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Welcome to Ask The Expert with John Lipman, MD, Interventional Radiologist. Each month Speaking of Women's Health brings you the opportunity to submit a question to one of our healthy lifestyle experts. For October we consulted John Lipman, MD about uterine fibroids. Ask The Expert with John Lipman, MD took place on Thursday, October 25th at 5 pm EDT. Good afternoon Dr. Lipman and welcome to Speaking of Women's Health's Ask The Expert. Here's our first question: 1. Question: What actually causes fibroids? Answer - Dr. Lipman: Fibroids are the most common tumors of the female pelvis. They are benign and will not become cancerous. No one knows exactly what causes fibroids. We do know that they respond to estrogen stimulation. That is why they tend to grow during pregnancy (when there are increased levels of estrogen), and why they tend to not to be an issue anymore with menopause (when there are decreased levels of estrogen present). |
John Lipman, MD, FSIR |
2. Question: Has there been any medical research to determine why uterine fibroids occur mostly in African American women?
Answer - Dr. Lipman: Unfortunately, there has been precious little research performed on fibroids. Despite the prevalence of this condition, and the often significant disabling symptoms, because these tumors are benign, it has not received the appropriate attention in research money. There are two pending bills (one in the House (#3034) and a similar Senate version #1289)) that would address this and provide more research funding. The specific act is the Uterine Fibroid Research & Education Act of 2005 which would authorize $30 million/year in fibroid research. Returning to your main question, African-American women disproportionately suffer with fibroids. Research has shown that they not only affect these women more commonly, but the tumors tend to be larger, and occur at an earlier age.
This means that they will be more likely to have symptoms and more often require treatment. There are two reasons that African-American women have a higher incidence of fibroids (i.e. higher than Caucasian, who have a higher incidence than Asian women) than all other ethnic groups. First is that in general, African-American women have a higher body fat, than the average Caucasian woman, who has more body fat than the average Asian woman. Estrogen is stored in fat, and therefore, having more fat will stimulate fibroid growth. This is one more reason to watch what we eat, exercise, and keep fat off our bodies. It will be good for your heart, it will prevent Type II diabetes, and it will also help with fibroids.
Body fat alone does not explain the whole story however. I commonly see African-American women in my practice with a very low body fat, and very big fibroids. In these patients, it is genetic, and it will passed on to female family members. The chromosome responsible has been identified, and once we can get to the gene level (through more research), we can develop drugs/vaccines to fight/prevent fibroid development.
3. My questions center around the return of uterine fibroids after you have undergone surgery.
3a: I had uterine fibroids two years ago and underwent the surgical myomectomy procedure. Well two years later, I have discovered I have two more fibroids. I am interested in the UFE procedure and wanted to know if I have the UFE procedure will it limit the chance of more fibroids reoccurring in the future?
Answer - Dr. Lipman - In general the answer is yes. Surgical myomectomy (the removal of fibroids surgically from the uterus and then sewing the uterus back together) is often a local therapy for a global problem. When a woman has numerous fibroids throughout the uterus, a number of them will be left behind after surgery (usually the smaller ones). These will then grow, and a woman is faced with the same symptoms again. Uterine fibroid embolization is a global therapy, and treats every fibroid in the uterus at the time of the procedure. That is why the recurrence rate for UFE is much lower than that seen with myomectomy.
3b: Previously my fibroids were located centrally and I had awful menstrual cycles. I would like to know what physically happens to a woman’s body during and after having fibroids. I’ve noticed a significant amount of weight gain primarily in the abdomen and hip area almost having me look like I’m expecting. I’m trying to exercise and diet to lose the weight but could I have gained the weight from having uterine fibroids? Additionally, what exercises would you recommend to help with this area?
Answer - Dr. Lipman - Fibroids are hard, firm tumors, and cause there symptoms based on their location in the uterus. The uterus has a thin lining which sheds each month and a larger thick muscular component. Menses stop through uterine contraction of the muscular layer deep to the lining. Central fibroids (i.e. ones near the uterine cavity and along the lining of the uterus) will stretch the lining of the uterus making the contraction of the muscular uterus ineffectual, and will cause women to have heavy, "gushing" periods with passage of large blood clots. This will often cause a woman to become anemic from the blood loss. This anemia can be profound make the patient weak and unable to exercise. This will often lead to weight gain. As a woman’s uterus enlarges from fibroids, her physician will often characterize the size of the uterus on physical exam and compare that to a pregnant woman’s uterine size. For example, a woman suffering with fibroids may have a 12-week or 16-week uterine size. Prior to an exercise regimen, I would check with your doctor for medical clearance. It will be important to know your Hemoglobin and iron levels are to see if there is a need for you to be on iron. There are not any specific exercises that I would recommend, rather a healthy eating and general exercise program will be the most beneficial.
3c: One of the main reasons I did not have the UFE procedure initially is because I was told I could not get pregnant after the procedure. Meanwhile, I have heard many rumors regarding this subject and I would like to know with new technology developing, can a woman get pregnant after undergoing the UFE?
Answer - Dr. Lipman - The simple answer is yes. A woman can get pregnant after UFE. When a woman is suffering with fibroids she should be told of her surgical options, as well as her non-surgical options, including UFE. While we know that with surgical myomectomy there is a significant impact on a woman’s fertility after each myomectomy (~60% fertility rate after one, and as low as 10% after two), we don’t yet know the impact after UFE. Until we know the impact on fertility from UFE, I tell patients that I would recommend myomectomy if the number of fibroids is low and it will be a simple myomectomy. When patients have numerous fibroids throughout the uterus, I believe these patients will be better served with UFE due to the unacceptably high recurrence rate. The best imaging method to determine the number and location of fibroids is with a pelvic MRI exam. I recommend patients that are considering UFE have this study prior to their consultation. Patients interested in UFE need to seek out an UFE-experienced Interventional Radiologist (i.e. the physicians that perform UFE) and see if this a reasonable option for them.
3d: Are you aware of any holistic healings that can treat uterine fibroids?
Answer - Dr. Lipman - There are holistic medicines (exs. Vitex, Indolplex, natural progesterone cream) that patients have told me that in their particular case has helped them. I am not aware of any true scientific research to validate this, but anyone interested can seek the advice of a naturopath or other holistic provider. Any regimen that is contemplated and/or instituted should be discussed with the patient’s gynecologist or primary care physician.
4a. Question - Is surgery always the best alternative? If a woman does not want surgery, are there other ways for fibroids to disappear?
Answer - Dr. Lipman - Surgery is an alternative. It is not always the best alternative. If a woman does not want surgery, UFE is an excellent alternative. The most important message is that women need to know that if they are suffering with fibroids, there are excellent non-surgical alternatives. If they are interested in UFE, they need to have a consultation with an Interventional Radiologist. A list of Interventional Radiologists who perform UFE can be accessed on the internet from the Society of Interventional Radiology at www.sirweb.org
4b. Question - What foods should a woman eat when diagnosed with uterine fibroids?
Answer - Dr. Lipman - As I discussed earlier, the most important dietary advice for women suffering with fibroids is to maintain a low fat, high fiber diet. It is important to be as close as possible to your ideal body weight. There is some evidence that limiting dairy, red meat, and caffeine are helpful.
5. Question - I am about 3.5 months pregnant and my doctor has confirmed via a vaginal ultrasound that I have a fibroid. The fibroid gets in the way of seeing the baby via ultrasound and hearing the heartbeat so I guess it is pretty big. It is certainly bigger than the baby. I wondered if my doctor can remove the fibroid during my scheduled C-Section? What do you recommend? We do plan on having more children after this pregnancy.
Answer - Dr. Lipman - I am not an Obstetrician/Gynecologist, so I would defer to their opinion. In my experience, this is not usually done. Depending on the location of your fibroid, it may or may not be accessible during surgery. Fibroids can interfere with every part of the "fertility pathway" from preventing fertilization (blocking the tubes), interfering with implantation, causing early miscarriage, blocking the birth opening necessitating a c-section etc.
6. Question - I have several large fibroids (size of an orange) and occasionally have urinary urge incontinence. Typically my bladder will be troublesome for several days and then will be fine for 3 or so weeks. Is it likely that the urge incontinence is related to the fibroids? If so, what’s a good way to determine if they are indeed related?
I’m 47 years old. In the last 10 years I’ve also had more cramping and sometimes nausea and vomiting with my periods. I’m debating whether to have the fibroids treated or just bear with the urge incontinence and menstrual problems and hope everything improves down the road when I hit menopause.
Answer - Dr. Lipman - It is very likely due to your fibroids. This is a very common symptom of fibroids. As I mentioned earlier, fibroids cause their symptoms due to their hard consistency. They stretch the lining causing heavy bleeding, press on pelvic nerves to cause pain, and in your case press on the bladder causing increased urinary frequency and difficulty controlling your urine. The fibroid(s) act like a paperweight on the bladder. The bladder is prevented from filling to normal capacity by the fibroid. This compression can be seen on the pelvic MRI (i.e the fibroid compressing the bladder like a wafer). Patients will often report that they get the signal to urinate and they will race to the bathroom only to urinate relatively little based on how urgent it was. This is perplexing to the patient, but when the patient sees the MRI it makes perfect sense. While the patient feels the urgency and believes that the bladder is full of urine, in reality, it is relatively empty (due to the fibroid compressing the bladder). That is why she often will go relatively little and have to go more often. Patients will often have to go multiple times each night and this can be very distressing to the patient.
If we knew when women would go into menopause, it would be easier to counsel them on waiting for menopause to fix the fibroid problem. Life is too short to put up with such bothersome symptoms when there are very good treatment options available. At 47, you could go 10 years without going into menopause. I would recommend you seek medical opinions about this.
7. Question - I recently found out I was pregnant and after several episodes of severe pain in the left lower side of uterus, my doctor found that I had a fibroid. She said it was hurting as it was degenerating. What does it mean and what other complications if can have because of it?
I am really concerned about my baby and fibroid too. Please let me know any possible options to remedy this situation.
Answer - Dr. Lipman - First of all congratulations!
Fibroids grow from nourishment they receive by nutrients diffusing from blood vessels at the periphery of the fibroid. As a fibroid grows, the distance from the center of the fibroid gets farther and farther away from these vessels. It gets to a point where the nutrients can’t make it to the center and this part of the fibroid will die off (i.e. degenerate). The pain from a degenerating fibroid can be quite severe. I have seen a number of young women who didn’t know they had fibroids who developed right lower quadrant pain that caused them to go to the Emergency Room. When first seen by the ER physician, it was assumed that they had appendicitis, but in actuality they had right sided fibroids which degenerated. The degenerated fibroid will calcify and heal and should not present any concern for the fetus.
8. Question - I had fibroid tumors and I had the uterine fibroid embolization procedure performed about a year ago. Now, my period is very, very light...almost nonexistent. Although I do have a cycle every month, it last up to 3 days and it's consistently light throughout my cycle as it is on the first day. Is this normal?
Answer - Dr. Lipman - Yes. UFE is not supposed to stop your period (although in women typically over 45 years of age it can in a small percentage). The goal of UFE is to significantly improve or eliminate the symptoms from fibroids. The heavy, gushing, clot producing bleeding is now a light manageable flow as you have found. Roughly 90% of patients will have significant or complete resolution of their symptoms.
9. Question - I recently underwent a surgery to remove my uterine fibroids. My doctor reported I had eleven and they varied in size from a cantaloupe to a walnut. He also tested my fallopian tubes to check for any damage the fibroids may have caused.
I suppose my question is two-fold. My husband and I want to have children. How soon do we need to try to conceive? And is conception difficult for those women who have had this issue? I am worried that the fibroids will go so much that I can not carry the fetus.
Answer - Dr. Lipman - I would discuss when to try to conceive with your Ob/Gyn. Typically in my experience patients are told to wait 6 months after surgery. Yes, as I mentioned earlier women who have had surgical myomectomy to remove fibroids will have a diminished fertility rate, and a harder time having a child. If a fibroid is shown to cause a miscarriage, that fibroid will often be treated prior to the next pregnancy attempt. While one could have this surgically removed, there are other alternatives that can be done. One relatively new method which is FDA-approved, but is still investigational, is MRI-guided focused ultrasound. This is a non-surgical, local (one or two fibroids) option that destroys a fibroid completely from outside the patient, with a focused beam of ultrasonic energy. This technologically is not widely available yet, and any consideration of this option should be through your doctor.
10. Question - I've had 3 myomectomies and am now in my 40's, I'm ready to have a baby but haven't had much luck conceiving. How much does this type of surgery affect a woman's ability to conceive?
If the fibroids return yet a 4th time, I really don't want to have another surgery so what are some of my options?
Can you elaborate on the effects of diet & alcohol on uterine fibroids? What's the best type of diet to prevent or reduce the chance of having uterine fibroids?
Answer - Dr. Lipman - As I mentioned earlier, surgical myomectomies will have a cumulative effect on a woman’s ability to conceive. After 3 myomectomies, the fertility rate is low, roughly ~1%. There is also increasing difficulty each year a woman has in conceiving over 40. After 3 local options, you might want to consider a global option if your fibroids return.
11. Question - I've suffered with uterine fibroids for nearly 10 years.
The abdominal disfigurement, severe anemia and frequent urination have really caused excess stress and truly a loss in quality of life. I had an open myomectomy in 2000 at age 29 and the fibroids have returned with a vengeance. Now, at age 36, my husband and I still without our first pregnancy, I've been told that I really don't qualify for anything other than another open myomectomy.
I've heard of the UA-emboliization procedure and other newer technologies but have been told that because of the size of my uterus (like a 15-week pregnancy) and the "too numerous to count" fibroids therein, I'm not a candidate. Other than additional injections, what recourse do I have to save my uterus?
Answer - Dr. Lipman - While I hear from patients that have told me that their doctor said that they don’t qualify for UFE due to the number of fibroids or the size of the uterus, this is absolutely false. UFE is an excellent global therapy for fibroids that treat every fibroid in the uterus whether there is one or a hundred. The size of the uterus also does not disqualify a patient from UFE. A 15-week size is very typical for the size of the uterus treated with UFE. The important point is that a woman who is considering UFE, must talk to an Interventional Radiologist (the doctors that perform UFE) to see if they are a potential candidate.
12. Question - I am 38 years old. I have uterine fibroids that my Gyn suggests I have Lap Hysterectomy to remove for good because we have had our children and he said they problem of fibroids is not going to go away for another 15 years so we should take care of the problem now vs. dragging this out.
Is the Lap Hysterectomy safe with large fibroids? Should I be asking any questions before done? Any other suggestions before I go through with the surgery? What are most common problems with that kind of surgery? How fast will I be back to work and out and about with the kids?
Answer - Dr. Lipman - Laparoscopic hysterectomy is a safe procedure. It is less invasive then the traditional open hysterectomy, allowing for a quicker recovery time than the 6-8 weeks from open surgery. You may want to discuss this with a gynecologist who performs this procedure, but in my experience, you should expect to be out 4-6 weeks. Just for comparison, UFE at our center is performed as an outpatient procedure (in other centers you can expect an overnight stay), and the patient leaves with a bandaid at the site of entry at the top of the right leg. Condoleeza Rice had the UFE procedure in November of 2004. She had the procedure on a Friday morning and she went back to work Monday morning. This illustrates how quickly a patient can recover with UFE, although the average recovery is 4-5 days, and I recommend patients be out of work for one week.
Thank you Dr. Lipman for your time and expertise!
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Join us next month for our 'Ask The Expert' session devoted to skincare with Tekeyla Perdue, Licensed Aesthetician. We're looking forward to answering your questions.
Read Dr. Lipman's recent article - Alternatives to Hysterectomy for Women Suffering with Fibroids
