showing promise in animal studies.
WHAT
ARE THE GENERAL GUIDELINES FOR UTERINE FIBROID SURGERY?
Indications
for Surgery
If nonsurgical
strategies do not relieve symptoms, surgery may be the best option
for treatment. Surgery may be indicated depending on a number of
factors:
Intractable Side Effects. Surgery may be warranted if fibroids
are causing distressing and intractable symptoms that have not been
relieved by nonsurgical or minimally invasive therapies. Assuming,
however, that symptoms do not pose serious health or life-threatening
conditions, a woman should make her own decision based on any factors
she deems important (the desire for children, for example).
Ureteral Obstruction. Large fibroids sometimes press down
on the ureters (the tubes going from each kidney to the bladder),
thereby blocking urine from emptying into the bladder. Because ureteral
obstructions can permanently damage kidneys, surgery may be indicated.
Inability to Evaluate Ovaries . The risk for missing a diagnosis
of ovarian cancer is higher when fibroids are too large to permit
evaluation of the ovaries by pelvic examination or ultrasound. Ovarian
cancer is particularly deadly because it is so difficult to catch
early enough for curative treatment. The risk for this cancer, however,
is very low in women without a family history , especially before
menopause. Women with a family history of ovarian cancer and large
fibroids may need to consider surgery.
Enlarging Fibroids . Rapidly growing fibroids may signify
cancer (leiomyosarcoma), which must be ruled out. In postmenopausal
women, even slow growth raises suspicions for cancer. Ultrasound
evaluation cannot always distinguish between benign and malignant
fibroids, therefore surgery is recommended.
Severe Anemia from Heavy Bleeding . When iron supplementation,
resection (surgical removal) of submucous fibroids by hysteroscopy,
or GnRH agonist therapy fails to resolve anemia and bleeding, major
surgery may be recommended (myomectomy or hysterectomy).
Basic
Surgical Options
- Hysterectomy.
Until recently, hysterectomy was the only surgical option for
uterine fibroids. This procedure involves the surgical removal
of the uterus and is often accompanied by oophorectomy
(the removal of the ovaries). With this procedure, fertility
is not preserved. Other options may be available for many women,
even some with large fibroids. They should discuss all possibilities
with their physician. [ See What Is a Hysterectomy?]
- Myomectomy.
Myomectomy involves surgical removal only of one or more fibroids.
It may be accomplished by performing a laparotomy (a procedure
that uses a wide abdominal incision) or with less invasive surgical
techniques such as laparoscopy and hysteroscopy. In such cases,
unlike hysterectomy, fertility may be preserved. [ See
What Are the Non-Hysterectomy Procedures for Uterine Fibroids.]
- Other
Procedures. Endometrial ablation (destruction of the lining
of the uterus) may be useful in women with small fibroids and
heavy bleeding. More investigative procedures include myolysis
and uterine artery embolism, which apply unique techniques to
shut off the blood supply to the fibroids. [ See What
Are the Non-Hysterectomy Procedures for Uterine Fibroids.]
Women should
discuss each option with their physician. Deciding on the surgical
procedure depends on the location, size, and number of fibroids
and the experience of the physician. The risk for bleeding increases
with the surgeon's inexperience, so patients are urged to investigate
the surgeon's track record.
WHAT
ARE THE NON-HYSTERECTOMY PROCEDURES FOR UTERINE FIBROIDS?
Basic
Surgical Approaches
In order to operate
on the uterus, the surgeon may choose to reach the area through
a wide abdominal incision (laparotomy) or using less invasive measures
with the use of endoscopy. The decision usually is based on the
severity of the case.
Laparotomy. Laparotomy is the standard abdominal surgical
procedure. It is invasive and usually requires a wide abdominal
horizontal incision right above the pubic bone, the so-called bikini
incision.
Endoscopy. Endoscopic techniques used for uterine disorders
are hysteroscopy and laparoscopy. Endoscopic techniques are used
increasingly to replace conventional surgical techniques for many
disorders. A common factor in all endoscopic procedures is the use
of a fiberoptic scope and tubes, tiny camera lenses, and minuscule
surgical instruments. Any incisions used are very small, Band-Aid
size.
- Operative
Hysteroscopy. In this procedure, the cervix is dilated, which
requires either a local or general anesthetic. A scope called
a hysteroscopy is inserted up through the vagina and cervix
into the uterine cavity. It contains tiny surgical instruments
as well as a mini-camera and light source to view images of
the uterus, which are transmitted to a video monitor. This approach
is becoming increasingly common. Complication rates include
excessive fluid absorption, infection, and uterine perforation.
- Laparoscopy.
This procedure employs two or more small incisions, one at the
navel, and one or more in the lower abdomen. Carbon dioxide
gas is injected into the abdomen, distending it and pushing
the bowel away. A laparoscope is inserted through the navel
incision and a probe is inserted through a second incision above
the pubic hairline. The probe allows the physician to directly
view the abdominal cavity, including the outer walls of the
uterus, fallopian tubes, and ovaries. The physician manipulates
surgical instruments that are passed through additional small
abdominal incisions, using the image of the uterus on the video
monitor as the guide.
|
Preoperative Hormone Treatment
GnRH agonists,
usually depo-Lupron or Synarel, are often used for about two
to three months before many uterine surgical procedures.
There are a number of benefits:
-
May reduce the volume of fibroids by 40% to 60%, in some
cases to the extent that a less invasive procedure may
be performed.
-
May reduce the risk of bleeding.
-
May shorten operating time.
-
May reduce postoperative symptoms for many patients.
Treatments
may not be useful, however, for small fibroids, which may
shrink to the point that they are no longer visible at the
time of surgery. Since fibroids regrow after treatment, the
problem would recur.
There has also been some question whether these drugs provide
any additional advantages for myomectomies that use conventional
surgical techniques. Ultrasound may be useful in helping to
detect fibroids most likely to benefit from GnRH agonists
before such a procedure. [ See What Are the Medications
Used for Uterine Fibroids?]
|
Myomectomy
A myomectomy
surgically removes only the fibroids and leaves the uterus intact,
often preserving fertility. Myomectomy may also help regulate abnormal
uterine bleeding caused by fibroids. Not all women are candidates
for myomectomy. If the fibroids are numerous or large, myomectomy
can become complicated, resulting in increased blood loss. If cancer
is found, conversion to a full hysterectomy may be necessary. To
perform a myomectomy, the surgeon may use standard surgical approaches
(laparotomy) or less invasive ones (hysteroscopy or laparoscopy).
- Laparotomy.
Laparotomy employs a wide abdominal incision and conventional
surgery. It is used for subserosal or intramural fibroids that
are very large (usually more than four inches), that are numerous,
or when cancer is suspected. Using this approach, the physician
may be able to feel the fibroids, particularly intramural types,
which can be missed during laparoscopy or hysteroscopy. (The
physician can only view the uterine cavity or outside surface
with these latter procedures.) After the fibroids are removed,
careful reconstruction of the uterine wall is critical in both
laparotomy and laparoscopy, so that bleeding and infection do
not occur. While complete recovery takes less than a week with
laparoscopy and hysteroscopy, recovery from a standard abdominal
myomectomy takes as long as six to eight weeks. It also poses
a higher risk for scarring and blood loss than with the less
invasive procedures, which is a concern for women who want to
retain fertility.
- Hysteroscopy.
A hysteroscopic myomectomy may be used for submucous fibroids
found in the uterine cavity. With this procedure, fibroids are
removed using an instrument called a hysteroscopic resectoscope,
which is passed up into the uterine cavity through the vagina
and cervical canal. A wire loop carrying electrical current
is then used to shave off the fibroid. In one study, nearly
60% of patients conceived after this procedure. However, it
is not appropriate for many women.
- Laparoscopy.
Women whose uterus is no larger than it would be at a six-weeks
pregnancy and who have a small number of subserous fibroids
may be eligible for treatment with laparoscopy. Laparoscopy
requires incisions but they are much smaller than with laparotomy.
As with hysteroscopy, a thin scope is employed that contains
surgical and viewing instruments. In centers with extensive
experience, laparoscopy has fewer complications, and also shorter
recovery time and lower costs than laparotomy. On the other
hand, compared to the invasive surgery, laparoscopy has a greater
chance for fibroid recurrence (over 16% at five years in one
study), and a greater danger for a weakened uterine wall, which
could threaten pregnancies.
Complications
and Postoperative Factors. Any procedure for myomectomy is very
complex. To reduce the risk for complication, patients should seek
a surgeon experienced in myomectomies. Complications that occur
during a myomectomy from any procedure include the following:
- Excessive
blood loss (higher incidence in laparotomy).
- Uterine
weakening and rupture during pregnancy. (This has been more
of a concern with laparoscopy. No reports of this have occurred
with hysteroscopic myomectomy.)
- Subsequent
scarring (higher incidence in laparotomy). Lubricating gels
(Intergel) used during such pelvic operations may help reduce
this risk. More studies are needed.
- Infection.
- Damage
to the bowel or bladder (higher incidence in laparotomy).
Pregnancies
After Myomectomy. Studies are finding that pregnancy can be
restored in more than half of women after the procedure. In appropriate
candidates, there appear to be no differences in fertility rates
and pregnancy complications between laparotomy or laparoscopy. The
best candidates for retaining fertility include women with pedunculated
and superficial serosal fibroids (stalk-like fibroids that grow
out from the uterine surface). Women with deep intramural fibroids,
for example, are at higher risk for infertility after myomectomy.
It should be noted that although studies indicate that between 40%
and 58% of women become pregnant after myomectomy, only about a
quarter of the women carry their babies to term. Women who become
pregnant subsequently face a higher risk for cesarean section or
miscarriage. It is still unresolved whether laparoscopic myomectomy
weakens the uterine walls and poses a higher risk for rupture during
pregnancy than laparotomy.
Recurrence of Fibroids. The recurrence rate for fibroid growth
after myomectomy is high. Between 11% and 26% of patients will have
recurring fibroids that are severe enough to need additional treatment.
Endometrial
Ablation or Resection
In either endometrial
ablation or endometrial resection, the entire lining of the uterus
(the endometrium) is removed or destroyed. Standard resection uses
an electrosurgical wire loop to surgically remove the lining. With
ablation, uterine tissue is usually vaporized using a thin powerful
laser beam or high electric voltage. These procedures are not useful
for large fibroids. They may be useful in combination with myolysis
for women with heavy bleeding and small fibroids (less than four
inches in diameter) [ see below ]. [For details on this procedure
see the Report #80 Menstruation: Heavy Bleeding
(Menorrhagia).]
Myolysis
A technique called
myolysis, or laparoscopic leiomyoma coagulation, uses either lasers
or electrosurgery to heat and coagulate the fibroid tissue. It is
proving to be beneficial for women with fibroids that measure a
diameter of 10 cm (about 4 in.) or less and that respond to hormone
treatments with GnRH agonists. [ See Box Preoperative
Hormone Treatment.]
It employs a needle or a Nd:YAG laser that rapidly punctures a number
of holes in the fibroid, heating and destroying the tissue in various
locations. (A variant called cryomyolysis, which uses a freezing
probe, may also prove to be useful.) This widespread destruction
cuts off the blood supply and shrinks the fibroid over ensuing months.
The uterus is left intact, but tissue destruction makes childbearing
unlikely.
In one study, myolysis performed either alone or with endometrial
resection was successful in avoiding the need for major surgery
in 97% of women. Advanced techniques that are performed by surgeons
who are highly skilled in the procedure may make it possible to
destroy even large intramural fibroids, but further study is required.
In most cases, patients return home the same day and can return
to normal activities within a week. There are few side effects.
However, as the fibroids degenerate over time, many women report
considerable pain.
Uterine
Artery Embolization
Uterine artery
embolization (UAE), also called uterine fibroid embolization, is
a very promising nonsurgical therapy. It destroys fibroids by depriving
them of their blood supply. More women are beginning to ask for
UAE as an option because it is less invasive and involves a shorter
recovery time than other procedures. In one study, 89% of fibroid
patients sought physicians who offered the UAE procedure rather
than staying with gynecologists who would not consider it. Still,
in spite of its promise, it is not yet known how its benefits or
risks compare to hysterectomy or myomectomy. Although it may protect
fertility in many women, it appears to pose some risk for ovarian
failure. At this time until more is known, experts advise against
VAE for women who want to preserve fertility.
The procedure is typically done in the following manner:
- Specialists
insert a catheter (a thin tube) into a uterine artery.
- Small
particles are injected at the point where the artery feeds the
blood vessels leading to the uterine fibroid. They can be made
of organic compounds (eg, polyvinyl alcohol particles) or acrylic
materials (Embospheres).
- The particles
block the blood supply to the tiny arteries that feed abnormal
fibroid cells and the tissue eventually dies. Circulation to
normal uterine tissue, however, is usually restored.
- Patients
can expect to stay in the hospital overnight after UAE, but
studies are underway to see if the procedure can be done on
an out-patient basis.
Complications
and Postoperative Effects. Serious complications occur in less
than 0.5% of cases, and no deaths have been associated with the
procedure.
- Pain.
Abdominal cramps and pain after the procedure are nearly universal
and may be intense. It usually begins soon after the procedure
and typically plateaus by six hours. On-demand painkillers may
be required. The pain usually improves each day over the next
several days, but some patients may experience pain for as long
as two weeks after treatment.
- Ovarian
Failure. Although UAE may protect fertility, research suggests
that ovarian failure is accelerated after UAE. One study reported
some ovarian damage in more than half of women with this procedure.
In some women, so far only those over 40 years old, normal menstrual
bleeding stopped altogether after therapy.
- Fibroid
Slough. A few patients experience fibroid slough, in which fibroid
material becomes trapped in another area (like the cervix) as
it is being expelled. This can cause intense labor-like pain
and also increase the risk for infection.
Success Rates.
Uterine artery embolization is a relatively new therapy. Still,
based on a few thousand procedures, patient satisfaction is high,
complication rates are low, and no deaths reported. Some studies
have reported success rates of over 90%. One analysis reported an
average fibroid volume reduction of 57% with the procedure. Patients
are also reporting an improvement in their sex life following the
procedure, including increased frequency of sex, increased desire,
and less pain during intercourse. About 10% to 15% of patients will
require further treatment. However, a less invasive approach may
be needed in these cases.
WHAT
IS A HYSTERECTOMY?
Indications
for Hysterectomy
Hysterectomy
is the surgical removal of the uterus. Fibroids are responsible
for as many as 60% of hysterectomies in the US, which is the surgical
removal of the uterus. By age 60, 25% of American women have had
this procedure. More than 500,000 hysterectomies are performed each
year in the US, which is the highest rate among any nations with
published data on this procedure. It is twice the rate of hysterectomies
in English women and four times the rate in French women.
Most women are satisfied with the procedure. A major analysis of
evidence on hysterectomies reported that symptoms related to menstrual
problems decline significantly in most women, although none completely
disappear for all women. The majority of women also experience improved
quality of life and emotional functioning, although 8% of women
who were not depressed and 12% of women who were not anxious before
the procedure developed these emotional states afterward.
Still, one study suggested that 70% of recommendations for hysterectomies
did not meet the standard of care as determined by expert groups.
In such cases, patients were not given alternative choices or adequate
diagnostic evaluations. Any woman, even one who has reached menopause,
who is uncertain about a recommendation for a hysterectomy for fibroids
should certainly seek a second opinion.
Determining
the Extent of the Hysterectomy
Once a decision
for a hysterectomy has been made, the patient should discuss with
her physician what will be removed. The common choices are:
- Total
Hysterectomy (Removal of uterus and cervix).
- Supracervical
Hysterectomy (Removal of uterus and preservation of the cervix).
Procedure is performed in about 20% to 25% of cases.
- Bilateral
Salpingo-Oophorectomy (Removal of the ovaries). It can be used
with either total or supracervical hysterectomy.
Total Hysterectomy
. In a total hysterectomy the uterus and cervix are removed;
this eliminates the risk of uterine and cervical cancer. (Given
technical advances and growing surgical experience, a total hysterectomy
may eventually be unnecessary except in special circumstances, such
as when cancer is present.)
Supracervical Hysterectomy. In a supracervical hysterectomy
the uterine body is removed and the cervix is retained. Retaining
the cervix helps support the pelvic floor and may help maintain
full sexual sensation, but the risk for cervical cancer remains.
Bilateral Salpingo-Oophorectomy . Bilateral salpingo-oophorectomy
is the removal of the fallopian tubes and ovaries. It may be performed
with either total or supracervical hysterectomy. In deciding to
remove the ovaries, a woman must be aware of various consequences,
both positive and negative.
- Oophorectomy
helps to reduce the risk for ovarian cancer by elimination of
ovaries and breast cancer by causing estrogen loss. Ovarian
cancer is very rare, in any case, except in women with a family
history of the disease. Even in these women, removal is not
100% preventive. It can still develop from cancer cells that
may be present in the lining of the pelvis (the peritoneum).
- Losing
ovarian function means estrogen and testosterone loss, which
can increase the risk for menopause-related conditions. These
include osteoporosis, heart disease, skin wrinkling, and reduction
in muscle tone. Estrogen replacement, however, can help offset
these problems.
Abdominal
vs. Vaginal Hysterectomy
There is still
a further choice, which is whether the hysterectomy should be performed
through an incision in the abdomen or performed through the vagina.
A variant of vaginal hysterectomy, called laparoscopic-assisted
vaginal hysterectomy (LAVH), is yet another option.
Abdominal Hysterectomy. Abdominal hysterectomy is the most
common procedure and used in about three-quarters of cases. It is
best suited for women with large fibroids, when the ovaries need
to be removed, or when cancer or pelvic disease is present. With
the abdominal procedure, wide incision is required to open the abdominal
area, from which the surgeon removes the uterus. If possible, the
incision should cut horizontally across the top of the pubic hairline
(the bikini incision). This incision heals faster and is less noticeable
than a vertical incision, which is used in more complicated cases.
The patient may need to remain in the hospital for three to four
days, and recuperation at home takes about four to six weeks.
Vaginal Hysterectomy. Vaginal hysterectomy is used in about
a quarter of the cases, although this procedure is being increasingly
performed. It requires only a vaginal incision through which the
uterus is removed. This approach is reasonable for small fibroids.
Laparoscopic-Assisted Vaginal Hysterectomy. Laparoscopic-assisted
vaginal hysterectomy (LAVH) is employed in only less than 4% of
procedures. It uses several small abdominal incisions through which
the surgeon severs the attachments to the uterus and ovaries. They
can then be removed through the vaginal incision, as in the standard
approach. Hospitalization stays may be longer and costs are greater
than with standard vaginal hysterectomy. At this time LAVH may be
an alternative to abdominal hysterectomy in certain cases when a
standard vaginal hysterectomy is not appropriate.
Postoperative
Care
If possible,
a patient should ask a family member or friend to help out for the
first few days at home. The following are some of the precautions
and tips for postoperative care:
- For a
day or two after surgery, the patient is given medications to
prevent nausea and pain killers to relieve pain at the incision
site.
- As soon
as the physician recommends it, usually within a day of the
operation, the patient should get up and walk in order to help
prevent pneumonia, reduce the risk of blood-clot formation,
and to hasten recovery.
- Walking
and slow, deep breathing exercises may help to relieve gas pains,
which can cause major distress for the first few days.
- Coughing
can cause pain, which may be reduced by holding a pillow over
a surgical abdominal wound or by crossing the legs after vaginal
surgery.
- Patients
are advised not to lift heavy objects (including small children),
not to douche or take baths, and not to climb stairs or drive
for several weeks.
- For the
first few days after surgery, many women weep frequently and
unexpectedly. These mood swings may be due to depression from
the loss of reproductive capabilities and form abrupt changes
in hormones, particularly if the ovaries have been removed.
The patient should
discuss with the physician when exercise programs more intense than
walking can be initiated. The abdominal muscles are important for
supporting the upper body, and recovering strength may take a long
time. Even after the wound has healed, the patient may experience
an on-going feeling of overall weakness, which can be demoralizing,
particularly in women used to physical health. Some women do not
feel completely well for as long as a year; others may recover in
only a few weeks.
Complications
Following the Procedure
Minor complications
after hysterectomy are very common. About half of women develop
minor and treatable urinary tract infections. There is usually mild
pain and light vaginal bleeding post operation. The infrequent occurrence
of severe bleeding or hemorrhaging after vaginal hysterectomy, or
laparoscopic-assisted vaginal hysterectomy, may be promptly treated
by laparoscopy.
More serious complications, such as those described below, are uncommon
but patients should be aware of their symptoms and call the physician
immediately if they occur.
Among the three procedures, a 2001 Australian study reported that
complication rates were 44% for abdominal hysterectomy, 24% for
vaginal hysterectomy, and only 2% for LAVH. (LAVH is used in less
than 4% of hysterectomies, however.)
Infection. Infection occurs in 10% to 15% of patients, the
risk being higher with abdominal than with vaginal surgery. Risk
factors for infection appear to be obesity, a longer than normal
operative time, and low socioeconomic status. Patients should be
aware of any symptoms and call the physician immediately if they
occur: Symptoms of infection might include:
- Continuing
or increasingly severe pain.
- Fever.
- Heavy
discharge.
- Bleeding
(antibiotics given at the time of surgery help to reduce this
risk).
Blood Clots.
There is a slight risk for small blood clots, usually in veins
of the legs (thrombophlebitis). A sudden swelling or discoloration
in the leg can indicate this condition and require immediate medical
attention.
Other Serious Complications. Other serious and even life-threatening
complications are rare but can include:
- Pulmonary
embolism (blood clots that travel to the lung).
- Surgical
injury of the urinary or intestinal tracts. (They are uncommon
and most are recognized and repaired during the hysterectomy.)
- Abscesses.
- Perforation
of the bowel.
- Fistulas
(a passage that bores from an organ to the skin or to another
organ).
- Dehiscence
(opening of the surgical wound).
Long-Term
Complications. Women who have had a total hysterectomy are at
higher risk for the following long-term complications:
- Muscle
weakness in the pelvic area.
- Prolapse
(descent) of the bladder, vagina, and rectum if the muscle's
walls are overly weakened. (This may require further surgery.)
- Bowel
problems may develop if adhesions (extensive scarring) have
formed and obstruct the intestines, sometimes requiring additional
surgery.
- Shortening
of the vagina is a possible complication specific to vaginal
hysterectomy. It can cause pain during intercourse.
It should be
noted that such complications are uncommon. In one study of 43 women,
satisfaction was high, and none reported significant problems in
the bladder or intestinal tract following hysterectomy.
Treating
Menopausal Symptoms and Premature Menopause after Hysterectomy
After hysterectomy,
women may experience hot flashes, a symptom of menopause, even if
they retain their ovaries. Surgery may have temporarily blocked
blood flow to the ovaries, therefore suppressing estrogen release.
If both ovaries have been removed in premenopausal women, the procedure
causes premature menopause . Symptoms come on abruptly and
may be more intense than those of natural menopause. Symptoms include
hot flashes, vaginal dryness and irritation, and insomnia. A significant
number of women gain weight.
Women should consider taking hormone replacement therapy (HRT) after
surgery if their ovaries have been removed. [
40, Menopause, Estrogen Loss, and Their Treatments .]
In premenopausal women, hormone replacement therapy is not needed
if the ovaries are left intact. The ovaries will usually continue
to function and secrete hormones even after the uterus is removed,
but the life span of the ovaries is reduced by an average of three
to five years. In rare cases complete ovarian failure occurs right
after hysterectomy, presumably because the surgery has permanently
cut off the ovaries' blood supply.
Psychologic
and Sexual Concerns after Hysterectomy
Sexual intercourse
may resume four to six weeks following surgery. The effect of hysterectomy
on sexuality is unclear. In one major study, 70.5% of women had
been sexually active before the procedure, which increased to 77.6%
within the year afterward. Other studies have reported that up to
25% of women experience increased sexual drive. Nevertheless, some
women report no change and other women develop problems related
to sexual function. For example, around 10% of women experience
vaginal dryness, about 2% of women develop pain during sex, and
another 2% also appear to lose capacity for orgasm.
Two procedures associated with hysterectomy may affect sexuality
directly.
- If the
cervix is removed, the clitoris located outside the vagina can
trigger orgasm, but many experts believe that uterine contractions
stimulated by sexual intercourse also cause a so-called "deep
orgasm." Retaining the cervix may help to retain this sensation.
- Patients
who have both ovaries removed may be at higher risk for loss
of sexuality. Ovaries produce small amounts of testosterone
(the male hormone responsible for sexual drive) even after menopause.
Testosterone
Replacement. Testosterone replacement therapy may restore sexuality
in women who experience a decline in sexual drive. Occasionally,
oral or injection treatments can produce male characteristics such
as facial hair and voice change. A slow-release pellet inserted
every six months under the skin in the hip appears to reduce these
side effects. A patch (Intrinsa) is also in development. Taking
hormones long term almost always carries some risks, and it is not
yet known what danger testosterone replacement may pose in women.
Support groups and counseling can provide important help for this
problem.
Pap
Smears
Annual Pap smears
are recommended for all women with cervix intact who have reached
the age of 18 or over or who have become sexually active. After
a total hysterectomy, in which the cervix has been removed, a woman
will still need Pap smears of the vagina, but because of the low
risk of vaginal cancer, these tests usually do not have to be performed
annually. The interval between Pap smears depends on the patient's
risk factors as determined by the physician. Women with a history
of abnormal Pap smears usually require annual screening. Women with
a supracervical hysterectomy, in which the cervix remains, still
need annual Pap smears. Annual pelvic and breast examinations are
important for all women, including those with a total hysterectomy.
WHERE
ELSE CAN HELP BE OBTAINED FOR UTERINE FIBROIDS?
RESOLVE, Inc.,
1310 Broadway, Somerville, MA 02144-1731. Call (617-623-0744) or
(http://www.resolve.org/)
American Society for Reproductive Medicine (Formerly the American
Fertility Society), 1209 Montgomery Highway, Birmingham, AL 35216-2809.
Call (205-978-5000) or (http://www.asrm.com/)
This organization provides useful information, including Clinic
Specific Annual Report . This valuable report gives the success
rates of treatment for fertility centers around the country. They
also publish the professional journal Fertility and Sterility
and publications for consumers.
Fertility Research Foundation, 877 Park Avenue, New York, NY 10021.
Call (212-744-5500) or (http://www.frfbaby.com/)Offers
information on treatment, latest research on male and female infertility.
American College of Obstetricians and Gynecologists, 409 12th St.,
SW, PO Box 96920, Washington, D.C. 20090-6920.
(http://www.acog.com/)
The American College of Obstetricians and Gynecologists (ACOG) has
published a pamphlet, Understanding Hysterectomy, which outlines
what constitutes a medically necessary hysterectomy and describes
what the surgery involves. To request a copy, send a self-addressed
envelope.
Hysterectomy Educational Resources and Services (HERS), 422 Bryn
Mawr Ave., Bala-Cynwyd, PA 19004. Call (888-750-HERS) or (610-667-7757)
or (http://www.ccon.com/hers/)
The American Association of Gynecologic Laparoscopists, 13021 East
Florence Avenue, Santa Fe Springs, CA 90670. Call (800-554-2245)
or (562-946-8774) or (http://www.aagl.com/)
American Medical Women's Association, 801 North Fairfax Street,
Suite 400, Alexandria, VA 22314. Call (703-838-0500) or (http://www.amwa-doc.org/)
National Women's Health Network, 514 10th St. NW, Suite 400, Washington,
DC 20004. Call (202-347-1140) or (http://www.womenshealth
network.org/) Membership is $25 per year and provides a bimonthly
newsletter and access to information. Reports cost $6.00 for members
and $8.00 for nonmember.
National Women's Health Resource Center, Inc. 120 Albany Street,
Suite 820, New Brunswick, New Jersey 08901. Call (877-986-9472)
or (http://www.healthywomen.org/)
Also:
Brigham and Women's
Hospital (www.fibroids.net)
UCLA medical group site offers good information on uterine embolization
(http://www.fibroids.org)
AGENCY FOR Health Care Policy (www.ahcpr.gov/consumer/uterine1.htm)
Women's Health Interactive (www.womens-health.com)
The National Institute of Child Health and Human Development (NICHD)
(http://www.nichd.nih.gov/)
Womens Health Alliance: www.womenshealthalliance.com
Fibroid Medical Center of Northern California (www.fibroidworld.com),
includes an in-depth look at Uterine Artery Embolization (UAE) plus
illustrations. This site received an "outstanding achievement" from
obgyn.net.
Georgetown University Hospital (www.fibroidoptions.com)
contains similar information as fibroidworld.com on both fibroids
and the UAE procedure, but also provides an excellent patient's
guide to UAE.
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