Part II: Can Fibroids Affect My Pregnancy?
By Alicia Armeli

Pregnancy

You’re having a baby—and you have fibroids. With the endless amount of information you’re absorbing in preparation for your little one, you may now also be wondering how fibroids could affect your pregnancy.

Fibroids have been reported in approximately 0.1-11 percent of all pregnancies and become more common in women 35 years and older, those who’ve never had children, and among African Americans.1

Although the majority of women with fibroids will have a smooth pregnancy, between 10-40 percent of women will experience complications.1 Facing this reality, it’s important to build awareness around the possible effects these benign tumors can have on a pregnancy in order to receive appropriate care.

Nearly 75 percent of fibroids increase in size during the first and second trimesters and 66 percent during the second and third trimesters. “The increased estrogen and progesterone during pregnancy can result in increased growth which can become problematic in about 5 percent of pregnant women with fibroids,” said Dr. Mark Perloe MD, an infertility specialist and Medical Director at Georgia Reproductive Specialists in Atlanta.

And although fibroids are seen to reduce in size for the majority of women by 50 percent after giving birth, until this occurs, they can be painful and cause pressure on the uterus.1

“Most physicians look at fibroids during pregnancy as a pressure effect,” explained Dr. Perloe. “If the fibroid is cutting down on the blood supply to the uterus by pressing on arteries or causing engorgement in the uterine lining because it’s pressing on the veins that return blood to the uterine lining, this could potentially bring about a miscarriage. Also, larger fibroids may impair the blood supply to the fetus so that growth is retarded or delayed and you have a smaller baby as a result.”

Other complications can include premature labor, postpartum bleeding, the baby being in the wrong position at birth—as seen with breech births, and an increased need for cesarean section.1

But complications and risk of pregnancy loss are significantly linked to several fibroid characteristics like number, location, and size.

A small study published by the American Journal of Obstetrics & Gynecology2 observed 121 women with fibroids between 2002 and 2012. Through ultrasound exam, Lam and colleagues noted the size, location, and number of fibroids in each woman. The authors then compared this information to a total of 179 pregnancy outcomes verified through the women’s medical records.

Results indicated that complications like preterm delivery were more common among women with multiple fibroids. Fibroids located in the lower part of the uterus were associated with the need for cesarean section. And in addition to location, larger fibroids were consistent with postpartum bleeding.

Other studies have shown that fibroids specifically growing into the uterine space or within the uterine wall—but not outside the uterus—are connected to higher rates of miscarriage. This is also true if the placenta grows next to or over an existing fibroid.1

Since having fibroids is associated with more complications, it’s important to see your gynecologist to learn more about your fibroids before conceiving and then also throughout your pregnancy—especially monitoring where they are in relation to the placenta and cervix.1  Doing so could help assess the pregnancy and any potential risks. “Each person’s fibroids offer a unique situation,” Dr. Perloe stressed. “This baby is going to be around for a lifetime and you want to make sure you’re doing everything to give the baby the best life.”

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  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. Guo, X. C., & Segars, J. H., (2012). The impact and management of fibroids for fertility: an evidence-based approach. Obstetrics & Gynecology Clinics of North America, 39(4): 521-533. doi: 10.1016/j.ogc.2012.09.005.
  1. Lam, S. J., Best, S., & Kumar, S. (2014). The impact of fibroid characteristics on pregnancy outcome. American Journal of Obstetrics & Gynecology, 211(4): 395.e1-5. doi: 10.1016/j.ajog.2014.03.066.

Part I: Can Fibroids Affect My Fertility?
By Alicia Armeli

fertility

Uterine fibroids are a common gynecological condition affecting as many as 1 in 5 women of childbearing years.1 Although these tumors are benign, they can have serious complications like heavy painful periods and may even make it difficult for a woman to get pregnant.

“The majority of women who have fibroids are not symptomatic,” explained Dr. Mark Perloe MD, an infertility specialist and Medical Director at Georgia Reproductive Specialists in Atlanta. In fact, statistics show that fibroids are only found in about 5-10 percent of infertile women and may be the standalone cause of infertility in approximately 1-2 percent.2

But for the small number of women who are affected, fibroids can impede the intricate process of conceiving.

“Through ultrasound, we now know there are tiny micro-contractions of the uterus and these are responsible for getting the sperm where they need to go,” Dr. Perloe told Ask4UFE. “If there’s a fibroid, it turns out that the uterus’ contribution to moving the sperm out toward the egg, or the fertilized embryo back toward the uterus, may be compromised.”

In women undergoing fertility treatments, recent studies have shown that the greater number of uterine contractions per minute a woman has during insemination is significantly associated with a higher success rate, or greater number of live births.3

But the presence or absence of fertility complications depends on more than just having fibroids. Specific factors like fibroid location and size also play a part.

“A fibroid that pushes into the endometrial cavity within the uterine lining can have an adverse effect on fertility,” Dr. Perloe clarified. “Also, if there’s a fibroid that’s larger than 3 cm in size in the wall of the uterus, it’s likely that it will interfere as well because it’s pressing on where the embryo would grow. If a woman has a fibroid that grows outside the uterus and gets pregnant—they will usually do just fine. It’s very rare that the fibroid grows to the point that it could cause problems.”

In order to remove fibroids, there are many treatments available that will provide relief, but a woman who wants to conceive must also consider whether these are fertility-friendly.

“There is no place for medical treatment of fibroids in someone wanting to conceive,” Dr. Perloe emphasized. Medical therapy for fibroids often suppresses ovulation and disrupts hormone levels necessary to make the uterine lining ready for implantation.4 Others, like non-steroidal anti-inflammatory drugs (NSAIDs), can be used to help with symptom relief but do not change fibroid size.2

Myomectomy, or the surgical removal of fibroids, has been a long-standing procedure that leaves the uterus intact and allows women to keep their fertility. For women who wish to become pregnant, “minimally invasive surgery such as laparoscopic myomectomy or robotic myomectomy may be the procedure of choice for women with myomas (uterine fibroids),” Dr. Perloe explained. “An MRI screening procedure is a helpful tool to make sure that all the fibroids are discovered. With robotic surgery alone, the physician is unable to palpate the uterus to determine if all fibroids have been removed.”

And finding all fibroids can help decrease the need for additional surgeries. Avoiding multiple myomectomies is important because any cuts made to internal organs can result in surgical scar tissue known as adhesions.5 Adhesions that grow in and around the uterus could decrease a woman’s ability to conceive6 and the more surgeries a woman has, the higher the risk for adhesions.5

Less invasive procedures like uterine fibroid embolization (UFE) and its effect on fertility are being studied. During UFE, particles are injected into the uterine arteries blocking blood flow to the fibroids causing them to shrink. A 2015 review published by Minimally Invasive Therapy & Allied Technologies6 showed that fertility success rates with UFE were comparable to that of myomectomy with 48 percent of women getting pregnant following UFE and 46 percent after myomectomy. And there’s another up side—UFE has an approximate 90 percent cure rate, which means less need for subsequent procedures.

But UFE does have its risks as well. Some research has shown that due to possible disruption of uterine blood flow, the ovaries could be affected resulting in early menopause.6 Other studies report the absence of menstruation post UFE and possible damage to the uterine lining.2

“Shrinking the fibroids with UFE may interfere with the uterine lining afterwards because the particles that cut off the blood supply to the fibroids can also cut off blood supply to the uterine lining,” Dr. Perloe said. “UFE is contraindicated in women wanting to conceive. While fertility is fine, pregnancy outcome is compromised.”

Another minimally invasive fibroid treatment that may show promise is magnetic resonance guided focused ultrasound surgery or MRgFUS—a non-surgical procedure that uses intense ultrasound waves to destroy fibroid tissue. “MR focused ultrasound does not work in everyone and it depends where the fibroids are located,” Dr. Perloe clarified. “And again you may not be getting rid of the fibroid completely so whether it’s actually improving the odds of pregnancy is unclear.” Research has shown that because of this, recurring treatments may also be necessary. More long-term larger studies are needed.6

Taking everything into account, what’s the first step for women with possible fibroid-related infertility?

“The body knows what it’s supposed to do,” Dr. Perloe said. “The question is whether fibroids are standing in the way of this and interfering with getting pregnant or the outcome of pregnancy.” Because of this, proper diagnosis of fibroids and assessment of the number, size, and location is the first step. This can help to ensure the best approach for treatment, thereby offering the greatest chances of conceiving and having a healthy pregnancy.

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 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. US National Library of Medicine. (2014). Uterine Fibroids. Retrieved September 16, 2015, from https://www.nlm.nih.gov/medlineplus/ency/article/000914.htm
  2. Guo, X. C., & Segars, J. H., (2012). The impact and management of fibroids for fertility: an evidence-based approach. Obstetrics & Gynecology Clinics of North America, 39(4): 521-533. doi:  10.1016/j.ogc.2012.09.005
  3. Blasco, V., Prados, N., Carranza, F., Gonzalez-Ravina, C., Pellicer, A., & Fernandez-Sanchez, M. (2014). Influence of follicle rupture and uterine contractions on intrauterine insemination outcome: a new predictive model. Fertility and Sterility, 102(4): 1034-1040. doi: 10.1016/j.fertnstert.2014.06.031.
  4. Carranza-Mamane, B., Havelock, J., Hemmings, R., Reproductive Endocrinology and Infertility Committee, Cheung, A., Sierra, S., Carranza-Mamane, B., Case, A., Dwyer, C., Graham, J., Havelock, J., Hemmings, R., Liu, K., Murdock, W., Vause, T., Wong, B., Burnett, M., & Society of Obstetricians and Gynaecologists of Canada. (2015). The management of uterine fibroids in women with otherwise unexplained infertility. Journal of Obstetrics and Gynaecology Canada, 37(3): 277-288.
  5. National Institute of Diabetes and Digestive and Kidney Diseases. (2013). Abdominal Adhesions. Retrieved October 12, 2015, from http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/abdominal-adhesions/Pages/facts.aspx
  6. McLucas, B., Voorhees Iii, W. D., & Elliott, S. (2015). Fertility after uterine artery embolization: a review. Minimally Invasive Therapy & Allied Technologies, 2: 1-7.
Celebrity UFE Physician to Answer your Questions

Dr. John LipmanIf you are Cynthia Bailey of the Real Housewives of Atlanta or Teresa Edwards of the WNBA, who do you call on to help you become fibroid free? You call Dr. John Lipman.

Dr. Lipman was the first interventional radiologist to perform uterine fibroid embolization (UFE) in Georgia. He was the National Physician Spokesperson for the Ask4Tell4 fibroid campaign with supermodel Beverly Johnson. He has helped over 5,000 women become fibroid free without open surgery and by using the UFE technique.

UFE is a process in which small plastic or gelatin particles are injected through a catheter into the arteries that supply blood to the fibroids, cutting off access to the blood supply and forcing the fibroids to shrink and die.

Dr. Lipman will present How (and Why) To Avoid Hysterectomy For Women With Fibroids and answer your questions in a FREE event, this Wednesday, Oct. 14. Register now to be a part of this unique opportunity to speak with one of the leading physicians in the field.

Who Am I Without My Uterus? The Psychological, Social, and Cultural Stigmas of Hysterectomy
By Alicia Armeli

Hysterectomy

A uterus can embody many things. For some women, it provides a sense of self, gender identity, and sexual prowess. For others, it signifies fertility and can even dictate a woman’s cultural desirability. And still, hysterectomy continues to be one of the most common gynecological surgeries performed worldwide.1

But women are speaking out. Stories of psychological, social, and cultural stigmas experienced by hysterectomized women are surfacing—many of which reveal the residual costs that have left some to question who they are now and how they can relate to the world around them post-hysterectomy.

“At the time, I had no idea what was happening to me,” recalled Lise Cloutier-Steele, whose own hysterectomy and bilateral salpingo-oophorectomy at age 38 spurred her to write the book, Misinformed Consent: Women’s Stories About Unnecessary Hysterectomy. “In my interviews, I was hearing the same things. A common thread between the hundreds of women I spoke to were feelings of betrayal. We weren’t told what would happen after the surgery.”

And experts agree. The experiences of women who undergo hysterectomy have not been given adequate attention—especially in the area of how reproductive organs can provide a sense of identity to women.

“Gender identity is one of the most fundamental means by which individuals are recognized, both by others and by themselves,” explained Dr. Jean Elson, PhD, MA, MEd, Sociologist and Senior Lecturer Emeritus for the Department of Sociology at the University of New Hampshire. “It is our core inner feeling of who we are as women, men, both, or neither.”

In Elson’s research, as discussed in her book, Am I Still a Woman? Hysterectomy and Gender Identity, she found that gender identity is produced through personal embodied experience. Depending on the culture and the individual, this gender identity could be affected if a woman experiences changes to her body. “Most women in my study found hysterectomy a crisis that prompted them to examine the connection between sexual reproductive organs and gender identity.”

Although the uterus itself is only a fraction of a woman’s gender identity, its presence—or absence—is part of how she relates to the world around her. This is especially true concerning her intimate relationships. The quality of relationships plays a significant role in whether a woman is able to maintain or reclaim gender identity after surgery.2 Elson explained that romantic partners could either reinforce or calm a woman’s fears surrounding the loss of sexual attractiveness post-hysterectomy.

“Sexuality is often a basic component of feminine gender identity,” explained Dr. Elson. “Some respondents found they no longer felt they measured up to appropriate cultural standards for sexual attraction, including maintaining a youthful appearance, a slim figure, and physical flawlessness.” Women who expressed concern regarding diminished sexual attractiveness were predominantly heterosexual. In addition, several women of differing sexual orientations perceived changes in their own sexual desire or response as a result of hysterectomy.

A woman’s perception of losing sexual attractiveness is compounded when sexual dysfunction becomes a reality following surgery. Earlier this year, one study3 found that some women who underwent hysterectomy for benign reasons experienced sexual dysfunction and increased depression.

These findings sounded all too familiar to Ms. Cloutier-Steele. Depression—due to loss of sexuality—was a common finding in her interviews. “No one asked us what sex was like before the surgery. No one explained that if they remove the cervix, the vagina will be shortened. And for those women who enjoy deep uterine orgasms, you can’t experience that anymore. It was devastating after the fact.” Patient information such as this is crucial since factors such as sexual function are significant predictors of hysterectomy satisfaction.4

Sexual dysfunction can be damaging to women in the healthiest of relationships but can hold even higher stakes for those who live in patriarchal societies where childbearing is highly valued and a woman’s role is to please her husband sexually.

“Most of the women I interviewed accepted strong cultural beliefs that motherhood is an essential component of women’s identity,” Elson explained. “Loss of reproductive organs created insecurity regarding gender identity for those women, including women who had already borne children or were past menopause.”

This ideation is prevalent in Middle Eastern countries and corresponding cultures where a woman’s value, social status, and self-esteem are linked to her ability to have children. Childbearing is perceived as a family commitment.5 If a woman cannot bear children, divorce is justified. High rates of anxiety and depression have been observed—even in menopausal women.6

In the Latin American world, women face similar hardships. Machismo7, a concept of extreme masculinity and unquestioned authority, places women in a subservient role. In such cases, a woman’s body is considered only for the enjoyment of men and changes to it, as seen with hysterectomy, can prove damaging to intimate relationships.

A study published in Health Care for Women International7 found that Mexican men who adopted the machismo role believed that without a uterus, a woman would be “incomplete, empty, her femininity adversely affected” and “she would have problems with her partner.” Mexican women reported feeling anxious around a procedure that would threaten their role and that may cause men to leave and seek sexual satisfaction elsewhere.

This harsh reality is not one that exists solely outside the US. A qualitative study8 found that African American women were aware of the social stigmas associated with hysterectomy in the black community. Several African American women reported keeping their surgery a secret for fear of losing a partner and that family members warned them against hysterectomy because “they (men) won’t want you.” The authors pointed out that, historically, black males associated fertility control with feeling powerless, which may have contributed to some of the responses to hysterectomy.

It’s undisputed that negative stereotypes exist regarding hysterectomized women, but it’s important to note these views are not universal. In the aforementioned studies, experiences differed between women with “a continuum of responses from very positive to very negative.” Several women reported feeling supported and that their partners “only wanted what was best for them.”8

Dr. Elson stressed, “Women are different from each other in many ways, and do not react similarly to the same medical procedure.”

As such, hysterectomy may be appropriate for some, but it’s not for everyone. Researchers have emphasized how limited women’s knowledge is in the area of their reproductive organs and, by extension, the consequences of their removal.4 It’s the responsibility of physicians to fill in the knowledge gaps. Women have reported their physicians recommending hysterectomy but no other alternatives.

“Women’s free choice to undergo hysterectomy is really only constrained choice when there are a lack of appropriate alternative options.” Dr. Elson clarified. “Women I interviewed often explained that they would have preferred less radical options if those had been offered. The power to choose is meaningless if women are given no alternatives.”

And it’s because of stories like these Ms. Cloutier-Steele is adamant that woman are completely informed. “It’s the misinformation—many women would not have surrendered to having these procedures if they had known. If a doctor’s only solution is to open you up and take everything out, he’s not the one for you. Find a doctor with the right skill,” Cloutier-Steele admonished. “Ask questions and talk to everyone on both sides, but look for the facts as to how real women live without their organs.”

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 Jean Elson has a PhD in sociology, a joint master’s degree in sociology and women’s studies, and a master’s degree in educational psychology. Her book, Am I Still a Woman? Hysterectomy and Gender Identity, has helped women and the medical community understand the complex interconnectedness of body and gender identity. She currently is Senior Lecturer Emeritus for the Department of Sociology at the University of New Hampshire. Areas of specialty include sociology of gender, family, women’s health and illness, and sexual behavior.

ABOUT CLOUTIER-STEELE Lise Cloutier-Steele is a communications specialist, professional writer and editor, and women’s rights advocate. She’s the author of Misinformed Consent: Women’s Stories about Unnecessary Hysterectomy. By telling the stories of hysterectomized women, Cloutier-Steele has encouraged her readers to look beyond surgery. She’s also author of the books Living and Learning with a Child Who Stutters and There’s No Place Like Home. Ms. Cloutier-Steele has received a Canada 125 Award in recognition of her significant work within the community.

REFERENCES

  1. Hammer, A., Rositch, A. F., Kahlert, J., Gravitt, P. E., Blaakaer, J., & Sogaard, M. (2015). Global epidemiology of hysterectomy: possible impact on gynecological cancer rates. American Journal of Obstetrics and Gynecology, 213(1): 23-29. doi: 10.1016/j.ajog.2015.02.019
  2. Elson, J. (2004). Am I still a woman? Hysterectomy and gender identity. Philadelphia, PA: Temple University Press.
  1. 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
  2. Harmanli, O., Ilarslan, I., Kirupananthan, S., Knee, A., & Harmanli, A. (2014). Women’s perceptions about female reproductive system: a survey from an academic obstetrics and gynecology practice. Archives of Gynecology and Obstetrics, 289: 1219-1223. doi: 10.1007/s00404-013-3116-1
  3. Serour, G. I. (2008). Medical and socio-cultural aspects of infertility in the Middle East. Human Reproduction, (1): 34-41. doi: 10.1093/humrep/den143
  4. Douki, S., Zineb, S. B., Nacef, F., & Halbreich, U. (2007). Women’s mental health in the Muslim world: Cultural, religious, and social issues. Journal of Affective Disorders, 102(1-3): 177-189. doi: 10.1016/j.jad.2006.09.027
  5. Marván, L., Quiros, V., López-Vázquez, E., & Ehrenqweig, Y. (2012). Mexican beliefs and attitudes toward hysterectomy and gender-role ideology in marriage. Health Care for Women International, 33: 511-524. doi: 10.1080/07399332.2011.610540
  6. Williams, R. D. & Clark, A. J. (2000). A qualitative study of women’s hysterectomy experience. Journal of Women’s Health & Gender-Based Medicine, 9(2): S15-S25.