Womens Health

FAQs: Uterine Fibroids and Leiomyomata

From the Woman's Diagnostic Cyber - Frederick R. Jelovsek MD

Fibroids - Uterine Leiomyomata

Click on the below questions to find out the correct answers about uterine fibroids.

 

Want pregnancy but have large submucosal fibroid.

 

I have a single submucosal fibroid that's been causing me horrible periods. It's 2-3 cm, and not far above my cervix. My uterus is 12 cm, while the doctor says normal is about 8 cm. He's referred me to a gyn who *should* be able to do a hysteroscopic resection of the fibroid. I'm 34, and we want to get pregnant. I don't want to sit around 'til 3 or 4 months, waiting 'til I see the other doctor (I'm Canadian). How risky is it for us to attempt a pregnancy now?

Moderately risky. I would wait for the resection of the submucosal fibroid before attempting pregnancy. First of all the fibroid may interfere with implantation of the placenta and you would have an increased risk of either not getting pregnant, miscarriage, preterm delivery or certainly bleeding during pregnancy.

I'm also afraid the myomectomy will turn into an emergency hysterectomy, or leave my uterus too damaged to be much use. There don't seem to be any more experienced docs in my area (my doc made a comment about recent "horror stories" of bleeding, etc., before thinking hard to come up with this referral). I'm reluctant to put my fertility on the line (if indeed I have any capacity to bear a child at this point to begin with).

The resection of the fibroid shouldn't damage the uterus. It's most likely to leave the uterus in much better shape for pregnancy than if nothing is done.

How likely do you think it is that the fibroid and enlarged uterus will prevent a successful pregnancy?

Fairly likely that the fibroid will cause some problems.

Thanks for your reply. Not what I wanted to hear, but at least it makes sense.

By the way, how do you know its a submucosal fibroid and not an endometrial polyp? Usually we can't tell until hysteroscopy. Even if you have intramural fibroids there can be polyps rather than fibroids.

I had a D&C/hysteroscopy last month, and two pelvic ultrasounds.

Why didn't they do the resection of the submucosal fibroid at the time of the hysteroscopy?

That gynecologist didn't feel qualified/sufficiently experienced to do it -- he said it was "too big". I was hoping I'd wake up and it would be over. If that's how he felt, I'm glad he backed off, but that's why I'm afraid the *next* guy may have trouble with the resection. I'm told it's not particularly new or difficult surgery, as long as the doc has experience with it, but there doesn't appear to be that much experience around. I also don't know how fast these things grow, and I don't want the delay to result in it being too large to remove hysteroscopically.

Fibroids grow fairly slowly. I don't think it will be too much bigger in 3 months but I think a year would be too long to wait.

 

Do fibroids causing pain mean a hysterectomy?

I have been having lower back pain and my sides have been hurting. Also I feel a lot of pressure on my bladder. My doctor told me that I have a fibroid of the uterus and referred me to an Ob- Gyn. Could someone tell me about this and will I have to have my uterus taken out?

Fibroids are benign muscle growths of the uterus. If they get big (like a 12 week pregnancy size) they can start giving pelvic pressure. If they are located anteriorly in the uterus just behind the bladder, they can give bladder pressure. Your doctor will probably do a pelvic ultrasound to see how big they are and where they are located.

You don't have to have the uterus taken out unless the pressure and bladder frequency are giving you a problem enough so that you want to undergo surgery to have relief. If that is the case, the treatments could be removal of the fibroids and leave the uterus alone or removal of the uterus. Both procedures take about the same time and involve the same recovery. If you want to be able to still get pregnant again, doing nothing or just having removal of the myomas (fibroids) would be all that needs to be done.

 

Submucosal fibroids and endometrial ablation

I have a uterus the size of a 12 to 14 week gestation. My doctor has performed an hysteroscopy and found numerous fibroids, large and small, I believe they are submucous. I wanted to find out if having an endometrial ablation would decrease the extremely heavy periods that I have. I have tried a few different BC pills with no luck. I have no pain associated with these. Any information would be greatly appreciated. I am against having an hysterectomy until all other options are tried.

Submucosal fibroids can often be removed at hysteroscopy and according to the following recent study, endometrial ablation and a hysteroscopic submucosal myomectomy has been quite successful, although I don't think many gynecologists are doing the two procedures together.

Remember though, in large studies, after ablation 25-60% had no subsequent periods, with most of the remainder having a decrease in the amount of menstrual flow. About 10% fail to improve and require another ablation or hysterectomy (about 2%).

*****

J Am Assoc Gynecol Laparosc 1997 May;4(3):369-374
Endometrial ablation and hysteroscopic myomectomy by electrosurgical vaporization.
Glasser MH
Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, San Rafael, CA 94903, USA.

Electrosurgical vaporization, first performed by urologists in prostate surgery, is useful during operative hysteroscopy for endometrial ablation and myomectomy. From June 1995 through May 1996, 9 surgeons performed 44 endometrial ablations and hysteroscopic myomectomies using the vaporization electrode. Our experience with this technique thus far has been very favorable. The procedure is less expensive than laser ablation and is easier to teach than wire loop resection. It is also less tedious than wire loop resection since myoma chips that often obstruct the operator's view are eliminated. Long-term efficacy of this technique remains to be proved.


Do hormone imbalances cause ovarian cysts or fibroids?

Just went to doctor today. Went to have a check up and also to rule out the possibility that I have another ovarian cyst on my one remaining ovary...SO, I'm having a vaginal sonogram on Thursday because she felt what she estimated to be a 4-5 cm. fibroid. Two years ago, I had an oophorectomy; left ovary and tube removed (via a vertical mid-line incision) for an ovarian cyst that was 13 cm and close to 3 lbs (6.6 kg) in weight.

I'm 38 and have had 6 pregnancies, and three live vaginal births, the last one being almost 7 years ago. I've had thyroid problems on and off for the past 12 years - sub-acute thyroiditis - and I wonder what, if any, connections are there between hormonal imbalances (producing too much estrogen?) and developing first the cyst and now the fibroid condition? And if so, would it be worth investigating via blood tests to see if I do have some sort of hormonal imbalance that would pre-dispose me to developing these problems.

There are three types of functional ovarian cysts. These include follicular, corpus luteum and theca lutein.

Follicular cysts are believed to be to be dependent on ovarian stimulation for growth. That means that it's FSH and LH, not the estrogen (E) or progesterone (P) that causes the cyst to enlarge.

Corpus luteum cysts may be associated with either normal endocrine function or prolonged secretion of progesterone.

Theca lutein cysts arise from either prolonged or excessive stimulation of the ovaries by FSH or LH such as levels seen in pregnancy or what are called molar pregnancies.

As far as uterine fibroids go, the present theory regarding their development is that neoplastic transformation of normal muscle cells occur under the influence of many hormones, including E and P. Fibroids have receptors for both E and P. The exact stimulus for growth is UNCLEAR but may be related to relative levels of E and P.

In summary, a connection between hormonal imbalances and etiology is not clear cut because our understanding of how the cysts develop is lacking. Since this is so, it is not worth doing blood tests since their results wouldn't really tell you anything.

 

Can fibroids cause urinary urgency?

Ever since I was told I had a fibroid I've been having bladder problems. Some say that in order for a fibroid to effect the bladder it has to be large. My MD said "wrong". It depends on where the fibroid is located. My fibroid was originally 1/8 of an inch. My OB-GYN stated she wanted to watch it grow. Grow for what? I'm urinating every 30 minutes. I do not have kidney stones.

I had an IVP and it stated I had an enlarged uterus and suggestive of fibroid. I have been checked and I do not have a urinary tract infection. I do not have burning or pressure. When I sit down in a chair or in the car I feel like I have to urinate. I've been tested many times for UTI's - always show up negative. I don't have kidney stones or blocked ureters. The IVP report suggests I get a pelvic ultrasound. My OB-GYN refuses to order one because she's convinced that this is not causing the problem. I was given antibiotics; they didn't help.

I also have a history of ovarian cysts which always burst inside me and the ob/gyn never prescribed antibiotics because she stated my body would absorb the blood. I was operated on for endometriosis and endometriosis was lasered. However, the fibroid was not. I have a retrograde (tilted uterus). Could this be the cause plus the fibroid?

Usually small fibroids don't cause bladder urgency as bad as you describe. Especially since you don't have a pressure feeling. I would be more suspicious of the endometriosis causing problems.

In either case, you have an "overactive" bladder, either due to endometriosis, fibroids or just unknown as many cases are. If you are having nighttime frequency of more than 3 times to get up at night, I would suggest getting a cystoscopy to look in the bladder for the possibility of interstitial cystitis (a sterile inflammatory condition of the bladder wall). Then if that is negative, you need treatment for the "overactive" bladder for which there is good medical therapy along with bladder retraining. That way you won't have to have any surgery to get over this problem.

 

What to expect with a sonohysterogram for possible submucosal fibroids

I went to my GYN and then a reproductive endocrinlogist. My GYN gave me another ultrasound that showed my existing fibroid and a new one. The tech said one was 11cm. That seems significant compared to the original 2.5cm 6 months ago. Of course she wasn't the least bit concerned. The Specialist wants to schedule me for a test, a sonohysterogram. She told me that she wants to do it 7 days into my period. Well it usually lasts for about 10-13 days. This seems confusing to me. Since this test is used for imagining. Won't the menses cloud the images?

No, the saline being injected gives a good fluid interface so any pathology can be seen. She needs to do it in the early phase of the cycle before the tissue gets thick and confuses the image.

My other concern is that my pelvic pain is becoming more chronic and almost always hurts. The doctor explained the procedure as using a catheter like tube placed in the uterus and inflating a balloon to seal the uterus and then filling the uterus with fluid(saline). How much will this increase the size of my uterus?

Not much, usually about a teaspoon (5 ccs) are used. You will get some cramps, however.

I was told to take an Advil® before I come in. (Advil® is a placebo to me.) If I am in all this pain almost constantly, what kind of pain am I going to experience with this test?

Take 2 Alleve® to help block the cramps and also take another pain pill (not a nonsteroidal) that you know works for you like Percocet® or Lortab® or Ultram®. If you don't have any, ask her nurse to call in a prescription for you for one tablet because you are quite sensitive to the pain. Have someone drive you to and from the office.

I am in disbelief that she wants to place these foreign objects into my body and I am supposed to be calm and relaxed. I can't even relax during a pelvic exam because of the pain and tenderness, and she know that from the examination I had.

This will help diagnose any fibroid or polyp that is impinging upon the endometrial cavity and causing bleeding.

 

Can five months size fibroids be reduced for hysterectomy?

I am 38 years old and I have a fibroid that is the size of a 5 month pregnancy. I will be starting the pill to help with the heavy bleeding and I hope that this will inhibit the growth of the fibroid.I am currently researching other treatments and I am quickly ruling out Lupron® and Depo Provera® due to the side effects. I had 2 C-sections in the past but my uterus ruptured during my second delivery. I was trying for a VBAC. If the fibroid gets bigger, what are my chances of my uterus rupturing again?

You have an increased chance for a repeat rupture again due to the previous rupture only if you get pregnant again. I would guess in about the 5-10% range. With 20 week size fibroids (5 month size) you would not be likely to get pregnant. Those size fibroids usually distort the endometrial cavity so much that either you don't get pregnant, or if you do, you are at risk for miscarriage or very premature delivery.

This is my biggest concern. I am trying to prepare myself to have the hysterectomy and I was hoping to reduce the size of the fibroid to get a less invasive treatment. I do not want anymore children and was considering a tubal anyway. I am experiencing discomfort and occasional twinges of pain in my lower abdomen. Any advice would be appreciated.

It is extremely difficult to shrink the 20 week fibroids down to a size (12-14 weeks or less) where you could have a laparoscopic assisted vaginal hysterectomy instead of an abdominal hysterectomy. Birth control pills and Depoprovera® won't do it. Lupron® might get it down in size far enough but chances are still less than 50% of that big decrease. Also, as you know, the symptoms of Lupron® are essentially menopause. It is a temporary menopause, however and goes away as soon as you stop the Lupron® at the time of surgery. Lupron® might get the size down to the point where your doctor would be willing to do a transverse incision (near hairline) rather than a midline incision (from pelvic bone to the naval), but that's about the best I think you could hope for.

It's difficult to decide about that, but if you have your hysterectomy, you will probably be surprised at how much different (better) you feel than when have a 5 month size uterus inside of you all the time.

 

Pain and bleeding - maybe not due to fibroids

I just got back from having a laparoscopy. The reason was to find a cause of my irregular bleeding, two periods a month and spotting in between, and the increasing pain I am experiencing before during and after my periods. Well the doctor told my husband that it was for nothing. I knew I had two fibroids (shown from a US about two weeks ago). The laparoscopy showed one fibroid on the outer part of my uterus. She was unable to find the other one. She said other than that everything was normal. Where do I go from here? The doctor said she thinks it is my bowels because I do have irritable bowel syndrome (IBS). But I know what kind of pain this causes, and my pelvic pain is very different and more consistent. My bowel pain is sudden attacks, very sharp, and last a few minutes and then go away. Occasionally I have fluttering and I have to go to the bathroom within about 15/20 minutes after eating. So I feel that they are totally separate. Do you have any advice as to what I am to do now? Am I just going to have to live with the pain and irregularity? I really don't think that is best. I am sick and tired of only having two-three painless, bloodless days a month. I have tried chemical therapy with no relief.

Laparoscopy does not discover the cause of irregular bleeding, it is only to diagnose pelvic pain. Hysteroscopy is to diagnose if there are any mechanical causes of bleeding. Did you have a hysteroscopy at the time of laparoscopy? If not, why not?

I don't believe I got a hysteroscopy. I was lightly on my period when I went in for the lap and when the procedure was over I hadn't continued to bleed as if my period stopped and nothing was disturbed. Another reason I think I didn't have one is she said she only found one of the fibroids the ultrasound showed. It was plainly on the outside of the uterus in the lining. ( She took pictures) . I think the other one is in the inner lining of my uterus. She also never said anything about doing a hysteroscopy. I have an appointment to see her in two weeks. So I will ask.

I remember you saying you were going to get a sonohysterogram. What did that show? I assume it was probably normal but they can miss polyps.

The doctor that recommended this procedure is a Repo/Endo specialist. She wanted to do this 7 days into my period and that was the same day of the lap so I was told to wait and see what the lap showed.

I think mostly in past postings we talked mostly about your pain and not so much about your bleeding. Can you review some of the bleeding history and studies?

Well the history starts way back when I had a Norplant placed in my arm. within 8 months I put on 100lbs. and was exhausted all the time. They did blood work and everything was normal. So they refused to remove it. Well a few months later I started experiencing horrible pain and I was spotting almost everyday between my periods. Finally the doctor said he would remove it if I would sign a consent form on my 21st birthday to have a tubal ligation. Being stupid and desperate, I agreed. Once removed everything turned back to normal. Well about two years ago I started have weird periods. Except this time they were really heavy, long 10-14 days, occurring twice a month, and I spotted continuously. I tried five different chemical therapies and none were successful . The pain started creeping up about 4 months ago and it has been getting worse.

If you are currently having 2 menses per month lasting 10-14 days and other spotting, some evaluation of the endometrium is needed (hysteroscopy, endometrial biopsy, sonohysterogram,) even though you are young. This is because the other hormonal (I assume from chemical) therapies have failed. Also thyroid studies and a bleeding time and possibly other coagulation studies if you have a family history or a personal history of easy bleeding or bruisability.

As an aside, what other problems did you have that led to the recommendation for the tubal ligation other than the bleeding?

My thyroid was normal, I had a prolactin and FSH test. I was told they were within a normal range. I do bruise easily. What is a bleeding time test? When I receive a cut or something my blood coagulates normally. There were no recommendations of my getting a tubal ligation. I was told by the doctor I was seeing that if I wanted the Norplant removed he would only do it if I signed consent forms, or I would have to tough it out for 4 more years until it was time to replace the Norplant. I felt like I was trapped. There was only one gyn in my town that did placement and removal of Norplants and he refused to take it out. I was told that my weight gain was because I was eating like a pig and my bleeding wasn't something to even be considered since Norplant was known to cause spotting and missed periods. But I wasn't missing periods I was having too many! I am very angry about what this doctor did to me. Now I have to spend approx. $10,000 if my husband and I decided to have a baby. All because he (the gyn) said he was tired of women complaining about the Norplant after they requested it. But I think gaining 100 lbs in 8 months was definitely the Norplant. I never had a weight problem before. I was 169lbs and I am 6' tall. Now I can't get below 280, not matter what I tried. I was even put on a restricted calorie liquid diet for three weeks and actually gained 8lbs.

I feel as though I am back were I started. My GYN now seems to think that I imagined the pain and bleeding problems. Even though every time I was at her office I had menses. I am so disgusted!! Got any ideas?

Drive a farther distance to your doctor's appointments.

 

Pregnancy risks with fibroids

I have three fibroids. 2 anterior and 1 interior. The one inside is the size of a 29cm by 48 cm. How big is that compared to a pregnancy?

I assume you mean 2.9 by 4.8 cm in size. That would be equivalent to the head size of a baby at about 6-7 months pregnancy.

My husband and I have discussed starting a family but I will have to have tubal rings removed from my tubes (tubal ligation 6 years ago). I was told that the two outer fibroids can't be removed because of location and depth into the uterus but shouldn't cause any problems getting pregnant. But doesn't pregnancy cause increased estrogen and in turn, feed the fibroids?

Yes it can, but usually getting pregnant is the problem with fibroids and then preterm labor. Enlarging fibroids is not usually the problem.

What are the chances of them getting worse?

Possible but that's not the main problem.

I was told that when and if they ever get large enough to cause problems I would have to have a hysterectomy. This doesn't really bother me, because I am almost to the point of giving up on the idea of have more children and just having everything taken out.

So my decision is whether to have the interior fibroid removed and try pregnancy, or have a hysterectomy. I also have a prolapsed uterus and know that pregnancy will make it worse and a suspension will only last for a while.

I am not asking for you to make a decision for me one way or the other but if you could help me out with the risks I face keeping my female organs and getting pregnant with fibroids I think that would help.

There are risks but the main risk is going thru a lot of surgery and then not being able to get pregnant, i.e., doing it all for nothing. I would guess that the chance of a successful pregnancy after all the surgery would be in the 30-40% range.

 

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SSA
I have just come from seeing my doctor to go over the results of my pelvic ultrasound. Fibroid uterus found and doctor recommends surgery and sent me to local surgeon. I have many questions, the more I think about what may happen. First of all, some details. 50 year old with abnormal uterine bleeding and pelvic pain & pressure. In fairly good health, aside from asthma. Current hormone levels are very good. The pressure and pain have increased over the past few months, and shortly after the ultrasound, there was so much bleeding that I was saturating tampons at the rate of 1 every 30-45 minutes. I have never had this amount of bleeding before and that actually kind of freaked me out. So, the procedure... high resolution real time technique, sagittal and transverse view of the pelvis were obtained endovaginally. Findings: Uterus measures 12.0 x 8.2 x 8.1 cm and appears heterogeneous in echotexture. At least 3 fibroids were identified. The largest is noted at the anterior uterine fundus on the left, 5.9 x 4.8 x 5.2 cm (since I keep seeing the comparisons here, how large is this compared to a fetus... and what does this mean if a hysterectomy is in order, i.e., laproscopic possible still)? A posterior fundal subserosal fibroid is identified, 4.5 x 2.6 x 3.8 cm. A smaller fibroid is noted in the posterior submucosal location, 0.9 x 1.1 x 1.4 cm in size. Endometrial echo stripe is measuring up to 8 mm (what does this mean?). The right ovary is measuring 2.5 x 1.8 x 1.5 cm and appears unremarkable, while the left measures 5.7 x 3.4 x 4.9 cm. Left ovarian cyst is noted, 3.6 x 2.8 x 3.1 cm. My ob/gyn highly recommends surgery to remove the uterus, but keep the ovaries. Will the surgeon likely order more tests before providing his/her recommendation? Also, I've read where there are times where the cervix is maintained and other times when the cervix is removed. What are the pros and cons to each? As this will be my very first surgery, how does one choose the best surgeon? Should one "interview" multiple surgeons, and if so, how do you know which is the better choice? If surgery is inevitable, how long is the typical recovery period and what should I expect with regard to pain, activity/limitations, etc.? I have so many questions. Are you able to assist/put some of my various thoughts to rest?
1 year ago
looneyk
Trying to decide if Lupron® is the way to go prior to an abdominal myomectomy. I am 32 years old and I have a 17cm fibroid (uterus the size of a 18 week pregnancy). I don’t have any heavy bleeding. I do have constant indigestion, nausea, stomach pain, pelvic/hip pain, etc., etc. The doctor is recommending Lupron® for 3 months to try and shrink the fibroid from 17cm to 14cm. The doctor said this would result in the possibility of a transverse incision rather than a midline incision. I don’t really care about the scaring. Since I am constantly uncomfortable, another 3 months of this pain would not be my first choice; especially coupled with the side effects from the Lupron®. Would there be any other benefits to decreasing the fibroid from 17cm to 14cm other than the type of incision?
2 years ago
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