Can Fibroids Recur?

If fibroids have been surgically removed completely then they cannot grow back. So strictly speaking, the word “recur” is not the correct one to use.

However new fibroids may grow after surgical removal and so it will seem as if the fibroids have “recurred”.

In these circumstances most women will not require any further treatment. If the initial operation is carried out to remove a solitary fibroid, then about 11% of women will go on to have further surgery during the next 10 years. If more than one fibroid is excised, about 26% of women go on to have a further surgical operation. The chance of needing further surgery is reduced for those women who are approaching the age of the menopause, after which time fresh fibroids do not arise.

Gynaecologists comment that it is rare for another surgical operation for a fibroid to be necessary, if a woman has undergone a myomectomy when she is past 40. Some specialists prefer the term "new appearance" to that of "recurrence"

A problem with surgical treatment of individual fibroids and minimally invasive surgical procedures is that new uterine fibroids tend to arise until women reach the age of the menopause.

It is important to note that fibroids are not a type of cancer and do not recur in the way that cancer does. Cells from the fibroid do not travel or spread to other parts of the body.

The problem with fibroids is that new ones develop in the uterus. If you have had a fibroid removed surgically, you do not want to have repeated surgery over the years to treat recurring fibroids.

Some gynaecologists divide fibroid recurrence into two different groups:

  1. Clinical recurrence describes a fibroid that recurs and causes symptoms or needs treatment
  2. Sub-clinical recurrence refers to those fibroids that recur and can be felt during a pelvic examination, seen using diagnostic investigations or laparoscopy, but do not produce any symptoms or require treatment. The rate of sub-clinical recurrence is very high.

Studies have looked at the rate of recurrence following an abdominal myomectomy. One study carried out in 1969 looked at the rate of recurrence after the removal of single and multiple myomas (fibroids). (reference: Malone L., Myomectomy: recurrence after removal of solitary and multiple myomas. Obstetrics & Gynecology 1969;34:200-203). This study is still widely cited by practising gynaecologists because it provides useful data for those women who are weighing up the pros and cons of surgical treatment.

The study followed 125 women who had undergone an initial abdominal myomectomy. The women were then followed up and asked about their symptoms and were clinically examined for a recurrence of a fibroid. The number of women who then required further surgery, based on clinical need, was documented. The average length of follow up was 8 years. It was discovered that 11% of women who had had a single fibroid excised and 26% of women who had had three or more myomas removed, needed further surgery.

Studies have also looked at the “recurrence” rate following laparoscopic myomectomy and hysteroscopic myomectomy. The studies have found a similar “recurrence” rate following these two types of surgical procedure. A widely reported study compared the rate of “new appearance” of myomas after laparoscopic myomectomy (carried out by skilled laparoscopic surgeons) with abdominal myomectomy. It was discovered that the rates of “new appearance” were similar.

The study followed the progress of 81 women, who were randomally allocated to have either and abdominal or laparoscopic myomectomy. The women were then followed up and underwent investigation using transvaginal ultrasound scans for at least 40 months. No women required further surgery and uterine fibroids larger than 1cm were subsequently diagnosed in 27% of women who had undergone laparoscopic myomectomy and a similar percentage – 23%- were diagnosed in women who had been randomised to have abdominal myomectomy. (reference: Rossetti A, Sizzi O, Soranna L, et al. Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy. Human Reproduction 2001;16:770-774).

The traditional method of detecting subclinical recurrence has been transvaginal ultrasound. Studies have found that about 50% of all women will have new fibroids that can be seen on ultrasound 5-10 years after surgery to remove fibroids. Earlier research gave lower figures for recurrence rates, but the quality of imaging has improved and the numbers of fibroids found to have recurred has increased.

In fact, the recurrence rate may be higher still when newer scanning techniques, such as 3D-ultrasound and magnetic resonance imaging (MRI) scans are used in the future to investigate fibroid recurrence.

For sub-clinical recurrence a more accurate imaging technique will show greater recurrence rates.

Women who have already had treatments for fibroids are most concerned about whether a new appearance or recurrence leads to a further surgical procedure. This type of recurrence is called a “clinical recurrence” by gynaecologists.

Gynaecologists are trying to work out which women are at the highest rate of recurrence. As already mentioned above having multiple fibroids at the time of abdominal myomectomy increased the rate of new appearance of fibroids. Other studies have suggested that having a term pregnancy (a pregnancy that lead to the birth of a baby) reduced the chances of requiring additional surgery for fibroids. One study followed women for 10 years after myomectomy. The rate of new appearance of fibroids 16% in women who subsequently had a term pregnancy, and the rate of new appearance was 28% in women who had not had a baby.

Having treatment with Lupron injection (leuprolide acetate for depot suspension) prior to myomectomy has the benefit of making the fibroids smaller, but this can make it more difficult for the surgeon to identify and excise them properly and increase the rate of new appearance of myomata post myomectomy. A study looked at the rate of fibroids being diagnosed after surgery in women who had received treatment with Lupron and women who had not been treated with Lupron. It was found that 63% of women who had been treated with Lupron had small leiomyomata discovered by ultrasound but only 13% of women who were not given Lupron had small fibroids diagnosed subsequently by ultrasound.

A study published in 2002 (Stewart EA, Faur AV, Wise LA, et al. Predictors of subsequent surgery for uterine leiomyomata after abdominal myomectomy. Obstetrics and Gynecology.2002;99(3):426–432.) looked at a group of 65 women who had a myomectomy performed for fibroids. The aim of the study was to ascertain whether any new risk factors for recurrence could be determined. A possible drawback of this study mentioned by one of the authors was that the women investigated were not typical of patients with uterine fibroids. The women were generally thinner than typical fibroid patients and all the women were Caucasian.

There were some interesting results from the research.

Firstly, it was found that the risk of having a second surgical procedure altered inversely with the size of the uterus and the size of the largest fibroid. To put it another way, the larger the fibroid, the less likely a woman was to require another surgical procedure. This seems an odd result, because larger fibroids should indicate worse disease and actually increase the risk of further surgery. The authors of the study contemplated the possible reasons for their findings. They decided that since fibroids are always forming, there may be some advantage to waiting longer. The longer you wait, the larger the leiomyomata become the easier they are to be removed by a surgeon.

Secondly, they have commented that research by geneticists has found that larger fibroids have different chromosome arrangements. It has been suggested that bulkier leiomyomata tend to be a less aggressive type with a particular chromosome pattern and reduced rate of recurrence.

The problem is that another study in another population showed the opposite result and it has been commented that larger studies in different populations are needed to clarify this issue. In their study the authors also discovered that putting on less weight from the age of 18 seemed to reduce the need for a second surgical procedure. It was found that those women who had put on more than 30 pounds since the age of 18 had an almost four times increased rate of requiring further surgery.

It is known that there are several links between weight and leiomyomata. Weight gain may alter or represent a hormonal environment that increases the recurrence rate. Again, studies from genetics suggest that a number of the genes controlling fat metabolism may also be involved in a particular subgroup of fibroids. The final finding from this study was that those women with a history of endometriosis had an increased risk of requiring further surgery. This may indicate that women with endometriosis and fibroids have two reasons for requiring a second surgery, but it may also suggest that there is a biological connection between the two conditions that leads to the leiomyomata being more aggressive.

Having menorrhagia (heavy periods) and one or more childbirths also led to an increased second surgery rate, but this may be a confounding factor. It may be that having children does not cause worse fibroids, but makes having further surgery and, potentially a hysterectomy, a less important obstacle. More needs to be learnt about the risk factors for recurrence or new appearance of fibroids, especially in African American women.

Also more research needs to be carried out into whether hormonal treatment before surgery increases or decreases the risk of new appearance. The long term aim has to be to reduce the risk of recurrence. This may be achieved in a number of ways: by using medications, by timing the surgery in particular ways or by proceeding with particular forms of procedure. There is also a role for lifestyle, nutritional, dietary and complimentary therapies (e.g. herbal treatments) which can prevent fibroids from forming and shrink fibroids as well. More research is needed.