JACIE LANDEROS / Union-Tribune
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In some ways, removing uterine fibroids is easy. The treatment gets complicated only for a woman who wants to lose the tumors but keep her uterus.
While hysterectomy remains the most common solution for fibroids, women can now consider having their tumors starved, removed, zapped or drugged. But the best option isn't always clear. Each method has its own drawbacks, and each must be considered in the context of a woman's life.
“It depends on the woman,” said Dr. Phyllis Gee of the North Texas Uterine Fibroid Institute. “It depends on her desire for future fertility. It depends on what the fibroids look like and where they are.”
Sometimes, it depends on the doctor.
“The therapy a woman gets is largely dependent on whose office you walk into,” said Dr. Scott Goodwin of the University of California Los Angeles.
Physicians can be apt to recommend the procedure most familiar to them.
Doctors predict that treatment choices may continue to expand when scientists answer some of the most basic questions. Among them: Where do fibroids come from?
For now, no one can say. They are benign, fibrous (as the name implies) growths that arise from the uterine muscle. The tumors can range from the size of a pebble to a grapefruit or larger. They can be lone or plentiful. And they are common, occurring in the vast majority of women, causing pain and other symptoms in about 25 percent. For reasons that are not understood, fibroids are more likely to occur – and more likely to be severe – among African-American women. They can run in families.
Fibroids tend to affect women most in their 30s and 40s. As the growths depend on a steady supply of estrogen, fibroids are less likely to bother women after menopause. Often, they don't cause problems at all.
“A lot of women come to me and say, 'I have fibroids,' and I say, 'So what?'” said Dr. Togas Tulandi, a fibroid expert from McGill University in Canada. “We do treatment only if they are symptomatic.”
The symptoms, when they do occur, can be excruciating – bleeding, cramping, miscarriage, an abdomen swollen large enough to appear pregnant. The tumors can put pressure on the bladder. These are the women who must make decisions.
Treatment options are evolving so quickly, said Dr. Elizabeth A. Stewart of Harvard Medical School, that “the option that's present now may be slightly different in a year.” For years, she said, fibroid treatment was an almost orphaned area of medicine because hysterectomy offered a cure. “We're behind in our research.”
Attitudes began to evolve in the late 1990s, when doctors in France described a radical idea for treating fibroids. In 1995, in the journal The Lancet, the French physicians reported that blocking the blood supply to the tumors caused the fibroids to soften and shrink. The discovery was accidental. Surgeons were blocking the arteries to cut down on bleeding during surgery; they noticed then that a startling percentage of women weren't returning because their symptoms had eased.
The findings got the attention of UCLA's Goodwin. He began describing his results among American women in 1997, he said, and “all of a sudden, I'm on 'Good Morning America.'” Women embraced the idea of having new choice for fibroid treatment, especially one that lessened pain and sped recovery.
Uterine artery embolization, as the technique is called, is now widely available as an option for fibroids. And in 2004, the federal government approved another technique, MRI-guided focused ultrasound.
For this procedure, a woman lies in an MRI machine while doctors blast the tumors with concentrated, high-intensity ultrasound. The waves heat the proteins of the tumors and destroy them.
“We call it cooking the egg,” said Harvard's Stewart.
And women still have the surgical route: hysterectomy and myomectomy, which involves just cutting out the tumors. Myomectomy has long been available, but some women's tumors reappear after removal, and some fibroids aren't candidates for surgery.
Researchers are also experimenting with drug therapy that might shrink the tumors by interfering with their stream of estrogen, though for now such drugs can be given only for the short-term.
None of the procedures is perfect, and none is good for every woman.
“It's really critical to find a gynecologist who is willing to talk to you about all the treatment options,” said Carla Dionne, executive director of the National Uterine Fibroid Foundation.
For example, myomectomy is the preferred route for women who still want to get pregnant, said Dr. Bruce Carr, a fertility specialist with the University of Texas Southwestern Medical Center at Dallas. Embolization may affect blood supply to the ovaries and uterus, he said, and too little is known about whether ultrasound may weaken the uterine wall.
Myomectomy success depends on how large the tumors are, where they are (some embed into the muscle), and how they are attached. And the techniques for surgical removal of fibroids alone are evolving, said Stewart.
“If you have the right kind of fibroid, it's a great option,” she said.
Other women choose embolization. Because it isn't a major operation, it doesn't have the risk of complications that can go with surgery. But the tumors don't vanish – they just become smaller and more pliable.
Why don't more women have it?
“I think the most common reason is that most women don't know about it,” said Goodwin. “The other reason is that embolization is by no means a perfect procedure.”
It works in about 80 percent of women who are candidates, he says. In others, new fibroids may appear.
Focused ultrasound, being new, is also the least-studied alternative.
“When I learned of the technology, I was very excited,” said Gee. “We are able to target the tissue that we're trying to destroy.”
Her office is participating in a study to try to gauge its long-term track record.
The advantage is that there is no incision – the sound waves pass harmlessly through the skin. The disadvantage is that it can take a long time in an MRI machine and may not be covered by insurance.
There also is a list of reasons a woman wouldn't qualify. Among them: If her fibroids can't be treated in three hours; if she wants to become pregnant; if she has any metal in her body; if the tumors are too close to other sensitive tissue.
“It not only has to be safe, it has to be effective,” Goodwin said of the ultrasound method. “I think it's far from being effective enough to be widely embraced.”
Some of the latest data on the ultrasound method was described in the January issue of the journal Fertility and Sterility. In an early study of 82 women followed for at least a year, 23 had gone on to seek other treatments and 42 reported improvement in their symptoms.
Meanwhile, research continues to examine why women get fibroids in the first place, with the hope that in the future, women may have one option not currently available: prevention.
One large study, sponsored by the National Institute of Environmental Health Sciences, involves 300 women with fibroids and hopes to uncover why some fibroids become health nuisances and others don't.
Each fibroid is thought to arise from just one muscle cell gone amok, but what is the trigger? No one knows, but more and more scientists are looking.
“Within the past 10 years, the field has grown exponentially,” said Darlene Dixon, a pathologist who specializes in fibroid research at the NIEHS. “I think women are saying, 'No, I want to maintain my uterus, but I want to have some sort of treatment for this disease.'”
FIBROID TREATMENTS
Although hysterectomy remains the most common treatment for fibroids, others include:
Watch and wait; drug therapy: After menopause, fibroids tend to shrink naturally. Medicines can provide some short-term symptom relief until a woman is old enough to reach this point. Drugs can include anti-inflammatory medications or birth control pills. Other types of hormonal treatments are under investigation.
Myomectomy: This is performed in numerous ways and involves taking out only the fibroids. Doctors often recommend this option for women who want future pregnancies. Can also be recommended for women past childbearing who want symptom relief until menopause.
Embolization: This procedure involves placing small particles into the blood vessels that supply the fibroids. Once they become blocked, the fibroids often become smaller and softer, relieving symptoms. It doesn't work for all types of fibroids, and doctors have concerns about fertility and pregnancy after the procedure.
Focused ultrasound: This is a relatively new procedure in which doctors aim high-intensity sound waves at the core of the fibroid, destroying the tissue. The advantage is that this is a noninvasive outpatient procedure. While initial results look promising, less is known about the treatment's long-term effects, and it cannot be performed on all women.
Sources: National Uterine Fibroids Foundation; Society of Interventional Radiologists; National Institute of Child Health and Human Development.
BOOKS:
“Fibroids: The Complete Guide to Taking Charge of Your Physical, Emotional and Sexual Well-Being,” Johanna Skilling (2006)
An updated version of Skilling's 2000 book of the same name, this is a comprehensive look at fibroids and includes true-life stories from women who suffer from these tumors.
“It's a Sistah Thing: A Guide to Understanding and Dealing with Fibroids for Black Women,” Monique R. Brown (2002)
According to NUFF, African-American women are two to three times more likely to have symptomatic uterine fibroids, and typically have them at a younger age. While a little dated, this book remains an important source if you're in this high-risk group.
WEB SITES:
www.fda.gov/womens/getthefacts/fibroids.html
The FDA's Office of Women's Health offers this page on fibroid details, including a list of symptoms.
www.fibroids.net/aboutfibroids.html
Center for Uterine Fibroids in Boston gives medical information about the uterus and fibroids.
www.nuff.org
The National Uterine Fibroid Foundation (NUFF) provides links to patient information and research updates.
– BETH WOOD, RESEARCH LIBRARIAN
