When Discomfort Turns Dangerous – How a Fibroid-Related Uterus can lead to Life-Threatening Blood Clots
By Alicia Armeli

BloodClots

A 49-year old Philadelphia woman was admitted to Temple University Hospital emergency room with difficulty breathing, lightheadedness, and swelling in her legs. Her tests revealed that she had blood clots in her lungs—a condition called Pulmonary Embolism (PE). These clots caused right-sided heart failure and elevated blood pressure in her lungs. She reported having a history of blood clots in her lungs and legs.1

Halfway around the world in Urmia, Iran, a 42-year old woman arrived at Seyyed-al Shohada University Hospital with some of the same symptoms. Complaining of difficulty breathing and chest pain, doctors ran tests and found she, too, had a blood clot in her right pulmonary artery—the artery that carries blood from the heart to the lungs—and another in her left leg.2

Both women were treated for their blood clots and something else entirely—an enlarged uterus caused by uterine fibroids.

Uterine fibroids are the most common noncancerous pelvic tumor in women over age 30.2 And although these growths don’t cause health problems in the majority of cases, 25 percent of reproductive age women with fibroids will experience heavy painful periods and bulk symptoms like constipation, pelvic pressure, and a rare complication many would never expect—blood clots.3

Ranging in size, uterine fibroids can be very small or grow to the size of a softball and larger. In unusual cases, these larger fibroids can compress adjacent blood vessels in the pelvis and those leading to the heart and lungs, slowing blood flow and causing clot formation.2

According to the American Journal of Case Reports, and as seen in these two women, the most common blood clots associated with a fibroid-related enlarged uterus were PE found in the lungs and clots in the legs called Deep Vein Thrombosis (DVT).2

Dr. Paul Forfia, MD, Director of the Pulmonary Hypertension/Right Heart Failure and Pulmonary Thromboendarterectomy Program at Temple University Hospital in Philadelphia, discusses in a recent article, “Deep vein thrombosis occurs when a blood clot forms in one or multiple veins deep in the body, most commonly in the legs. The clots can break loose and travel to, get lodged in, and block blood flow in, the lungs—a condition called pulmonary embolism.”1 He further explains that these blood clots can impede “blood flow through the lungs and cause right-sided heart failure, shortness of breath, and other issues.”

Fibroid-related PE and DVT are rare but can happen quickly and may be life-threatening. Proper treatment can reduce this risk, resulting in a good prognosis. With the help of a doctor, women are encouraged to monitor fibroid growth to avoid serious health complications.

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering in her community.

REFERENCES

  1. Forfia, P. (2016). Medical Mystery: Difficulty breathing, light-headedness in walking. Retrieved July, 25, 2016, from http://articles.philly.com/2016-05-15/news/73105069_1_pulmonary-hypertension-pulmonary-embolism-clots
  2. Khademvatani, K., Rezaei, Y., Kerachian, A., Seyyed-Mohammadzad, M. H., Eskandari, R., & Rostamzadeh, A. (2014). Acute pulmonary embolism caused by enlarged uterine leiomyoma: A rare presentation. American Journal of Case Reports, 15: 300-303. doi: 10.12659/AJCR.890607
  3. Brigham and Women’s Hospital—Center for Uterine Fibroids. (2016). About Uterine Fibroids. Retrieved July 26, 2016, from http://www.fibroids.net/fibroids.html
Benefits Of Ginger That May Surprise You: Hangover Cure, Motion Sickness Remedy, And Menstrual Cramp Relief

Ginger

Chinese medicine has been using ginger for over 2,000 years to settle upset stomachs. Its medicinal benefits extend beyond cracking open a ginger ale for the classic stomach ache; more recently, ginger has been found to pack just the right amount of vitamins and minerals to help treat the occasional hangover.

Ginger grows naturally as a root and can be eaten or drunk in various forms, and although it’s more often used for its flavor, ginger is also used to prevent several ailments. Ginger contains magnesium, zinc, and chromium which promotes healthy circulation, which in turn helps prevent chills, fevers and excessive sweating. It can be taken to reduce pain and inflammation in the same way aspirin and ibuprofen are used. For those with a wicked hangover, a ginger tea may do the trick.

Continue on to the full article.

Change is Good. Treat Fibroids Without Surgery.
Fibroid Free, by Dr. Suzanne Slonim

Slonim PhotoChange is good.

It took 13 years of training and 21 years in practice, but I am now doing exactly what I was meant to do – educate women about and treat women for uterine fibroids.

I am an Interventional Radiologist (IR). This vibrant field of radiology allows me to do medical procedures using imaging-based technologies including ultrasound, CT scans and fluoroscopy.

I know. It sounds complicated and maybe even intimidating. So in layman terms, I do procedures similar to cardiologists (heart doctors) except in all of the other blood vessels, and use tiny tubes to do them.

This translates into no surgery.

Instead, I diagnose and treat conditions through mildly invasive procedures.

From draining abscesses with ultrasound guidance to fixing ruptured abdominal aortic aneurysms with stent grafts, I’ve loved (almost) every minute of the 21 years I’ve practiced.

Here’s an example of the kind of cases an IR would deal with: Let’s say (heaven forbid) that you were in an accident that caused internal bleeding. Rather than having a big surgery to find where the bleeding is coming from and stop it, I can feed a tiny tube through the blood vessels right to the trouble spot and plug it from the inside. This means no big incision, no scar and a shorter recovery time.

Make sense?

So recently I was given the opportunity to change from a general hospital based IR practice, doing every type of procedure, to a practice focusing my attention on just the areas about which I feel the most passion.

I jumped at the chance.

You see, I’ve always felt that if you could treat a problem without surgery, you should. And there should be a way to treat a lot more problems that have been treated with surgery in the past without making an incision. I tell my patients that a surgery should always be avoided if possible. But if you have a medical problem that requires treatment, do it in the most effective and least invasive way possible.

Getting back to earlier when I mentioned that I’m now doing what I was meant to do, I focus almost all my attention on treating uterine fibroids without surgery.

Conventional medical training taught us that if a woman is finished having children and has any kind of problem with her uterus, take it out. Get rid of it. It’s not serving any purpose and is a potential source of future problems. Gynecologists who recommend hysterectomy have the patient’s best interest in mind. They are not cavalier or just trying to make some money. They have been taught, as I was, that hysterectomy is the proper treatment for fibroids in women who do not intend to have children in the future.

But I listen to my patients. A lot of women do not want a hysterectomy for all kinds of reasons. For example:

“I was born with it and I want to keep it.”

“God put it there for a reason.”

“It’s part of being a woman.”

“It’s where my children came from.”

“I’m afraid I won’t be able to enjoy sex if it’s gone.”

I’ve heard all of those, but the most common reason I hear for not wanting a hysterectomy is this: “I don’t want surgery. Period.” That reason also rules out some of the less invasive treatments for fibroids, including laparoscopic or robotic myomectomy.

Wanting to avoid surgery is a very reasonable sentiment. Surgery has risks. Hysterectomy is a big surgery. It’s painful. It leaves scars. There could be undesirable side effects. There’s a long recovery time. It’s scary. Those are all good reasons to avoid surgery, especially if there’s an alternative. And there is.

Uterine Fibroid Embolization (UFE) is a procedure that treats uterine fibroids without surgery. It involves making a tiny skin nick the size of a grain of rice over a blood vessel and feeding a tube to the blood supply to the fibroids. Tiny particles are injected through the tube to clog the blood vessels to the fibroids. That kills the fibroids, and they shrink away. About 90% of the time, the symptoms caused by the fibroids go away too. Presto! The fibroids are treated without surgery.

I love being able to tell women what they want to hear. “Yes, your fibroids can be treated without surgery.” It’s so rewarding. It makes them happy, which makes me happy.

As I’m building my UFE practice, I’m meeting the most amazing people. Women who are smart enough and brave enough to go looking for an alternative to hysterectomy. Women who are educating themselves about their options. Doctors who are empowering their patients to make informed choices. Men and women who, like me, are dedicated to spreading the word about UFE.

There’s a lot I’m learning about building this practice. As lessons come up, I plan to share them with you. Hopefully I’ll write about something you were wondering. Hopefully, I’ll answer some of your questions. If there’s something you want to ask, just send me an email and I’ll answer it if I can. I’m loving this practice and I feel blessed to be able to do what I love.

Suzanne Slonim, MD, FSIR, FACR
Fibroidfree.com
https://www.facebook.com/fibroidfreecom/?fref=ts

Tranexamic Acid: a Medical Option for Women with Heavy Menstrual Bleeding
By Alicia Armeli

NSAID-Tranexamic-Acid

Imagine periods that make it impossible to sit through your favorite movie because you have to change your tampon—twice. Or bleeding that involves passing clots the size of quarters. Picture this happening every month to the point of becoming anemic. According to one US survey, heavy menstrual bleeding is common—so common that if affects one out of every five women.1

To treat relentless periods, doctors often suggest medical therapy as the first line of defense. One drug in particular called tranexamic acid has shown to reduce heavy menstrual bleeding and improve overall quality of life without major side effects.

“Tranexamic acid, also known as Lysteda, isn’t a hormone but an antifibrinolytic agent,” explains Dr. Linda Bradley, MD, Gynecologic Surgeon, Professor of Surgery, Vice Chair of OB/GYN & Women’s Health Institute, and Director of the Center for Menstrual Disorders, Fibroids, and Hysterscopic Services at the Cleveland Clinic in Cleveland, Ohio. “Antifibrinolytics target the endometrium, which are the cells that produce menstruation, and decrease the breakdown of blood, making you bleed less.”

In clinical trials, tranexamic acid reduced heavy bleeding by over 40 percent and provided greater relief in comparison to placebo, NSAID medications, and some hormonal drugs.2,3,4 These benefits were seen to be consistent for a number of conditions, including inherited bleeding disorders, uterine fibroids, and in women where the cause for heavy bleeding is unknown.

“It’s important for women to understand that for the medication to work, it has to be taken as prescribed, which is two pills every eight hours for the first five days of your period—even if your first day isn’t heavy,” Dr. Bradley recommends.

A major benefit is that when taken properly, results are immediate. Unlike other drugs that take months to see improvement, tranexamic acid starts working during the first period. Seeing fast results helps women and doctors decide whether to continue this line of therapy or try something different.

Another advantage is minimal side effects. Reactions to the medication are usually symptoms related to menstruation—like headache, back pain, and fatigue. In rare events, tranexamic acid has been shown to cause uterine fibroid tissue break down, which could cause low-grade fever and pelvic pain in these women.5

Given the nature of the drug and its ability to slow the dissolving of clots, a recent concern with tranexamic acid is the risk for blood clot formation. “Tranexamic acid isn’t recommended for patients with a history of blood clots, heart attack, or stroke,” Bradley tells Ask4UFE. “However, in clinical trials among patients without these risks, there have been zero reports of blood clots when the drug is taken orally.”

Because of its safety and efficacy, tranexamic acid is used to treat more than heavy periods. Studies have shown it to help control bleeding in gynecological, urologic, orthopedic, vascular, and hepatic surgeries, as well as reduce blood loss among trauma patients. 6,7 Intravenously, its effectiveness in treating postpartum bleeding is currently being studied.7

Although just approved by the FDA in 2009 to treat heavy menstrual bleeding, for years tranexamic acid has been available over the counter in countries like Canada and Britain. “Tranexamic acid is an effective non-invasive treatment option and can provide relief to women with heavy bleeding who also want to spare their fertility,” says Dr. Bradley. “Now that it can be prescribed in the US, I think patients and doctors should be aware of its benefits.”

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

ABOUT THE DOCTOR  Linda Bradley, MD is an internationally recognized gynecologic surgeon, professor of surgery, Vice Chair of OB/GYN & Women’s Health Institute, and Director of the Center for Menstrual Disorders, Fibroids, and Hysterscopic Services at the Cleveland Clinic in Cleveland, Ohio. As founder of the Celebrate Sisterhood program and recipient of the American College of Obstetricians and Gynecologists Pete and Weesie Hollis Community Service Award, Dr. Bradley is dedicated to empowering multicultural women to take charge of their health, embracing self-care, and creating positive change in the world.

REFERENCES

  1. Centers for Disease Control and Prevention. (2015). Heavy Menstrual Bleeding. Retrieved July 11, 2016, from https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
  2. Bradley, L. D., & Gueye, N. A. (2016). The medical management of abnormal uterine bleeding in reproductive-aged women. American Journal of Obstetrics and Gynecology, 214(1): 31-44. doi: 10.1016/j.ajog.2015.07.044
  3. Lukes, A. S., Moore, K. A., Muse, K. N., Gersten, J. K., Hecht, B. R. Edlund, M., Richter, H. E., Eder, S. E., Attia, G. R., Patrick, D. L., Rubin, A., & Shangold, G. A. (2010). Tranexamic acid treatment for heavy menstrual bleeding: a randomized controlled trial. Obstetrics & Gynecology, 116(4): 865-875. doi: 10.1097/AOG.0b013e3181f20177
  4. Leminen, H., & Hurskainen, R. (2012). Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. International Journal of Women’s Health, 4: 413-421. doi: 10.2147/IJWH.S13840
  5. Ip, P. P., Lam, K. W., Cheung, C. L., Yeung, M. C., Pun, T. C., Chan, Q. K., & Cheung, A. N. (2007). Tranexamic acid-associated necrosis and intralesional thrombosis of uterine leiomyomas: a clinicopathologic study of 147 cases emphasizing the importance of drug-induced necrosis and early infarcts in leiomyomas. The American Journal of Surgical Pathology, 31(8): 1215-1224.
  6. Peitsidis, P., & Koukoulomati, A. (2014). Tranexamic acid for the management of uterine fibroid tumors: A systematic review of the current evidence. World Journal of Clinical Cases, 2(12): 893-898. doi: 10.12998/wjcc.v2.i12.893
  7. Bonnett, M. P., & Benhanou, D. (2016). Management of postpartum haemorrhage. F1000 Research. doi:  10.12688/f1000research.7836.1
Will a Menstrual Cup Work for Me if I Have Fibroids?
By Alicia Armeli

Menstrual-Cup

“I have found the answer to a problem as old as Eve,” said Leona Chalmers, advertising her 1937 invention of the first modern menstrual cup.1 Menstruation is nothing new, but for women with symptomatic uterine fibroids, can these discreet cups provide protection from the heaviest of periods?

For decades, menstrual cups have been used throughout Europe and Finland, and yet, for many US women they’re a brand new way of handling menstruation.1

Made from medical-grade silicone, these soft and flexible cups are inserted into the vagina during menstruation to collect blood—instead of absorbing it like pads or tampons. But whether menstrual cups work or not depends entirely on a woman’s body—especially if she has uterine fibroids.

According to Dr. Elisa Ross, MD, an OBGYN at the Cleveland Clinic, individual anatomy can affect how a cup fits inside a woman’s body. Women with fibroids, she notes in a Cleveland Clinic Health Essentials article, could make a menstrual cup “not fit in place properly.”2

Fibroids are the most common tumors of the female genital tract and can cause symptoms like heavy painful periods.3 And although over 99 percent of fibroids are noncancerous, they can grow in a number of shapes and sizes anywhere in the uterus, including the cervix.4

According to the American Society for Reproductive Medicine, uterine fibroids can push on other areas, such as the vagina or pelvic wall.5 This added pressure could pose a problem since menstrual cups work by forming a seal between the cup and the vagina. In cases like these, the cup might not be able to stay in place.

For women whose fibroids don’t inhibit wearing a menstrual cup, doing so could offer many advantages.

Women with fibroid-related heavy periods know that changing tampons and pads throughout the day (and night) can seem endless. Menstrual cups, however, don’t have to be emptied as often. Several popular menstrual cup manufacturers instruct emptying a cup at least every 12 hours depending on flow versus every 4 to 8 hours as seen with tampons.6,7,8

Disposable menstrual cups are available for purchase but so are reusable cups that can be used safely for several years—two to three years according to the FDA—before needing to be replaced.9 This can mean more money in your wallet and less waste in landfills. To get the most use out of a menstrual cup, always follow the care instructions provided by the manufacturer.

Using menstrual cups can also help keep track of changes in menstruation. For example, if a woman notices changes in the amount of bleeding per period or the passing of clots, she can quickly discuss these changes with her doctor.

Made in different sizes to accommodate a woman’s changing body, menstrual cups offer an innovative way to manage that time of the month. The only way to know if a menstrual cup works—with or without fibroids—is to try it out. And who knows? It might turn out to be the perfect fit.

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering within her community.

REFERENCES

  1. Lunette. (2015). Short History of Menstrual Cups. Retrieved July 18, 2016, from https://www.lunette.com/blog/short-history-of-menstrual-cups.html
  2. Cleveland Clinic. (2015). Tired of Tampons? Here Are Pros and Cons of Menstrual Cups. Retrieved July 17, 2016, from https://health.clevelandclinic.org/2015/02/tired-of-tampons-here-are-pros-and-cons-of-menstrual-cups/
  3. Society of Interventional Radiology. (2016). Uterine Fibroids, Diagnosis and Treatment. Retrieved July 17, 2016, from http://www.sirweb.org/patients/uterine-fibroids/
  4. UCLA Obstetrics and Gynecology. (2016). Fibroids. Retrieved July 18, 2016, from http://obgyn.ucla.edu/body.cfm?id=302&fr=true
  5. The American Society for Reproductive Medicine—Reproductive Facts. (2016). Fibroid Tumors. Retrieved July 19, 2016, from http://www.reproductivefacts.org/fibroid_tumor_video/
  6. The Diva Cup. (2016). Care and Cleaning. Retrieved July 18, 2016, from http://divacup.com/how-it-works/care-and-cleaning/#Care
  7. Intimina. (2016). How a Menstrual Cup Can Change Your Life—Infographic. Retrieved July 18, 2016, from https://www.intimina.com/blog/whats-new-menstrual-cup-infographic/
  8. Lunette. (2016). How To Use. Retrieved July 18, 2016, from https://www.lunette.com/us/how-to/how-to-use.html
  9. Lunette. (2016). Menstrual Cup Safety. Retrieved July 19, 2016 from https://www.lunette.com/about/faq/safety.html
Is There a Link Between Fibroids and Uterine Cancer?
By Alicia Armeli

Fibroids-cancer

Uterine fibroids can differ drastically in size. For some women, a fibroid can resemble the head of a pin. For others, fibroids can grow to the size of a melon. A common fear among women is the risk of these otherwise benign tumors becoming cancerous—especially when they grow rapidly in size.

Previous medical opinion linked rapidly growing fibroids to the risk of developing a cancerous tumor called uterine leiomyosarcoma or LMS. A 1994 study published in Obstetrics & Gynecology discredited this belief by showing that the risk of overall uterine cancer among women who underwent surgery for presumed fibroids was low at 0.23 percent.1 Of these women who reportedly had “rapidly growing fibroids,” the total risk of uterine cancer—specifically LMS—was only 0.27 percent.

Over a decade later, there’s still public concern regarding the risk of fibroid-related uterine cancer.

To address this concern, a team of researchers led by Dr. Elizabeth A. Pritts, MD, of Wisconsin Fertility Institute in Middletown, Wis., combed through thousands of scientific journals, narrowing down their search to 133 studies. Results published in Gynecological Surgery showed an estimated rate of LMS found at surgery for presumed benign fibroids to be approximately 1 in every 2000 women or 0.05 percent.2 Much less than previously thought.

Restricting their inclusion criteria further, Dr. Pritts and her team used a final 64 prospective studies and found an even lower risk of approximately 1 in 8300 cases or 0.012 percent. “Results suggest that the prevalence of occult LMS at surgery for presumed uterine fibroids is much less frequent than previously estimated,” Pritts and her team wrote. “This rate should be incorporated into both clinical practice and future research.”

These statistics are notably lower in comparison to previous risk rates calculated by the FDA, which hover around 2 per 1000 surgeries or 0.2 percent.2 These numbers give the medical community pause mainly because approximately 600,000 hysterectomies and nearly 40,000 myomectomies are performed annually in the US alone—many of which are done using laparoscopic power morcellation in order to avoid open surgery.3, 4 And according to the American Congress of Obstetricians and Gynecologists, the majority of hysterectomies—nearly 41 percent—are performed to treat symptomatic fibroids.5

Often used during what are considered “minimally invasive” surgeries, morcellation is a method of breaking up tissue into smaller pieces to help remove it laparoscopically or through smaller incisions. “When used for hysterectomy or myomectomy in women with uterine fibroids, laparoscopic power morcellation poses a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond the uterus,” the FDA reported. “While the specific estimate of this risk may not be known with certainty, the FDA believes that the risk is higher than previously understood.”6

This leaves the public questioning the discrepancy between reported risks. Reviewing available literature is a widely accepted method of assessing medical risk—but it can be done in a number of different ways, leaving much open to interpretation.

According to Pritts, “While differences in methodology accounted for some of the difference in estimated rates, differences in the evidence base accounted for a much larger share.” In both investigations, researchers used their professional judgment to select specific search criteria, choose which studies to include or exclude, and determine which statistical test to use when analyzing collected data. All of these steps can be done differently and can result in higher or lower risk values.

What’s also unclear is how uterine LMS tumors develop. LMS could grow on its own or, albeit rare, arise from mutations found in preexisting fibroids. Genetic studies have shown that even though fibroids and LMS have different microRNA—a particle that regulates gene expression—genetic mutations found in fibroids can also be seen in LMS and may contribute to its development.7

Increasing age is another factor that can influence a woman’s risk of uterine cancer—including LMS. A study published last year in The Oncologist investigated over 2000 women who had undergone surgery for fibroid treatment.8 Results showed that women in their mid to late 70’s were five times more at risk of developing uterine cancer versus women younger than 30 years of age.

What’s also alarming is that uterine fibroids are exceedingly common—affecting up to 70 percent of white women and 90 percent of black women by age 50—and can present with similar symptoms associated with LMS, like abnormal vaginal bleeding, lower abdominal pain, and a pelvic or abdominal mass.9, 10 At this time, there still aren’t any reliable tests available that can predict if a woman with fibroids has uterine cancer until after these masses are surgically removed.

“While we have found that the prevalence of occult LMS is less than previously estimated, this does not negate the fact that such occult malignancies can and do occur,” concluded Pritts and her team. Since the exact change from benign fibroids to LMS isn’t understood and may happen suddenly or over time, women with fibroids are recommended to maintain regular check ups with their gynecologists.

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering in her community.

REFERENCES

  1. Parker, W. H., Fu, Y. S., & Berek, J. S. (1994). Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstetrics & Gynecology, 83(3): 414-418.
  2. Pritts, E. A., Vanness, D. J., Berek, J. S., Parker, W., Feinberg, R., Feinberg, J., & Olive, D. L. (2015). The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis. Gynecological Surgery, 12(3): 165-177. doi: 10.1007/s10397-015-0894-4
  3. Centers for Disease Control and Prevention. (2016). Fact sheet: Hysterectomy in the United States, 2000–2004. Retrieved July 13, 2016, from http://www.cdc.gov/reproductivehealth/data_stats/
  4. National Uterine Fibroids Foundation. (2010). Statistics. Retrieved July 13, 2016, from http://www.nuff.org/health_statistics.htm
  5. The American Congress of Obstetricians and Gynecologists. (2011). Choosing the Route of Hysterectomy for Benign Disease. Retrieved July 13, 2016, from http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Choosing-the-Route-of-Hysterectomy-for-Benign-Disease
  6. US Food and Drug Administration. (2014). UPDATED Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication. Retrieved July 13, 2016, from http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm
  7. Verit, F. F., & Yucel, O. (2013). Endometriosis, leiomyoma and adenomyosis: the risk of gynecologic malignancy. Asian Pacific Journal of Cancer Prevention, 14(10): 5589-5597. doi: http://dx.doi.org/10.7314/APJCP.2013.14.10.5589
  8. Brohl, A. S., Li, L., Andikyan, V., Obican, S. G., Cioffi, A., Hao, K., Dudley, J. T., Ascher-Walsh, C., Kasarskis, A., & Maki, R. G. (2015). Age-stratified risk of unexpected uterine sarcoma following surgery for presumed benign leiomyoma. The Oncologist, 20(4): 433-439. doi: 10.1634/theoncologist.2014-0361
  9. US Department of Health and Human Services. (2013). How many people are affected by or at risk of uterine fibroids? Retrieved July 13, 2016, from https://www.nichd.nih.gov/health/topics/uterine/conditioninfo/Pages/people-affected.aspx
  10. Up To Date. (2016). Differentiating uterine leiomyomas (fibroids) from uterine sarcomas. Retrieved July 13, 2016, from http://www.uptodate.com/contents/differentiating-uterine-leiomyomas-fibroids-from-uterine-sarcomas