What is a Fibroid?
Fibroids are benign muscle tumors that can grow in a woman’s uterus. They are present in up to 20% of reproductive age women. They are a common cause of heavy, painful periods. They can also dramatically increase the risk for miscarriage and diminish fertility. The symptoms depend in large part on the size and location of a fibroid. Sometimes a fibroid will grow larger than a grapefruit. When they grow large they can cause symptoms from pushing on other organs in the pelvis – such as the bowel and bladder. Not all fibroids cause problems or need any treatment. Fibroids tend to run in families, suggesting a genetic disposition. No one fully understands why some women grow them while others do not. These tumors start to fade away after menopause because they are dependent on the female hormones estrogen and progesterone which drop after the “change of life”.
Our Approach to Fibroid Treatment
Treatment for fibroids is only necessary for those women who are bothered by fibroid-related symptoms or for those with fibroids greater than 3-5 cm in size who want to conceive a baby. Fibroids near the inner lining of the uterus can be the cause for heavier than normal menstrual periods and can make a woman bleed in between her regular menses. Those same fibroids are also the worst offenders when it comes to causing a woman to miscarry a pregnancy (especially after 10 weeks gestation). Fibroids larger than 5 cm (regardless of their location) have been definitively linked to impaired fertilty and higher miscarriage rates. As fibroids get even larger than 5 cm they commonly cause pain, discomfort, or fullness in the pelvic region. The fibroids can press on other nearby organs such as the bowel or bladder which can cause constipation or the need to urinate ferquently. The pain can sometimes be intermittent, yet intense, when a part of the fibroid may “infarct”, which is to say a portion of it can outgrow its supply of blood. At those times the “dying” tissues sends out pain signals.
In the medical field fibroids are called myomas, so the surgery to remove these from the uterus is termed a myomectomy. A myomectomy leaves the uterus in place. A hysterectomy is the term for removing the uterus. Thus a hysterectomy can be a solution for fibroids for those women who no longer care to become pregnant. The doctors at South Jersey Fertility Center don’t perform hysterectomies because we concentrate on women hoping to maintain their fertility. The women suffering with fibroids who want to maintain their ability to bare children can choose a myomectomy. There are at least 3 different surgical approaches by which a myomectomy can be performed. The type of surgical approach depends on the location, size and number of fibroids present. There are also a couple of non-surgical measures to try to alleviate the suffering from fibroids, though pregnancy is not recommended with the non-surgical methods.
The least invasive surgical approach is through the vagina utilizing a thin lighted scope (hysteroscope) that can slip in through the natural opening in the cervical canal. However, this approach, call hysteroscopy, can only access fibroids that extend partly into the central cavity of the uterus, termed the endometrial cavity. A relatively small proportion of women have their bothersome fibroids limited to only that location, but it is a very satisfying surgery for those candidates since the recovery is the easiest and the return to usual activity from hysteroscopy is generally 3 days.
When fibroids are located in the middle of the muscular uterine wall or even on the outer boundaries of the uterus, an approach through the abdominal skin is necessary. Traditionally this has been done by laparotomy, which means opening the abdomen with a large enough incision for the surgeon to reach in both hands. Most of the time the incision is made horizontally along the top edge of the pubic hair line. Occasionally the incision needs to be done “up and down” approaching the belly button if the fibroids are quite large. The recovery includes 2 nights in the hospital and 6 weeks before a return to full physical activity.
Fortunately a new revolutionary method is now available which utilizes a minimally invasive approach called laparoscopy. The woman typically returns home the same day as the surgery and recovers sufficiently to return to work in 1-2 weeks since the 5 incision are only as long as the width of their thumbnail. Laparosocpy consists of a lit scope for visualization and narrow instruments which can dissect the fibroids out, repair the uterus with suture, and remove the group up fibroid material through small keyhole incisions in the abdomen.
This is generally performed with the assistance of the da Vinci surgical device (sometimes referred to as “the robot”. The robot allows the surgeon to manipulate the narrow instruments with much more accurate control than with standard laparoscopy. This allows the surgeon to perform the closure of the uterine incisions with the same strong suturing technique as is used with the open myomectomy, but without the extended post-operative recovery that comes with the larger abdominal incision. Patients usually return home the same day as the surgery. The “robot” holds the camera steady and provides 3D high-definition visualization that is far superior to that of standard laparoscopy. Studies have found that the “Robot-assisted” laparoscopic myomectomies have an even lower risk for poor healing of the surgical incision and loses less blood. Not every patient with fibroids is a candidate for the robotic-assisted laparoscopic approach. This minimally invasive technique is usually an option when there are fewer than 10 fibroids and none exceed 12 cm in size.
Any time that an incision is made fairly deep into a woman’s uterine wall she should have (according to normal standards) a C-section delivery when she is 9 months pregnant rather than trying to push the baby out in labor. This caution is taken due to concern that her weakened uterus may not hold up to the stress of labor. One potential complication of any abdominal surgery is scar formation involving the pelvic organs, such as the ovaries and fallopian tubes. This scarring could potentially limit fertility unless In Vitro Fertilization is pursued. To lower the risk of adhesion formation most surgeons place a dissolvable barrier over the uterine scars. Patients who have had a myomectomy should not get pregnant for 3 months after surgery to allow the uterus to heal well.
Non-Surgical Fibroid Treatment Options
Medical therapy (monthly injections for 6 months or so) can induce a temporary menopause to shrink them. The benefit is only transient unless the woman is going to be going through natural menopause soon. This medical therapy is useful to bridge the gap to menopause when the time window is sufficiently narrow. It is also used when the woman’s hemoglobin is so low due to the heavy periods that she is too anemic to be accepted for surgery.
The chance for more fibroids to form following removal or ablation of fibroids is approximately 30%, but only about 10% of patients will require another procedure for their recurrent fibroids because of symptoms.