LOS ANGELES — Just about everything once taught in medical schools about fibroids should now be recognized as myth, Dr. William Parker said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.
Those myths include the idea that rapidly growing, apparent fibroids could be sarcoma, that all fibroids impair fertility, and that hysterectomy is better than myomectomy because fibroids just come back, said Dr. Parker, an obstetrician-gynecologist who practices in Santa Monica, Calif.
Speaking in a meeting session about alternatives to hysterectomy, Dr. Parker identified the misbegotten notions and made the following points:
▸ Myth No. 1. A rapidly growing fibroid could be or become a leiomyosarcoma.
As a matter of fact, genetic studies have shown that different mutations create fibroids and cancer, and so one does not lead to the other, Dr. Parker said.
In a study he conducted in the early 1990s, in which he reviewed 1,332 patients admitted to the hospital for fibroid surgery, he found that only 3 of those women had a sarcoma. Of 371 patients with rapidly growing fibroids, only 1 had a sarcoma. Moreover, MRI with gadolinium enhancement and lactate dehydrogenase isoenzymes can be used to differentiate malignancies from fibroids, he added.
▸ Myth No. 2. If you can't feel the ovaries because fibroids are in the way, you need to do a hysterectomy because if the patient develops ovarian cancer you would never pick it up.
This is not a good rationale because the clinical diagnosis of ovarian cancer is unreliable anyway, and no one ever suggests to heavy patients that they have a hysterectomy for this reason. Also, if one feels the need to examine the ovaries, there is ultrasound, Dr. Parker said.
▸ Myth No. 3. Intramural fibroids will impair fertility so we need to take them out.
Most studies on this question are actually small series of patients, and that has made the situation somewhat confusing. However, in 2001, a meta-analysis combined studies to total 3,900 patients. The author concluded that intramural fibroids had no effect on any aspect of fertility, including pregnancy rates, implantation likelihood, or deliveries; but fibroids with a submucosal or intracavitary component decreased the likelihood of pregnancy by 70% and removing those fibroids increased the likelihood of pregnancy by 70%.
“Intramural fibroids by themselves do not cause infertility and removing them does not increase fertility,” Dr. Parker said.
▸ Myth No. 4. Fibroids will just grow back after myomectomy, so one might as well do a hysterectomy.
There are many ways of looking at recurrence, and that includes ultrasound, he said. Ultrasound studies suggest that recurrence occurs in 50% of myomectomy cases. But ultrasound picks up fibroids that are small and often clinically insignificant.
In a meta-analysis of seven studies, with 872 women, only 11% of myomectomy patients needed reoperation, with follow-ups that ranged from 10 to 25 years.
That means the gynecologist can tell a 25- to 30-year-old woman that she has a 90% chance of never needing another operation for fibroids before she reaches menopause, Dr. Parker said.
▸ Myth No. 5. Hysterectomy is safer than myomectomy.
Some studies indicate that bleeding problems occur more frequently in myomectomy with increasing uterine weights, but it appears that other complications occur at the same rate with either operation. In fact, hysterectomy actually may be more likely to have complications because with myomectomy the surgeon stays in the uterine space, not outside where there could be damage to the ureters, bowel, and/or bladder, Dr. Parker said.
Gynecologic surgeons have tended not to pay enough attention to bleeding, Dr. Parker asserted. Some of the steps he takes include treating anemic patients with epoetin alfa (Procrit), making transverse incisions in the myometrium to avoid the large arcuate arteries there, and not using a tunneling incision with myomectomy because difficulty in sealing the tunnels can lead to continued bleeding. Instead, he makes one incision for one or two fibroids and closes each when he is finished.
“I think a lot of the things we were taught about [fibroid surgery] were not correct, they were anecdotal,” Dr. Parker concluded.