What Your Doctor May Not Tell You About Fibroids

Excerpted from
What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies-Including Breakthrough Alternatives to Hysterectomy
By Scott C. Goodwin, M.D., Michael S. Broder, M.D., M.S.H.S., David Drum

How does an interventional radiologist end up writing a book about uterine fibroids? The story began on Thanksgiving Day in 1994. I was on call at UCLA and received a page from the Department of Obstetrics and Gynecology about a patient who was having severe bleeding after myomectomy. We brought her down to Radiology and embolized her uterine arteries. Embolization is a procedure that eliminates the blood flow to the uterine arteries. Her bleeding stopped immediately, and her vital signs stabilized. Although embolization had been used for decades to stop bleeding after childbirth or gynecologic surgery, this case affirmed its importance to me and the referring physician.

The next piece of the puzzle dropped into place in 1995 when Dr. Ravina and his colleagues in France published the first report of treating fibroids with uterine artery embolization. We started our program in 1996 and presented our early results at the 1997 Society of Cardiovascular and Interventional Radiology annual meeting. The response to that presentation astounded me. Women came from the world over to have embolization to save their uteri and/or avoid major surgery. Virtually every major media outlet carried the story including television and radio stations, newspapers, and magazines. I was asked nearly one hundred times to lecture on embolization at national and international meetings.

Eventually the idea of this book came into being. I knew that the book would be more complete if an obstetrician and gynecologist was a coauthor. Happily, Dr. Michael Broder agreed to write the book with me. Over the years, I have collaborated with several obstetricians and gynecologists. What has impressed me about Dr. Broder is his evidence-based approach to medicine. Simply put, he wants to do what is in the patient's best interest based on the available scientific evidence with no regard to personal gain.

Most, but not all, physicians take their fiduciary responsibility to their patients very seriously. Once, following a lecture on fibroid embolization to an obstetrician and gynecologist group, I asked one of the physicians why there was so much resistance to embolization in the obstetrician and gynecologist community. He told me that gynecologists consider fibroids an annuity. He related that in today's managed care environment physicians receive relatively little for deliveries and routine visits-the only significant payday is the hysterectomy.

The most important thing I have learned from my experiences with women with fibroids is that removing the uterus of approximately three hundred thousand women per year in the United States for benign disease is simply not acceptable. The most significant contribution the development of uterine fibroid embolization has made, in my opinion, is to serve as a wake-up call to researchers and clinicians to come up with something better than the scalpel. Hopefully, some day hysterectomy, myomectomy, and embolization will all be paragraphs on a page of a medical history textbook. When fibroids as a whole are understood well enough, noninvasive treatments will be developed. Ultimately, our goal as physicians ought to be to put ourselves out of business.

Michael S. Broder, M.D.

I didn't begin my career as a gynecologist specializing in uterine fibroids. I really had no intention of helping women find alternatives to hysterectomy for this common condition. I did my residency in obstetrics and gynecology at UCLA and then started a fellowship in an area of research that deals with measuring and improving the quality of health care. During the course of the fellowship, I became involved in a research project at the RAND Corporation. You may know of the RAND Corporation because of its involvement in military and government policy planning. The truth is, RAND does far more health-related research now than it does military research. RAND is a think tank, and one type of health care research that originated there is sometimes called 'appropriateness" work. These types of studies involve picking a procedure or a condition and examining medical records or interviewing patients to determine whether those patients received the ideal care for that condition. In 1996 I joined a group of researchers who had started doing this type of study about hysterectomy. While past research had examined the appropriateness of hysterectomies, this one was a little different. We took a very in-depth look at almost five hundred women who had had hysterectomies at a variety of medical centers in Southern California. We reviewed each medical record and spoke to every patient.

What we learned was shocking even to us. We found that more than seven out of ten women did not have adequate evaluations before they were told they needed hysterectomy. Seven out of ten. We checked and rechecked our results but couldn't come to any other conclusion. The quality of care for women who have hysterectomies is entirely inadequate. We published our results in the Journal of Obstetrics and Gynecology in 2000. The response was overwhelming. Many, many gynecologists were sure we had done something wrong or that our methods were flawed. Many patients were sure we were right. My office began to overflow with women who had been told they needed hysterectomies and who wanted my opinion about whether this was the right step.

Sadly, I found that the results of my study played out in my practice as well. About one-third of the women I saw not only didn't need hysterectomies, but in my opinion they didn't need anything at all-not medications, not more tests, not anything. Their doctors had recommended hysterectomies for conditions that were not causing these women any problems and were not likely to any time in the near future. Another third of the women probably needed something, but hysterectomy certainly wasn't their only option. Finally, about one-third did seem to be best served by hysterectomy. But even these women benefited by a discussion of the other potential options and why their condition really could be best treated with hysterectomy.

Because fibroids are one of the most common reasons for hysterectomy, I started seeing more and more patients with uterine fibroids, and many of them tell the same story. The doctor diagnoses them with fibroids and tells them the only solution is a hysterectomy. Many women take this at face value and submit to the operation. A few others search and search for other options: some find what they need, some do not. The lucky ones learn through this process that how to treat fibroids is their choice, not their doctor's. This is a liberating realization, but not nearly enough women reach this level of understanding.

If you have uterine fibroids, hysterectomy is not the only option. Alternative treatments, both invasive and noninvasive, do exist. Uterine fibroids are a benign condition. For many women, just the knowledge that they do not have cancer and that their fibroids can be watchcd is treatment enough.

The body is an amazing piece of machinery, but it is more than a machine. In a car, we know that brakes have one function (an important function, but still only one function). The body is not that simple. It is true that the main function of the uterus is bearing children. However, it is presumptuous to assume that one function is everything. Some studies suggest that the uterus secretes its own hormones that interact with the ovaries and perhaps other organs in the body. Perhaps there are more functions of the uterus that remain unknown. But without good evidence that the uterus is useless beyond childbearing, we ought to try our best to leave it where it is.

Many women try to find a doctor who is willing to listen to their concerns and end up disappointed. Too many doctors take the position that only a doctor can decide whether a uterus stays in or comes out. The truth is that nobody is more invested in medical treatment than the patient herself.

I want women to know the history of the treatment of fibroids; to know about the various experimental and investigational techniques; and to understand the issues surrounding alternative medications, exercise, and other ways to treat fibroids. This book is aimed at giving women with a new diagnosis of uterine fibroids all the information they need to make informed decisions. Only when patients are truly partners with their doctors can the best outcome be ensured.