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Fibroid patients need personalized care by Heather Woolwine Public Relations Hidden inside the female body, uterine fibroids are the most common gynecological tumor and the No. 1 cause of hysterectomies each year. At MUSC, Department of Obstetrics and Gynecology physicians and other clinicians hope to decrease the number of hysterectomies related to fibroids, and are committed to minimizing the impact of a condition that can negatively affect a person’s quality of life.   In January, MUSC conducted the first symposium for its Center for Uterine Fibroids.   Surgeons prepare to remove a uterine fibroid. According to David Soper, M.D., Obstetrics-Gynecology professor and Clinical Affairs vice chairman, fibroids are seen every day in obstetrics and gynecology practices throughout the country. Twenty-five percent to 30 percent of American women experience fibroids, while that number increases to 77 percent for women of African-American descent. Some symptoms and side effects of fibroids include infertility, pregnancy loss, pelvic pain and excessive uterine bleeding.   As he introduced the reasons for the symposium, Soper highlighted what is needed to better treat patients who have fibroids. “We need state-of-the-art choices so that patients can realize their reproductive potential, minimize morbidity and promote individualized care based on patients’ needs,” he said.   Soper acknowledged the need to expand fibroid knowledge at MUSC and said that an innovative approach to diagnostic imagery to help geographically map fibroids in the uterus, as well as better understanding their physiology, would place the MUSC Center for Uterine Fibroids at the forefront of decreasing what Soper called the unnecessary numbers of hysterectomies for fibroids.   “A decade ago this was the only treatment, but today other options are looking more promising,” Soper said. “We now have opportunities to refine minimally invasive surgeries, uterine artery embolization and other up-and-coming medical therapies. There is a lot of NIH [National Institutes of Health] interest in this as well… We need to establish more collaborative research with MUSC basic scientists so we can determine a standardized system of classification for fibroids, history and racial difference studies, genetic and molecular studies, and more clinical trials for various hysterectomy modalities.”   Thus, the goal of the MUSC Center for Uterine Fibroids is to provide comprehensive evaluations and treatment of fibroids with a multi-disciplinary approach, capable of offering several options for treatment, from minimally invasive surgeries to traditional hysterectomies. What is a fibroid? Michael Armstrong, M.D., Obstetrics-Gynecology assistant professor, described fibroids as benign tumors that happen because of any one or combination of factors, including genetic predisposition, steroid hormones, peptide growth factors and adequate blood supply. He mentioned evidence supporting the idea that estrogen especially promotes their growth and said that some studies show an increase in fibroid risk with the earlier onset of menarche (getting a first period). While Armstrong said that some risk factors are still debated among experts today, fibroid production seems to have association with age, obesity, African-American heritage, and hormone replacement therapy.   Three kinds of fibroids are: intramural (within the wall of the uterus and the most common); subscrosal (grow from the wall and outside the uterus); and submucous (grow from the wall and inside the uterus).   Armstrong discussed several other interesting points from medical literature, and said that postmenopausal women actually have 70 percent to 90 percent reduction in risk for developing fibroids. For women aged 40-to 44-years-old, the risk increases two- to-three fold versus other women.   The most common symptoms associated with fibroids are increased abdominal girth and pressure, sometimes resulting in urinary frequency, outflow obstruction or compression of the uterus and other organs. Most patients with fibroids will have uncomplicated pregnancies, but some may experience degeneration and pain, abruption, abortion, malpresentation and/or pre-term labor. Armstrong reported the number of women with fibroids treated each year as approximately 600,000, with one in three of those women having a hysterectomy. He cited hospital charges associated with hysterectomies in excess of $2 billion per year.   Hence the mission of the Center for Uterine Fibroids is to learn more about them through research into their causes and treatments. Investigating the hormones and extracellular matrix proteins that promote the processes of fibroid growth and development may lead to innovative treatment options that do not involve removing the uterus. By combining the expertise of physicians in gynecology, interventional radiology and basic science research, patients will obtain access to all the current treatment options for fibroids, Armstrong said.   Bryan Toole, Ph.D., Cell Biology and Anatomy professor, discussed the similarities and differences among fibroids, wounds and cancer, and how that information helps scientists and physicians to better understand how fibroids function. While Toole noted that many of the growth characteristics of fibroids and tumors may be similar, he said it was important to note that fibroids are non-malignant. In addition and despite similarities with some of the body’s wound healing processes, fibroids are non-healing. Treating and looking at fibroids Donald Fylstra, M.D., Obstetrics-Gynecology associate professor, explained the importance of using imaging techniques to look at fibroids. “It’s important to use imaging to look at fibroids, because patients may have symptoms that are not easily explained by a pelvic exam. There may be another need to evaluate the pelvic mass, and it helps to pinpoint the location of the fibroid,” he said. “Imaging gives us a better picture of what treatment options a patient has, as well as providing a sound method for post-treatment follow-up.”   Another promising approach to reducing the impact of hysterectomies is via removal of uterine fibroids laproscopically, thus rendering the surgical experience easier for the patient. James Carter, M.D., Obstetrics-Gynecology associate professor, briefly discussed dramatic advances made in instrumentation that gave rise to the current landscape of minimally invasive surgical procedures. “In the mid-90s, 70 percent of hysterectomies were done abdominally, while 29 percent were done vaginally,” he said. “About this time, the debate began over which method was better, the traditional abdominal incision, or the use of laproscopic hysterectomy. Laproscopic surgeries are consumer-driven, the patients are asking for them and they offer better alternatives in terms of scarring and recovery.”   Carter outlined the six overall hysterectomy techniques available, and presented information showing laproscopic hysterectomies as promoting lower pain scores, better sexual function, decreased pain, quicker recovery and decreased complications and urinary symptoms. Noting varying opinions among practitioners, Carter acknowledged that little actual study data have made some in the medical community skeptical. “It’s a promising, minimally invasive procedure, but the techniques need to be standardized,” he said. It is also the center’s priority to facilitate research studies conducted on the cause and treatment of fibroids. By looking at fibroids via advanced imaging techniques and working with basic scientists to better understand physiology, physicians can better determine the proper medical management of fibroids. Ashlyn Savage, M.D., Obstetrics-gynecology assistant professor, said that around $3 billion to $5 billion is spent annually on the diagnostic measures and treatments for fibroids. Savage presented information that she believes supports the ideal situation of having medical therapies replace the need for surgery. “By doing that, medical costs are lower, we minimize side effects and risks to the patient, and we promote little to no impact on reproduction,” she said.   Savage presented several current hormone treatments and therapies, showcasing a variety of results when the treatments were used individually or in combination. She emphasized that any new therapies should focus on the reproductive goals of the patient, the side effects and the patient’s primary treatment goals. Why a fibroid center? With a growing need for research aimed at developing less invasive alternatives for uterine fibroids, uterine artery embolization (UAE) has shown promise in controlling symptoms caused by fibroids. UAE is performed by specialists in interventional radiology. While radiologists are experienced in angiographic X-ray procedures, they have little experience in the treatment of fibroids. Conversely, gynecologists see fibroids often, but are not trained to perform UAE. Working together, the two disciplines can offer a unique, minimally invasive way to treat fibroids.   The finale delivered by J. Bayne Selby, M.D., Radiology professor, included information about how, through better relationships, radiology and OB/GYN can work together to solve fibroid issues for some patients. According to Selby, in the 90s physicians in France were embolizing fibroids prior to hysterectomies to minimize bleeding during surgery. What they found, however, was that some of those patients did not need surgery because the fibroids did not cause anymore problems after embolization.   “Acceptance of embolization has been slow because traditionally OB/GYN and interventional radiology don’t work together often,” he said. “But we’re working on establishing a better relationship so we can look at this as a viable treatment option for patients with fibroids.”   Selby outlined the process for patients undergoing the procedure, including post-embolization follow-up plans. He cautioned attendees that “pain or lack thereof is not a predictor of the outcome, nor can the level of pain be predicted by the size or number of fibroids.”   While all of these innovative techniques for the alternative treatment of fibroids and related conditions may prove to be effective treatments when compared to traditional hysterectomy, the number of patients treated by these methods has been small. Armstrong said, “The MUSC Center for Uterine Fibroids will focus on alternatives to hysterectomy for the treatment of fibroids and follow-up, which to date has been relatively short term. Furthermore, the Center for Fibroids will evaluate the safety of these alternatives with respect to women desiring pregnancy. To date, this has not been well established in the medical literature. The center will offer comprehensive evaluation and treatment of uterine fibroids and related conditions.”   For more information about the Center for Uterine Fibroids, visit http://www.muschealth.com or call 1-800-424-MUSC (6872).     Friday, March 2, 2007 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.