Fibroids are commonly occurring, benign tumors of the uterus that may cause abnormal bleeding, pelvic pain, and infertility.
It is important to choose a physician with significant experience in treating uterine fibroids. It is also important to choose a doctor who will objectively discuss all appropriate treatment options. Dr. Goldberg, Director of the Philadelphia Fibroid Center at Einstein, has over 20-years of experience evaluating and treating fibroids. With a special interest in uterine preservation, he has performed over 1,000 myomectomies, with many resulting pregnancies, as well as other fibroid-related surgeries. He has also referred more patients for UFE than any other gynecologist. For patients considering hysterectomy, we offer extensive experience with minimally invasive techniques. Dr. Goldberg has additionally published numerous research articles and lectured extensively, both nationally and internationally, on fibroids.
Fibroids very rarely are cancerous (leiomyosarcoma). In one study of patients suspected of having cancerous fibroids due to rapid growth, only 1 in 400 women actually did have a malignancy. Leiomyosarcomas also rarely occur in patients younger than 50. Leiomyosarcoma, however, is a very aggressive tumor, with a very high mortality rate. Thus, leiomyosarcoma should be considered in the case of a rapidly enlarging suspected fibroid in a postmenopausal woman. Small research studies have suggested the ability to diagnose leiomyosarcoma with a combination of imaging studies and blood tests. In routine clinical practice, the diagnosis of leiomyosarcoma is rarely made prior to pathology examination of a surgical specimen.
Many women will develop fibroid-related symptoms. Many asymptomatic women with fibroids will be diagnosed through either (1) physician palpation of an enlarged or irregularly shaped uterus during a pelvic exam; or (2) unexpected finding on an imaging study (ultrasound, CT or MRI).
Symptomatic women with fibroids develop three categories of symptoms or combinations of them: (1) bleeding (heavy menses / irregular uterine bleeding / anemia); (2) bulk (pelvic pressure or pain / urinary frequency / painful intercourse / abdominal distension); (3) infertility (inability to conceive / miscarriage / pregnancy complications). Many women with fibroids, however, may be asymptomatic.
As fibroids are almost always benign, treatment is dictated by their effect on a woman’s quality of life. If symptoms are absent or minimal, with no fertility issues, no treatment is usually the best option. It is possible that symptoms might develop in the future. When she reaches menopause, with its decrease in estrogen and progesterone levels, her fibroids will significantly decrease in size. Other patients with significant symptoms and fertility issues may benefit by fibroid treatment.
Treatments options depend on symptoms, fertility desire, size and location of fibroids, and patient characteristics (prior surgeries, medical conditions, etc.). They include no treatment, medical therapy (NSAIDS, oral contraceptives, Lupron), Mirena IUD, endometrial ablation, hysteroscopic myomectomy, myomectomy, uterine fibroid embolization (UFE), and hysterectomy. Use the Goldberg Fibroid Treatment algorithm to learn more about treatment options that might be appropriate for you.
Many women consulting with Dr. Goldberg for a second opinion have previously only been recommended hysterectomy to treat their fibroids. Unless the patient has cancer, there are usually other appropriate options besides hysterectomy. While hysterectomy is often an excellent treatment in patients not desiring future fertility, many woman wish to keep their uterus. A study by Dr. Goldberg found that up to 61 percent of patients with symptomatic fibroids not desiring fertility had a negative attitude towards hysterectomy. Many patients are only given the option of hysterectomy.
The decision to remove or keep your ovaries should be discussed with your physician. Factors considered should include a patient’s age, family history, and all risks/benefits. In most women, the risks of oophorectomy (acute menopause, increased risk of cardiac disease, etc.) outweigh the benefits (decreased risk of ovarian cancer). When oophorectomy is performed, fallopian tubes should also be resected, as some serous cancers may start within the fallopian tube rather than the ovary.
Fibroids most likely to affect fertility are those distorting the endometrial cavity, both submucosal (within the uterine cavity) fibroids and those pressing into the cavity. Small fibroids not distorting the cavity should not decrease pregnancy rates.
This depends on the size and location of fibroids, as well as prior infertility/pregnancy history. The best option may be no treatment. If treatment is required, myomectomy is usually the best option.
No studies have been performed following myomectomy to determine how long a patient needs to wait after myomectomy before attempting to conceive. As with anything, risks and benefits should be considered. Patients in their later 30s and 40s, with decreasing ovarian function, may do themselves a disservice by waiting too long. Additionally, many women may eventually develop new fibroids. The major risk factors for developing new fibroids after myomectomy are large fibroids and multiple fibroids.
Mode of delivery following myomectomy is controversial. Some physicians will allow a patient to labor, as long as the endometrial cavity has not been entered. These patients, however, will be at increased risk for uterine rupture (separation of the uterine scar) during labor. Dr. Goldberg usually recommends future cesarean delivery if > 50 percent of the uterine wall has been incised during myomectomy. ACOG currently recommends cesarean section following myomectomy be performed between 37 and 38 week to decrease the chance of the patient first going into labor with its risk of uterine rupture.
In patients undergoing hysterectomy, vaginal hysterectomy should be the first choice for appropriate patients. With vaginal hysterectomy, no abdominal incisions are made. Recovery time is much quicker. To be a candidate for a vaginal hysterectomy, uterine size, descensus, and prior pelvic surgery are considered. Dr. Goldberg has extensive experience with vaginal hysterectomy, including the use of morcellation techniques for larger uteri. In patients not candidates for the vaginal route, other hysterectomy techniques include mini-lap, laparoscopic, open laparotomy, and robotic.