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Fibroids After 50 (Why They Don’t Always Disappear!)

 

Fibroids, also known as leiomyomas, are estrogen-dependent. As a result, they typically grow and present symptoms during a woman’s reproductive years, when the ovaries are active. Once the ovaries stop naturally producing estradiol (estrogen)—usually in her mid-50’s— a woman is said to have entered menopause. Logically, the drop in estrogen production that occurs in menopause would cause any uterine fibroids to gradually shrink, and this is typically the case. Fibroids and their accompanying symptoms often diminish after menopause. But what if they don’t?

There are a number of reasons why a woman would continue to have difficulty with a fibroid tumor during this stage of her life: stimulation from exogenous estrogen production (i.e. hormone replacement therapy), cancerous tumors, or malignant uterine/fibroid changes are a few possible causes.

Hormone replacement is commonly prescribed for menopausal women to reduce the uncomfortable symptoms that result from estrogen-deficiency, including hot flushes, vaginal dryness, mood fluctuations, and reduced desire for sex. Estrogen deficiency can also compromise bone health, increasing the risk of fractures; adding supplemental estrogens back into the body can help maintain a woman’s bone strength after menopause.

Replacing estrogen with hormone therapy can drastically increase the quality of life for many women in menopause. However, the risks of hormone replacement can sometimes outweigh the benefits, the recurrence or worsening of fibroid symptoms being one example. Dr. Donald Galen, OB-GYN and former Surgical Director at the Reproductive Science Center of the San Francisco Bay Area explains, “if fibroids are present, the addition of estrogens will generally stimulate fibroid growth, or minimize fibroid regression which otherwise would occur during natural menopause.” A study by Lamminen et al. that compared the activity of fibroids in pre- and post-menopausal women found just that: proliferative activity was low in the post-menopausal subjects who weren’t receiving hormone replacement, whereas those women who were receiving hormones had “fibroid proliferative activity equal to premenopausal women”. Dr. Galen also advises patients of other risks related to hormone therapy, as well. He explains, “estrogen can increase health risks, such as an increased risk of blood clots, increased risk of breast hyperplasia/cancer, and increased risk of endometrial hyperplasia and/or endometrial cancer.”

Hormone replacement therapy isn’t the only reason women see a persistence in fibroid symptoms after menopause. Malignant changes in existing fibroids or the emergence of new, cancerous tumors (“neoplasia”) on the uterus or reproductive organs can produce symptoms like those of benign leiomyomas.  Dr. Galen advises, “as a precaution, any woman with an increase in uterine growth/size and/or post-menopausal uterine bleeding should be evaluated to rule-out malignant uterine/fibroid changes.”

 

 

SOURCES:

Burbank, Fred. Fibroids, Menstruation, Childbirth and Evolution: The Fascinating Story of Uterine Blood Vessels. Tucson, AZ: Wheatmark, 2009. 93. Print.

Lamminen, S. et al.”Proliferative activity of human uterine leiomyomacells as measured by automatic image analysis”,Gynecologic and Obstetetric Investigation. 1992; 34:111-114

 

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The 5 Biggest Myths Surrounding Uterine Fibroids

 

shutterstock_325530068Fibroids are the most common type of pelvic tumor among women of reproductive age. Despite their prevalence, however, fibroids are widely misunderstood. A number of popular misconceptions, in particular, create confusion for women with fibroids who are trying to understand their condition and treatment options. To clear up some of this confusion, we’re breaking down five of the most common myths surrounding fibroids.

 

MYTH: If you have fibroids, you will experience symptoms like heavy menstrual bleeding and pain.
As common as the condition is, researchers estimate that between 50-80% of women with fibroids will experience no fibroid symptoms at all. Many women with asymptomatic fibroids never even know that they have the condition. And, because fibroid tumors are almost always benign, women who aren’t experiencing symptoms may opt to forgo treating their fibroids.

MYTH: A routine ultrasound will detect any uterine fibroids that are present.
If fibroids are suspected, the first diagnostic tool gynecologists employ to confirm the suspicion is transvaginal ultrasound. However, this imaging method doesn’t always reveal all existing fibroids. The size and location of uterine fibroids varies greatly, and extremely small fibroids, submucosal fibroids, and small fibroids that are hidden behind larger tumors, aren’t always detectable through a routine pelvic ultrasound. For clearer visualization of the tumors, physicians frequently rely on laparoscopic ultrasound, which requires inserting a scope through the vagina and into the abdominal cavity provides. Research has shown that laparoscopic ultrasound can detect up to twice as many fibroids as transvaginal ultrasound.

MYTH: Fibroid tumors will become cancerous.
Uterine fibroids, also known as leiomyomas, are almost always benign: in women of reproductive age, less than 0.01% of (removed) fibroids become cancerous. While fibroids typically shrink after menopause, those that do appear in post-menopausal women may be the cancerous type, called leiosarcomas. It’s important to note, however, that – regardless of age – simply having fibroids does not increase a woman’s chances of developing cancer in her reproductive organs.

MYTH: Endometrial ablation is a method of treating fibroids
Endometrial ablation (EA) is a commonly used to treat abnormal uterine bleeding. The technique entails destroying the layer of tissue that lines the uterus known as the endometrium, preventing new tissue from growing and thereby reducing or eliminating menstrual bleeding. While you may have heard EA discussed in the context of fibroids, it is not, in fact a fibroid treatment. The destruction of fibroids that can occur with EA is incidental, and is not likely complete. In such cases, the ablated fibroids will often regrow, since subserosal fibroids – the type that grow inside the uterus and are therefore subject to destruction during EA – often originate below the endometrium layer.

MYTH: If left untreated, fibroids will continue to grow throughout a woman’s lifetime.
Fibroid growth is fueled by estrogen. Accordingly, fibroids will grow and shrink in response to the body’s hormone fluctuations. Pregnant women often experience rapid growth in existing fibroids and may develop new fibroids during pregnancy, due to the heightened levels of estrogen that their bodies are producing. Conversely, fibroids typically shrink after menopause, because the ovaries have stopped producing estrogen. (Post-menopausal women undergoing hormone replacement therapy can expect the opposite to occur, however, since they are artificially replacing the missing estrogen.) Although fibroids do tend to disappear naturally after menopause, pre-menopausal women who are suffering with symptoms of uterine fibroids may not want to wait.

When fibroids are interfering with the quality of life, it’s advisable to discuss treatment options with a gynecologist. With a plethora of treatments available to women with fibroids, including uterine conserving methods like Acessa Procedure, it’s not necessary to endure long-term suffering!

 

SOURCES:

American Society for Reproductive Medicine, “What Are Fibroids? Fact Sheet”, Resources, ReproductiveFacts.org: rev. 2012. Retrieved Aug 26, 2015, from http://www.reproductivefacts.org/FACTSHEET_What_are_Fibroids/

Levine, D.J. et al. “Sensitivity of Myoma Imaging Using Laparoscopic Ultrasound Compared With Magnetic Resonance Imaging and Transvaginal Ultrasound”, Journal of Minimally Invasive Gynecology. Nov/Dec 2013; Vol 20(6): 770-4

Burbank, Fred. Fibroids, Menstruation, Childbirth and Evolution: The Fascinating Story of Uterine Blood Vessels. Tucson, AZ: Wheatmark, 2009. 135. Print.

 

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What Causes Fibroids: The Known Risk Factors

 

Uterine fibroids, also known as leiomyomas, are the most common benign pelvic tumor in pre-menopausal women. According to the American Society for Reproductive Medicine, uterine fibroids will affect 8 in 10 African American women and 7 in 10 Caucasian women before menopause.

Despite the prevalence of the condition and the plethora of studies that have sought to explain it, the cause of fibroids is still not fully understood. However, evidence suggests that fibroids’ development can be attributed to a combination of genetic and hormonal traits.

Hormonal Risk Factors

The link between fibroids and hormones is well documented. Specifically, it is known that fibroids are estrogen-dependent. As a result, fibroids grow during a woman’s childbearing years, while the ovaries are naturally producing estrogen, and they typically shrink after the onset of menopause, when levels of the hormone drop. The influence of hormones on fibroid growth renders the following traits “risk factors”:

Age – The risk of fibroids increases with age, up to the point of menopause. Once menopause is reached and the body’s estrogen production naturally declines, fibroids typically shrink and – in many cases – disappear entirely.
Contraceptive use – Women who began taking oral contraceptives before the age of 16 are at a greater risk of developing fibroids. However, studies have revealed that using progestin-only injectable contraceptives is associated with a reduced risk of fibroids.

Obesity – Researchers believe that being obese increases the risk of uterine fibroid development, possibly due to the association between obesity and high circulating estrogen levels.


Genetic Risk Factors

Race – The connection between race and fibroids isn’t entirely understood, but an abundance of clinical data shows it to be a significant risk factor. Black women are nearly three times more likely to develop fibroids than white women. Furthermore, research has shown that black women tend to have larger and more symptomatic fibroids than women of other races.

Family health history – Researchers and medical practitioners have long observed a familial predisposition to fibroids. To date, various clinical studies have identified over 100 specific genes as having potential links to fibroid development. OB-GYN Dr. Donald Galen frequently observes the genetic trend in his fibroid patients: “It is common for a woman with fibroids to have a history of her mother, maternal aunt, or sister who also have fibroids, ” he says.


Other Risk Factors

Certain lifestyle and environmental traits have been thought to play a role in the development of fibroids, though clinical studies have yielded somewhat contradictory results.

Diet – Research has shown that women who eat a vegetarian diet are less likely to develop fibroids than women whose diets include meat. Some studies suggest that consuming more fruits, vegetables, and low-fat dairy products could reduce the risk of developing fibroids; however, the effectiveness of changing dietary habits in slowing the growth of existing fibroids or preventing the development of new fibroids has not been conclusively established.
While the exact cause of fibroids remains unclear, existing research points to a confluence of genetic and hormonal traits. Given the prevalence of the condition of uterine fibroids, its epidemiology will undoubtedly continue to be the subject of research. The risk factors that have been established, however, help us to understand who is susceptible to developing fibroids and what physical and lifestyle changes may prevent or minimize fibroids’ occurrence.

 

SOURCES:

  1. American Society for Reproductive Medicine, “Fibroid Tumor Video Transcript”, ReproductiveFacts.org: 2011.
  2. Retrieved July 13, 2015, from http://www.reproductivefacts.org/Fibroid_tumor_video/
  3. Stewart, E. “Uterine Fibroids”, New England Journal of Medicine. 2015; 372: 1646-55.
  4. Wise, L. et al. “Age-Specific Incidence Rates for Self-Reported Uterine Leiomyomata in the Black Women’s Health Study”, Obstetrics & Gynecology. Mar 2005; 105(3): 563–568.
  5. Levy, B., “Modern management of uterine fibroids”, Acta Obstetricia et Gynecologica. April 2008; 87: 812-823
  6. Burbank, F. Fibroids, Menstruation, Childbirth, and Evolution, pp. 89-90. Wheatmark, 2009. Tucson, AZ.

Fibroid Treatments Demystified, Part I: Uterine Artery Embolization

Many women of reproductive age seek uterine-sparing methods of fibroid treatment: uterine artery embolization (UAE), sometimes called uterine fibroid embolization (UFE), is one of the hysterectomy alternatives available to women with fibroids.

How UAE Works

Uterine artery embolization (UAE) is a minimally-invasive procedure that is performed by an interventional radiologist. UAE treats fibroids “in situ”, meaning ‘in place’, by cutting off their blood supply and causing them to die from what is known as “ischemic necrosis”. To do so, an interventional radiologist inserts a catheter through the femoral artery (located in the upper thigh) and into the uterine artery, which supplies blood to the uterus. A type of material known as an “embolic agent” is then injected through the catheter, into the blood vessels that supply blood to the fibroids. Typical embolic agents include polyvinyl alcohol (PVA), gelatin sponge plegets, or gelatin microspheres. Once injected, particles of the agent block the blood supply to the tiny arteries that carry blood to the fibroids. Without adequate blood flow, the fibroids shrink and, ultimately, die.

Treatment Outcomes

UAE is successful in diminishing fibroids and associated symptoms in an estimated 85% of cases. For patients who are looking for a minimally invasive fibroid treatment, embolization’s non-surgical approach is appealing. The recovery period is generally short, though it is notoriously painful. Fred Burbank, author of Fibroids, Menstruation, Childbirth, and Evolution, states “nearly all women who undergo [UAE] have severe pelvic pain generally lasting 4 to 6 hours, but others, lasting up to a day” (p.124). The American Society For Reproductive Medicine also notes, “patients typically experience several days of pain after the procedure”. Many women are hospitalized overnight for pain control.

The incidence of fertility-compromising outcomes has called into question the appropriateness of the procedure for women seeking to get pregnant, though additional research is needed to assess the risk. Here’s what researchers do know: once the embolic agent has been injected, the particles stay in the body. In some cases, those particles can migrate to the ovarian blood supply, compromising fertility and triggering the onset of menopause. Burbank describes the physiological process after injection of the embolic agent:

Anatomically, connections exist that allow particles injected into the uterine artery to reach any structure supplied by branches of the uterine artery. The physiology of blood flow from the uterine artery to its branches determines the relative number of particles that reach the myometrium, fibroids, and the ovaries. Injected particles are indifferent to where they go.(p.111) A significant number of women who undergo UAE become amenorrheic (cease to have periods)as a result of the procedure; however, research has indicated that younger patients see fewer complications of this nature. A longitudinal study by Goodwin et. al found that, at 36 months post-procedure, approximately 85% of patients had no intervention but 28.6% of UAE patients were amenorrheic with the largest proportion(78.9%) of patients over the age of 45.

UAE isn’t right for everyone: women with fibroids should talk to a gynecologist about the risks and benefits of UAE and other available fibroid treatment options, before seeking treatment. However, as one of the less invasive methods for treating fibroids, UAE helps meet the growing demand for alternatives to hysterectomy.

SOURCES:

  1. American Society for Reproductive Medicine, “Treatment of Uterine Fibroids”, ReproductiveFacts.org: 2011. Retrieved May 25, 2015, from http://www.reproductivefacts.org/FACTSHEET_Treatment_of_Uterine_Fibroids/
  2. Goodwin, S. et al./Fibroid Registry for Outcomes Data (FIBROID) Registry Steering Committee and Core Site Investigators.”Uterine Artery Embolization for the Treatment of Leiomyomata: long term outcomes from the FIBROID Registry”, Obstetrics & Gynecology, Jan 2008; Vol 11(1):22-33
  3. Burbank, F. Fibroids, Menstruation, Childbirth, and Evolution, p. 110. Wheatmark, 2009. Tucson, AZ.

 

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Fibroids Are Not Color Blind

Over the years, researchers have examined the epidemiological connection between a wide variety of patient characteristics and the occurrence of uterine fibroids, seeking to identify risk factors. Age, weight, diet, geographic location, lifestyle factors like cigarette smoking, medical conditions, and history of childbirth have all been studied, and many have been correlated with fibroids in one way or another. But time after time, study after study, one characteristic has stood out as a major indicator of fibroid risk: race. And the conclusion that researchers have consistently reached is this: uterine fibroids (also known as leiomyomas) disproportionately affect women of color.

Certain, specific differences have been seen in the cases of black women: research shows that, in comparison to white women, black women tend to develop a larger number of fibroids and experience more fibroid-related symptoms. A study published in 2013 by the American Society for Reproductive Medicine reported that, “African-American women had substantially more fibroids” with an average of 9.9 fibroids compared to the Caucasian subjects’ average of 4.5 fibroids. Additionally, Weiss et al. conducted a multi-ethnic, multisite, longitudinal study of 3,302 women ages 42-52 and concluded that “previously diagnosed leiomyomas were presenting symptoms more frequently in African-American woman than Caucasian women (85% vs. 63%)”.

The racial disparity in fibroid occurrence isn’t fully understood. The research that exists mostly defines the relative risk of the condition in terms of black and white. Obviously, black and white women aren’t the only ones affected by uterine fibroids. While very little data exists on the differences in susceptibility and symptoms between other ethnicities, a 2011 study conducted by the U.S. Armed Forces identified the relative risk of fibroids for multiple ethnic groups. The study looked at the population of active military women who were diagnosed with fibroids between 2001 and 2010: 11,931 cases were recorded. The researchers concluded that, relative to the white, non-Hispanic population, the risk of fibroids was slightly higher (1.1 times) for Hispanics and Asians/Pacific Islanders, and slightly lower (.9 times) for American Indians/Alaskan Natives. By comparison, African American women were 4.4 times more likely to have the same diagnosis, and women in the ethnic category of “Other” had almost double (1.9 times) the incidence of fibroids. These findings are depicted in the graph below.

Fibroids--race_MSMRgraph

As of now, there are no clear answers to explain why symptoms and presentation of uterine fibroids are different in women of color. However, the connection between fibroids and race is certainly a topic of interest to researchers, physicians and fibroid patients alike, and one that continues to be the subject of medical research.

Sources:

  1. Schwartz, S.M. “Epidemiology of uterine leiomyomata”, Clinical Obstetrics & Gynecology. June 2001; Vol.44(2):316-26
  2. Moorman, P.G. et al. “Comparison of characteristics of fibroids in African American and white women undergoing premenopausal hysterectomy”, Fertility & Sterility, March 2013; Vol.99(3)768-776>
  3. Weiss, G. et al. “Racial differences in women who have a hysterectomy for benign conditions”, Women’s Health Issues, May-June 2009; Vol.19(3):202-10
  4. Eltoukhi, H.M. et al. “The health disparities of uterine fibroid tumors for African American women: a public health issue”, American Journal of Obstetrics & Gynecology, March 2014; Vol.210(3)
  5. “Uterine Fibroids, Active Component Females, U.S. Armed Forces, 2001-2010”, Medical Surveillance Monthly Report, December 2011; Vol.18(12):10-13

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