Uterine Fibroids - Women's Health Update

Uterine Fibroids – Women’s Health Update October 17th, 2006 by Tori Hudson, N.D.

Over the more than 15 years that I have been in clinical practice, not many health problems have eluded successful treatment with alternative therapies as consistently as uterine fibroids. Women who are seeking an alternative to pharmaceutical or surgical interventions for the treatment of uterine fibroids will not find an easy, reliable alternative to shrink the tumors. Therapies that I have come to use can be confidently recommended for the management and amelioration of most symptoms related to the fibroids such as abnormal bleeding, pelvic pain/pressure, back aches, bloating and digestive problems. With less optimism, I recommend a regimen with the hopes of inhibiting continued growth, realizing that only on occasion, they will reduce significantly in size, due to the natural therapies.

Many alternative practitioners and women who use alternative medicine have reported individual case histories that create some hope for reducing the size of fibroids. They report reduction in size on pelvic ultrasound, disappearance of symptoms and even total disappearance of any evidence of fibroids. I myself can report cases where the fibroid growths and the size of the uterus have been significantly reduced. The problem is that the results are very inconsistent and random. Often the cases that have shown the most dramatic improvements are the women who are in their late forties and early fifties and are in fact almost menopausal or in fact menopausal. The fibroids of these women will tend to shrink because of the natural decrease in their endogenous estrogen levels regardless of any natural therapies. One of the main goals of managing women with fibroids is to achieve improvement of symptoms caused by fibroids, and buying time so to speak, until menopause when this potential natural reduction in size is possible. For symptom management, a treatment plan separate from the one discussed here, is recommended to address the situation. For an overall protocol to attempt the difficult task of actually slowing growth or inhibiting growth, I offer some nutritional and botanical approaches backed only by ideas, logic, and traditional botanical and naturopathic principles.

Fibroids come in all sizes and shapes and usually occur as multiple tumors, although each fibroid is discrete. Most discernible fibroids are between the size of a walnut and the size of an orange, but unusual tumors have been reported up to 100 pounds. The classification of fibroids is according to their location. They are either submucosal (just under the endometrium), intramural (within the uterine muscle wall), or subserosal (from the outer wall of the uterus). They can also be intraligamentous ( in the cervix between the two layers of the broad ligament) or pedunculated and dangling from a stalk into the uterine cavity (pedunculated submucous) or pedunculated on the outside of the uterine wall (pedunculated subserous). The pedunculated submucous fibroids can on occasion protrude through the cervix and appear in the vagina. Other pedunculated fibroids on a long stalk outside the uterus can be mistaken for an ovarian mass or attach to the bowel.

Even though simply changing one’s diet is unlikely to shrink one’s fibroids, good dietary habits are still important. Clinical observation has taught me that all natural therapies work best in the context of a healthy lifestyle including dietary changes. Improving one’s diet can help to decrease heavy bleeding by increasing foods and spices that have an anti-inflammatory effect such as the bioflavonoids rich in citrus fruits and berries, garlic and curcumin. Improving ones’ diet can also improve the digestion of many individuals thereby possible relieving some of the gas and bloating associated with the pressure of the enlarged uterus or fibroid on the digestive organs. Acidophilus yogurt added to the diet may also offer some benefit in these situations.

Poor nutritional habits can alter and slow down the body’s metabolization and detoxification of estrogens and the elimination. Alcohol in particular, slows down the metabolism of estrogens in the liver. The tradition of naturopathic medicine holds that the health and vitality of an individual depends on the health of the liver. The liver’s basic functions are vascular, secretory, and metabolic. As a vascular organ, the liver is a major reservoir of blood and filters over one quart of blood per minute. The liver removes bacteria, endotoxins, antigen-antibody complexes, and other particles from the circulation. The liver’s secretory functions are the synthesis and secretion of bile. The liver manufactures about one quart of bile on a daily basis. Bile is required for the absorption of fat-soluble substances including some of the vitamins. The majority of the bile secreted from the liver into the intestines is reabsorbed by the many toxic substances that are eliminated from the body by the bile. The metabolic functions of the liver are involved in carbohydrate, fat, and protein metabolism; the storage of vitamins and minerals; the formation of numerous biochemical factors; and the detoxification or excretion into the bile of hormones such as estrogen as well as histamines, drugs, and pesticides.

The liver not only has to process the foods that we eat on a daily basis, but also serves as the great detoxifier of harmful substances (both internal and external) and metabolizes and deactivates hormones. The liver metabolizes estrogen so it can be eliminated from the body by converting it to estrone and finally to estriol, a weaker form of estrogen that has very little ability to stimulate the uterus. If the liver cannot effectively metabolize estradiol, this may be one mechanism by which the uterus becomes overestrogenized and responds with fibroid growths.

Saturated fats, sugar, caffeine, alcohol, and junk foods are presumably problematic in two main ways:

1. they interfere with the body’s ability to metabolize estradiol to estrone to estriol, and
2. some of these foods are deficient in vitamin B or interfere with B-vitamin metabolism. If B vitamins are lacking in the diet, the liver is missing some of the raw materials it needs to carry out its metabolic processes and regulate estrogen levels.

Whole grains such as brown rice, oats, buckwheat, millet, and rye are excellent sources of B vitamins. Whole grains also help the body to excrete estrogens through the bowel. The role of whole grain fiber in lowering estrogen levels was first reported in 1989. It was observed that vegetarian women who eat a high fiber, low fat diet have lower blood estrogen levels than omnivorous women with low fiber diets. Once again, we can see how a high fiber diet might be able to help prevent and perhaps reduce uterine fibroids.

Because there may be an association between having uterine fibroids and a fourfold increase in the risk of endometrial cancer, three dietary considerations stand out above all else: increase the fiber, lower the dietary fat, and increase the soy products and other legumes. Researchers in Hawaii examined the role of dietary soy, fiber and related foods and nutrients on the risk of endometrial cancer. Over 300 women with endometrial cancer were compared with women in the general multiethnic population. The researchers found a positive association between a higher level of fat intake and endometrial cancer as well as a higher level of fiber intake and a reduction in risk for endometrial cancer. They also found that a high consumption of soy products and other legumes was associated with a decreased risk of endometrial cancer.

Some people have raised the question that since soy foods are high in phytoestrogens, specifically soy isoflavones, and if phytoestrogens have the ability to have a weak estrogenic effect, then maybe patients with uterine fibroids or endometrial cancer should avoid soy foods. So far it appears as though soy isoflavones do not have an estrogenic effect on the uterus in humans. Soy isoflavones appear to be selective in terms of which tissues they have a weak estrogenic effect on and which tissues or organs they have a weak anti-estrogenic effect on. It seems that in the uterus, soy isoflavones have an antiestrogen effect.

Reduction in dietary fat intake results in a reduction in serum estradiol levels, which could influence the rate of uterine fibroid growth. The data on dietary fat and estradiol levels come from a meta-analysis published in the Journal of the National Cancer Institute. Researchers reviewed 13 studies published between 1987 and 1997 that investigated the effect of dietary fat intervention on serum estradiol levels. For both pre and post menopausal women, the analysis revealed significant decreases in serum estradiol among women who restricted fat intake. Estradiol levels were reduced by 7.4% among premenopausal women and 23% among postmenopausal women. In 11 of the studies, dietary fat intake was reduced by 18 percent to 25 percent.

Supplements such as inositol and choline exert a lipotropic effect. This means they promote the removal of fat from the liver. Lipotropic supplements are usually a combination vitamin and herbal formulation and sometimes an animal liver extract designed to support the liver’s function in removing fat, detoxifying the body’s wastes, detoxifying external harmful substances, and metabolizing and excreting estrogens.

Dose: Lipotropic factors 1-4 tablets per day with meals

Supplementation with pancreatic enzymes is usually done to treat pancreatic insufficiency. Symptoms of abdominal bloating, gas, indigestion, undigested food in the stool, malabsorption, and nutrient deficiencies are the usual manifestations of pancreatic insufficiency. The logic for the treatment of uterine fibroids is similar to the logic for the treatment of cancer. Enzyme preparations have been used at the Contreras Clinic in Tijuana, Mexico, under the direction of Dr. Ernesto Contreras and by Drs. William Kelley and Nicholas Gonzalez in New York City, as part of a cancer treatment protocol. There is little evidence in the scientific literature to support their use, but the logic is that the pancreatic enzymes will digest the cell membrane surrounding the malignant cells. By doing so, the natural killer cells will then be able to enter the cancer cells and alter the abnormal cell division. In the case of uterine fibroids, the theory is that the pancreatic enzymes will help to digest the fibrous/smooth muscle tissue and dissolve the fibroids. When used for this purpose, the pancreatic enzyme supplement must be taken between meals rather than with meals.

Dose: Pancreatic enzymes 2-4 capsules 3 times per day between meals

Many plants have been used in traditional herbal medicines in an attempt to treat women with uterine fibroids. The plants and herbal formulations discussed here are used to try to shrink uterine fibroids. Other treatments are used to address abnormal bleeding, uterine cramping, urinary frequency and digestive problems.

One of the most commonly used herbal formulations in traditional naturopathic medicine is what has come to known as the Turska formula. It is a tincture formulation of gelsemium , poke root, aconite and bryonia. These are toxic herbs if used incorrectly. In a one ounce bottle, it contains 1 &#frac12; drams of aconite, 1 &#frac12; drams of gelsemium, 1 &#frac12; drams of bryonia, 3 drams of poke root and &#frac12; ounce of water. 5 drops are recommended 3 times per day. The alkaloids, coumarins, saponins, lectins and aglycones contained in these herbs are thought in traditional botanical terms to dislodge and slough off catabolic waste tissue and promote the drainage of lymphatic fluids from areas affected by the buildup of wastes. This formula is available through Gaia Herbs in Bravard, North Carolina or NF Formulations in Wilsonville, Oregon.

Three other formulations are a proposed herbal protocol for the reduction in the size of uterine fibroids and inhibition of continued growth: (source: Gaia Herbs)

1. Compounded Echinacea/Red root
   Echinacea – Echinacea species
   Red root – Ceanothus americanus
   Baptisia – Baptisia tinctoria
   Thuja – Thuja occidentalis
   Stillingia – Stillingia sylvatica
   Blue flag – Iris versicolor
   Prickly ash – Xanthoxylum clava-herculus

   Dose: 30-40 drops in a small amount of warm water between meals 3 times daily

2. Scudder’s Alterative
   Corydalis tubers – Dicentra canadensis
   Black alder bark – Alnus serrulata
   Mayapple root – Podophyllum peltatum
   Figwort – Scrophularia nodosa
   Yellow dock root – Rumex crispus

   Dose: 30-40 drops in a small amount of warm water 3 times daily between meals

3. Fraxinus/Ceonothus Compound
   Mountain ash bark – Fraxinus americanus
   Red root – Ceonothus americanus
   Life root – Senecio aureus
   Mayapple root – Podophyllum peltatum
   Helonias root – Chamaelirium luteum
   Goldenseal root – Hydrastis canadensis
   Lobelia – Lobelia inflata
   Ginger root – Zingiber officinalis

   Dose: 30 drops to a small amount of warm water 3 times daily between meals

Several old studies have suggested that progesterone may inhibit growth of uterine fibroids. Lipshutz demonstrated that progesterone administered to guinea pigs prevented formation of tumors that had been induced by estrogen. In 1946, Goodman reported six cases of clinically diagnosed uterine fibroids that regressed after using progesterone therapy.

Dr. John Lee poses that because uterine fibroids are a result of estrogen stimulation and what he calls “estrogen dominance,” the corrective solution is to use progesterone. He asserts that estrogen dominance is a much greater problem than recognized by conventional medicine. “Since many women in their mid-thirties begin to have nonovulating cycles, they are producing much less progesterone than expected, but still producing normal ( or more) estrogen. When sufficient natural progesterone is replaced, fibroid tumors no longer grow in size (they generally decrease in size) and can be kept from growing until menopause, after which they will atrophy. This is the effect of reversing estrogen dominance.”

The form of natural progesterone that is best used, again according to Dr. John Lee, is a topical cream with about 400 mg of USP progesterone per one ounce of cream.

Dose: &#frac14; tsp twice daily for at least two weeks out of the month before menses. Another recommended regimen is 3 weeks on and one week off (during menses).

There is another theory and counter-opinion about the relationship of progesterone to uterine fibroids. Dr. Mitchell Rein and his colleagues at Brigham and Women’s Hospital published a report in 1995 stating that not only is there no evidence that estrogen directly stimulates myoma growth, but that it is actually progesterone and progestins that promote the growth of fibroids. The authors site the biochemical, histologic, and clinical evidence that supports an important role for progesterone and progestins in the growth of uterine myomas.

In my clinical experience these last 15 &#frac12; years, I have utilized dozens of herbal nutritional supplements, , topical oils of poke root, castor oil packs, hydrotherapy treatments and strict dietary regimens in attempt to halt the growth and shrink the size of uterine fibroids. We have achieved only occasional unpredictable success with premenopausal women in shrinking fibroids based on ultrasound monitoring. With more consistent success the natural therapies and lifestyle changes, and perhaps just the normal course of their condition have ended up in stabilization of their fibroids with no continued growth and modest to moderate reduction in size in postmenopausal women. My goal has by and large been to achieve stabilization of the fibroids while focusing on resolving the symptomatic problems associated with the fibroids. The majority of the time, I have clinically observed that women can achieve stability and symptomatic relief until menopause when things would have tended, yet not necessarily improved.

Some individuals have fibroids that are just too large and/or too problematic. More and more surgical options are now available besides the traditional hysterectomy including hysteroscopic resection, myomectomy, laparoscopic surgery, and uterine embolization and supracervical hysterectomy as an alternative to the traditional hysterectomy. If surgery is recommended or preferred, it is important to individualize the recommendation to meet not only the medical needs of the woman but her values and emotional needs as well.

An alternative hysterectomy much more common in Europe but gaining popularity in this country is a supracervical hysterectomy. With an abdominal incision, the body of the uterus is removed but the cervix is spared. By leaving the cervix, the vagina is unaffected, and the normal length and sensations of the vagina are maintained. Myomectomy is abdominal/pelvic surgery where just the fibroids are removed but the uterus is spared. Many women prefer this surgery, and I encourage women to find a surgeon who will agree to this surgery it if is appropriate for their size and location and extent of fibroids. However, compared with hysterectomy, some myomectomies may be associated with more blood loss and more complications, and 15-30 percent of women who have a myomectomy eventually require further surgery because the fibroids recur. Even if you do not want to retain your fertility, myomectomy should be seriously considered. Dr. Vicki Hufnagel, a surgeon formerly practicing in California, is considered a progressive surgeon by some and a risky renegade with bizarre and unsafe surgical techniques by others; in any case, she is far from conventional. In her book No More Hysterectomies,

Dr. Hufnagel promotes reconstructive surgical techniques that avoid the need for a hysterectomy. Some of these techniques and recommendations are very controversial and may even be considered surgical catastrophies by other surgeons. Perhaps her greatest contributions have been to point out more clearly for women some of the potential complications from a hysterectomy and how it may affect future quality of life. She also stresses the number of unnecessary hysterectomies that have been performed in the United States each year.

A number of newer procedures have more recently become available at least by some doctors and in some hospitals. A hysteroscopic resection has been used to remove fibroids within the uterine cavity. A hysteroscope, an instrument that is inserted through the vagina into the uterus, provides a view of the interior of the uterus. The surgeon uses an instrument to remove the fibroids and cauterize the endometrium. Submucous fibroids or pedunculated submucous fibroids are the fibroids that lend themselves to this kind of surgical treatment. Subserosal fibroids cannot be reached with this procedure.

Uterine embolization is designed to reduce fibroids by obstructing the blood supply that nourishes them. It entails making a small incision in the groin and threading a small catheter into the femoral artery. The doctor works the catheter up to the vessels that supply the fibroid with the help of a dye and Xray. Microscopic plastic particles are injected into the catheter to close off those vessels. The fibroid shrinks because it is deprived of its blood flow. This is a very new procedure and not that women yet have been treated or involved in a research study. Not all fibroids are candidates for this procedure and undoubtedly there are downsides and side effects yet to be well understood at this point in time.

Laparoscopic surgery is the least invasive approach for removing subserous and subserous pedunculated fibroids. It is similar to the hysteroscopic resection. With a laparoscopy, the scope and surgical instruments are inserted through two small incisions in the abdomen. When the fibroid is small, the surgeon removes the fibroid using the myomectomy technique (i.e., cut out the fibroid and suture up the uterus where the fibroid is plucked out.) For fibroids that are larger or inaccessible, the surgeon ma use myolysis. Using a laser or electrical needles, the fibroids are cauterized, and the shrink. I’ve even heard of a large fibroid uterus being removed using laparoscope. Since there is no major abdominal incision through all the muscles of the abdomen, the recovery time is much shorter and the cosmetic advantages are obvious. However, a laparoscopic hysterectomy is much more time-consuming and may take as long as seven hours to perform.

Even with all of these surgical alternatives, there are situations where a conventional hysterectomy is necessary and appropriate. The most important concern about a hysterectomy is preserving the ovaries. A uterine fibroid uterus that necessitates the additional removal of both ovaries is uncommon. None the less, it is often recommended in women who are already beyond their fertility and postmenopausal. The doctor will often recommend removing the ovaries to reduce the risk of ovarian cancer. What if we started removing all our organs to reduce the risk of ovarian cancer ? Special circumstances might warrant the removal of the ovaries, including a mother or sister with ovarian cancer; but as a routine preventive I don’t recommend it. The lifetime risk of ovarian cancer is 1 in 70 women. If the ovaries are removed, and conventional estrogen replacement therapy is then needed, the risk of breast cancer will then increase by as much as 30% after 5 years of use. Better to keep the ovaries. Most of the time there is no pressing medical need to remove them.

Not often do women have to rush to any decisions about surgical interventions. Excessive bleeding problems, a rapidly enlarging fibroid uterus, interference with kidney function and prolonged or severe pain are the motivating circumstances. If surgical intervention becomes appropriate, remember that there are options. Explore some of the newer surgical techniques to see what might be the best option in the particular clinical circumstances that exist. A knowledgeable and respectful surgeon with experience in the different skills and techniques along with a knowledgeable, respectful and open minded alternative practitioner can help to make the right decision on behalf of what is the right intervention for the patient.