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* 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.


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.



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.]


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).




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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