Dr. Parker's Fibroids Blog

Second Opinions

December 11, 2010 – 8:54 am

Dr. Parker,

I am 49 yrs. old in good physical health. I walk or run several times a week, and am slim(5ft.115 lbs) and look youthful. However, I have a lot of stress-6 children, 2 with drug addictions, a difficult marriage, etc. I have a 10 cm fibroid that is putting pressure on my rectum. I had bleeding and huge clots but taking progesterone 10 days of my cycle has alleviated that. My gyn recommends hysterectomy. I am scheduled for this Thursday, Dec.16, but have a lot of anxiety about it, because I am depressed and worried about how it will affect my emotional state which is already terrible. When I called my gyn he was in his other office further away, and could not call me back. He told his office manager that he already went over everything with me, and to tell me a hysterectomy was the best course of action. He said a myomectomy would thin the lining of my uterus too much. He never mentioned UFE. He seems perturbed that I did go to another gyn for a second opinion. The other gyn said hysterectomy also, not mentioning UFE. I called an interventional radiologist and they said they could see me. Have I broken the doctor-patient trust factor? Will he treat me differently now?

Doctors should welcome a second opinion. You need to do what is best for you and getting a second opinion when surgery is recommended is always a good idea. UAE works very well for heavy bleeding and shrinks fibroids about 40%, so if this would help you, you should see the interventional radiologist to see what they recommend. Myomectomy is always possible and it will not thin the uterine lining no matter what the size of your fibroid. A 10 cm fibroid can be removed laparoscopically as an outpatient by a skilled laparoscopic surgeon.

If the doctor does treat you badly because you got a second opinion, you should consider getting another doctor.

Bill Parker, MD

By Bill Parker, MD | Posted in Answers to Patient Questions | Tagged doctor with an attitude, fibroids, hysterectomy, myomectomy, second opinion, UAE, UFE | Comments (4)

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The Extra Cost of Robotic Surgery

December 6, 2010 – 8:30 am

Cost comparison among robotic, laparoscopic, and open hysterectomy for endometrial cancer.

Journal: Obstetrics and Gynecology. 2010;116:685-93.

Authors: Barnett JC, Judd JP, Wu JM, Scales CD Jr, Myers ER, Havrilesky LJ.

Study from: Duke University, Durham, North Carolina

Problem: Robotic surgery has recently become popular, although the costs of robotic surgery are thought to be significantly higher than laparoscopic surgery. This study, compares the costs of laparoscopic, abdominal and robotic hysterectomy.

Study: The costs associated with robotic, laparoscopic, and abdominal hysterectomy were compared, including hospital and surgical costs, as well as lost income and caregiver costs (societal costs).

Results: The study calculations, which included hospital costs and societal costs, found that laparoscopic surgery was the least expensive approach. Abdominal surgery was the most expensive and robotic surgery was in between. Robotic surgery cost about $2,500 more per case due to the costs of the robot ($1.75 million), additional time needed for each surgery and the costs of disposable robotic equipment.

Authors’ Conclusions: Laparoscopy is the least expensive surgical approach for hysterectomy. Robotic is less costly than abdominal hysterectomy when the societal costs associated with recovery time are accounted for.

Dr. Parker’s Comments: Robotic surgery is being heavily promoted by the company that makes the robot and by surgeons who have been trained to do robotic surgery. However, it has been fairly clear that the robot is very expensive, the surgeries take longer and the disposable robotic instruments are also very expensive. Many of the gynecologists who have adopted robotic surgery were not accomplished laparoscopic surgeons, but are now able to perform minimally invasive surgery using the robot. While robotic surgery is more expensive than laparoscopic surgery, it is less expensive than abdominal surgery because it still provides a faster recovery and less time away from work and home.

(disclaimer – I have been doing laparoscopic surgery since 1987, and have been trained to do robotic surgery, but have only been performing this surgery for about two years with much fewer cases).

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged abdominal and robotic hysterectomy, comparing the costs of laparoscopic, cost of robotic surgery, higher costs of robotic hysterectomy, higher costs of robotic surgery, robotic hysterectomy, robotic myomectomy, robotic surgery, surgical costs | Comments (2)

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New Medication for Heavy Menstrual Bleeding

November 29, 2010 – 8:30 am

Tranexamic Acid Treatment for Heavy Menstrual Bleeding

Journal: Obstetrics and Gynecology. 2010;116:865-75

Authors: Lukes AS, Moore KA, Muse KN, Gersten JK, Hecht BR, Edlund M, Richter HE, Eder SE, Attia GR, Patrick DL, Rubin A, Shangold GA

Study from: Carolina Women’s Research and Wellness Center, Durham, North Carolina

Problem: Heavy menstrual bleeding is a common problem for women and often leads to surgery or other treatments. Birth control pills help some women, but not all. Another oral medication option would be welcome.

Study: Adult women with heavy menstrual bleeding were randomized to receive either tranexamic acid (Lysteda) or a placebo for up to 5 days per menstrual cycle for six cycles. The amount of bleeding and health-related quality of life was measured using a questionnaire.

Results: Women who received tranexamic acid had a significant reduction in menstrual blood loss and this reduction was considered meaningful to women, in that they had improvements in limitations in social or leisure and physical activities and work inside and outside the home. Gastrointestinal side-effects were no more than with the placebo.

Authors’ Conclusions: Oral tranexamic acid treatment was well tolerated and significantly improved both menstrual blood loss and health-related quality of life in women with heavy menstrual bleeding.

Dr. Parker’s Comments: Tranexamic acid has been available in Europe for more than 15 years and has been found to be an effective treatment option for many women with heavy bleeding. Unfortunately, the drug had been around so long that it could not be patented in the US (the down side of the patent system). Recently, a slightly different compound was able to be patented and is now available here.

The medication works by allowing the blood to clot faster, so less is lost. There is some evidence that this medication also works for women with fibroids and may be worth trying, since there are minimal side-effects.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged drugs, Heavy menstrual bleeding, Lysteda, medication, menstrual blood loss, oral medication, pharmaceuticals, tranexamic acid | Comments (2)

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Outcomes from fibroid (leiomyoma) therapies: comparison with normal controls.

November 22, 2010 – 8:30 am

Journal: Obstetetrics and Gynecology. 2010 Sep;116(3):641-52.

Authors: Spies JB, Bradley LD, Guido R, Maxwell GL, Levine BA, Coyne K.

Study from: Georgetown University Hospital Department of Radiology, Washington, DC

Problem: Despite the very common occurrence of fibroids, very few studies have evaluated the severity of symptoms caused by uterine fibroids, their effect on health-related quality-of-life, or the changes in symptoms after treatment compared with women who do not have fibroids.

Study: Groups of women with fibroids who were scheduled for hysterectomy, myomectomy, or uterine artery embolization, as well as women without fibroids were assessed using questionnaires designed to measure quality of life and symptoms, including physical functioning, pain, sexual function, vitality, energy/mood, social functioning and mental health. Questionnaires were completed before treatment and again at 6 and 12 months after treatment.

Results: A total of 375 women Participated in the study: 101 without fibroids, 107 who had embolization, 61 who had a myomectomy, and 106 who had a hysterectomy. Before treatment women with fibroids had more severe symptoms than women without fibroids. At both 6 and 12 months after treatment, women having treatment for their fibroids had as few symptoms as women who did not have fibroids. One year after treatment, the women who had a hysterectomy reported less symptoms and better health-related quality of life than women who had embolization or myomectomies. However, the majority of the benefit of hysterectomy was attributed to the absence of menstrual periods.

Authors’ Conclusions: At 12 months after treatment, all three leiomyoma therapies resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy due to the absence of menstrual periods.

Dr. Parker’s Comments: Since myomectomy, embolization and hysterectomy all reduce symptoms to the levels seen with women without fibroids, all three treatments should be very effective for women who have bothersome symptoms related to fibroids. Therefore, a woman’s choice for treatment should depend on other individual factors including the desire for fertility, the desire to preserve her uterus, willingness to undergo surgery and anesthesia, willingness to undergo embolization, etc. The other point here is that the women choosing to have treatment had significant symptoms; most women with minor symptoms will often choose watchful waiting and wait for menopause when fibroids shrink and bleeding stops.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged fibroid symptoms, fibroid symptoms after treatment, hysterectomy, myomectomy, qualty of life, symptom relief, UAE, uterine artery embolization | Comments (6)

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Fibroids (leiomyomas) at routine second-trimester ultrasound examination and adverse obstetric outcomes.

November 8, 2010 – 2:17 pm

Journal: Obstet Gynecol. 2010 Nov;116(5):1056-63.

Authors: Stout MJ, Odibo AO, Graseck AS, Macones GA, Crane JP, Cahill AG.

Study from: Washington University, St Louis, Missouri

Problem: Numerous studies have been conducted to see if the presence of fibroids during pregnancy affects the outcome of the pregnancy or the health of the baby. Most of these studies have been poorly designed and have failed to answer these important questions.

Study: Between 1990 and 2007, 64,047 consecutive pregnant women had a routine second-trimester ultrasound and the presence or absence of fibroids was routinely noted. The outcomes of the pregnancies in women with fibroids were compared to pregnancies in women without fibroids.

Results: Fibroids were seen on ultrasound in 3.2% of all pregnant women. The following findings were noted.

Babies were breech in 5.3% of women with fibroids compared with 3.1% of women with no fibroids.
Placenta previa (placenta partially or completely blocking the cervix) was found in 1.4% (fibroids) compared with 0.5% (no fibroids).
Placental abruption (placenta separating from the uterine wall, causing bleeding) was found in 1.4% (fibroids) compared with 0.7% (no fibroids).
Preterm rupture of membranes was found in 3.3% (fibroids) compared with 2.4% (no fibroids).
Preterm birth less than 37 weeks was found in 15.1% (fibroids) compared with 10.5% (no fibroids) and at less than 34 weeks was 3.9% (fibroids) compared with 2.8% (no fibroids).
Intrauterine fetal death in women with a baby with growth restriction (small baby) was found in 3.9% (fibroids) compared with 1.5% (no fibroids).
Cesarean delivery was performed in 33% (fibroids) compared with 24% (no fibroids).

Authors’ Conclusions: Women with fibroids are at low risk for obstetric complications compared with women without fibroids.

Dr. Parker’s Comments: Two other excellent studies have been published previously on this topic: one showed absolutely no increased risk of complications for women who became pregnant with fibroids; the other showed very minimal increased risks.

This new study shows very minimal increased risks: a 0.9% increased risk of the placenta blocking the cervix; a 0.7% increased risk of placental separation; a 0.9% increased risk of early ruptured membranes; a 4.6% increased risk of delivery before 37 weeks (where the babies usually do extremely well) and a 1.1% increased risk of delivery before 34 weeks (most babies also do well, but need neonatal ICU care); and, a 1.4% increased risk of fetal death in babies who were very small at birth. The new study was conducted at an urban referral hospital and the women had a high rate of alcohol use, smoking and high blood pressure, so the results might be even better in a healthier group of women.

The findings of the three well-performed studies show an extremely small increased risk, which ought to be reassuring for women with fibroids who wish to become pregnant. It should also be noted that, based on a review of the literature I did for a chapter on fibroids to be published in Berek and Novak’s Gynecology textbook, in the past 30 years there have been only four babies born in the world who have been reported to have birth defects related to the presence of fibroids during pregnancy. This is also very reassuring news.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged baby, fibroids, fibroids and pregnancy, health of baby, pregnancy, pregnancy complications, pregnancy outcomes, risks of fibroids during pregnancy, ultrasound | Comments (0)

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Pregnancy after Uterine Fibroid Embolization

November 2, 2010 – 8:30 am

Journal: Fertil Steril. 2010 Sep 24. [Epub ahead of print]

Authors: Pisco JM, Duarte M, Bilhim T, Cirurgião F, Oliveira AG.

Study from: Department of Radiology, St. Louis Hospital; New University of Lisbon, Portugal.

Problem: The safety of pregnancy following embolization (UAE) is uncertain because there have been few publications examining this issue.

Study: In a single hospital in Portugal, UAE was performed in 74 patients who wanted to become pregnant.

Results: Of the 74 women who wanted to become pregnant, 44 of them became pregnant (59.5%). Thirty-nine women completed pregnancies resulted in 33 successful live births (84.6%), four miscarriages (10.3%), one induced abortion, and one stillbirth. Two women delivered early, at 36 weeks (6.1%), and five babies were low birth-weight. At the time of publication, five other women had ongoing pregnancies.

Authors’ Conclusions: Pregnancy after UAE appears to be safe.

Dr. Parker’s Comments: Although this is a small study (only 44 pregnant women), it is reassuring. An earlier study from Toronto found a slightly higher risk of bleeding from the placenta or difficulty removing the placentas after delivery in women who had UAE. The current study did not find these problems. Unfortunately, there are very few studies of women who have had a myomectomy before getting pregnant to see if there were any problems with their pregnancies.

Many interventional radiologists do not perform UAE for women who wish to get pregnant and I wonder if this new information will change their opinions. Personally, I will advise women about this study and suggest that there is less reason to be nervous about getting pregnant after UAE. It would be nice to have more information to help advise women regarding the outcomes of pregnancies for women who get pregnant with fibroids, and for women who have had UAE or myomectomies.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged fibroids and pregnancy, pregnancy, risks of pregnancy after UAE, safety, UAE, UAE and pregnancy, uterine artery embolization | Comments (2)

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Cancer Experts Agree: Keep Your Ovaries

September 13, 2010 – 8:30 am

Prophylactic and Risk-Reducing Bilateral Salpingo-oophorectomy: recommendations based on risk of ovarian cancer.

Authors: Berek JS, Chalas E, Edelson M, Moore DH, Burke WM, Cliby WA, Berchuck A; Society of Gynecologic Oncologists Clinical Practice Committee.

Study From: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Stanford University School of Medicine.

Journal: Obstetrics and Gynecology 2010 September, v. 116:733-43.

Problem: Nearly 300,000 US women have their ovaries removed unnecessarily every year.

Study: The authors examined all the studies about whether women should, or should not, have their ovaries removed when they have a hysterectomy.

Authors’ Conclusions: Women who do not have the BRCA cancer gene or a strong family history of ovarian cancer should strongly consider keeping their ovaries, especially if they are not menopausal.

Dr. Parker’s Comments: Traditionally, doctors have recommended removing the ovaries and tubes (medical term – bilateral salpingo-oophorectomy) in order to prevent the later development of ovarian cancer. While ovarian cancer remains a terrible disease, it affects less than 1% of women without a family history of ovarian cancer.

Recent studies show that the ovaries continue to make some hormones until at least age 80 and these hormones protect against heart disease, osteoporosis, and possibly lung cancer. Since these conditions kill 30 times more women per year than ovarian cancer, women without a family history of ovarian cancer should consider keeping their ovaries if they choose to have a hysterectomy. For women with the BRCA gene or a strong family history of ovarian cancer, there is a very strong recommendation to have their ovaries removed since the risk of ovarian cancer is high.

While this study is not a “fibroid” study, this issue comes up continually on my blog as women continue to get recommendations from their doctors to remove their ovaries at the time of (often unnecessary) hysterectomies. The first author of this paper, Dr. Jonathan Berek, was a co-author of a study we published last May that showed, among women in the Nurses’ Health Study, the long-term health benefits of keeping ovaries.

The important issue for me is that this paper was endorsed by the Society of Gynecologic Oncologists, for the past 30 years the major force convincing doctors to remove ovaries. So, this is a major reversal of policy and, I think, the right one.

You can find a summary of our Nurses’ Health Study on this webpage: Do you need a hysterectomy for fibroids?

Bill Parker, MD

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged bilateral sapingo-oopherectomy, BRCA1, hysterectomy, keeping ovaries, ovarian cancer, ovarian cancer risk, ovaries, ovary, ovary removal | Comments (0)

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How Do Women Feel after Treatment for Fibroids with Myomectomy, Embolization or Hysterectomy?

September 6, 2010 – 8:30 am

Outcomes from leiomyoma therapies: comparison with normal controls.

Authors: Spies JB, Bradley LD, Guido R, Maxwell GL, Levine BA, Coyne K.

Study From: Georgetown University Hospital, Cleveland Clinic, University of Pittsburgh, Walter Reed Army Medical Center, and United BioSource Inc.

Journal: Obstet Gynecol. 2010;116:641-52.

Problem: There are very few studies that measure how women feel after treatment for fibroids.

Study: Four medical centers collaborated to measure fibroid symptoms and quality-of- life both before and after hysterectomy, myomectomy, or uterine artery embolization (UAE) compared to each other and to women without fibroids.

Findings: 101 women without fibroids, 107 women having an embolization for fibroids, 61 having a myomectomy and 106 women having a hysterectomy for fibroids participated in the study. At the beginning of the study, the women filled out questionnaires asking about their level of activity, energy level, sexual function, pain, social functioning, general health and mental health. Women with fibroids scored much worse than women without fibroids.

With treatment, no women in any group died or had a permanent injury.

Six and 12 months later, questionnaires showed that, after any of the three fibroid treatments, most women felt as good as women without fibroids. At 12 months, women who had a hysterectomy had fewer symptoms (no bleeding) than women who had myomectomies or UAE.

Authors’ Conclusions: One year after treatment, all three fibroid treatments resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy. The authors felt this was because after hysterectomy women had no further bleeding.

Dr. Parker’s Comments: UAE, myomectomy and hysterectomy all make women feel better than before they had treatment and most women return to feeling normal. There were a few short-comings of the study, though. First, the study is a statistical analysis of groups of women and it is not possible to tell from the article if some women did not improve or had bothersome side-effects after treatment. Also, each woman chose her treatment and, therefore, might be inclined to score the questionnaires higher to support her choice. However, this is what happens in real life and if you feel better, who cares what the scientists think??

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged after treatment, bleeding, fibroid removal, fibroids, how women feel after treatment, hysterectomy, myomectomy, symptom relief, UAE, uterine artery embolization | Comments (0)

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Vitamin D May Help to Slow Down Fibroid Growth

August 30, 2010 – 2:38 pm

Vitamin D inhibits proliferation of human uterine leiomyoma cells via catechol-O-methyltransferase.

Authors: Sharan C, Halder SK, Thota C, Jaleel T, Nair S, Al-Hendy A.

Study From: Meharry Medical College, Nashville, Tennessee

Journal: Fertility and Sterility, 2010, Aug 23. E-pub

Problem: Women are looking for something they can do to control fibroid growth. Dietary changes and vitamin supplements would be one possible thing they can easily modify.

Laboratory Study: Human fibroid cell cultures were treated with vitamin D and the effect of vitamin D on fibroid genes and proteins was measured.

Results: Vitamin D interfered with the way human fibroid cells make enzymes that either use or block estrogen and inhibited the growth of fibroid cells by 47%.

Authors’ Conclusions: Since Vitamin D inhibits growth of human fibroid cells a deficiency of vitamin D might allow fibroids to grow. The authors reference another article that found that while 45% of African-American women have vitamin D deficiency, only 4% of white women have this deficiency.

Dr. Parker’s Comments: While it is always good to be cautious when interpreting laboratory studies, vitamin D has also been shown to regulate cell growth and inhibit cancer cells. It also helps the body absorb calcium. And, when taken in recommended doses (800-1,000 units per day), the side-effects and risks appear to be almost non-existent. So, even though these results are very preliminary, vitamin D might be worth a try

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged dietary changes, dietary supplements, fibroid growth, laboratory study, Vitamin D, vitamin d and fibroids, vitamin d inhibits fibroid growth, vitamins | Comments (2)

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Fibroids and Sexuality

August 2, 2010 – 7:45 am

The Effect of Myoma Uteri and Myomectomy on Sexual Function.

Authors: Devrim Ertunc, Roza Uzun, Ekrem C Tok, Arzu Doruk, and Saffet Dilek

Study from: Mersin University School of Medicine, Mersin, Turkey.

Journal: Journal of Sexual Medicine, 2009;6:1032-38.

Problem: To my knowledge this is the first good study of sexual issues for women with fibroids before and after myomectomy surgery.

Study: The authors studied 80 women with fibroids and 75 women without fibroids using an established questionnaire to determine how women felt about sexual matters before and after myomectomy surgery. Specifically, the questionnaires asked about libido, arousal, lubrication, orgasm, satisfaction and pain with intercourse.

Findings: Women with fibroids had worse pain and over-all sexual satisfaction scores than women without fibroids, but there were no differences in libido, arousal, lubrication or orgasm. Fibroids on the top of the uterus (fundal) and in the back wall of the uterus (posterior) caused more pain with intercourse. Women with a very large fibroid uterus had worse sexual satisfaction and pain with intercourse. Due to the relief of pain, total sexual satisfaction improved for most women after a myomectomy.

Author’s Conclusions: Fibroids appear to interfere with sexual satisfaction mainly due to pain during sexual intercourse, although fibroids do not seem to have an effect on libido, arousal, lubrication or orgasm. Myomectomy may alleviate pain during intercourse, and thereby improve sexual satisfaction.

Dr Parker’s Comments: There have been very few studies examining the effect of fibroids on women’s sexual satisfaction, and even fewer on the effects of different treatment options on sexual satisfaction. For that reason, the current findings that women with fibroids have more pelvic pain with intercourse and that myomectomy appears to help many of these women are good steps in helping women understand their symptoms. Similar research with regard to other treatment options including uterine artery embolization, focused ultrasound, mefipristone, etc, are sorely needed.

The Effect of Myoma Uteri and Myomectomy on Sexual Function.

Authors: Devrim Ertunc, Roza Uzun, Ekrem C Tok, Arzu Doruk, and Saffet Dilek

Study from: Mersin University School of Medicine, Mersin, Turkey.

Journal: Journal of Sexual Medicine, 2009;6:1032-38.

Problem: To my knowledge this is the first good study of sexual issues for women with fibroids before and after myomectomy surgery.

By Bill Parker, MD | Posted in Recent Fibroid Research | Tagged fibroids, myomectomy, pain, sexual satisfaction, sexuality, study | Comments (0)

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