FAQs: Uterine Fibroids and Leiomyomata
From the Woman's Diagnostic Cyber - Frederick R. Jelovsek MD
Fibroids - Uterine Leiomyomata
   
Want pregnancy but have large submucosal fibroid.
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.
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.
Fairly likely that the fibroid will cause some problems.
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.
Why didn't they do the resection of the submucosal fibroid at
the time of the hysteroscopy?
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?
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
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?
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?
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
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.
Not much, usually about a teaspoon (5 ccs) are used. You will get some cramps, however.
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.
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?
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.
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
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 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.
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?
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?
Drive a farther distance to your doctor's appointments.
Pregnancy risks with fibroids
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.
Yes it can, but usually getting pregnant is the problem with fibroids and then preterm labor. Enlarging fibroids is not usually the problem.
Possible but that's not the main problem.
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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