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Friday, April 19, 2019

No “best” treatment for common uterine fibroids

The other night, I sat in a restaurant with a group of girlfriends. We shared laughter, good conversation and some great wine. As I looked around, I realized that we were likely to share something else: uterine fibroids. Of the ten women sitting at the table, there was a good chance that seven of us would have uterine fibroids at some point in our lives.

Fibroids are noncancerous tumors that grow in the uterus. They may be smaller than a seed or bigger than a grapefruit. A woman may have only one fibroid or she may have many. Depending on their size, number, and location, fibroids can cause heavy bleeding and long menstrual periods (which can, in turn, cause anemia), pelvic pain, frequent urination, or constipation. Fibroids can also cause infertility and repeated miscarriages.
No “best” treatment

Given how common uterine fibroids are, you’d think there would be a lot of research comparing treatment options. In fact, there are only a few randomized trials to guide treatment. In a clinical practice article in today’s New England Journal of Medicine, Dr. Elizabeth A. Stewart, professor of obstetrics and gynecology at the Mayo Clinic, lays out the options and discusses the factors that women and their doctors should consider when making treatment decisions.

First, are the fibroids causing symptoms? If not — which is often the case — no treatment is needed.

Next, what are the symptoms? These can be broadly divided into two categories: heavy menstrual bleeding and “bulk” symptoms. Bulk symptoms, like pelvic pain and frequent urination, are caused by the presence of large fibroids in the abdomen.

“I consider the severity of symptoms and the impact of those symptoms on a woman’s quality of life to be the foundation of treatment decision making,” says Dr. Aaron Styer, an obstetrician-gynecologist at Harvard-affiliated Massachusetts General Hospital. “For example, is the woman missing work, requiring frequent hospitalizations, or missing out on normal, daily life? If so, that information will guide the treatment I recommend.”

Whether a woman would like to have children, her age, and how close she is to menopause can also ninfluence the treatment decision. Once a woman enters menopause, fibroids often shrink or even disappear. But until menopause, they may continue to form or reappear after they are removed.
Hysterectomy, hold the power morcellation

Removal of the uterus (hysterectomy) is a popular option for women who are done having children. With the uterus gone, new fibroids can’t form. But traditional hysterectomy, in which a surgeon makes a large incision in the abdomen, is major surgery.

In laparascopic hysterectomy, the surgeon removes the uterus through three or four small incisions in the wall of the abdomen. Recovery is quicker and there are usually fewer complications than with a traditional hysterectomy.

Laparascopic hysterectomy has historically been accompanied by a procedure called power morcellation. It uses a device to cut the uterus into fragments so it can be removed through the small incisions. But the FDA recently recommended limiting the use of power morcellation because of the small chance that a woman having surgery to remove fibroids may have undiagnosed uterine cancer. If power morcellation is performed in these women, there is a risk that the procedure will spread the cancer throughout the abdomen and pelvis. This is precisely what happened in the much-publicized case of Dr. Amy Reed, an anesthesiologist at Boston’s Brigham and Women’s Hospital.
Treatment options for heavy bleeding

Women with heavy bleeding who do not want to have a hysterectomy can turn to both medical and surgical options. Some medications reduce heavy bleeding by helping blood clot. Hormonal birth control works by thinning the endometrium. This is the nutrient-rich lining of the uterus that is shed during a woman’s period. Medications can relieve symptoms, but they don’t treat the underlying problem.

A surgical option to treat heavy bleeding is hysteroscopic myomectomy. In this procedure, a thin tube called an endoscope is passed through the cervix and into the uterus. The fibroid is shaved and removed, but the uterus is left intact. If a woman does not want to have children, she can opt for endometrial ablation. In this procedure, the endometrium is destroyed, often with heat or cold.
Treatment options for bulk symptoms

When fibroids cause pelvic pain or frequent urination, the goal of treatment is to reduce the size of the fibroids. Medications called GnRH agonists effectively shrink fibroids. However, fibroids grow back once the treatment is stopped, and these drugs are not intended for long-term use.

Myomectomy — this time done through a larger incision in the abdomen — can reduce the size of the fibroids while preserving a woman’s ability to have children. However, fibroids can recur after myomectomy. Another option is uterine artery embolization. This procedure blocks the blood supply to fibroids, causing them to shrink and die. Women are significantly more likely to have a successful pregnancy and delivery after myomectomy than after embolization.

A treatment option that is increasingly being used to treat uterine fibroids is MRI-guided ultrasound surgery. It uses ultrasound waves to shrink fibroids and reduce heavy menstrual bleeding.
Which treatment is right for you?

While there are many treatment options for uterine fibroids, there is no clear winner. That means you and your doctor can choose a treatment based on your preferences and reproductive plans along with other medical considerations.

As you decide, ask your doctor:

    Which treatment gives me the best chances of having a healthy pregnancy?
    Which treatment is most likely to offer permanent removal of fibroids?
    What are my personal risks and benefits of medical versus surgical treatment options?

Let your doctor know:

    whether you plan to have more children
    if you’d prefer to keep your uterus, even if your childbearing days are over
    which symptoms you find most bothersome and how they affect your quality of life.

There may be no “best” treatment for uterine fibroids. But there is a best treatment for you. One morning not long ago, my teenage daughter started to black out. After an ambulance ride to our local hospital’s emergency department, an electrocardiogram, and some bloodwork, she was sent home with a follow-up doctor appointment. We got the good news that Alexa is perfectly healthy, but should avoid getting too hungry or thirsty so she doesn’t faint again. And I’m feeling lucky that she didn’t need to be hospitalized, because a research letter in this week’s JAMA Internal Medicine points out that hospitalization for low-risk fainting can do more harm than good.

Doctors use something called the San Francisco Syncope Rule to identify individuals who are at low risk for serious short-term problems after fainting and who don’t need to be hospitalized. Yet up to one-third of fainters at low risk are still hospitalized. “Most patients in the U.S. are admitted even if they don’t need to be, because doctors worry there might be a life-threatening cause,” says Dr. Shamai Grossman, an associate professor of emergency medicine at Harvard Medical School, who’s conducted about 20 studies on fainting.
The new research

Researchers at Johns Hopkins University followed more than 200 people between the ages of 19 and 97 (average age of 61) who were admitted to the hospital for fainting, also called syncope (SIN-co-pee). This is the sudden loss of consciousness resulting from reduced blood flow to the brain, followed by spontaneous recovery. About one-third of all those admitted were at a low risk for short-term serious problems like heart failure or an abnormal heart rhythm.

Among the low-risk fainters, the average hospital stay lasted almost two days. During that time, they underwent a variety of tests, including CT and MRI scans of the head, ultrasounds of the heart, and imaging of the spine.

Is all that testing and evaluation necessary if you’re at low risk for more serious problems? “Complete loss of consciousness always deserves a thorough medical evaluation,” says Dr. Deepak Bhatt, a cardiologist and the editor in chief of the Harvard Heart Letter. “On the other hand, if someone is feeling lightheaded from not eating or drinking all day on a hot day, that may not be serious, yet may lead to a series of unneeded tests.”
The risks of unnecessary treatment

There were a few people in the study whose hospital stay or follow-up care uncovered a serious condition. But far more often, fainters at low risk for serious problems wound up experiencing more harms than benefits by being hospitalized.

For example, among the low-risk fainters in the study, testing uncovered “incidental findings of unclear significance” in 23 people. In other words, tests revealed other medical conditions that weren’t necessarily helpful to discover, such as calcified lymph nodes, spine fractures that had no symptoms, and changes in white matter in the brain. Those people experienced the inconvenience and expense of testing, only to come away with information that did little to pinpoint the cause of the fainting but that probably caused them anxiety and prompted even more tests.

What’s more, some problems that happened to low-risk fainters during hospitalization could have been prevented. Nine (mostly older) individuals experienced adverse events such as blood transfusion errors, falls, delirium, medication errors, and complications from the placement of an IV drip or a urinary catheter.

Hospitalization isn’t cheap, either. “A recent study suggests the average cost for a syncope admission is $2,420 per day. Being held for observation has an average cost of $1,400 a day,” says Dr. Grossman. In addition, admitting people to the hospital when they’re at low risk for additional problems means that they’re taking up valuable hospital beds that sicker people might need.
Fainting risks

Sometimes fainting is nothing to worry about. It can be caused by stimulation of the vagus nerve. This can happen if you strain while urinating, have blood drawn, get an injection, hear bad news, or even laugh too hard. These kinds of fainting episodes are known as vasovagal syncope; it commonly affects young people.

Sometimes the cause of fainting is never determined. “In about half of the cases, we don’t have a clear cause for fainting. So in low-risk individuals, we send them home and often they get more tests, and even then we still don’t find a cause,” says Dr. Grossman.

But you shouldn’t ignore losing consciousness, especially if you’ve never fainted before or if you have other medical problems or symptoms. For example, chest pain or shortness of breath either before or after fainting could indicate a heart problem. Other serious causes of fainting include a ruptured aneurysm, gastrointestinal bleeding, or a ruptured ectopic pregnancy.

So when should you be hospitalized after fainting? “The problem is that you can’t evaluate yourself, and you should let a physician determine if fainting is worrisome or not,” says Dr. Grossman. “But just because you’re in the emergency department doesn’t mean you need to be admitted to the hospital.”

He recommends that you ask your physician if you’re at risk for a worse event if you go home, and to make sure that if you’re admitted, it’s because there’s a potential serious cause to your fainting that can’t be fully assessed in the emergency department.

In our case, Alexa didn’t need to be hospitalized. But I’m glad she was fully evaluated; it was a relief to know she’s okay. I’ll just have to stay vigilant about keeping her well fed, well hydrated, and well advocated-for if fainting ever lands her in the emergency department again. I never planned on running a marathon, even though I had run for fitness and enjoyed going longish distances. I’ve never been fast, and any run over 8 miles had me wishing I had thought to use the bathroom again before heading out or thinking about how much laundry I could have finished in the time it would take me to finish a route.

But when a friend asked me to train with him to run the Boston Marathon for charity, I decided to go for it. The training was long and sometimes tedious but it was worth it to be part of this extraordinary event. I was pleased to finish in a respectable time, but what made it so rewarding was running “my” marathon (I won’t say race because I was not racing by any stretch).

Here are a few tips I’d like to share with Monday’s marathoners.

    You’ll find this advice in many running resources, but never, ever wear something on marathon day that you haven’t worn for a distance run before. Preferably many times before. That includes socks, definitely shoes, shorts, underwear, watches, sunglasses, hats, you name it. The last thing you need is unexpected discomfort, chafing, or blisters.
    If you have family or friends watching you along the route, try to know in advance where they will be. My best memories of the marathon were being able to hug friends and give my sisters and my husband a kiss on my way. Knowing where they were going to be made it easier for me to see them and to maneuver to the correct side of the road for a sweaty public display of affection.IMG_5213
    “The wall” is real so have a plan. I didn’t. I was quite pleased with myself that I made it through Newton and Heartbreak Hill in relatively good shape. But when I rounded into Cleveland Circle, my body said “I am D-O-N-E, done.” In that moment, I had no idea what to do. If this happens to you, try walking for five minutes or, if you’re running with music, cranking up your most inspiring tunes.

At the rate I was going, walking wouldn’t be that much slower or easier, so I kept shuffling. I could at least say I ran the whole thing. Which I did. But I think I would have been just as satisfied if I had to walk.

    Try to take in the atmosphere—and I don’t just mean breathing hard! The last 4 miles were tough for me. I was running along and looked up and saw a sign that said “Go Nancy.” “Wow,” I thought. “Someone has a sign for someone with my name!” As I glanced up, I saw it was for me. A friend from work had made it and was rooting me on.

But even if it wasn’t for me, I was amazed at all the support and encouragement the crowds offered all the runners. Tune into that goodwill and support. The crowd appreciation can help you keep moving. It really is for you and can help keep you moving.

    Enjoy the camaraderie. As I was turning onto Gloucester Street — the final stretch — a runner I’d never met looked at me and said “I can’t believe we’re here!’ I couldn’t either and it was great to share that moment (especially when you’re one of the back-of-the-pack runners). Throughout the race, don’t hesitate to connect with your fellow runners.

If you are running the Boston Marathon on Monday, I wish you a joyous and rewarding run. No matter how fast you go, how far you make it, or what shape you’re in when you’re done, you’ve been a part of something special. I’ll be cheering you on.

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