In a post-Isadora Wing, post-Carrie Bradshaw universe, women discuss many previously unmentionable things about their bodies: orgasms and bikini waxes and Keigels and stretch marks. But when it comes to the medical maladies of their insides -- the plumbing problems that used to be written off simply as "female trouble" -- there often remains a deep, dark silence.
"Uterine fibroids" are not words likely to be uttered anytime soon on either "Lipstick Jungle" or "The L Word." But it's a condition that affects one in four women, and nearly three in four black women, beginning as early as their 20s. Knots of smooth muscle that grow in the uterine wall, fibroids can be tiny or as big as grapefruits; women can have one or several. And symptoms can be nasty: heavy (heavy, heavy) bleeding, back pain, the look of early pregnancy even in those who are not having any sex. For women whose fibroids grow early and in particular spots on their womb, there is a risk of trouble getting or staying pregnant. Fibroids are the leading cause of hysterectomy, and when surgery is used to remove the tumors individually, they will often grow back. But as common as fibroids are, they have not gotten a lot of conversational airtime in social or medical circles.
Now, however, as more women postpone childbearing into their 30s, the little buggers are becoming a lot more troublesome, and simply removing the womb -- who needs it, anyway? -- is no longer the go-to option for women who'd prefer to keep working and having kids, or just keep their uterus, thank you very much.
And so, after decades in the medical closet, the condition is finally getting some respect from doctors like Elizabeth Stewart, a senior associate consultant at the Mayo Clinic, who has published "Uterine Fibroids: The Complete Guide," in which she addresses the newest research into fibroids and their treatment. She recently spoke to Salon about what fibroids are and what women can do about them.
What causes fibroids?
No one knows. For many years we've just relied on surgery to take them out, and no one thought it was important enough to understand why they formed. But now we're searching for more treatments, because as women have increasing roles in the workplace, and are major wage earners in the family, the solution of surgery is much less attractive.
Are they cancerous?
They're not cancerous, and they're not pre-cancerous, but they're the leading cause of hysterectomy. It is much more common to have a hysterectomy for uterine fibroids than it is to have a hysterectomy for any kind of gynecologic cancer.
What are some of the symptoms?
Symptoms fall into three big categories. The first is heavy menstrual bleeding. Women can have long menstrual periods lasting seven to 14 days, or regular-length periods that are excessively heavy, so they can't go even an hour before they have problems and end up with socially embarrassing side effects.
The second major category is size. Fibroids can get to be quite large, the size of an orange or grapefruit, so if it's pressing on your bladder you can have urinary frequency and have to get up at night to urinate. Some women have difficulty emptying the bladder, and they can cause back pain.
The third category is that some fibroids can cause problems with women getting pregnant or having complications during pregnancy, but that isn't a given. There are many women who can get pregnant and have perfectly normal pregnancies.
How many women have fibroids?
It's estimated that at least 25 percent of all women will have a fibroid big enough to feel or see on an ultrasound. In African-American women, that number gets up to 75 percent.
One of the things that I've heard about fibroids is that more childless women in their 30s are getting them because they tend to grow when you don't have anything else growing in the womb. Is there any truth in that rather macabre diagnosis?
What an awful way to put it. But there is some truth in it, in that having a term pregnancy seems to decrease your risk. After the uterus remodels itself after a pregnancy, and gets back to its normal size, it may clear some of the fibroids. But "Just have a baby and everything will be fine" is old-fashioned advice. I think women deserve to have therapies for problems, whether or not they want to bear children.
Is there an age at which fibroids tend to strike?
In pre-menopausal women. Typically we think of women in their 40s having fibroids, but some recent data suggests that African-American women tend to develop fibroids five or six years earlier, so late 20s and early 30s is not uncommon.
The good thing about fibroids is that if you can get to menopause, many times your symptoms are substantially decreased. It's during women's reproductive years that they run into the most severe symptoms.
It's probably just my age, but I feel like I've heard about fibroids more in recent years. Have they become more prevalent?
No, we don't think the incidence has gone up. It's been a major problem for women for decades, but I think in the past we just dealt with them with hysterectomy. When you had your kids in your 20s and then had fibroids in your 30s and then a hysterectomy in your 40s, that was a reasonable solution. But fibroids may be having more impact now that women wait later to have children. These days many women have fibroids that may be a problem for getting pregnant or safely carrying a pregnancy, and as they seek alternatives to hysterectomy, women will deal with them more frequently, or at a later age.
Are there new treatments for fibroids?
Yes. Many women have good alternatives. Sometimes just using medications that we typically think of as just birth control can control symptoms; either pills or a progesterone-containing IUD can control the bleeding. But the only medicines that shrink them are drugs that shut down the whole reproductive system. Those can have pretty severe side effects, menopause-like side effects. Women also get rapid return of symptoms when they stop the drugs.
Also, there are some minimally invasive therapies that work for removing some fibroids. Some that are in the right location can be taken out with a hystroscope and telescope inside of the uterus. We can also decrease fibroid symptoms with a procedure called uterine artery embolization [which cuts the blood flow to the tumors]. It's not an ideal option for women who want children, but for women who have significant fibroid symptoms and no plans for future pregnancy, it's very good.
The other new option is an MRI-guided focused ultrasound, which uses strong ultrasound waves to destroy the fibroids. One of the disadvantages is that we don't have long-term information about outcomes, or good information for women who want future pregnancies. But at least the initial information we're getting seems to be encouraging.
And is there currently a lot of new research into fibroid treatment under way?
There are some big studies under way into the genetics. The real impediment for research is that there's not a lot of funding available in the NIH budget. There are some new private philanthropic organizations that are trying to raise funds, but compared to other diseases that affect similar numbers of individuals, funding is pretty limited. I think that some people feel that hysterectomy is an adequate solution and that new treatments really aren't necessary. Some have argued that because it's a disease that affects only women and preferentially minority women, that may be a factor in less priority of funding.
Short of medical intervention, are there changes women can make to decrease their symptoms or the size of their fibroids?
There are no good studies documenting that, though there are certainly women who find that changing diet and exercise does decrease their symptoms.
What about acupuncture?
Again, there aren't a lot of good studies, but acupuncture does seem to have an effect on menstrual cycles, and there is some evidence that it works for endometriosis, which is another gynecological disease found frequently with fibroids.
And for those who opt for surgery, are the fibroids likely to grow back?
Unless you're doing hysterectomy, you have a chance of having new fibroids form. The worst thing is to have surgery for fibroids and then wait a couple of years and when you're ready to have kids, they've grown back. It's optimal if you can have surgery close to the time you're ready to have a pregnancy. But that's not always possible because of severe symptoms.