Uterine fibroids and hysterectomy
Highlights
Uterine Fibroids
Uterine fibroids, also called leimyomas or myomas, are non-cancerous growths that originate in the thick wall of the uterus. Fibroids are the most common type of tumor found in female reproductive organs. Uterine fibroids are very common among women, especially African-American women.
Symptoms of Uterine Fibroids
Symptoms occur in about 25% of women who have fibroids. The most common symptoms are:
- Heavy and prolonged menstrual bleeding
- Pressure and pain in the abdomen and lower back
- Frequent urination
- Constipation
- Pain during intercourse
Complications of Uterine Fibroids
- Large fibroids may reduce fertility.
- Fibroids can increase pregnancy complications and delivery risks.
- Anemia due to iron deficiency may result from heavy menstrual bleeding.
Treatment
Many women with fibroids choose not to have treatment, especially if they are approaching the age of menopause. Fibroids grow slowly and usually shrink after menopause. Treatment may include various drug and surgical options.
Medications for Fibroids
- New continuous-dosing oral contraceptives can reduce or eliminate menstrual periods.
- Progestin-releasing intrauterine devices can help control excessive menstrual bleeding.
- Gonadotropin-releasing hormone (GnRH) agonists reduce estrogen and progesterone levels, which diminishes the size of fibroids.
- Androgens, such as danazol, reduce fibroid size but can cause unpleasant side effects.
- Other types of medications are also being investigated.
Surgical Options
Invasive and less-invasive surgical methods include:
- Myomectomy
- Uterine artery embolization
- Endometrial ablation
- Myolosis
- Magnetic resonance-guided focused ultrasound
- Hysterectomy
Introduction
A uterine fibroid (known medically as a leiomyoma or myoma ) is a noncancerous (benign) growth of smooth muscle and connective tissue. Fibroids can range in size from as small as a pinhead to larger than a melon. Fibroids have been reported weighing more than 20 pounds.
Fibroids originate from the thick wall of the uterus and are categorized by the direction in which they grow:
- Intramural fibroids grow within the middle and thickest layer of the uterus (called the myometrium). They are the most common fibroids.
- Subserosal fibroids grow out from the thin outer fibrous layer of the uterus (called the serosa). Subserosal can be either stalk-like (pedunculated) or broad-based (sessile). These are the second most common fibroids.
- Submucous fibroids grow from the uterine wall toward and into the inner lining of the uterus (the endometrium). Submucous fibroids can also be stalk-like or broad-based. Only about 5% of fibroids are submucous.
The Female Reproductive System
The Primary Organs and Structures in the Reproductive System. The primary structures in the reproductive system are as follows:
- The uterus is a pear-shaped organ located between the bladder and lower intestine. It consists of two parts, the body and the cervix.
- When a woman is not pregnant the body of the uterus is about the size of a fist, with its walls collapsed and flattened against each other. During pregnancy the walls of the uterus are pushed apart as the fetus grows.
- The cervix is the lower portion of the uterus. It has a canal opening into the vagina with an opening called the os, which allows menstrual blood to flow out of the uterus into the vagina.
- Leading off each side of the body of the uterus are two tubes known as the fallopian tubes. Near the end of each tube is an ovary.
- Ovaries are egg-producing organs that hold 200,000 - 400,000 follicles (from folliculus, meaning "sack" in Latin). These cellular sacks contain the materials needed to produce ripened eggs, or ova.
The inner lining of the uterus is called the endometrium. During pregnancy this inner lining thickens and becomes enriched with blood vessels to house and support the growing fetus. If pregnancy does not occur, the endometrium is shed as part of the menstrual flow. Menstrual flow also consists of blood and mucus from the cervix and vagina.
Reproductive Hormones. The hypothalamus (an area in the brain) and the pituitary gland regulate the reproductive hormones. The pituitary gland is often referred to as the master gland because of its important role in many vital functions, many of which require hormones.
In women, six key hormones serve as chemical messengers that regulate the reproductive system:
- The hypothalamus first releases the gonadotropin-releasing hormone (GnRH).
- This chemical, in turn, stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
- Estrogen, progesterone, and the male hormone testosterone are secreted by the ovaries at the command of FSH and LH and complete the hormonal group necessary for reproductive health.
Click the icon to see an image of the uterus.
Click the icon to see an image of the pituitary gland.
Click the icon to see an image of the hypothalamus.
Causes
Inherited genetic factors may be important in many cases of fibroids. Researchers are investigating unique genetic factors that regulate hormones. Proteins called growth factors may be responsible for some of the abnormalities leading to uterine muscle overgrowth and fibroids. Scientists have identified chromosomes carrying a total of 145 genes that may affect fibroid growth. Some experts report that uterine fibroids are inherited from paternal (the father's) genes.
Female Hormones
Uterine fibroids often grow during pregnancy, and they degenerate after menopause. From these observations and certain studies, researchers are fairly certain that the female hormones, both estrogen and progesterone, play a role in their growth. Their role, however, is not clear. Some theories about the relationship to fibroids and estrogen include the following:
- Estrogen patterns in fibroids are similar to those in pregnancy. That is, like smooth muscle cells in the uterus during pregnancy, fibroid cells exposed to female hormones do not respond normally to signals that would make them self-destruct and return to a nonpregnant state. (This natural self-destruction is a process called apoptosis). Instead, they continue to grow.
- Some evidence suggests that estrogen may inhibit a tumor-suppressor gene called p53 in fibroid tissue, therefore triggering cell proliferation leading to fibroid growth. (P53 plays a role in some cancer-cell growth, although in this case the process is not cancerous.)
Growth Factors
The formation of fibroids may be attributable to abnormalities in substances called growth factors. These special proteins, secreted by different cell types, are responsible for cell-to-cell interaction. Many of these substances regulate a process called angiogenesis, which causes new blood vessels to sprout from pre-existing ones. The production of new blood vessels then feeds any existing growth, such as a fibroid.
The growth factors that appear to play an important role in many female reproductive disorders are Basic Fibroblast Growth Factor (BFGF) and Vascular Endothelial Growth Factor (VEGF). BFGFs are involved in the proliferation of cells that form connective tissue, which supports the body's organs and structure. VEGFs are involved with cell growth in smooth muscles that line blood vessels. Some evidence suggests they play a role in uterine fibroids.
Other growth factors being studied specifically for fibroids include Insulin-like Growth Factor (IGF)-I, Epidermal Growth Factor (EGF), Platelet Derived Growth Factor (PDGF), and Transforming Growth Factor (TGF).
Symptoms
Fewer than 25% of patients with fibroids have symptoms. When they do, symptoms include:
- The most common symptom is prolonged and heavy bleeding during menstruation. This is caused by fibroid growth bordering the uterine cavity. In severe cases, heavy bleeding may last as many as 2 weeks. Fibroids rarely bleed between periods, except in a few cases of very large fibroids.
- Large fibroids can also cause pressure and pain in the abdomen or lower back that sometimes feels like menstrual cramps.
- As the fibroids grow larger, some women feel them as hard lumps in the lower abdomen.
- Very large fibroids may give the abdomen the appearance of pregnancy and cause a feeling of heaviness and pressure. In fact, large fibroids are defined by comparing the size of the uterus to the size it would be at specific months during gestation.
- Unusually large fibroids may press against the bladder and urinary tract and cause frequent urination or the urge to urinate, particularly when a woman is lying down at night.
- Abnormal pain during intercourse (called dyspareunia).
- Fibroids pressing on the ureters (the tubes going from the kidneys to the bladder) may obstruct or block the flow of urine.
- Fibroid pressure against the rectum can cause constipation.
Risk Factors
Uterine fibroids are the most common tumor found in female reproductive organs. It is estimated that over 50% of women age 30 - 50 have fibroids, although they cause symptoms in only about 25%. A survey of 1,364 women suggested an even higher prevalence of over 80% in African-American women and almost 70% in white women. A number of possible risk factors have been identified, but very little research exists to confirm them.
Being African-American
Uterine fibroids are particularly common in African-American women, with an estimated prevalence of 50 - 75%. These women are also more likely to have severe pain, anemia, and larger and more numerous fibroids than women in other population groups. Although genetics may play a role, women of African descent who live in other countries do not appear to have as high an incidence of fibroids. This suggests that diet or other environmental factors are at work in the development of fibroids in African-American women.
High Exposure to Estrogen
Fibroids can start to grow soon after puberty, although usually they are detected when a woman reaches young adulthood. Women with fibroids are at risk for accelerated fibroid growth when estrogen levels are high or when lifestyle behaviors keep estrogen levels high.
Some examples of risk factors for fibroids that are also associated with high estrogen exposure include:
- Early onset of menstrual period (before age 12)
- Being overweight and sedentary
- Never being pregnant. The risk for fibroids decreases with more children. (This factor may be due to fibroids causing a greater risk for infertility in the first place.)
Combined Oral Contraceptives. Combined oral contraceptives (OC) contain estrogen and progesterone. Evidence on their effects on fibroids has been conflicting. Early reports suggested such OCs might be a risk factor. Most newer studies, however, have found no association, and some even suggest that the newer low-dose OC combinations may be protective.
Hormone Replacement Therapy. Hormone replacement therapies (HRT) contain estrogen alone or estrogen plus progesterone. After menopause, fibroids usually shrink. Researchers are investigating whether the hormones used in HRT could cause existing fibroids to persist or even grow.
If HRT has an effect on fibroid growth, it is unlikely to be severe. Any increase in fibroid growth during menopause must be evaluated surgically by a gynecologist since such growth, even if a woman is on hormone replacement therapy, may mean cancer.
High Blood Pressure
High blood pressure (hypertension) may be associated with increased fibroid risk. Epidemiologic findings from the Nurses Health Study found that for every 10 mm/Hg increase in diastolic blood pressure, the risk for developing fibroids increased by 8 - 10%. (Interestingly, women who used antihypertensive medications had the highest risk.). Researchers reported that women with hypertension were 24% more likely to develop fibroids and that the longer a woman had hypertension, the greater her risk.
Other Risk Factors
Other risk factors commonly associated with the development of uterine fibroids include obesity, never having had children, tamoxifen use, and family history of uterine fibroids.
Complications
Effect on Fertility
The effect of fibroids on fertility is controversial and considered the source of infertility only in a very small percentage of women with this problem. Large fibroids may cause infertility by:
- Impairing the uterine lining
- Blocking the fallopian tubes
- Distorting the shape of the uterine cavity
- Altering the position of the cervix and preventing sperm from reaching the uterus
Some evidence suggests that even small fibroids may reduce the chances of pregnancy in women who are undergoing assisted reproductive techniques. Treatments to reduce fibroids may be helpful in such women, although there has been little research on this subject.
Effect on Pregnancy
Fibroids can increase pregnancy complications and delivery risks. These include:
- Cesarean section delivery
- Breech presentation (baby enters the birth canal upside down with feet or buttocks emerging first)
- Preterm birth
- Placenta previa (placenta covers the cervix)
- Excessive bleeding after giving birth (postpartum hemorrhage)
Anemia
Anemia due to iron deficiency can develop if fibroids cause excessive bleeding. Oddly enough, smaller fibroids, usually submucous, are more likely to cause abnormally heavy bleeding than larger ones.
Most cases of anemia are mild. Mild anemia can cause weakness and fatigue. Moderate-to-severe anemia can cause shortness of breath, rapid heart rate, lightheadedness, headaches, ringing in the ears (tinnitus), irritability, pale skin, restless legs syndrome, and mental confusion. Heart problems can occur if prolonged and severe anemia is not treated. Pregnant women who are anemic, particularly in the first trimester, have an increased risk for pregnancy problems.
Urinary Tract Infection
Large fibroids that press against the bladder occasionally result in urinary tract infections. Pressure on the ureters may cause urinary obstruction and kidney damage.
Severe Pain
Fibroids can cause cramping during a period, which can be quite intense at times.
Pain can also develop if the blood supply is cut off from the fibroid tissue. In such cases, the cells blacken and die (a process called necrosis) from lack of oxygen. This event may occur under the following circumstances:
- A very large fibroid outgrows its own blood supply.
- A pedunculated fibroid (one that grows on a stem from the uterine wall) becomes twisted, thus cutting off its blood supply.
- Pregnancy occurs, in which the risk for fibroid cell degeneration and necrosis increases.
Leiomyomas that Spread Outside the Organ
Rarely, a fibroid breaks away from the uterus and develops in other locations. They are typically one of the following:
- Benign Metastasizing Leiomyoma, or BML (which usually spreads to the lung)
- Disseminated Peritoneal Leiomyomatosis (which spreads to the abdominal wall)
Neither is cancerous, although there is some evidence that BML, which often occurs after menopause, may represent a slow-growing variant of leiomyosarcoma.
Uterine Cancer
Fibroids are nearly always noncancerous, even if they have abnormal cell shapes. Cancer of the uterus nearly always develops in the lining of the uterus (endometrial cancer). Only in rare cases (fewer than 0.1%) does cancer develop from a malignant change in a fibroid (called leiomyosarcoma). Nevertheless, rapidly enlarging fibroids in a premenopausal woman or even slowly enlarging fibroids in a postmenopausal woman need evaluation to rule out cancer.
Click the icon to see an image of uterine cancer.
Diagnosis
A doctor will perform a pelvic examination to check for pregnancy-related conditions and signs of fibroids or other abnormalities, such as ovarian cysts.
Medical and Personal History
The doctor needs to have a complete history of any medical or personal conditions that might be causing heavy bleeding, including:
- Any family history of menstrual problems or bleeding disorders.
- The presence or history of any medical conditions that might be causing heavy bleeding. Women who visit their gynecologist with menstrual complaints, particularly heavy bleeding, pelvic pain, or both may actually have an underlying medical disorder, which must be ruled out.
- The pattern of the menstrual bleeding. (If it occurs during regular menstruation, nonhormonal treatments are tried first. If bleeding is irregular, occurs between periods, with premenstrual pain, after sex, or is associated with pelvic pain, the doctor should look for specific conditions that may cause these problems.)
- Regular use of any medications (including vitamins and over-the-counter drugs).
- Diet history, including caffeine and alcohol intake.
- Past or present contraceptive use.
- Any recent stressful events.
- Sexual history. (It is very important that the patient trust the doctor enough to describe any sexual activity that might be risky.)
Ruling out Other Conditions that Cause Heavy Bleeding (Menorrhagia)
Almost all women, at some time in their reproductive life, bleeding heavily during menstrual periods (menorrhagia). Being taller, older, and having a higher number of pregnancies increase the chances for heavier-than-average bleeding. In some cases the cause of heavy bleeding is unknown, but a number of conditions can cause menorrhagia or contribute to the risk:
- Menstrual disorders
- Miscarriage. An isolated instance of heavy bleeding usually after the period due date may be due to a miscarriage. If the bleeding occurs at the usual time of menstruation, however, miscarriage is less likely to be a cause.
- Having late periods or approaching menopause. These events may cause occasional menorrhagia.
- Uterine polyps. (These are small benign growths in the uterus.)
- Certain contraceptives. (Oral contraceptives or an intrauterine device, an IUD.)
- Bleeding disorders. Bleeding disorders that impair blood clotting can cause heavy menstrual bleeding and, according to different studies, have been associated with 10 - 17% of menorrhagia cases. Von Willebrand disease, a genetic condition, is the most common of these bleeding disorders. Most studies report this problem to be more common in African-American than Caucasian women. Most bleeding disorders have a genetic basis and should be suspected in adolescent girls who experience heavy bleeding.
- Uterine cancer
- Pelvic infections
- Endometriosis. (These are small implants of uterine tissue. They are more likely to cause pain than bleeding.)
Click the icon to see an image of endometriosis.
- Adenomyosis. This condition occurs when glands from the uterine lining become embedded in the uterine muscle. Its symptoms are nearly identical to fibroids (heavy bleeding and pain), and in one study fibroids were also present in 62% of cases. It is most likely to develop in middle-aged women who have had many children.
- A number of medical conditions, including thyroid problems, systemic lupus erythematosus, diabetes, certain cancers and chemotherapies, and some uncommon blood disorder.
- Certain drugs, including anticoagulants and anti-inflammatory medications.
- Often, the cause of heavy bleeding is unknown.
Hysteroscopy
Hysteroscopy is a procedure that may be used to detect the presence of fibroids, polyps, or other causes of bleeding. Although less invasive procedures can also detect causes of abnormal uterine bleeding, hysteroscopy has the added advantage of serving as a surgical procedure for the removal of submucous fibroids. It is also quite useful in ruling out cancer. If cancer is suspected, more invasive procedures, such as dilation and curettage (D&C) or endometrial biopsy, are warranted.
It is done in the office setting and requires no incisions. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber optic light source and a tiny camera in the tube allow the doctor to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.
Hysteroscopy is non-invasive; however, 30% of women report severe pain with the procedure. The use of an anesthetic spray, such as lidocaine, may be highly effective in preventing pain during this procedure. Other complications include excessive fluid absorption, infection, and uterine perforation.
Imaging Techniques
Ultrasound (Transvaginal or Pelvic). Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors, and also obstructions in the urinary tract. It uses sound waves to produce an image of the organs and entails no risk and very little discomfort.
Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus. This technique is proving to be more accurate than standard ultrasound in identifying potential problems. Some experts believe it should be the first-line tool for diagnosing heavy bleeding.
Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) provides a better image of any fibroids that might be causing bleeding. An MRI can help the doctor decide if a woman is a candidate for minimally invasive uterine artery embolization (UAE). Fibroids with low blood flow (nonviable tumors) may not be suitable for UAE. An MRI may also be better than an ultrasound for evaluating uterine size and fibroid location.
Endometrial Biopsy and Dilation and Curettage (D&C)
When heavy or abnormal bleeding occurs, an endometrial (uterine) biopsy can be performed in the office along with an ultrasound. A biopsy may help determine whether there are abnormal cells in the lining of the uterus that suggest cancer.
A dilation and curettage (D&C) is a more invasive procedure, but may help to treat other causes of uterine bleeding besides fibroids.
- A D&C is usually done in an outpatient setting so that the patient can return home the same day, but it sometimes requires a general anesthetic. It may need to be performed in the operating room to rule out serious conditions or treat some minor ones that may be causing the bleeding.
- The cervix (the neck of the uterus) is dilated (opened).
- The surgeon scrapes the inside lining of the uterus and cervix.
Click the icon to see an image of a D&C.
The procedure is used to take samples of the tissue and to relieve heavy bleeding in some instances. D&C can also be effective in scraping off small endometrial polyps, but it is not very useful for most fibroids, which tend to be larger and more firmly attached.
Lifestyle Changes
Because fibroids are almost never life threatening, watchful waiting is a reasonable option for many women (even those with large fibroids), particularly if they are approaching menopause.
Regular Monitoring
Any woman who chooses watchful waiting should be sure other causes of heavy bleeding have been ruled out. She should also have regular pelvic examinations and ultrasounds performed to monitor the growth of the fibroid.
Dietary Factors for Preventing Anemia
Foods for Maintaining Healthy Iron Stores. The following are some suggestions for increasing iron levels in the diet:
- The best foods for increasing or maintaining healthy iron levels contain absorbable iron, called heme iron. Such foods include (in order of iron-richness) clams, oysters, organ meats, beef, pork, poultry, and fish.
- About 60% of iron in meat is poorly absorbed; this is a form called non-heme iron. Eggs, dairy products, and vegetables that contain iron only have the non-heme form. Such plants include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds.
- Increasing intake of vitamin-C rich foods can enhance absorption of non-heme iron during a single meal, although regular intake of vitamin C does not appear to have any significant effect on iron stores. In any case, vitamin-C rich foods are healthy and include broccoli, cabbage, citrus fruits, melon, tomatoes, and strawberries. One orange or 6 ounces of orange juice can double the amount of iron your body absorbs from plant foods.
- Foods containing riboflavin (vitamin B2) may help enhance the response of hemoglobin to iron. Sources include liver, dried fortified cereals, and yogurt.
- Cooking in cast iron pans and skillets is known to increase iron content of food. According to one study, however, boiling, steaming, or stir-frying many vegetables in utensils composed of any material significantly increases the release of iron stored in plants so it is available to the body.
- Certain nutrients, such as tannin (found in tea) or phytic acid (found in foods such as seeds and bran) interfere with the body's absorption of dietary iron. (It is commonly believed that fiber impedes iron absorption, but researchers report that it most likely has no effect.)
Sources of Vitamins B12 and Folate. Vitamins B12 and folate are important for prevention of anemia related to nutritional deficiencies. Although this anemia is not necessarily related to fibroids, these vitamins are very important for good health in general and for reproductive health in women.
- The only natural dietary sources of B12 are animal products such as meats, dairy products, eggs, and fish (clams and oily fish are very high in B12). Like other B vitamins, B12 is added to commercial dried cereals. The recommended daily allowance (RDA) is 2.4 mcg a day. Deficiencies are rare in young people, although the elderly may have trouble absorbing natural vitamin B12 and require synthetic forms from supplements and fortified foods.
Click the icon to see an image of vitamin B12 sources.
- Folate is best found in avocado, bananas, orange juice, cold cereal, asparagus, fruits, green, leafy vegetables, dried beans and peas, and yeast. The synthetic form, folic acid, is added to commercial grain products. Vitamins are usually made from folic acid, which is about twice as strong as folate. Many experts recommend that adults have 400 mcg of folic acid daily, which is considerably higher than standard recommendations of 400 mcg of folate. Low levels of folate during pregnancy are common without supplements; deficiencies at that time increase the risk of neural tube defects in newborns. Women who are planning to get pregnant should take 400 mcg of folic acid before conception as well as when they are pregnant or breast feeding.
Click the icon to see an image of folate sources.
- Iron Supplements. Iron supplements are best for restoring iron levels, but they should be used only when dietary measures have failed. Women should always discuss such supplements with their doctor.
[For more information, see In-Depth Report #57: Anemia.]
Alternative Treatments
Many women with menstrual disorders may resort to alternative treatments. There has been little research on whether any such therapies benefit fibroids.
Yoga. Yoga exercises help some women relieve sensations of heaviness and pressure.
Herbal Remedies. Herbal remedies used for fibroids include ginseng or herbal combinations of rhubarb, cinnamon, and sargassum seaweed. There is no scientific evidence that these herbs are effective. Pycnogenol is a plant extract from the bark of the French maritime tree. Some small studies suggest it may provide some relief for menstrual pain (dysmenorrhea).
Herbs and Supplements
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should check with their doctor before using any herbal remedies or dietary supplements.
Medications
Because fibroid growth tends to stop and regress after menopause, the important reproductive hormones -- estrogen, progesterone, or both -- most likely play a critical role in their survival. Some drugs that block either of these hormones are used to treat severe fibroids with some success.
Contraceptives
Oral contraceptives (OCs) are sometimes used to control the heavy menstrual bleeding (menorrhagia) associated with fibroids, but they do not help prevent fibroid growth. Newer types of continuous-dosing OCs reduce or eliminate the number of periods a woman has per year.
Intrauterine devices (IUDs) that release progestin can be very beneficial for menorrhagia. Specifically, the levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena, FibroPlant), has shown excellent results. Many experts now recommend the LNG-IUS as a first-line treatment for menorrhagia, particularly for women who may face hysterectomy (removal of uterus), conservative surgery such as endometrial resection (removal of endometrial lining), or endometrial ablation (destruction of endometrial lining). [For more information, see In-Depth Report #100: Menstrual disorders.]
GnRH Agonists
Gonadotropin releasing hormone (GnRH) blocks the release of the reproductive hormones LH (luteinizing hormone) and FSH (follicular-stimulating hormone). As a result, the ovaries stop ovulating and no longer produce estrogen. GnRH agonists include goserelin (Zoladex), buserelin, a monthly injection of leuprolide (depot Lupron), and nafarelin (Synarel), a nasal spray. Such drugs may be used alone or in preparation for procedures used to destroy the uterine lining.
These drugs may be used in the following situations:
- As preoperative treatment 3 - 4 months before uterine surgery. The use of GnRH agonists preoperatively reduce fibroid size and uterus volume, help correct any existing anemia due to blood loss, reduce blood loss during surgery, and reduce the duration of hospital stay. (Some experts question, however, whether the benefits outweigh the costs.)
- For women with fibroids nearing menopause, but only for a short period of time.
While GnRH agonists can reduce fibroids by 30 - 90% of original size, they have certain limitations:
- They are not permanent cures, and fibroids regrow after the drugs are discontinued.
- They are injected drugs and cannot be taken by mouth.
- They are expensive.
- Long-term use of GnRh agonists causes bone density loss, which can lead to osteoporosis.
Before using these drugs, the doctor should be certain that no other complicating conditions are present, particularly leiomyosarcoma (cancer). The use of these drugs can delay treatment of the malignancy and cause severe complications.
Commonly reported side effects, which can be severe in some women, include menopausal-like symptoms. These symptoms include hot flashes, night sweats, changes in the vagina, weight change, and depression. The side effects vary in intensity, depending on the GnRH agonist. They may be more intense with leuprolide and persist after the drug has been stopped.
The most important concern is possible osteoporosis from estrogen loss. Women should not take these drugs for more than 6 months. Certain approaches may preserve enough estrogen to protect bones and still effectively relieve endometriosis symptoms:
- Add-back therapy, which provides doses of estrogen and progestin that are high enough to maintain bone density but too low to offset the beneficial effects of the GnRH agonist.
- Intermittent leuprolide, which uses repeated 6-month courses of GnRH agonists followed by an average of 9 months of symptom control only.
- Taking GnRH agonists in very low doses is an alternate approach but is still largely untested.
- Adding a bone-protective drug may be helpful. The standard ones are bisphosphonates, which include alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva). Other drugs are being tested in combination with a GnRH agonist to preserve bone. They include the parathyroid hormone teriparatide (Forteo) and selective estrogen-receptor modulators (SERMs), such as raloxifene (Evista).
GnRH treatments used alone do not prevent pregnancy. Furthermore, if a woman becomes pregnant during their use, there is some risk for birth defects. Women who are taking GnRH agonists should use non-hormonal birth control methods, such as the diaphragm, cervical cap, or condoms while on the treatments.
Androgens
Danazol (Danocrine) resembles a male hormone. It suppresses estrogen and is effective for heavy menstrual bleeding caused by fibroids. In some women it produces male characteristics, such as facial hair and voice change. Other side effects include weight gain, acne, and dandruff. It may increase the risk for unhealthy cholesterol levels. A few cases of blood clots and strokes have been reported. There is no available long-term experience using danazol for fibroids.
Antiprogestins
Mifepristone. Mifepristone (Mifeprex) is an anti-progestin that has reduced fibroid size in some studies. In one study, it reduced fibroids as significantly as GnRH agonists, and the fibroids were less likely to recur. However, this medicine can have severe side effects. Patients who have increased uterine bleeding need to be evaluated.
Selective Estrogen-Receptor Modulators (SERMs)
Selective estrogen-receptor modulators (SERMs) are drugs that have some of the effects of estrogen but do not produce some of its complications, such as a higher risk for uterine cancer. Raloxifene (Evista) is proving to help prevent bone loss in patients taking GnRH agonists for uterine fibroids. Raloxifene may have benefits for reducing fibroid size when used with GnRH agonists.
Aromatase Inhibitors
These drugs reduce the amount of estrogen being made and seem to reduce size of uterine fibroids. More research is needed.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Although they have not been studied for fibroids, nonsteroidal anti-inflammatory drugs (NSAIDs) taken on a regular schedule reduce heavy menstrual bleeding and pain from unknown causes. These drugs reduce inflammation, in part by their action against prostaglandins, the chemicals that stimulate uterine contractions and cause pain. Aspirin is the most common NSAID, but there are dozens of others, including ibuprofen (Advil, Motrin) and naproxen (Aleve, Anaprox, Naprosyn). Both ibuprofen and naproxen are recommended for menstrual pain. However, long-term use of any NSAID can increase the risk for gastrointestinal bleeding and ulcers. In addition, long-term use of high-dose NSAIDs (with the exception of aspirin) can increase the risk for heart attacks and strokes. To reduce these risks, it is best to take the lowest dose of NSAIDs for the shortest time possible.
Surgery
If nonsurgical strategies do not relieve symptoms, surgery may be the best option for treatment.
Surgery may be indicated depending on a number of factors:
- Intractable Side Effects. Surgery may be warranted if fibroids are causing distressing and intractable symptoms that have not been relieved by nonsurgical or minimally invasive therapies. Assuming, however, that symptoms do not pose serious health or life-threatening conditions, a woman should make her decision based on the factors she deems important (the desire for children, for example).
- Ureteral Obstruction. Large fibroids sometimes press down on the ureters (the tubes going from each kidney to the bladder), thereby blocking urine from emptying into the bladder. Because ureteral obstructions can permanently damage kidneys, surgery may be indicated.
- Inability to Evaluate Ovaries. The risk for missing a diagnosis of ovarian cancer is higher when fibroids are too large to permit evaluation of the ovaries by pelvic examination or ultrasound. Ovarian cancer is particularly deadly because it is so difficult to catch early enough for curative treatment. The risk for this cancer, however, is very low in women without a family history, especially before menopause. Women with a family history of ovarian cancer and large fibroids may need to consider surgery.
- Enlarging Fibroids. Rapidly growing fibroids have traditionally been felt to signify an increased risk for cancer (leiomyosarcoma). In postmenopausal women, even slow growth raises suspicions for cancer. However, many hysterectomies have been inappropriately performed because of large noncancerous fibroids that were only suspected to be cancerous. Women should discuss the option of monitoring when the fibroid is asymptomatic and appears normal on imaging tests. Current evidence does not support hysterectomy for uterine fibroids based on size alone when there are no symptoms or complications present.
- Severe Anemia from Heavy Bleeding. When iron supplementation, resection (surgical removal) of submucous fibroids by hysteroscopy, or GnRH agonist therapy fails to resolve anemia and bleeding, major surgery (myomectomy or hysterectomy) may be recommended.
Basic Surgical Options
Despite how common uterine fibroids are and the frequent use of surgical treatment, there are few randomized controlled trials that compare one treatment option to another. Surgical options include:
- Hysterectomy. Until recently, hysterectomy was the only surgical option for uterine fibroids. This procedure involves the surgical removal of the uterus and is often accompanied by oophorectomy (the removal of the ovaries). With this procedure, fertility is not preserved. Other options may be available for many women, even those who have large fibroids. Discuss all possibilities with your physician.
- Myomectomy. Myomectomy is the surgical removal of one or more fibroids. Myomectomy usually involves a laparotomy (a procedure that uses a wide abdominal incision) or less invasive surgical techniques, such as laparoscopy and hysteroscopy. In such cases, unlike with hysterectomy and uterine artery embolization, this technique is more likely to preserve fertility.
- Uterine Artery Embolization (UAE). UAE, also called uterine fibroid embolization (UFE), is a non-surgical radiology procedure. An interventional radiologist injects small plastic particles through a catheter placed in the uterine artery. The particles block the blood supply to the fibroids and cause them to shrink. Long-term effect on fertility is not yet known.
- Other Procedures. Endometrial ablation (destruction of the lining of the uterus) may be useful in women with small fibroids and heavy bleeding. Myolysis is another procedure best suited for women with specific types of small fibroids. Magnetic resonance-guided focused ultrasound (MRgFUS) is the newest type of fibroid procedure. Myolysis and MRgFUS use heat to cut off the blood supply to fibroids.
Women should discuss each option with their doctor. Deciding on the surgical procedure depends on the location, size, and number of fibroids. Certain procedures affect a womens fertility and are recommended only for women who are past childbearing age or who do not want to become pregnant. The risk for bleeding increases with the surgeon's inexperience, so patients are urged to investigate the surgeon's track record.
Alternative Procedures to Hysterectomy
In order to operate on the uterus, the surgeon may choose to reach the area through a wide abdominal incision (laparotomy) or use less invasive measures with the use of endoscopy. The decision is usually based on the severity of the case. Women should discuss all options very carefully and be sure that their surgeons have had experience with any procedure they choose.
Laparotomy. Laparotomy is the standard abdominal surgical procedure. It is invasive and usually requires a wide abdominal horizontal incision right above the pubic bone, the so-called bikini incision.
Endoscopy. Endoscopic techniques used for uterine disorders are hysteroscopy and laparoscopy. Endoscopic techniques are used increasingly to replace conventional surgical techniques for many disorders. A common factor in all endoscopic procedures is the use of a fiberoptic scope and tubes, tiny camera lenses, and minuscule surgical instruments. Any incisions made are very small, Band-Aid size.
- Operative Hysteroscopy. In this procedure, the cervix is dilated, which requires either a local or general anesthetic. A device called a hysteroscope is inserted up through the vagina and cervix into the uterine cavity. It contains tiny surgical instruments as well as a mini-camera and light source to view images of the uterus, which are transmitted to a video monitor. This approach is becoming increasingly common. Complication rates include excessive fluid absorption, infection, and uterine perforation.
- Laparoscopy. This procedure uses two or more small incisions, one at the navel, and one or more in the lower abdomen. Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away. A laparoscope is inserted through the navel incision and a probe is inserted through a second incision above the pubic hairline. The probe allows the doctor to directly view the abdominal cavity, including the outer walls of the uterus, fallopian tubes, and ovaries. The doctor manipulates surgical instruments that are passed through additional small abdominal incisions, using the image of the uterus on the video monitor as the guide.
Preoperative Hormone Treatment
GnRH agonists, usually depo-Lupron or Synarel, are often used for 2 - 3 months before many uterine surgical procedures.
These drugs may help by:
- Reducing the volume of fibroids by 40 - 60%, in some cases to the extent that a less invasive procedure may be performed
- Reducing the risk of bleeding
- Shortening surgical time
- Reducing postoperative symptoms
Treatments may not be useful, however, for small fibroids, which may shrink to the point that they are no longer visible at the time of surgery. Since fibroids regrow after treatment, the problem would recur.
There has also been some question whether these drugs provide any additional advantages for myomectomies that use conventional surgical techniques. Ultrasound may be useful in helping to detect fibroids most likely to benefit from GnRH agonists before such a procedure.
Myomectomy
A myomectomy surgically removes only the fibroids and leaves the uterus intact, often preserving fertility. Myomectomy may also help regulate abnormal uterine bleeding caused by fibroids. Not all women are candidates for myomectomy. If the fibroids are numerous or large, myomectomy can become complicated, resulting in increased blood loss. If cancer is found, conversion to a full hysterectomy may be necessary.
To perform a myomectomy, the surgeon may use standard surgical approaches (laparotomy) or less invasive ones (hysteroscopy or laparoscopy).
- Laparotomy. Laparotomy uses a wide abdominal incision and conventional surgery. It is used for subserosal or intramural fibroids that are very large (usually more than 4 inches), that are numerous, or when cancer is suspected. Using this approach, the doctor may be able to feel the fibroids, particularly intramural types, which can be missed during laparoscopy or hysteroscopy. (The doctor can view only the uterine cavity or outside surface with these latter procedures.) After the fibroids are removed, careful reconstruction of the uterine wall is critical in both laparotomy and laparoscopy, so that bleeding and infection do not occur. While complete recovery takes less than a week with laparoscopy and hysteroscopy, recovery from a standard abdominal myomectomy takes as many as 6 - 8 weeks. It also poses a higher risk for scarring and blood loss than with the less invasive procedures, a concern for women who want to retain fertility.
- Hysteroscopy. A hysteroscopic myomectomy may be used for submucous fibroids found in the uterine cavity. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed up into the uterine cavity through the vagina and cervical canal. Standard endometrial resection uses an electrosurgical wire loop to surgically remove the lining. With endometrial ablation, uterine tissue is usually vaporized using a thin powerful laser beam or high electric voltage. These procedures are useful for women with severe heavy menstrual bleeding, including some with fibroids. They are generally not useful for large fibroids.
- Laparoscopy. Women whose uterus is no larger than it would be at a 6-week pregnancy and who have a small number of subserous fibroids may be eligible for treatment with laparoscopy. Laparoscopy requires incisions, but they are much smaller than with laparotomy. As with hysteroscopy, thin scopes are used that contain surgical and viewing instruments. In centers with extensive experience, laparoscopy has fewer complications, and also shorter recovery time and lower costs than laparotomy. On the other hand, compared to the invasive surgery, laparoscopy has a greater chance for fibroid recurrence (over 16% at 5 years in one study), and a greater danger for a weakened uterine wall, which could threaten pregnancies.
Complications and Postoperative Factors. Any procedure for myomectomy is very complex. To reduce the risk for complication, patients should seek a surgeon experienced in myomectomies. Complications that occur during a myomectomy from any procedure include:
- Excessive blood loss (occurs more often with laparotomy)
- Uterine weakening and rupture during pregnancy (more of a concern with laparoscopy)
- Development of scar tissue called adhesions (more common with laparotomy)
- Infection
- Damage to the bowel or bladder (more common with laparotomy)
Pregnancies after Myomectomy. Studies suggest that pregnancy is possible in more than half of women after the procedure. In appropriate candidates, there appears to be no differences in fertility rates and pregnancy complications between laparotomy and laparoscopy. The best candidates for retaining fertility include women with pedunculated and superficial serosal fibroids (stalk-like fibroids that grow out from the uterine surface). Women with deep intramural fibroids are at higher risk for infertility after myomectomy.
Although studies indicate that 40 - 58% of women become pregnant after myomectomy, only about a quarter of the women carry their babies to term. Women who become pregnant face a higher risk for cesarean section or miscarriage. It is unclear whether laparoscopic myomectomy weakens the uterine walls and poses a higher risk for rupture during pregnancy than laparotomy.
Recurrence of Fibroids and Recurrent Surgeries. The recurrence rate for fibroid growth after myomectomy is high. Between 11 - 26% of patients will have recurring fibroids that are severe enough to need additional treatment.
Uterine Artery Embolization
Uterine artery embolization (UAE), also called uterine fibroid embolization (UFE), is a relatively new way of treating fibroids. UAE deprives fibroids of their blood supply, causing them to shrink. UAE is a minimally invasive radiology treatment and is technically a nonsurgical therapy. It is much less invasive than hysterectomy and myomectomy, and involves a shorter recovery time than the other procedures. The patient remains conscious, although sedated, during the procedure, which takes around 60 - 90 minutes.
The procedure is typically performed in the following manner:
- The patient receives a sedative to cause drowsiness, and a local anesthetic is applied to the skin around the groin.
- An interventional radiologist makes a small quarter-inch incision in the skin and inserts a catheter (a thin tube) into the femoral artery. The femoral artery is a large artery that begins in the lower abdomen and extends down to the thigh. The radiologist then threads the catheter into the uterine artery.
- Small plastic particles are injected into the artery. These particles block the blood supply to the tiny arteries that feed fibroid cells, and the tissue eventually dies.
- Patients usually stay in the hospital overnight after UAE and are given pain medication. Pelvic cramps are common for the first 24 hours after the procedure.
- It takes 1 - 2 weeks for the patient to recover from the procedure and return to work. It may take 2 - 3 months for the fibroids to shrink enough so that symptoms improve.
Effect on Fertility. In general, UAE is considered an option for only those who have completed childbearing. Although UAE may protect fertility in many women, the procedure does pose some risk for ovarian failure and infertility. In 2004, the American College of Obstetricians and Gynecologists issued an opinion statement advising women who wish to have children that it is not yet known how this procedure affects their potential for becoming pregnant. A 2005 British study of 671 women who underwent UAE found that the procedure did not interfere with fertility. The study did find a slight increase in caesarean section delivery.
Complications and Postoperative Effects. UAE has a lower rate of complication than hysterectomy and myomectomy and a shorter hospital stay. Compared to other procedures, women who have UAE miss fewer days of work. Serious complications occur in fewer than 0.5% of cases, and no deaths have been associated with the procedure.
- Pain. Abdominal cramps and pelvic pain after the procedure are nearly universal and may be intense. Pain usually begins soon after the procedure and typically plateaus by 6 hours. On-demand painkillers may be required. The pain usually improves each day over the next several days. A low-grade fever is also common in the first week after the procedure.
- Fibroid slough. Around 2 - 3% of patients pass small fragments of fibroid tissue during the first few days after UAE. This can cause intense labor-like pain and also increase the risk for infection. Some women may need dilation and curettage (D&C) to make sure that infection does not develop.
- Early menopause. Most women who have UAE will continue to have normal menstrual periods. Around 1 - 5% of women, however, go through menopause after the procedure. Menopause is more likely to occur in women over age 45 who have UAE.
Success Rates. Studies on uterine artery embolization show high patient satisfaction (over 90%) and low complication rates. Uterine artery embolization is effective for a large majority of patients. Around 10% of women who have UAE may need a repeat procedure (embolization or hysterectomy) during the first year, and another 10% after the first year. Several studies, including randomized controlled trials, have shown that 20 - 30% of women need hysterectomy within 5 years of having the procedure.
For around 10 - 20% of women, symptom control fails or fibroids reoccur. Some studies suggest that women with large fibroids are not good candidates for UAE.
Myolysis (Laparoscopic Leiomyoma Coagulation)
Myolysis, or laparoscopic leiomyoma coagulation, uses either lasers or electrosurgery to heat, coagulate, and destroy the fibroid tissue. This approach may prove to be beneficial for women with fibroids that measure a diameter of 10 cm (about 4 inches) or less and that respond to hormone treatments with GnRH agonists.
Myolysis uses a needle or a Nd:YAG laser that rapidly punctures a number of holes in the fibroid, heating and destroying the tissue in various locations. This widespread destruction cuts off the blood supply and shrinks the fibroid over ensuing months. The uterus is left intact, but tissue destruction makes childbearing unlikely.
In most cases, patients return home the same day and can return to normal activities within a week. There are few side effects. However, as the fibroids degenerate over time, many women report considerable pain.
Magnetic Resonance Guided Focused Ultrasound (MRgFUS)
MRgFUS is a non-invasive procedure that uses high-intensity ultrasound waves to heat and destroy (ablate) uterine fibroids. This thermal ablation procedure is performed with a device that combines magnetic resonance imaging (MRI) with ultrasound. The Food and Drug Administration approved this device, the ExAblate 2000 System, in 2004.
During the 3-hour procedure, the patient lies inside an MRI machine. The patient receives a mild sedative to help relax but remains conscious throughout the procedure. The radiologist uses the MRI to target the fibroid tissue and direct the ultrasound beam. The MRI also helps the radiologist monitor the temperature generated by the ultrasound.
MRgFUS is appropriate only for women who have completed childbearing or who do not intend to become pregnant. The procedure cannot treat all types of fibroids. Fibroids that are located near the bowel and bladder, or outside of the imaging area, cannot be treated.
However, this procedure is new and long-term results are not yet available. Likewise, it requires an extensive period of time involving MRI equipment. Many insurance companies do not pay for this treatment.
Hysterectomy
Hysterectomy, the surgical removal of the uterus, is the second most frequently performed surgery in premenopausal women (Cesarean sections are first). About 600,000 hysterectomies are performed each year in the U.S., among the highest rate of all countries. By age 60, about a third of American women have had this procedure. The highest hysterectomy rates are in women age 40 - 44. Women in the southern and midwestern areas of the U.S. are more likely to have the operation than those in the northeast and west.
A 2007 study suggested that a combination of factors predicts whether a woman will decide to have a hysterectomy. A woman who meets all three of these factors has a 95% chance of having a hysterectomy:
- Presence of symptoms (pelvic pain, bleeding, symptomatic fibroids)
- Lack of symptom improvement or resolution despite treatment
- Previous use of GnRH agonist drugs
The number of procedures has continued to increase, but the rise has slowed substantially in recent years. The percentage of hysterectomies performed because of fibroids, however, has risen significantly. Fibroids now account for 38% of these operations, but the rates vary widely by ethnic group.
Most women are satisfied with the procedure. A major analysis on hysterectomies reported that symptoms related to menstrual problems decline significantly in most women (although none completely disappear for all women). Most women also experience improved quality of life and mood. Women who have a hysterectomy are less likely to have hot flashes than women who have a natural menopause.
Still, in one study in 70% of cases when doctors recommended hysterectomies, they did not give their patients alternative choices or adequate diagnostic evaluations. Any woman, even one who has reached menopause, who is uncertain about a recommendation for a hysterectomy for fibroids should certainly seek a second opinion.
Determining the Extent of the Hysterectomy
Once a decision for a hysterectomy has been made, the patient should discuss with her doctor what will be removed. The common choices are:
- Total hysterectomy (removal of uterus and cervix).
- Supracervical hysterectomy (removal of uterus and preservation of the cervix); performed in about 20 - 25% of cases.
- Bilateral salpingo-oophorectomy (removal of the fallopian tubes and ovaries); used with either total or supracervical hysterectomy.
Total Hysterectomy. In a total hysterectomy the uterus and cervix are removed, which eliminates the risk of uterine and cervical cancer. (Given technical advances and growing surgical experience, a total hysterectomy may eventually be unnecessary except in special circumstances, such as when cancer is present.)
Supracervical Hysterectomy. In a supracervical hysterectomy (also called subtotal hysterectomy) the uterine body is removed, and the cervix is retained. Retaining the cervix helps support the pelvic floor and may help maintain full sexual sensation, but the risk for cervical cancer remains. Women may have cyclical bleeding for up to a year after surgery.
Bilateral Oophorectomy. Bilateral oophorectomy is the removal of both ovaries. (When only one ovary is removed, the procedure is called oophorectomy.) Bilateral salpingo-oophorectomy is the removal of both fallopian tubes and ovaries. These procedures may be performed with either total or supracervical hysterectomy. When deciding to remove the ovaries, a woman must be aware of various consequences, both positive and negative.
- Oophorectomy helps to reduce the risk for ovarian cancer, by elimination of ovaries, and breast cancer, by causing estrogen loss. Ovarian cancer is relatively uncommon, in any case, except in women with a family history of the disease. Even in these women, removal is not 100% preventive. Cancer can still develop from cancer cells that may be present in the lining of the pelvis (the peritoneum).
- Removal of the ovaries ceases estrogen and testosterone production, which can increase the risk for menopause-related conditions. These include osteoporosis, heart disease, skin wrinkling, and reduced muscle tone. Estrogen replacement, however, can help offset these problems. Women who have a bilateral oophorectomy and do not receive hormone replacement therapy may have more severe hot flashes than women who enter menopause naturally.
Abdominal vs. Vaginal Hysterectomy
There is still a further choice, which is whether the hysterectomy should be performed through an incision in the abdomen or through the vagina. A variant of vaginal hysterectomy, called laparoscopic-assisted vaginal hysterectomy (LAVH), is yet another option.
Abdominal Hysterectomy. Abdominal hysterectomy is the most common procedure. It is best suited for women with large fibroids, when the ovaries need to be removed, or when cancer or pelvic disease is present. With the abdominal procedure, a wide incision is required to open the abdominal area from which the surgeon removes the uterus. If possible, the incision should cut horizontally across the top of the pubic hairline (the bikini incision). This incision heals faster and is less noticeable than a vertical incision, which is used in more complicated cases. The patient may need to remain in the hospital for 3 - 4 days, and recuperation at home takes about 4 - 6 weeks.
Vaginal Hysterectomy. Vaginal hysterectomy requires only a vaginal incision through which the uterus is removed. This approach is most often performed for small fibroids (although advances in imaging and other techniques may allow it to be used on larger fibroids).
A variation of the vaginal approach is called laparoscopic-assisted vaginal hysterectomy (LAVH). It uses several small abdominal incisions through which the surgeon severs the attachments to the uterus and ovaries. They can then be removed through the vaginal incision, as in the standard approach. Hospital stays may be longer and costs are greater than with standard vaginal hysterectomy. The use of LAVH has risen significantly and is used in over a quarter of vaginal procedures. LAVH is very costly and time consuming, however, and some experts question whether it adds any significant benefits compared to the standard vaginal procedure.
Postoperative Care
The patient should ask a family member or friend to help out for the first few days at home. The following are some of the precautions and tips for postoperative care:
- For 1 - 2 days after surgery, the patient is given medications to prevent nausea and painkillers to relieve pain at the incision site.
- As soon as the doctor recommends it, usually within a day of the operation, the patient should get up and walk in order to help prevent pneumonia, reduce the risk of blood-clot formation, and speed recovery.
- Walking and slow, deep breathing exercises may help to relieve gas pains, which can cause major distress for the first few days.
- Coughing can cause pain, which may be reduced by holding a pillow over a surgical abdominal wound or by crossing the legs after vaginal surgery.
- Patients are advised not to lift heavy objects, not to douche or take baths, and not to climb stairs or drive for several weeks.
- For the first few days after surgery, many women weep frequently and unexpectedly. These mood swings may be due to depression from the loss of reproductive capabilities and from abrupt changes in hormones, particularly if the ovaries have been removed.
The patient should discuss with the doctor when exercise programs more intense than walking can be started. The abdominal muscles are important for supporting the upper body, and recovering strength may take a long time. Even after the wound has healed, the patient may have an on-going feeling of overall weakness, which can be demoralizing, particularly in women used to physical health. Some women do not feel completely well for as long as a year while others may recover in only a few weeks.
Complications Following the Procedure
Minor complications after hysterectomy are very common. About half of women develop minor and treatable urinary tract infections. There is usually mild pain and light vaginal bleeding post operation. The infrequent occurrence of severe bleeding or hemorrhaging after vaginal hysterectomy, or laparoscopic-assisted vaginal hysterectomy, may be promptly treated by laparoscopy.
More serious complications, such as those described below, are uncommon, but patients should be aware of their symptoms and call the doctor immediately if they occur.
Infection. Infection occurs in 10 - 15% of patients, the risk being higher with abdominal than with vaginal surgery. Risk factors for infection include obesity, a longer than normal operative time, and low socioeconomic status. Patients should be aware of any symptoms and call the doctor immediately if they occur. Symptoms of infection include:
- Continuing or increasingly severe pain
- Fever
- Heavy discharge
- Bleeding (antibiotics given at the time of surgery help to reduce this risk)
Blood Clots. There is a slight risk for small blood clots, usually in veins of the legs (thrombophlebitis). A sudden swelling or discoloration in the leg can indicate this condition and require immediate medical attention.
Other Serious Complications. Other serious and even life-threatening complications are rare but can include:
- Pulmonary embolism (blood clots that travel to the lung)
- Surgical injury of the urinary or intestinal tracts
- Abscesses
- Perforation of the bowel
- Fistulas (a passage that bores from an organ to the skin or to another organ)
- Dehiscence (opening of the surgical wound)
Long-Term Complications. Women who have had a total hysterectomy are at higher risk for the following long-term complications:
- Muscle weakness in the pelvic area.
- Prolapse (descent) of the bladder, vagina, and rectum if the muscle's walls are overly weakened; may require further surgery.
- Bowel problems if adhesions (extensive scarring) have formed and obstruct the intestines; may require additional surgery.
- Shortening of the vagina is a possible complication specific to vaginal hysterectomy. It can cause pain during intercourse.
Such complications are uncommon.
Treating Menopausal Symptoms and Premature Menopause after Hysterectomy
After hysterectomy, women may have hot flashes, a symptom of menopause, even if they retain their ovaries. However, women who have a hysterectomy are less likely to have hot flashes than women who have a natural menopause. Surgery may have temporarily blocked blood flow to the ovaries, therefore suppressing estrogen release. If both ovaries have been removed in premenopausal women, the procedure causes premature menopause. Other menopausal symptoms include vaginal dryness and irritation, insomnia, and weight gain.
The most important complications occur in women who have had their ovaries removed. This causes estrogen loss, which places women at risk for osteoporosis (loss of bone density) and a possible increase in risks for heart disease and stroke. A number of drugs are available that can help protect both bones and heart. [For more information, see In-Depth Reports #40: Menopause and #18: Osteoporosis.]
In premenopausal women, the ovaries will usually continue to function and secrete hormones even after the uterus is removed, but the lifespan of the ovaries is reduced by an average of 3 - 5 years. In rare cases, complete ovarian failure occurs right after hysterectomy, presumably because the surgery has permanently cut off the ovaries' blood supply.
Psychologic and Sexual Concerns after Hysterectomy
Sexual intercourse may resume 4 - 6 weeks following surgery. The effect of hysterectomy on sexuality is unclear. Studies have reported that up to 25% of women experience increased sexual drive. Nevertheless, some women report no change, and other women develop problems related to sexual function. For example, around 10% of women have vaginal dryness, about 2% of women develop pain during sex, and another 2% also appear to lose capacity for orgasm.
Two procedures associated with hysterectomy may affect sexuality directly:
- Although the clitoris can trigger orgasm even if the cervix is removed, many experts believe that uterine contractions stimulated by sexual intercourse also cause a so-called deep orgasm. Retaining the cervix may help to retain this sensation. However, a 2006 review found that women who have a total hysterectomy (removal of both uterus and cervix) are no more likely to have sexual difficulties or problems with urinary and bowel function than women who have only their uterus removed.
- Patients who have both ovaries removed may be at higher risk for loss of sexuality. Ovaries produce small amounts of testosterone (the male hormone responsible for sexual drive) even after menopause.
Testosterone Replacement. Testosterone replacement therapy may restore sexuality in women who experience a decline in sexual drive. Occasionally, oral or injection treatments can produce male characteristics such as facial hair and voice change. A slow-release pellet inserted every 6 months under the skin in the hip appears to reduce these side effects. Taking hormones long term almost always carries some risk, and it is not yet known what danger testosterone replacement may pose in women.
Pap Smears
Annual Pap smears are recommended for all women with an intact cervix who are 18 years or older or who have become sexually active. After a total hysterectomy, in which the cervix has been removed, a woman does not need annual Pap smears of the cervix. However, she still should get regular pelvic and breast exams.
Resources
- www.asrm.com -- American Society for Reproductive Medicine
- www.acog.org -- American College of Obstetricians and Gynecologists
- www.sirweb.org -- Society of Interventional Radiology
- www.nuff.org -- National Uterine Fibroids Foundation
- www.rsna.org -- Radiological Society of North America
- www.radiologyinfo.org -- Radiology info from the American College of Radiology and the Radiological Society of North America
- www.radiologyinfo.org/content/interventional/ufibroid-embol.htm -- Information on uterine fibroid embolization
- www.nichd.nih.gov -- National Institute of Child Health and Human Development
References
Chen WY, Manson JE, Hankinson SE, Rosner B, Holmes MD, Willett WC, et al. Unopposed estrogen therapy and the risk of invasive breast cancer. Arch Intern Med. 2006 May 8;166(9):1027-32.
Edwards RD, Moss JG, Lumsden MA, Wu O, Murray LS, Twaddle S, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med. 2007 Jan 25;356(4):360-70.
Evans P, Brunsell S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician. 2007 May 15;75(10):1503-8.
Gabriel-Cox K, Jacobson GF, Armstrong MA, Hung YY, Learman LA. Predictors of hysterectomy after uterine artery embolization for leiomyoma. Am J Obstet Gynecol. 2007 Jun;196(6):588.e1-6.
Griffiths A, D'Angelo A, Amso N. Surgical treatment of fibroids for subfertility. Cochrane Database Syst Rev. 2006 Jul 19;3:CD003857.
Hehenkamp WJ, Volkers NA, Donderwinkel PF, de Blok S, Birnie E, Ankum WM, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol. 2005 Nov;193(5):1618-29.
Kaunitz AM. Progestin-releasing intrauterine systems and leiomyoma. Contraception. 2007 Jun;75(6 Suppl):S130-3. Epub 2007 Mar 9.
Learman LA, Kuppermann M, Gates E, Gregorich SE, Lewis J, Washington AE. Predictors of hysterectomy in women with common pelvic problems: a uterine survival analysis. J Am Coll Surg. 2007 Apr;204(4):633-41. Epub 2007 Feb 23.
Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004993.
Olive DL, Lindheim SR, Pritts EA. Conservative surgical management of uterine myomas. Obstet Gynecol Clin North Am. 2006 Mar;33(1):115-24.
Rackow BW, Arici A. Options for medical treatment of myomas. Obstet Gynecol Clin North Am. 2006 Mar;33(1):97-113.
Schwartz PE, Kelly MG. Malignant transformation of myomas: myth or reality? Obstet Gynecol Clin North Am. 2006 Mar;33(1):183-98, xii.
Smart OC, Hindley JT, Regan L, Gedroyc WG. Gonadotrophin-releasing hormone and magnetic-resonance-guided ultrasound surgery for uterine leiomyomata. Obstet Gynecol. 2006 Jul;108(1):49-54.
Stefanick ML, Anderson GL, Margolis KL, Hendrix SL, Rodabough RJ, Paskett ED, et al. Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. JAMA. 2006 Apr 12;295(14):1647-57.
Viswanathan M, Hartmann K, McKoy N, Stuart G, Rankins N, Thieda P, et al. Management of uterine fibroids: an update of the evidence. Evid Rep Technol Assess (Full Rep). 2007 Jul;(154):1-122.
Volkers NA, Hehenkamp WJ, Birnie E, Ankum WM, Reekers JA. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2007 Jun;196(6):519.e1-11.
Reviewed By: Reviewed by Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
