Thursday, 28 October, 2010
Not so long ago, women typically had babies in their 20s, developed fibroids in their 30s and underwent hysterectomies in their 40s. For most, at least, that was the typical progression. But these days, as more women hold demanding jobs, many delay childbearing — and most expect more say in their health care. Hysterectomy is just one choice in a growing menu of treatments for uterine fibroids, one of the most common and least discussed of female afflictions.
Several procedures, each new one less invasive than the last, have become available in the last decade, enabling women to avoid major surgery, protect their fertility and return to work within days rather than weeks.
With myomectomy, for example, doctors cut out the fibroids but leave the uterus intact. A technique called uterine artery embolization shrinks fibroids by blocking their blood supply. And with M.R.I.-guided ultrasound, tightly focused ultrasound beams zap fibroids, using magnetic resonance imaging to guide the process.
Moreover, new medicines are in development, including a class of drugs called progesterone receptor modulators that may shrink fibroids without inducing menopause and bone loss, as existing medications do.
All the new treatments, as well as more sophisticated diagnostic techniques, are part of a growing interest in a condition long considered too unpleasant and embarrassing to talk about, even though nearly three-quarters of women are affected.
“Because fibroids are benign, we overlook the significant burden on health,” said Dr. Barbara J. Davis of Millennium Pharmaceuticals, a drug researcher who was the principal investigator for the Fibroid Growth Study, a four-year project tracking 100 women that was sponsored by the National Institutes of Health. The study is one of several reflecting increased interest in, and financing for, fibroid research in the past decade. Although the study is finished, the results are still being analyzed.
Fibroids, which are abnormal, multishaped growths of tissue and fat, appear in only one place in the body: the uterus. The tumors are almost always benign but can grow to the size of a football and cause menstrual bleeding and pelvic pain so severe that some women plan their schedules around their monthly periods. The excessive bleeding is not only disruptive but can also lead to anemia.
Depending on their size and location, fibroids can also reduce fertility by as much as 70 percent and and cause several obstetric complications, including premature birth.
Though scientists still do not know what causes fibroids, they believe the answer will not only lead to new treatments for the disease but also shed light on the origins of cancer.
“If we could understand why fibroids remain benign even though they’re so prevalent and so large, we might be able to learn something about how to stop malignant tumors,” said Cheryl Walker, a researcher at the M.D. Anderson Cancer Center in Texas. Her lab discovered fibroids in a species of rodent called the Eker rat that turned out to be remarkably similar to those found in humans.
“Mother Nature gave us a wonderful model,” said Dr. Walker, who is continuing to study the genetic makeup of the rats’ fibroids as well as their response to potential drugs.
In both Eker rats and humans, pregnancy appears to protect against fibroids. That supports one theory that modern women may be suffering more from the benign tumors than their ancestors, who spent most of their short lives either pregnant or nursing, with fewer menstrual cycles and less hormonal fluctuation to disturb the uterus.
“I call it my broken light bulb hypothesis,” said Dr. Elizabeth A. Stewart, a professor of obstetrics and gynecology at the Mayo Clinic. “If you keep flicking it on and off it will eventually blow.”
Though hysterectomy remains the only foolproof cure for fibroids, alternative treatments continue to gain popularity and surgical techniques continue to be refined. Myomectomy, for example, once required surgery to open up the abdomen. Today it can be done laparoscopically, through a small incision into the navel, or hysteroscopically, by vaginally inserting a telescope through the cervix and into the uterus.
Uterine artery embolization, originally used to treat postpartum hemorrhage, was introduced in the United States in 1997 after first being used for fibroids in France. The patient is sedated, a catheter is inserted into her groin, and tiny plastic pellets are blown in until they plug up the blood vessels feeding the fibroids. The patient is usually released after an overnight stay at the hospital, followed by a week of rest at home.
Once the fibroids are deprived of blood, they usually shrink within a few menstrual cycles. Symptoms like pain, bleeding and frequent urination ease in 85 to 95 percent of patients, said Dr. James B. Spies of Georgetown University, an interventional radiologist who has performed the procedures on thousands of patients, including Secretary of State Condoleezza Rice.
“She went back to work in something like three days, which wasn’t my recommendation, but she’s a very dynamic person,” Dr. Spies said.
In M.R.I.-guided ultrasound, the newest and least invasive of the procedures, tightly focused ultrasound waves burn up the fibroids “like a magnifying glass with the sun’s rays,” said Dr. James Segars, head of fibroid research for the National Institute of Child Health and Human Development. During the outpatient procedure, the woman lies inside an M.R.I. tube, while the images help the doctor focus high-intensity beams on her fibroids.
A big caveat to all these new treatments is that the fibroids can grow back, prompting the need for more procedures. And because the techniques are still so new, their effect on fertility, despite preserving the uterus, is not yet known.
Still, most experts agree that they represent a huge boon to millions of women who have been suffering in silence.
“This is an incredibly interesting disease,” Dr. Walker said. “It’s the elephant in the room in that it has a huge impact on women’s lives, yet you almost don’t hear it discussed because it’s not cancer.”
By LESLIE BERGER, NYT