What Your Doctor May Not Tell You About Fibroids
by Scott C. Goodwin, M.D., Michael Broder, M.D. and David Drum
Excerpt from Dr. Michael Broder's book, What Your Doctor May Not Tell You
About Fibroids: New Techniques and Therapies:
Including Breakthrough Alternatives to Hysterectomy
One summer day in Atlanta, Georgia, an attractive businesswoman named Victoria emerged from her doctor's office. The well-dressed forty-year-old seemed composed, but inside she was in turmoil. She had just seen her gynecologist because of some puzzling and excessive vaginal bleeding. She came out with an unexpected diagnosis of uterine fibroids.
Victoria stepped into the elevator and pushed the "down" button. She didn't know anything about fibroids. Her gynecologist told her she had "at least one" growing inside her uterus. It was the size of a tennis ball, perhaps. "For now, let's just watch it," her doctor said. Victoria trusted her doctor, who explained medical issues in a frank, matter-of-fact way. However, her doctor said that if the fibroids continued growing, Victoria would need a hysterectomy. The word was like a depth charge inside her. The idea that her uterus might be surgically removed from her body sent a primitive ripple of fear through her, and she involuntarily shuddered as she got off the elevator and walked outside into the bright afternoon sun.
It seemed to Victoria as though her entire body was suddenly under attack. She was afraid of fibroids. She feared cancer. She didn't want surgery. She didn't want to lose her uterus. She wanted children. The prospect of a hysterectomy seemed at that moment to roll toward her like a wild, unstoppable freight train. Unlocking the door to her car, Victoria burst into tears.
Fibroids are small, noncancerous growths that appear in the vast majority of female uteri. Most American women will die at a ripe old age without ever experiencing problems from their fibroids, or even knowing they had them. Fibroids are usually not a problem, but they can grow to produce extremely bothersome symptoms such as bleeding, pain, or infertility, which can drastically lower a woman's quality of life. The symptoms of fibroids can be troublesome, or even unbearable. The good news is that many new treatments can control symptoms without surgery. Hysterectomies are often recommended for women with fibroids, but there are many other options.
Hysterectomies do offer women the certainty of an absolute cure for fibroids, but many hysterectomies are unnecessary, the medical equivalent of killing flies with a sledgehammer. Lifestyle strategies, medical therapies, uterine fibroid embolization, and less invasive forms of surgery can help most women control fibroids without undergoing hysterectomy. Many new treatments control symptoms and make life livable again.
Fibroids have a tendency to run in families. Educated women are more likely to get them. For unknown reasons, black women have a much higher incidence of fibroids than white, Hispanic, or Asian women. Women who have never had children are most likely to be diagnosed with fibroids.
Women who are obese or women with diabetes or high blood pressure may be more likely to have a problem with fibroids.
Fibroids are more common than many women think. One African American woman we know, a college professor at a major university, recalls going to a party with about eight of her women friends. She mentioned in passing that she had fibroids, which had recently been diagnosed.
"I have fibroids," volunteered one friend. "I have them too," said another.
Altogether, about half the women at the party said they had fibroids. After they talked about them, the college professor no longer felt quite so isolated or alone.
Who Gets Fibroids?
Race Incidence* Population of New Cases
Women** Diagnosed Annually
Black 30.6 per 1,000 18,309,891 560,283
White 8.9 per 1,000 98,476,381 876,440
Asian 8.0 per 1,000 5,489,427 43,915
Hispanic 11.0 per 1,000 16,089,357 176,983
American Indian/ Not determined 1,201,634 Not determined
Source: National Uterine Fibroids Foundation.
The uterus supports new life in the form of a developing fetus. While the uterus is not as vital to life as the heart, kidneys, or lungs, it is not a disposable organ. Few men or women want to lose a part of their bodies. The uterus is an important symbolic organ for many women, a testament to their femininity and a living witness to their role in carrying on the human race. The uterus may also play a role in a woman's normal hormone balance and be involved in orgasm and sexual response. Over the ages the uterus has been shrouded in mystery and myth. Some primitive peoples endowed the uterus with magic powers, celebrating it as the very crucible of life. The ancient Egyptians regarded the uterus as a sort of free-roaming animal that moved around a woman's body and acted independently of the woman herself. Over the ages the uterus has been viewed not only as a sexual organ, but also as a source of energy and vitality, and as an organ that helps every woman maintain her youth and attractiveness. Whatever else may be said about it, the uterus is important for the continuation of the human race, the only location on earth in which a fertilized egg can develop into a newborn baby.
Despite the amazing properties of the uterus, many doctors don't think twice about removing it. Beginning in the l970s physician authors were asserting the limited usefulness of a woman's uterus. In All about Hysterectomy, published in 1977, Dr. Harry C. Huneycutt, a Duke University-trained gynecologist, wrote, ". . . the uterus is essentially only a baby carriage. . . ." Dr. Philip Cole, an epidemiologist and head of the Harvard School of Public Health, wrote in 1979: "If a woman is 35 or 40 years old and has an organ that is disease prone and of little or no further use, it might as well be removed." Are these statements really true?
Imagine a man coming to his doctor's office with a benign tumor on one testicle. His doctor informs him that removing the benign tumor and leaving the testicle gives him more than an 80 percent chance of permanent cure. However, the good doctor confidently recommends surgery to remove both testicles because it will guarantee no recurrence of the tumors. "We want to take your testicles, but we'll guarantee you'll never get another benign tumor," the doctor might tell the frightened man.
"But my testicles are part of me," the patient protests. "These are my body parts, and I'd like to keep them." While this example may seem absurd, some gynecologists are recommending a similar solution to women: hysterectomies for benign tumors called fibroids. Just remove that little uterus, and you'll get rid of fibroids forever too. Too many times, women are told hysterectomies are "the only reasonable option." Well, times have changed. This is no longer true.
Advice And Consent
Many women become confused when they receive the diagnosis of fibroids. Being confused makes them vulnerable, and they are inclined to trust their doctors' advice about fibroids. Unfortunately, many doctors have been trained to believe that when fibroids reach a certain size, the only way to proceed is with a hysterectomy. This is not always the best advice. While this surgery does get rid of the fibroids along with the uterus and generally improves the quality of life for most women who choose it, there are many other options. When treating benign conditions such as fibroids, what the patient wants is at least as important as what the doctor recommends.
In so frequently recommending hysterectomies for fibroids, some doctors shirk their important advisory and educational role. A good, ethical medical doctor presents all medical options to the patient, offers an assessment, and allows the patient to decide. However, some doctors try to push patients toward what the doctor believes is the most reasonable option, even if the patient wants something else. In some cases, recommending a hysterectomy may make sense, but it should still be part of a discussion that includes all appropriate treatment options.
A good doctor explains the risks and benefits of each treatment and helps you choose a treatment that is right for you. Even so, this process takes time, and most doctors do not have much time to spend with patients these days. It's not that doctors are greedy or don't care about their patients; some doctors simply feel it is a waste of time to explain every fibroid treatment option to their patients when a hysterectomy will solve the problem once and for all. Some doctors and patients are uncomfortable with long, emotional conversations about a wide range of medical treatments and troublesome side effects. Many doctors can't answer questions about alternative therapies, vitamin supplements, or other therapies they didn't study in medical school.
This book aims to provide what many doctors can't or won't: unbiased, detailed information on all your treatment options. Armed with this information, you will be able to work together with your doctor to choose the best possible treatment for your situation.
After cesarean delivery, hysterectomy is the most common operation performed on American women. Every ten minutes, twelve hysterectomies are performed in the United States. According to the National Health Interview Survey, uterine fibroids are the most common reason for hysterectomy.
Hysterectomy is used much more in the United States than in Europe. Among American women aged eighteen to fifty, more than nine women in every thousand will be advised by their doctors to have a hysterectomy this year. While articles in scientific journals detailing the overuse of hysterectomy date back to the 1940s, there has been essentially no change in hysterectomy rates since that time.
We recently led a government-funded research study that found that perhaps three-fourths of all women are undergoing hysterectomies without a thorough medical evaluation. Published in the medical journal Obstetrics and Gynecology and conducted under the auspices of the RAND Corporation, we used a panel of medical experts to examine the appropriateness of nearly five hundred hysterectomies done on California women by almost a hundred different Southern California doctors. In an astounding 76 percent of cases, doctors failed to meet professional treatment criteria set by the American College of Obstetricians and Gynecologists when recommending hysterectomies. Too often, important diagnostic tests, as well as less invasive and more conservative treatments, were skipped as doctor after doctor rushed their female patients onto the fast track for a hysterectomy.
In our study, a surprising 6 percent of women who had a hysterectomy to treat fibroids did not even have fibroids when pathologists carefully examined their uteri after the procedure.
This suggests that tens of thousands of women who have hysterectomies for fibroids do not even have fibroids. As surprising as this sounds, other studies have found the same thing. An analysis published in the Journal of Public Health found that 4 to 9 percent of women who underwent hysterectomy for fibroids had no evidence of fibroids.
Facts About Fibroids
Here are some facts about fibroids:
- As many as 77 percent of all women have fibroids.
- Between 20 and 40 percent of fibroids create symptoms such as excessive bleeding or pain.
- Over six hundred thousand hysterectomies are performed in the United States each year, 89 percent of them for benign conditions.
- Fibroids account for approximately 45 percent of all hysterectomies.
- Women using hormone replacement therapy are at greater risk for continued symptoms of fibroids compared to women who do not use hormone replacement therapy.
According to our study, many doctors did not perform endometrial biopsies to diagnose the cause of abnormal bleeding, something that is often standard procedure to rule out uterine cancer. Many women with bleeding and pain from their fibroids were never given a chance to see if drug treatments could control their symptoms. In many cases, doctors didn't do enough to rule out other causes of pain before recommending hysterectomy. It is unthinkable that the physicians whose patients we studied intended to harm their patients. However, in three out of every four cases, doctors neglected potentially useful treatments and tests, possibly leading many women to have much more invasive treatment than they needed.
Since 1945 study after study has revealed that huge numbers of hysterectomies performed on American women are unnecessary. Although the large majority of women tell their doctors they are doing just fine after a hysterectomy, small but significant numbers of women are psychologically or physically damaged and experience compromised libido, diminished sexual enjoyment, or pain. Unnecessary hysterectomies may contribute to an early and sometimes painful menopause, creating a cascade of overlapping symptoms that can sometimes be countered only by additional medical treatment in the form of hormone replacement therapy.
In our study, fully 14 percent of the women met no valid medical criteria for undergoing a hysterectomy. While hysterectomies may have been an appropriate recommendation for some of the women, for at least 14 percent in this study, the recommendation was dead wrong. It is a little frightening to think that so many women undergo major surgery without adequate evaluations, or without the chance to try treatments that might have controlled the symptoms with less risk.
The treatment of fibroids has a huge impact on our health care system. Costs include billions of dollars for conventional and alternative treatments, surgeries, medicines, insurance payments, hospitalization, and days lost from work. In 1997 the U.S. Department of Health and Human Services estimated the costs for surgical and other inpatient care for women with fi-broids at more than $2 billion every year, and even this is understated. Hysterectomy costs an average of approximately $6,000 per surgery, which alone adds up to more than $1 billion per year. Hysterectomies for fibroids cause women to spend nine hundred thousand days in the hospital per year, more days than are spent in the hospital for either breast cancer or AIDS.
Myomectomies to remove fibroids cost approximately $5,000 apiece, adding another $200 million per year. When office visits, drugs, and diagnostic procedure costs are included, the cost of treating fibroids easily exceeds $3 billion per year. If you look at such things as time missed from work, child care, or recovery care costs provided by husbands or other relatives, the amount of time lost to fibroids is staggering. If the average woman with symptoms such as bleeding or pain misses only two days a month from work in the six months before and the six weeks after hysterectomy, then fibroids cause between five and eleven million lost days of work every year.
Risk Factors For Fibroids
- Fibroids develop more commonly in women who began menstruating at younger ages.
- Black women are two to three times more likely than white women to be diagnosed with fibroids.
- Women who have never had children develop fibroids more than women who have.
- Women who have had four to five children are at the lowest risk of all: 70 to 80 percent less likely to develop fibroids than those who have no children. (Miscarriages or abortions do not change the risk of getting fibroids.)
- Obese or overweight women tend to have more problems with fibroids.
- Use of birth control pills has no effect on the development of fibroids.
- Fibroids run in families. One study suggested that women are twice as likely to develop fibroids if they run in the family.
- Women who have gone through menopause are less likely to be diagnosed with fibroids.
- Women who smoke are less likely to develop fibroids (even so, the adverse health effects of smoking far outweigh any possible benefits).
These figures do not even include the money spent on newer treatment alternatives such as uterine fibroid embolization, drug treatments that work, or even alternative therapies. These figures do not include money spent on treatments for related psychological problems such as anxiety and depression, and certainly the emotional costs are incalculable. Despite the phenomenal cost of fibroids, tragically little is spent on researching this condition. The dearth of research into new, less invasive treatments has undoubtedly contributed to doctors' overuse of hysterectomy.
About The Book,
What Your Doctor May Not Tell You About Fibroids
This book is written for the woman who wants to learn more about fibroids. While not intended as medical advice, this book does include information on tests and new treatments that your doctor may not have the time to explain during a short office visit. This first chapter introduced the topic of fibroids, offered some surprising statistics, and looked at overall costs of treating fibroids.
In the next few chapters we will explain how fibroids grow and develop, look at how doctors diagnose fibroids, discuss the medical tests used, and explain how your doctor can distinguish fibroids from other conditions, such as adenomyosis and ovarian cysts. In addition, we will help you understand the major symptoms of fibroids, including excessive bleeding, pain, sexual issues, and problems with fertility or pregnancy. In the core of this book we explain why "watchful waiting" may be the best strategy for dealing with fibroids. Diet, exercise, and stress reduction can all help you to control your fibroid symptoms and may reduce the incidence and recurrence of fibroids. We will discuss what you can do about each of these items in taking charge of your own personal health. In covering your potential treatment options for symptomatic fibroids, we discuss alternative medical treatments such as acupuncture, herbs, and homeopathy as well as conventional drug treatments, which may be useful in controlling your symptoms or shrinking your fibroids.
In the last third of the book we cover uterine fibroid embolization, the most promising and important new technique in the battle against fibroids. Pioneered in the United States by Scott Goodwin, M.D., this book's lead author, uterine fibroid embolization is a safe, reliable alternative to surgery for many women with fibroids. In addition, we examine myomectomy, surgery to remove fibroids without removing the uterus, along with hysterectomy, the most definitive but also the most invasive fibroid treatment.
In closing, we take a brief look at promising but experimental new treatments.
A helpful resources section at the back of the book lists books, professional organizations, and Internet sources of interest. A glossary explains common medical terms.
You should use this book as a starting point to educate yourself about the newest and best medical treatments for fibroids. No matter what you may have heard from friends. relatives, or doctors, fibroids are harmless most of the time and usually do not need to be removed with a radical operation such as a hysterectomy. You may be scared by the diagnosis of fibroids, but take heart; there are many good treatments for women with fibroids. More information than ever before is available to the average person, and progress is being made by the day. Many doctors are becoming open to a variety of new approaches to the treatment of fibroids, some of which may be able to reduce or eliminate the need for surgery.
We hope much unnecessary suffering can be prevented as women become more knowledgeable about fibroids, since in an age of continuous medical progress, an educated patient is the best patient of all.
Copyright © 2003 by Scott Goodwin, M.D., and Michael Broder, M.D.
With permission from Hatchett Book Group (formerly Time Warner Books)
Read the transcript of Dr. Michael Broder, author of "What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies--Including Breakthrough Alternatives to Hysterectomy"
Treating Fibroids Without Surgery, Uterine Artery Embolization