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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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Fibroid Treatments Demystified, Part IV: Myomectomy

 

Myomectomy, a widely practiced method of removing subserosal or intramural uterine fibroids, is an alternative to hysterectomy for fibroid patients seeking uterine preservation.

How Myomectomy Works

In myomectomy, a surgeon removes one or more fibroids by cutting them out of the uterine wall. While incisions are made in its tissue, the uterus itself ultimately stays in place. Depending on the type and location of the fibroids, myomectomy may be performed laparoscopically (accessing the uterine cavity through abdominal incisions) or hysteroscopically (accessing the uterine cavity by way of the vagina).
The method used for performing myomectomy dictates the recovery and hospitalization time. Post-operative hospital stays currently range from 0-2 days, and recovery time ranges from 4-6 weeks.

Treatment Outcomes

Myomectomy patients typically see an enduring reduction in symptoms: in a recently published study, the research team of Pitter et al. reported that 62.9% of the myomectomy patients in their study population were free of symptoms at three years post-procedure.

Once a fibroid is completely removed, it will not grow back. That is not to say, however, that new fibroids won’t develop, potentially triggering the return of symptoms. A study by Yoo et. al assessed the probability of fibroid recurrence in laparoscopic myomectomy patients over an 8-year follow-up period. The researchers observed that the cumulative probability increased steadily from 11.7% at 1 year post-procedure to 84.4% at the 8 year mark. Factors influencing fibroid recurrence were found to be patient age, number of fibroids, pre-operative uterine size, and childbirth following the procedure. Another team of researchers, Obed et al., added family history of fibroids and multiple symptoms as to that list of factors, and concluded from their own study that “there is a high recurrence of uterine fibroids following myomectomy”.

Risks associated with myomectomy include post-surgical adhesions and both intra- and post-operative bleeding. Dubuisson et al. observed adhesions, or scars produced as incisions in the uterine tissue heal, in 35.6% of patients during “second-look” laparoscopy; this result that has been corroborated by additional studies. Cases of uterine rupture during pregnancy following a laparoscopic myomectomy have also been reported.

Since a myomectomy does not involve removal of the uterus, it is possible to preserve the patient’s fertility. Research largely suggests that myomectomy is an appropriate procedure for fibroid patients who desire pregnancy. That said, certain complications associated with myomectomy, such as adhesions, can, themselves, impair fertility – a fact that should be taken into account when considering the fertility-sparing aspects of the procedure.

One technique for removing larger fibroids through small ports in laparoscopic myomectomy, called power morcellation, has recently been the subject of major controversy. In power morcellation, a tool called a morcellator is used to dissect large fibroids, so that the dead tissue may be more easily extracted without expanding the abdominal incisions. In April 2014, the Federal Drug Administration (FDA) released a safety communication notice discouraging use of power morcellation, citing concerns that the technique could spread cancerous cells within the abdominal cavity if it came in contact with cancerous tissue. While uterine fibroids (also called leiomyomas) are almost always benign, the rare fibroid (about 1 in 1,000) that is malignant may not be detected as such in advance of surgery. Several manufacturers of the power morcellator have since pulled the device from the market, and power morcellation is now rarely used in laparoscopic myomectomies.

 

 

SOURCES:

Pitter, M.C. et al. “Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy”, Obstetrics & Gynecology, Apr 19, 2015. ePub. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417601/. Retrieved July 2, 2015

Yoo, E. et al. “Predictors of leiomyoma recurrence after laparoscopic myomectomy.” Journal of Minimally Invasive Gynecology, Nov-Dec 2007; Vol. 14(6):690-7

Obed et al. “Uterine fibroids: risk of recurrence after myomectomy in a Nigerian population.” Archives of Gynecology and Obstetrics, Feb 2011; Vol. 283(2):311-5

Dubuisson J.B., et al. “Second look after laparascopic myomectomy”, Human Reproduction. 1998; Vol. 13:2102–6

“FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids”, FDA News Release, Apr 17,2014. Web: http://www.fda.gov/newsEvents/Newsroom/PressAnnouncements/ucm393689.htm. Retrieved July 2, 2015.

 

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The Fibroids-Diet Connection

 

More than a decade ago, researchers identified a connection between a meat-heavy diet (specifically, the consumption of ham and beef) and uterine fibroids. The same study, published in the medical journal Obstetrics & Gynecology, produced evidence that diets heavy in green vegetables reduced the risk of developing fibroids. Since that time, numerous studies have sought to further explain the connection between diet and fibroid risk. Unfortunately, that research has yielded few answers, and the connection remains largely misunderstood and widely debated.

Foods Impacting Fibroid Growth

While no causal links have been established, there are clear themes emerging from study data. Multiple studies have correlated increased consumption of fruit, vegetables, and low-fat dairy products with reduced risk of developing fibroids. A study published in 2010 in the American Journal of Epidemiology was one such study. The research team of Wise et al. followed trends in the dietary intake of more than 22,000 premenopausal black women from the US Black Women’s Health Study over a 10-year period. Self-reported data from questionnaires gave the researchers insight into participants’ intake of dairy foods – including milk, cheese, yogurt, and ice cream – and nutritional components of dairy – like calcium, vitamin D, and butyric acid. The collected data revealed a connection between higher dairy consumption and a lowered risk of uterine fibroids. The researchers theorize that calcium and butyric acid (present in milk fat) inhibit the proliferation of cells that would otherwise form the benign pelvic tumors.

In a separate research effort, Wise et al. used the diet questionnaires collected from a cohort of participants in the Black Women’s Health Study to gather evidence regarding the link between fibroid risk and the consumption of fruits, vegetables, and carotenoids. In the December 2011 issue of American Journal of Clinical Nutrition, the researchers reported finding a reduced risk of uterine fibroids among the women with higher levels of fruit and retinol in their diets. These findings build upon those reported more than a decade ago by Chiaffarino and colleagues, who determined that a high intake of green vegetables has a protective effect against fibroids.

Margaret Wertheim, MS, RD, LDN, a Chicago-based dietitian, sees the same value in green vegetables. She advises her clients with fibroids to increase their intake of cruciferous vegetables like cabbage, broccoli, and kale. “This group of vegetables, in particular, contains indole-3-carbinol,” she explains, “which research has suggested may prevent estrogen-driven tumors due to its effect on estrogen metabolism.”

While research has drawn attention to the protective effects of foods like dairy consumption and green vegetables, it has also revealed a heightened risk of fibroids associated with the consumption of meat products. Women whose daily diets include meats like beef and ham are – according to the research – more likely to develop fibroids than women who consume a strictly vegetarian diet.

Some research, including a 2010 study by Di and colleagues, has suggested that certain phytoestrogens found in soybeans, called isoflavones, may inhibit the growth of estrogen-dependent uterine fibroids. Contradictory evidence was produced by Radin et al, however, when they examined the soy intake of a subpopulation from the aforementioned U.S. Black Women’s Health Study and found no connection between soy consumption and uterine fibroid risk.

Fibroid growth is fueled by estrogen. Thus, in theory, any chemicals or nutrients that affect the body’s estrogen levels will impact fibroids in some way. Growth hormones in non-organic beef and phytoestrogens in soy are simple examples, but other potentially problematic substances are those that indirectly impact the body’s hormonal balance. For example, Wertheim recommends that women with fibroids watch their caffeine and alcohol intake. Both caffeine and alcohol stress the liver, which can make the liver work less effectively at metabolizing estrogen in the body. “With fibroids,” she explains, “you want to support the health of the liver by getting rid of alcohol and caffeine so it may optimally metabolize circulating estrogen.”

Finally, the role of vitamin D in affecting fibroid growth has been a subject of recent interest. A study published in a 2011 issue of Fertility and Sterility reported that vitamin D inhibits the growth of cells involved in uterine fibroid growth. The data produced by the researcher team of Sharan et al. suggested that low levels of vitamin D may be a risk factor for their developing fibroids.

Diet Modification: Does It Help?

Though certain dietary connections may seem clear, the implications of dietary modification for treating existing fibroids certainly aren’t. Bala Bhagavath, MD, an endocrinologist at the Center for Reproduction & Infertility at Women & Infants Hospital in Rhode Island, explains the limitations of the existing data in a 2012 article from Today’s Dietitian. He points out that the studies that have been conducted are all observational in nature; no interventional studies have been conducted to determine the effectiveness of diet modification as a treatment strategy. “It’s not known if modification of diet in women with established uterine fibroids will result in resolution of these tumors,” he says. “Even if they do, the length of time this dietary modification has to be maintained has to be established. It’s possible that dietary modification may decrease the incidence of fibroids in women at high risk for developing them. However, even this question of prevention remains unanswered at this time.”

Based on what we know (and don’t know!) about the fibroids-diet connection, it’s unrealistic to expect that dietary changes alone can eliminate and/or prevent fibroids. However, the knowledge that has been uncovered regarding dietary risk factors can be useful in guiding nutritional strategies that will support a broader treatment protocol. Simply understanding the impact – direct or indirect – that certain vitamins and nutrients have on fibroid growth enables women with symptomatic fibroids to make better dietary choices, avoiding foods that could worsen their condition, and possibly enhancing the effectiveness of other medical treatments as a result.

 

SOURCES:

Stewart, E. “Uterine Fibroids”, New England Journal of Medicine. 2015; 372: 1646-55

Chiaffarino et al. “Diet and uterine myomas”, Obstetrics & Gynecology. 1999; 94(3): 395-398

Tempest, M. “Uterine Fibroids and Nutrition — Studies Suggest Healthful Dietary Modifications May Cut Risk and Ease Symptoms” Today’s Dietitian. May 2012; 14(5): 40

Levy, B., “Modern management of uterine fibroids”, Acta Obstetricia et Gynecologica. April 2008; 87: 812-823

Wise, et al. “A prospective study of dairy intake and risk of uterine leiomyomata”, American Journal of Epidemiology. 2010; 171(2): 221-232

 

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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.

“Won’t My Fibroids Go Away On Their Own?” Weighing the Wait-And-See Option

If you’ve done any Internet research on fibroids at all, you’ve probably encountered some mention of a woman’s fibroids disappearing on their own after menopause. It’s most likely a true story. Indeed, as the body’s natural production of estrogen declines in menopause, the estrogen-fueled fibroid tumors, also called leiomyomas, will follow suit—at least, in theory.

There are a number of reasons why a woman would continue to see the persistence or even growth of her fibroids after menopause: the reintroduction of estrogen with hormone replacement therapy or malignant changes in the tumor (cancer known as leiomyosarcoma) are two possible explanations for the continuation of symptoms. Hormone replacement, in particular, is commonly necessitated when a woman’s menopausal symptoms impact her quality of life, but the need isn’t foreseeable in pre-menopausal years. In such cases, fibroids that may have otherwise gone away naturally could continue to present problematic symptoms far later in life than anticipated.

Still, the natural disappearance of fibroids is a viable possibility. For many women, this raises the question, if fibroids will potentially shrink or even disappear on their own after menopause, should a pre-menopausal woman take steps to have them treated, or should she simply wait and see? The urgency for treatment typically depends on the severity of symptoms, according to Dr. Donald Galen, OB-GYN and former Surgical Director at the Reproductive Science Center of the San Francisco Bay Area.

The degree to which women experience common fibroid symptoms like heavy menstrual bleeding, pelvic pain and pressure, and urinary frequency varies substantially. For many women, fibroid symptoms are more than inconvenient: they can interfere with all aspects of her life and relationships. When symptoms are debilitating, a woman may want to consider treating her fibroids sooner, rather than later. With many available treatment options, including minimally invasive options like Acessa Procedure, treating any existing fibroids will improve her quality of life.

Women whose symptoms are less severe, on the other hand, may choose to delay treatment. “If symptoms are minimal,” Dr. Galen explains, “it is reasonable to follow these patients and as they progress in menopause…their fibroids and symptoms should progressively diminish and thus no other treatment may be needed.” Stressing the importance of the patient’s participation in the decision-making progress, he adds, “this decision is made by the woman, with counseling from her physician as to all available risks, treatments, alternatives, etc.”

Sources:

  1. Burbank, Fred. Fibroids, Menstruation, Childbirth and Evolution: The Fascinating Story of Uterine Blood Vessels. Tucson, AZ: Wheatmark, 2009. 135. Print.
  2. American Society for Reproductive Medicine, “What Are Fibroids”, Resources, ReproductiveFacts.org: 2011. Retrieved April 6 2015, from http://www.reproductivefacts.org/FACTSHEET_What_are_Fibroids/

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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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