Could Reproductive Tract Infections Cause Fibroids?
By Alicia Armeli

Uterus with fibroidsLittle is known about the etiology of fibroids. Although certain risk factors have been pinpointed, only hypotheses exist as to what actually causes fibroids to develop.

With many of today’s chronic conditions having an inflammatory component,1 could this also be true for fibroids?

The initial theory linking uterine inflammation and fibroids dates back to the early 1930s.2  Decades later in 2001, this assumption was tested and published in the American Journal of Epidemiology.3 By interviewing 318 women with fibroids, Faerstein, Szklo, and Rosenshein found that those who reported having three or more past episodes of pelvic inflammatory disease were almost four times more likely to have fibroids in comparison to women who never had the disease.

What’s more, the authors of the study found that having reproductive tract infections (RTI) such as chlamydia—a common cause of pelvic inflammatory disease, increased a woman’s risk of fibroids by approximately three-fold; although it was found that this estimate may not have been precise. There was no fibroid risk associated with having genital warts or herpes.

Almost 15 years later, have we gotten any closer to finding whether uterine inflammation plays a role in fibroid formation? A 2015 study in the Journal of Women’s Health4 further investigated this premise.

The study examined ultrasound results and self-reported questionnaires of 1,656 African American women ages 23-34 in the Detroit area who were enrolled in the National Institute of Environmental Health Sciences (NIEHS) Study of Environment, Lifestyle, and Fibroids (SELF).

Moore and her colleagues found that women with a history of bacterial vaginosis had a 21 percent increased risk of having fibroids in general (the study pointed out this was statistically insignificant), 47 percent increased risk of having two or more fibroids, and a 41 percent increased risk of having a larger total fibroid volume.

On the other hand, the authors ironically observed that having a history of chlamydia or pelvic inflammatory disease resulted in a reduced risk of having two or more fibroids.

Given the inconsistency of these results the authors wrote, “Overall, the studies of RTIs and fibroids, including ours, reveal no strong associations.”

“In this large study of young African American women, there was little overall support for an association between women’s self-reported histories of RTIs and subsequent fibroid development,” the authors explained. “Even those having a history of three or more different RTIs or multiple diagnoses of the same RTI showed no indication of elevated odds of fibroids.”

Although results were stated inconclusive, how might we explain the link found between bacterial vaginosis and fibroids, not to mention the findings of previous studies?

Viral and bacterial infections are a known cause of human inflammation5, which in the aforementioned studies, is the proposed reasoning behind fibroid formation.

Uterine fibroids are thought to arise from a single abnormal smooth muscle cell located in the uterine wall.6 Infectious agents have been seen to induce abnormal cell growth3 and it’s thought that inflammation and irritation caused by infection could lead to irregular repair of smooth muscle cells that then lead to fibroid tumor growth.4 5 A closer look at fibroid tissue has even shown increased levels of inflammatory molecules, especially Transforming Growth Factor-Beta (TGF-ß).6

Although we have theories and studies that include interviews and self-reported data that could possibly make a connection, it’s not substantial enough. “Self-reported data…may be subject to error,” Moore and colleagues clarified. “Perhaps a more important problem is that the majority of RTIs can often be [without symptoms], so even those who have not had a previous diagnosis may still have had or currently have an RTI.”

They continued to write, “Some women also may have been tested and were positive but never received their results, did not understand them, or just did not report them due to confidentiality concerns or social desirability bias.”

More attention is needed within this area of women’s healthcare, the authors emphasized. “Future studies are needed to take the next step…to better investigate associations between RTIs and fibroids.”

REFERENCES

  1. Tabas, I. & Glass, C. K. (2013). Anti-inflammatory therapy in chronic disease: challenges and opportunities. Science, 339(6116): 166-172. doi:10.1126/science.1230720
  1. Witherspoon, J. T., & Butler, V. W. (1934). The etiology of uterine fibroids with special reference to the frequency of their occurrence in the Negro: A hypothesis. Surgery, Gynecology, & Obstetrics, 58(4).
  1. Faerstein, E., Moyses, S., & Rosenshein, N. B. (2001). Risk factors for uterine leiomyoma: a practice-based case-control study. II. Atherogenic risk factors and potential sources of uterine irritation. American Journal of Epidemiology, 153(1): 11-19.
  1. Moore, K. R., Cole, S. R., Dittmer, D. P., Schoenback, V. J., Smith, J. S., & Baird, D. D. (2015). Self-Reported Reproductive Tract Infections and Ultrasound Diagnosed Uterine Fibroids in African-American Women. Journal of Women’s Health, 24(6): 489-495. doi:10.1089/jwh.2014.5051
  1. Wegienka, G. (2012). Are uterine leiomyoma a consequence of a chronically inflammatory immune system? Medical Hypothesis, 79(2): 226-231. doi:10.1016/j.mehy.2012.04.046
  1. Maybin, J. A., Critchley, H. O. D., & Jabbour. H. N. (2011). Inflammatory pathways in endometrial disorders. Molecular and Cellular Endocrinology, 335(1): 42-51. doi:10.1016/j.mce.2010.08.006
Is It Necessary to Remove My Ovaries During a Hysterectomy?
By Alicia Armeli

save ovaries blog photo

When other treatment options fail, women with fibroids may choose to have a hysterectomy—a procedure that surgically removes their uterus. With fibroids, the issue lies within the uterus. However, statistics show that half of the hysterectomies performed in the US for benign reasons1, like fibroids, include the removal of the ovaries.  This procedure is known as an elective bilateral oophorectomy (EO).

A 2014 nationwide survey2 found similar results. One third of obstetrician-gynecologists opt for an EO during hysterectomy among premenopausal women—even when the ovaries are still healthy and normally functioning.

According to these findings, removing the ovaries may seem to be a common practice, but is this procedure within every patient’s best interest?

Choosing to remove healthy ovaries is often done to reduce the risk of ovarian cancer later on. Ovarian cancer is the fifth leading cause of death among women in the US and the fourth leading cause of death in women ages 40-59.1 However, removing the ovaries at the time of a hysterectomy should be looked at on a case-by-case basis, as individual factors need to be taken into consideration.

“It really depends on what the patient wants as well as other factors,” says Dr. Mark Perloe MD, an infertility specialist and Medical Director at Georgia Reproductive Specialists in Atlanta. “For example, age has to be considered. We have to be concerned about the potential for disturbing or interfering with normal ovarian function.”

Endogenous estrogen, or the estrogen produced in the body, is linked to having several protective benefits that are lost when the ovaries are removed. For example, women ages 40-44 years of age who undergo an EO have double the risk of heart attack in comparison to women with intact ovaries. A Mayo Clinic Study found that women who had both ovaries removed before the age of 45 had a 67% higher mortality risk.3

Estrogen deficiency following EO is associated with cognitive decline especially within women younger than age 50. Estrogen also plays a role in maintaining bone mineral density and sexual function—both of which have been seen to decrease after surgical menopause.1

When a hysterectomy is used to treat benign conditions like fibroids, ovary removal isn’t necessary unless an additional issue is found with the ovaries.4 Given this fact, in which cases would EO be medically sound? “In many cases now, people are far more conservative,” Dr. Perloe explained. “But if the ovaries are damaged, for example with significant cysts, then it might be appropriate to remove them. It also depends on what the patient’s risks are,” especially when considering ovarian cancer.

The American Congress of Obstetricians and Gynecologists use the onset of menopause as a deciding factor when considering EO during a hysterectomy. As stated in a Practice Bulletin5, “a strong consideration should be made for retaining normal ovaries in premenopausal women who are not at an increased risk of ovarian cancer.”

Effective ovarian cancer screening is a challenge. Statistics show that 63% of cases are diagnosed late due to lack of symptoms, resulting in a 44% 5-year survival rate at all stages.1 Because of this, ovarian removal may be recommended for women who are at a high risk for ovarian cancer—especially those who have a family history or carry genetic mutations. Removing the ovaries as a preventative measure in these cases does not only reduce the risk of ovarian cancer but can reduce the risk of breast cancer6 and associated gynecologic cancers as well.1

For other women who aren’t genetically predisposed, some may argue that removing the ovaries for preventative measures is wise since the disease is so common within the fourth and fifth decade of life. Additionally, several risk factors outside of family history also need to be considered. Being Caucasian, never having been pregnant, late age of menopause, and a long number of years of ovulation are all considered risk factors for ovarian cancer.1

An alternative to removing the ovaries to decrease ovarian cancer risk is the removal of the fallopian tubes—a procedure referred to as a bilateral salpingectomy. “Patients and physicians are showing a growing acceptance of routinely removing the fallopian tubes but preserving the ovaries during hysterectomy,” writes the American Congress of Obstetricians and Gynecologists. “Removing the fallopian tubes during a hysterectomy may lower the risk of developing the most common type of ovarian cancer—[ovarian serious carcinoma]. Increasing evidence points toward the fallopian tubes as the origin of this type of cancer.”7

If one decides to remove the ovaries, hormone replacement therapy needs to be considered since menopausal symptoms are a concern. “Side effects such as painful intercourse or decreased sexuality should not really be a problem—if the ovaries are left intact.” Dr. Perloe clarifies. “But if the ovaries are removed, estrogen replacement may help maintain adequate vaginal function and also help with sleep disturbances, osteoporosis, hot flashes and memory disorders.”

Estrogen-alone therapy is recommended for women who have had their uterus removed8, but it should be noted that hormone therapy, as with any medication, is not risk-free. Some studies show estrogen-alone therapy may be linked to an increased risk of blood clots9 during the first two years of administration.10

If deciding to take hormone therapy, it’s important to consider more than just the general risks involved. “Factors like a family history of stroke, clotting factors, and lipid levels all need to be considered.” Dr. Perloe explains. “Instead of treating everyone exactly the same, we need to look at individual risks for being on estrogen. I think too much of medicine tries to take a one-size-fits-all approach when what we need is to be seen as individuals with our own risk profiles to any medical treatment.”

The choice to have a hysterectomy, or by extension a bilateral oophorectomy or salpingectomy, should be discussed in depth with your doctor. “It’s something the patient and the physician should be deciding together,” encourages Dr. Perloe. “It’s important that patients have a physician they can trust who is going to provide them with all the options, then together they can weigh the pluses and minuses.”

ABOUT THE AUTHOR   Alicia Armeli has a Master of Science in Nutrition and Whole Foods Dietetics (MSN/DPD) and is a Registered Dietitian Nutritionist, a Certified Dietitian, and a Holistic Life Coach. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

ABOUT THE DOCTOR  Mark Perloe is an infertility specialist and Medical Director at Georgia Reproductive Specialists. Dr. Perloe has extensive experience treating conditions related to infertility including menstrual disorders, uterine fibroids, endocrine and other reproductive health problems. He presently serves on the advisory board of the journal of Fertility and Sterility.

REFERENCES

  1. Erekson, E. A., Martin, D. K., & Ratner, E. S. (2013). Oophorectomy: the debate between ovarian conservation and elective oophorectomy. Menopause, 20(1): 110-114. doi:  10.1097/gme.0b013e31825a27ab
  1. Harmanli, O., Shinnick, B. S., Jones, K., & St. Marie, P. (2014). Obstetrician-gynecologists’ opinions on elective bilateral oophorectomy at the time of hysterectomy in the United States: a nationwide survey. Menopause, 21(4): 355-360. doi: 10.1097/GME.0b013e31829fc376.
  1. Parker, W. H. (2014). Ovarian conservation versus bilateral oophorectomy at the time of hysterectomy for benign disease. Menopause, 21(2): 192-194. doi: 10.1097/gme.0b013e31829be0a0
  1. University of Maryland Medical Center. (2012). Uterine fibroids and hysterectomy. Retrieved July 1, 2015, from http://umm.edu/health/medical/reports/articles/uterine-fibroids-and-hysterectomy
  1. The American Congress of Obstetricians and Gynecologists. (2008). ACOG Practice Bulletin No. 89. Elective and risk-reducing salpingo-oophorectomy. Obstetrics & Gynecology, 111(1): 231-41.
  1. Wise, J. (2015). Ovary removal is linked to lower breast cancer mortality in BRCA1 carriers. British Medical Journal, 350: h2182. doi:10.1136/bmj.h2182
  1. The American Congress of Obstetricians and Gynecologists. (2013). Growing acceptance of removing fallopian tubes but keeping ovaries to lower ovarian cancer risk. Retrieved July 1, 2015, from http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Growing-Acceptance-of-Removing-Fallopian-Tubes
  1. Cleveland Clinic. (2013). Hormone Therapy. Retrieved July 1, 2015, from http://my.clevelandclinic.org/health/diseases_conditions/hic-what-is-perimenopause-menopause-postmenopause/hic-hormone-therapy
  1. Eisenberger, A., & Westhoff, C. (2014). Hormone replacement therapy and venous thromboembolism. The Journal of Steroid Biochemistry and Molecular Biology, 142: 76-82. doi:10.1016/j.jsbmb.2013.08.016
  1. Curb, J. D., Prentice, R. L., Bray, P. F., Langer, R. D., Van Horn, L., Barnabei, V. M., Bloch, M. J., Cyr, G. G., Gass, M., Lepine, L., Rodabough, R. J., Sidney, S. Uwaifo, G. I., & Rosendaal, F. R. (2006). Venous thrombosis and conjugated equine estrogen in women without a uterus. The Journal of the American Medical Association, 166(7): 772-780. doi:10.1001/archinte.166.7.772
Is It Necessary to Remove My Uterus?
By Alicia Armeli

NecessarytoRemoveUterus

In the United States alone, 400,000 hysterectomies are done annually with 68% performed to treat benign conditions like abnormal uterine bleeding and fibroids.1 With numbers this high, it raises the following question, Is a hysterectomy medically necessary for fibroid treatment?

“While hysterectomy is an option for women suffering with symptomatic fibroids, it’s completely unnecessary,” says Dr. John Lipman MD, Medical Director and Interventional Radiologist at the Atlanta Interventional Institute in Atlanta, Georgia, and a pioneer developer of uterine fibroid embolization (UFE). “If you have cancer, hysterectomy is completely appropriate,” he emphasizes. “But fibroids are benign tumors.”

Yet, ironically, statistics show that hysterectomy continues to be the second most common surgery in the U.S. performed on women of reproductive age.2

Three types of hysterectomies exist and, depending on the reason for surgery, can also include the removal of the ovaries and fallopian tubes. A radical hysterectomy removes the uterus, cervix, and surrounding tissue that hold these structures in place. A total hysterectomy removes the uterus and cervix, whereas a partial or simple hysterectomy removes the uterus but leaves the cervix intact.3

Hysterectomies can also be performed differently. For example, an abdominal hysterectomy is an open procedure with large incisions and a slow recovery time that can last between four to six weeks4—and, for some women, could take up to eight weeks.5

A hysterectomy can also be performed through the vagina or laparoscopically—a type of surgery that makes small incisions in the abdomen and then uses slender instruments to help guide the surgeon in removing the uterus. This technique avoids the need for a larger incision, as seen in an abdominal hysterectomy3 and has a recovery time of about three to four weeks.4 However, as Dr. Lipman points out, this is performed in the minority of cases.

Although one technique may be considered less invasive than another, each has its own set of risks and complications both during and after surgery. “With any surgery there are risks of bleeding, infection, and adhesions,” Lipman explains. “The risks and recovery time of UFE are much lower than surgery. Our patients go home the same day with just a Band-Aid and are back at work typically one week after the procedure.”

Multiple studies have indicated potential post-procedural complications such as bladder dysfunction following all three types of hysterectomies.6,7  A five-year follow-up study published in the British Journal of Obstetrics and Gynecology found persistent vaginal bleeding to follow partial hysterectomy.7 Other possible complications can include constipation, pelvic pain, sexual dysfunction, and depression.7,8

Despite the potential consequences seen in the majority of women, some gynecologists still believe hysterectomy is best and should be recommended more often to pre- and perimenopausal women. The authors of a paper entitled, Should We Recommend Hysterectomy More Often to Pre-Menopausal and Climacteric Women? contend that benefits associated with having a hysterectomy outweigh potential risks of living with a postmenopausal uterus.9 Authors Erik Qvigstand and Anton Langebrekke wrote, “We argue that hysterectomy should be considered with myomas (uterine fibroids) and/or abnormal uterine bleeding if [women] have no desire for pregnancy and are aged above 40 years.” They added, “minimally invasive techniques…will never be 100% successful, and many women will require retreatment.”

“While some women will require retreatment, this is the exception,” Dr. Lipman disputes. “Ninety percent of women who undergo UFE will find relief from their symptoms and in women treated who are over 40 years of age, the majority will make it to menopause without any additional therapy.”

Furthermore, the benefits to a woman keeping her uterus may outweigh the retreatment risk. “The uterus is important for women beyond childbearing,” Dr. Lipman continues. “It’s important for them physically—women having hysterectomies are seen to experience bone loss, as well as experience psychological and sexual obstacles. Some women see losing their wombs as losing their womanhood and struggle with this.”

Albeit Qvigstad and Langebrekke’s second argument is true, that there’s never a total guarantee with any medical procedure, studies show that less-invasive techniques like UFE are promising for the majority of women suffering from fibroids.

According to a study published in the American Journal of Obstetrics and Gynecology,10 a reintervention hysterectomy following uterine fibroid embolization (UFE) was performed in approximately 28% of women who saw no relief in heavy bleeding. But upon further analysis, the authors of the study found that only women with higher body mass indices experienced unsuccessful UFE. The results of this study mirror other studies that found long-term improvement of heavy bleeding in nearly 75% of women who underwent UFE.11

With effective and minimally invasive techniques like UFE available, the question still remains, Why are so many women still opting to part with their wombs? The truth is that many women are unaware of alternatives to surgery, prior to hysterectomy.

Over a decade ago, a Yale University study showed only 5 percent of gynecologists were suggesting UFE as a treatment option.12 Another study revealed many women who underwent UFE had learned about it from family, friends, the media, and researching online—but not by gynecologist referral.13 Today referral statistics have improved but still have a long way to go.

Earlier this year at the 40th Annual Society of Interventional Radiology Meeting, Dr. Lipman presented data from his research revealing that out of 234 women who later underwent UFE to treat their fibroids, 57 percent of these women were told surgery was their only option and weren’t informed of UFE as a potential treatment.

“It’s 2015 and most women today who suffer from uterine fibroids and go to their gynecologist may not hear about UFE,” says Dr. Lipman. “A woman has the right to know all of her options. UFE is safer, less invasive, less expensive, and has a much shorter recovery time than surgery. But most importantly, a woman finds the relief she is looking for and gets to keep her uterus.”

If a woman is experiencing fibroid symptoms such as heavy bleeding, pelvic pain, and increased urinary frequency, the best action she can take is to seek out medical advice from physicians who work in a collaborative fashion. Detailed counseling from medical professionals regarding the effects of every procedure should be an integral part of each care plan. Creating such a dynamic has been show to improve overall patient care and satisfaction, says a study published in the Journal of Minimally Invasive Gynecology.14

“A woman should see her gynecologist and have a thorough exam to see if she does indeed have fibroids,” encourages Dr. Lipman. “If she does, then her gynecologist will give her a range of treatment options. Once she has her gynecologist’s recommendation, she should then seek out an interventional radiologist who has expertise in UFE and get an additional opinion. Once she’s presented with all the tools and information she needs, she can weigh the pros and cons and decide what’s best for her.”

ABOUT THE AUTHOR Alicia Armeli has a Master of Science in Nutrition and Whole Foods Dietetics (MSN/DPD) and is a registered dietitian nutritionist, a certified dietitian, and a holistic life coach. In addition to writing, she enjoys singing, traveling abroad and volunteering with her local animal shelter.

ABOUT THE DOCTOR John Lipman is Medical Director and Interventional Radiologist at the Atlanta Interventional Institute in Atlanta, Georgia, and a pioneer developer of UFE. With his extensive UFE experience and by actively participating in clinical research trials, Dr. Lipman strives to help the public and other physicians become better informed about uterine fibroids and all treatments available.

REFERENCES

  1. Corona, L. E., Swenson, C. W., Sheetz, K. H., Shelby, G., Berger, M. B., Pearlman, M. D., Campbell, D. A., Delancey, J. O., & Morgan, D. M. (2015) Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. American Journal of Obstetrics & Gynecology, 212(3): 304.e1-7. doi:10.1016/j.ajog.2014.11.031
  2. National Women’s Health Network. (2015). Hysterectomy. Retrieved July 14, 2015, from https://nwhn.org/hysterectomy?gclid=CMzggab63cYCFYU5aQodVJwPxQ
  3. The American Congress of Obstetricians and Gynecologists. (2015). Hysterectomy. Retrieved July 14, 2015, from http://www.acog.org/Patients/FAQs/Hysterectomy
  4. Office on Women’s Health, US Department of Health and Human Services. (2014). Hysterectomy. Retrieved July 17, 2015, from http://womenshealth.gov/publications/our-publications/fact-sheet/hysterectomy.html
  5. Royal College of Obstetricians and Gynaecologists. Recovering Well: Information for you after an abdominal hysterectomy. Retrieved July 22, 2015, from https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/recovering-well/abdominal-hysterectomy-recovering-well.pdf
  6. Maneschi, F. (2014). Urodynamic study of bladder function following nerve sparing radical hysterectomy. Journal of Gynecologic Oncology, 25(3):159-161. doi:10.3802/jgo.2014.25.3.159
  7. Andersen, L. L., Zobbe, V., Ottensen, B., Gluud, C., Tabor, A., & Gimbel, H. (2015). Five-year follow up of a randomised controlled trial comparing subtotal with total abdominal hysterectomy. British Journal of Obstetrics and Gynecology, 122(6):851-857. doi:10.1111/1471-0528.12914.
  8. Goktas, S. B, Gun, I., Yildiz, T., Sakar, M. N., & Caglayan, S. (2015). The effect of total hysterectomy on sexual function and depression. Pakistan Journal of Medical Sciences, 31(3):700-705. doi:10.12669/pjms.313.7368
  9. Qvigstad, E., & Langebrekke, A. (2011). Should we recommend hysterectomy more often to pre-menopausal and climacteric women? Acta Obstetricia et Gynecologica Scandinavica, 90: 811-814.
  10. van der Kooij, S. M., Hehenkamp, W. J. K., Volkers, N. A., Birnie, E., Ankum, W. M., & Reekers, J. A. (2010). Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. American Journal of Obstetrics & Gynecology, 203:105.e1-13.
  11. Scheurig-Muenkler, C., Koesters, C., Powerski, M. J., Grieser, C., Froeling, V., & Kroencke, T. J. (2013). Clinical long-term outcome after uterine artery embolization: sustained symptom control and improvement of quality of life. Journal of Vascular and Interventional Radiology, 24(6):765-771. doi:10.1016/j.jvir.2013.02.018
  12. Yale University. Section of Vascular and Interventional Radiology. (2001). Women would rather switch than fight with gynecologist over uterine fibroid embolization. Retrieved July 23, 2015, from http://yaleir.vasculardomain.com/images/uploaded/yale/switch_ufe.cfm
  13. Lvoff, N. M., Omary, R. A., Ryu, R. K., Chrisman, H. B., Resnick, S. A., Vogelzang, R. L., et al. (2002). The role and effect of gynecologists in referring patients for uterine artery embolization; Abstract presented at the 27th Annual Scientific Meeting of the Society of Cardiovascular and Interventional Radiology (SCVIR). Baltimore, MD.
  14. Zurawin, R. K., Fischer, J. H., & Amir, L. (2010). The effect of a gynecologist-interventional radiologist relationship on selection of treatment modality for the patient with uterine myoma. Journal of Minimally Invasive Gynecology, 17(2):214-221. doi:10.1016/j.jmig.2009.12.015