Women's Bodies, Women's Wisdom (44 page)

As I mentioned earlier, GnRH agonists are very expensive, and they are not recommended for use longer than six months. Once use of the drug has stopped, the fibroids grow back quite rapidly unless a woman becomes naturally menopausal during the time she is on the drug.

Many women are understandably hesitant to use such synthetic hormones. Baby-boom-generation women remember that diethylstilbestrol (DES) was enthusiastically used for more than thirty years to prevent miscarriage. In 1971, the drug was withdrawn after it was linked to certain rare vaginal cancers and other genital tract abnormalities in some of the female (and even male) offspring of the women who used it. Having said that, it is clear that GnRH agonists do have a place in the treatment of fibroids. They can be used to shrink fibroids while administering enough “add back” hormones to lessen their menopausal side effects without compromising their effectiveness. This approach can save some women from undergoing perimenopausal hysterectomies.

Endometrial Ablation

Christine had heavy periods for years—she had to use two super tampons at a time, as well as a pad. Sometimes these needed to be changed every half hour during day two of her period, making it very difficult for her to travel or even leave the house to grocery shop. The minimal dietary changes she made had not worked. Further testing revealed that she had multiple, very small fibroids in the uterine wall. Christine very much wanted to avoid hysterectomy, so we tried syn thetic progestin therapy for the last two weeks of each month for three months.
²⁸
Even though this treatment almost always decreases bleeding, it didn’t work in her case. A D&C also failed to alleviate her bleeding. I referred her for a procedure called endometrial ablation using hys teroscopy. Hysteroscopy is a surgical technique in which the lining of the uterus can be visualized and operated on by passing a scope through the cervix from the vagina. Various techniques are available, including cautery and laser. The technique used depends on the patient’s condition and the choice of the surgeon. Submucosal fibroids can sometimes be removed this way by surgeons skilled in this technique. This procedure, done under anesthesia in the operating room, cauterizes and obliterates the endometrial lining—the part of the uterus that bleeds every month. When it works, menstrual periods cease or become very light. For Christine, the procedure worked beautifully. Instead of recuperating for a month from the removal of her uterus, she went into the hospital the day of her surgery and left the next. Though this type of surgery isn’t ap propriate for everyone, it is a great option for some. It cannot be done in some cases, depending upon the position of the fibroids.
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Fibroid Embolization

Uterine artery embolization (UAE) involves in jecting a substance such as polyvinyl alcohol particles into the uterine artery, blocking the fibroid’s blood supply and shrinking the fibroid. Interventional radiologists specifically trained in this technique thread a catheter into the femoral vein of the thigh to reach the uterine arteries. The patient is usually conscious during the procedure (although sedated and in no pain) and typically spends one night in the hospital afterward. Most women resume normal activities within seven to ten days.

The results are encouraging. The Society of Interventional Radiology reports that 85 to 90 percent of women who have this procedure expe rience significant or total relief of their symptoms, including heavy or irregular bleeding, pain, uterine enlargement, and symptoms like in creased urinary frequency that relate to the size of the fibroid. Recurrence within ten years of the procedure is rare, although long-term follow-up data aren’t yet available. The complication rate is low, espe cially when compared to that of myomectomy or hysterectomy. Even so, some serious complications do exist, including renal failure or an allergic reaction to the clotting agent.
³⁰

One of my ob-gyn colleagues had the procedure done and was very happy with her result. Given that she has spent her career doing lots of hysterectomies and myomectomies, this speaks volumes in my mind. If this procedure appeals to you, seek out the advice of a special ist at a center where UAE is frequently done, call the Society of Interventional Radiology at 800-488-7284, or visit their website,
www.scvir.org
.

ExAblate: Ultrasound Treatment for Fibroids

In the fall of 2004, the FDA approved a new device that combines MRI imaging to map out uterine fibroids followed by high-intensity focused ultrasound that heats up and destroys fibroid tissue. Fibroid tissue is very well suited to this treatment because the blood vessels in fibroids help the body dissipate the excess heat that is generated. The procedure is called ExAblate and is done on an outpatient basis. It is noninvasive, leaving the uterus and ovaries intact. It involves lying on your abdomen in an MRI tube for up to three hours while ultrasound heats up and destroys the uter ine tissue. Side effects may include blisters on the abdominal skin, cramping, nausea, and some pain that is alleviated by over-the-counter pain medication.

Studies show that the treatment successfully reduces fibroid symptoms in about 70 percent of women, but 20 percent will require additional surgery within a year. The FDA reports that though the ExAblate treatment successfully reduces symptoms in the majority of women who undergo the procedure, those symptoms will return in some women. And so will the fibroids. This is why I recommend that
all
women suffering from fibroids also do their best to employ the kind of lifestyle changes mentioned above that change the metabolism of hormones to reduce fibroid symptoms naturally. Still, I feel that ExAblate is a major step forward and a very exciting use of technology. If it had been available when I had my fibroid (mine was very large), I would have strongly considered this treatment. Note: ExAblate should not be used by those who want to get pregnant because we don’t yet have enough data to determine what happens to the uterine wall and uterine lining following the procedure. For more information about ExAblate, call 214-630-2000 or check out the website for InSightec, the company that developed the technology, at
www.uterine-fibroids.org
.

Myomectomy (Surgical Removal of Fibroids)

Myomectomy is a surgical procedure in which the fibroid tumors are removed, but the uterus is repaired and left in place. Advances in surgical techniques over the past ten years have made this a very nice option for women who want to keep their pelvic organs intact or have children.

Many of my patients elected to have myomectomies even after they’d eliminated all of their symptoms with dietary changes. The presence of the fibroid can still cause an enlarged abdomen that affects how they look and feel about themselves. (I felt the same way.) More and more myomectomies are being done through the laparoscope (a tele scopic instrument that is inserted through the abdominal wall into the pelvic cavity, thus making a large abdominal incision unnecessary). Typically this procedure is reserved for fibroids that are six centimeters or smaller, but that depends upon the surgeon. Many physicians prescribe a GnRH agonist to shrink the fibroid(s) first so that the surgery will be easier. The smaller the fibroid, the better the chance that it can be removed through the laparoscope.

Gloria was forty-five when she first came to see me. She had borne two children, and her husband had had a vasectomy. Gloria had a large fibroid that was pressing on her bladder, causing urinary frequency that kept her up at night. Her periods were regular, and she had no pain. Her gynecologist had recommended a hysterectomy, but this choice felt entirely too drastic to her. Instead, she opted for a myomectomy. Today I would have offered her the choices of uterine artery embolization or ExAblate. At the time, her gynecologist wouldn’t do this procedure “be cause of her age,” an ageist attitude on his part. Like many convention ally trained gynecologists, this one felt that Gloria’s uterus was useless, since she was over forty and didn’t want more children. The myomec tomy that Gloria ultimately had completely relieved her urinary symp toms, and she started sleeping through the night. She is very glad to have kept her uterus.

When the position or size of a fibroid makes childbearing an issue, myomectomy is a good choice. (Neither ExAblate nor uterine artery embolization is recommended for women who wish to become pregnant. We don’t yet know how these procedures affect fertility.) Before they undergo myomectomy, some women are told that once they are in surgery the surgeon may find it necessary to turn the procedure into a hysterec tomy. I never saw a single case in which this was necessary, either in my own experience or in the experience of those patients whom I referred out for the procedure. In general, myomectomies are best done by those gynecologists who have specialty training in infertility surgery. This type of surgery focuses on repairing the pelvis, not on removing organs.

Hysterectomy

Hysterectomy is probably the option most commonly offered to American women who have fibroids. This option is often chosen when a woman has been bleeding for months or even years, is anemic from the blood loss, has an abdomen that looks pregnant, can’t leave home for fear of bleeding through her clothes, and has urinary frequency from a fibroid pushing on her bladder.

Studies have shown that a hysterectomy can improve the quality of a woman’s life if she is given the choice of options other than surgery.
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If, however, a woman has surgery for which she isn’t really ready, with out adequately exploring the alternatives, the results can be devastating. Over the years, I’ve come to see that women who give their options a great deal of consideration before deciding on surgery are much happier with the outcome. (On how to prepare for surgery and the recov ery process, see
chapter 16
.) Unfortunately, there’s often a tendency in medicine to create a crisis situation and rush in. Sometimes a woman who has had a single frightening episode of bleeding with a fibroid will be told to have a hysterectomy as soon as possible. Because of her fear and the sense of being pushed by her doctor or family, she will often go along, when she could have waited. The women who often regret their decisions later, I believe, are the ones who did not feel that they had any choice except surgery, usually hysterectomy. Before embarking upon any course of treatment, a woman should allow herself the time to gather all necessary information and weigh all her options.

Fran, a teacher with one daughter, came to see me when she was forty-two. Over the previous six months, she had developed bleeding between periods, increasing cramps, and some pain during intercourse. When I examined her, I found that she had a fibroid the size of a large grapefruit (about eleven centimeters in diameter). I had known Fran for many years before this, and I had delivered her daughter. She traveled to many different schools during the course of her teaching day and had always found it difficult to maintain a healthful diet. She was significantly overweight and married to a man who hated his job and was somewhat depressed. Given her life situation, her treatment choice was hysterectomy with preservation of her ovaries. She knew that although I could remove the fibroid and leave the uterus intact, this would not guarantee that she’d be rid of her cramps and irregular bleeding.

Fran wasn’t interested in taking the time to pursue alternative treat ment modes, nor was she interested in learning about what her fibroids might be saying to her. The idea of being free from periods, cramps, and the fear of pregnancy was very appealing to her. She had her sur gery without complications and returned to her normal routine within one month. She has never had second thoughts or regrets. Fran is a good example of a woman who knew she had options and was very clear about her choice.

Sexual Response.
About half of women who have their ovaries sur gically removed (most often accompanying hysterectomy), no matter their age, will develop testosterone deficiency rather suddenly due to the total loss of ovarian testosterone production and the subsequent reduc tion in adrenal androgens.
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In general, the incidence of sexual dysfunc tion following hysterectomy is anywhere between 10 and 40 percent. In studies conducted in the United Kingdom, for example, 33 to 46 percent of women reported a decreased sexual response after a hysterectomy-oophorectomy (removal of the uterus and the ovaries).
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But the Maine Women’s Health Study, done in 1994, failed to show a rate that high.
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And some women actually report
increased
sexual response after hysterectomy. For example, Dutch researchers reported that among women who underwent hysterectomies for reasons other than cancer, postsurgical sexual pleasure increased. The results held true regardless of the type of hysterectomy. Of the women studied who were not sexually active before surgery, 53 percent became sexually ac tive after the procedure.
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Doctors haven’t paid nearly enough attention to the connection between hysterectomy and sexual response and have regarded changes in sexual response or loss of interest in sex following hysterectomy as psychogenic only, or “all in the head.” Though the brain is clearly the biggest sex organ in the body, it is also true that hys terectomy can and does affect pelvic nerves and blood supply, which are important for sexual response. One of my patients came to me for a second opinion when her doctor asked her why she was so attached to her ovaries (he wanted to remove them at the time of her hysterectomy). To put it into perspective for him, she asked him why he was so attached to his testicles. As most women know, the mind and the body are a unity. Quite simply, if a woman feels positively connected to her sexual organs, then their removal can affect her sex life for both biological and psychological reasons. We now know that there is a physiological basis for decreased sex ual response in
some
women following hysterectomy-oophorectomy. For example, the androgenic hormone loss associated with the removal of the ovaries is a factor in loss of libido following surgery. Even if the ovaries are left intact, some women experience orgasm dif ferently after hysterectomy, probably because the cervix and uterus act as a trigger point for orgasm. These women feel the deep, rhyth mic contractions of the uterus as a very satisfying part of orgasm. Once the uterus is gone, they sometimes experience the loss as a change, an actual decrease in orgasmic depth. Women who experi ence orgasm mainly through clitoral stimulation may not have this same experience.