What are uterine fibroids? They are very common non-cancerous tumors that grow within the wall of the uterus, and are most often found among women of reproductive age.
Fibroids, known technically as leiomyomata, can vary in size and number, and often cause no symptoms at all. But when they are noticed, pain, heavy bleeding and pelvic pressure are just a few of the things women may experience.
What are uterine fibroids?
Fibroids may grow as a single tumor or in clusters. A single fibroid can be microscopic in size, or can grow to eight inches or more across, though most fibroids range from about the size of a large marble to slightly smaller than a baseball. In many cases, a single uterus can contain many fibroids.
Bunches or clusters of fibroids are often of different sizes. Not all fibroids grow — some may shrink, while others might remain constant over time.
Healthcare providers categorize fibroids based on where they grow:
- Submucosal fibroids grow just underneath the uterine lining and into the endometrial cavity.
- Intramural fibroids grow inside the muscular wall of the uterus.
- Subserosal fibroids grow on the outside of the uterus.
Some fibroids grow on stalks that emerge from the surface of the uterus or into the cavity of the uterus, and are called pedunculated fibroids.
Fibroid signs and symptoms
Uterine fibroids can cause uncomfortable or sometimes painful symptoms, such as:
- Heavy bleeding or painful periods
- Bleeding between periods
- Feeling “full” in the lower abdomen (pelvic pressure)
- Frequent urination (caused by a fibroid pressing on the bladder)
- Abdominal pain
- Lower back pain
- Pain during sex
- Reproductive problems, such as infertility, multiple miscarriages, and early onset of labor during pregnancy
- Obstetrical problems, such as increased likelihood of cesarean section
However, it’s important to note that many women have no symptoms of fibroids.
How are uterine fibroids diagnosed?
Unless you have symptoms, you probably won’t know that you have uterine fibroids.
Sometimes, health care providers find fibroids during a routine gynecological exam. During this exam, the health care provider checks the size of your uterus by putting two fingers of one hand into the vagina while using the other hand to press lightly on your abdomen.
If you have fibroids, your uterus may feel larger than normal or it may feel irregularly shaped. But even small growth in the uterus may cause considerable symptoms and heavy periods leading to anemia. Smaller fibroids that can’t be found through a routine manual examination can be detected with ultrasound.
If your health care provider thinks you have fibroids, he or she may use one or more types of imaging technology to confirm the diagnosis.
Some common types of imaging technology are:
- Ultrasound, which uses sound waves to form the picture
- Saline infusion sonography, which uses an injection of salt solution into the uterus to help create the ultrasound image
- Magnetic resonance imaging (MRI), which uses magnets and radio waves to create the picture
- X-rays, which use a form of electromagnetic radiation to “see” into the body
- Computed tomography (CT) or computer-assisted tomography (also called a “CAT” scan), which scans the body with X-rays from many angles to create a more complete picture
We don’t know what causes uterine fibroids. Scientists have a number of theories, but none of these ideas explains these uterine growths completely.
Some factors researchers believed to be related to fibroid growth are:
- Growth hormones
- Genetic changes
- Misplaced cells present in the body before birth
Other factors that may affect fibroid growth:
- Quantity of micronutrients — nutrients, such as iron, that the body needs only small amounts of — in the blood. For instance, a deficiency of vitamin D may be associated with uterine fibroids.
- Major stresses
It is likely that fibroids are caused by many factors interacting with one another. Once we know the cause or causes of these tumors, our efforts to find a cure or even prevent fibroids could move ahead more quickly.
How many women are affected by uterine fibroids?
One study found that between 80% and 90% of African American women and 70% of white women will develop fibroids by age 50. Some may have no symptoms, however, hundreds of thousands of women seek treatment for fibroids each year.
Research shows that over 90% of women who are newly diagnosed will seek medical or surgical treatment for the condition within a year of the diagnosis. In 2000, more than 250,000 hospital admissions were related to uterine fibroids.
Every year, fibroids lead to more than 200,000 hysterectomies. Women who wish to have children have the option of myomectomy, a surgical procedure that removes the timors while leaving the uterus intact.
Which women are at risk of uterine fibroids?
Fibroids usually grow in women of childbearing age. Among US women ages 25 to 44, about 30% have symptoms of fibroids. Affected African American women are more likely to have multiple tumors. We don’t know exactly how many new cases of fibroids occur in a year, as they may not cause any symptoms, but clearly millions of American women have them at any one time.
There have been reports of rare cases in which young girls, who have not yet started their periods (prepubertal), had small fibroids. For African American women, fibroids typically develop at a younger age, grow larger, and cause more severe symptoms.
Fibroids may shrink after menopause. However, research shows that they are more likely to shrink in postmenopausal white women than in premenopausal black women.
Several factors affect a woman’s risk of having uterine fibroids. Factors that increase the risk of fibroids:
- Age older than 40 years
- African American race
- Family history of uterine fibroids
- High blood pressure
- No history of pregnancy
- Low levels of vitamin D
Factors that lower the risk of fibroids:
- Pregnancy (the risk decreases with increasing number of pregnancies)
- Long-term use of progestin-only birth control pills or oral contraceptives
- Use of the birth control shot (depot medroxyprogesterone acetate [DMPA], or Depo-Provera)
How are fibroids treated?
Hysterectomy — the removal of the uterus — is the only certain cure for uterine fibroids. But it’s important to note: That is not the only treatment option, and it is not the best treatment for every woman with fibroids.
How uterine fibroids are treated
Uterine fibroids, or leiomyomas, are non-cancerous tumors that grow inside the uterine wall. As scary as that sounds, fibroids are actually very common.
Despite millions of women living with undetectable fibroids, when they grow big — or even if there are a lot of little tumors — they can cause problems, like pain and bleeding. That’s when it’s time to talk to a healthcare professional to get some help.
Medical treatments for fibroids
Uterine fibroids get a lot of attention, both because of the large number of women affected by them, and due to the large number of hysterectomies people undergo to treat the symptoms they cause.
Your health care provider may suggest medical treatments to reduce the symptoms of fibroids or to stop the growth of fibroids. These treatments are less invasive than surgery. However, if the medical treatments are not helpful, then surgery is often recommended. Certain medical treatments to reduce fibroid size and blood loss may be used to help the surgery succeed.
Common medical treatments for fibroids include:
- Pain medication. Over-the-counter or prescription medication is often used for mild or occasional pain from fibroids.
- Birth control pills or other types of hormonal birth control. These medications control heavy bleeding and painful periods. However, this therapy can sometimes cause fibroids to grow larger.
- Progestin-releasing intrauterine device (IUD). The IUD, also called intrauterine contraception (IUC), reduces heavy and painful bleeding but does not treat the fibroids themselves. It is not recommended for women whose fibroids result in an extremely large uterine cavity.
- Gonadotropin-releasing hormone agonists (GnRHa). These medications block the body from making the hormones that cause women to ovulate and have their periods. The medications also reduce the size of fibroids. Because this treatment can cause side effects that mimic the symptoms of menopause (such as hot flashes, night sweats, and vaginal dryness) and bone loss (which weakens the bones), it is not meant for long-term use. Most of the time, these medications are used for a short time to reduce the size of fibroids prior to surgery, or to treat anemia. If you need to take this treatment for a long time, the doctor may prescribe medication to put back the hormones that were blocked.
- Antihormonal agents. These drugs, which include mifepristone, can slow or stop the growth, but the FDA has not approved their use for this purpose.
Medical treatments may give only temporary relief from the symptoms of fibroids. Once you stop the treatment, they often grow back and symptoms return.
Medications are generally safe, but they can have side effects, some of which may be serious. Be sure to talk to your health care provider about the possible side effects of any medical treatment you consider.
If you have moderate or severe symptoms of fibroids, surgery may be the best treatment for you.
Surgical treatment can be a major procedure or a minor one. The type of surgery depends on the size, location, and number of fibroids present, and your desire to bear children in the future.
Sometimes, there are a variety of surgical options from which to choose. Talk to your health care provider about the different types of surgical treatments and about the possible risks, side effects, and recovery time of each procedure.
The current surgical treatments for fibroids are:
- Endometrial ablation
Endometrial ablation destroys the lining of the uterus. It is used to treat small fibroids inside the uterus. Two common ways of doing an ablation are with a heated balloon, and with a tool that uses microwave energy to destroy the uterine lining and fibroids.
Pregnancy is unlikely after this procedure, but it can happen. Women who get pregnant after endometrial ablation are at higher risk for miscarriage and other problems. If you are going to have this treatment, talk to your health care provider about the risks of getting pregnant after the procedure. You might want to use birth control to prevent pregnancy until after you go through menopause.
This procedure removes only the fibroids, and leaves the healthy areas of the uterus intact, and can preserve your ability to get pregnant.
Myomectomy can be performed in one of three ways. The method you need will depend on the location and size of your fibroids.
- Hysteroscopy: For this procedure, the surgeon inserts a long, thin telescope with a light through the vagina and cervix (the opening of the uterus). The doctor then uses electricity or a mechanical device to cut or destroy the fibroids. The doctor will inject a fluid into the uterus to make it easier to see before trying to remove the tumors.
- Laparotomy: The surgeon removes the fibroids through a cut in the abdomen.
- Laparoscopy: The surgeon uses a long, thin telescope to see inside the pelvic area, and then removes the fibroids using another tool. This procedure usually involves two small cuts in the abdomen.
Studies show that myomectomy can relieve fibroid-related symptoms in 80% to 90% percent of patients. The original fibroids do not regrow after surgery, but new ones may develop.
Hysterectomy is the only sure way to cure uterine fibroids completely. Health care providers usually recommend this option if your fibroids are large, you have very heavy bleeding, and you are near or past menopause.
During a hysterectomy, the whole uterus or just part of it is removed. The types of hysterectomy include:
- Subtotal, or partial, hysterectomy. In this procedure, only the upper part of the uterus is removed.
- Total hysterectomy. The entire uterus and the cervix are removed. Sometimes the ovaries and fallopian tubes are also removed. This procedure is called a total hysterectomy with bilateral salpingo-oophorectomy.
- Radical hysterectomy. This procedure removes the uterus, the tissue on both sides of the cervix, and the upper part of the vagina.
There are several approaches to doing a hysterectomy:
- Abdominal hysterectomy. The surgeon removes the uterus through a cut in the abdomen. This incision may be similar to what is done during a cesarean section. Full recovery time from an abdominal hysterectomy is one to two months. Removal of the ovaries is not required for treatment of fibroid symptoms. Similarly, some women may desire to preserve the cervix, if there is no history of abnormal pap smears.
- Vaginal hysterectomy. Instead of making a cut into the abdomen, the surgeon removes the uterus through the vagina. This method is less invasive than an abdominal hysterectomy, so recovery time is usually shorter. Vaginal hysterectomy may not be an option if your fibroids are very large.
- Laparoscopic hysterectomy. Minimally invasive approaches may include laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, or robotic-assisted laparoscopic hysterectomy. Not all cases of uterine fibroids can be treated with such approaches, but these methods may result in reduced postoperative recovery time.
- Robotic hysterectomy. Robotic hysterectomy is becoming more common. The surgeon sits at a console near the patient and guides a robotic arm to perform laparoscopic surgery. Like laparoscopic myomectomies, this technique requires only small incisions in the uterus and abdomen. As a result, recovery can be shorter than with more invasive procedures. More research is needed to understand how (and how well) these procedures work and to compare the outcomes with those of other established surgical treatments.
If you have not gone through menopause and are considering a hysterectomy for your fibroids, talk to your health care provider about keeping your ovaries. The ovaries make hormones that help maintain bone density and sexual health even if the uterus is removed. If your body can continue to make these hormones on its own, you might not need hormone replacement after the hysterectomy.
Having a hysterectomy means that you will no longer be able to get pregnant, so you will probably want to talk to your partner or spouse before deciding to have a hysterectomy. The process cannot be reversed, so be certain about your choice before having the surgery.
Radiological treatments for fibroids
Radiologic treatments (also called radiation therapy or radiotherapy) use ionizing radiation, similar to what you are exposed to when you get an X-ray, to treat fibroids.
Such treatments might be indicated if you want a minimally invasive option that avoids surgery and typically involves a short hospital stay. Before undergoing any treatment for uterine fibroids, you should discuss your options with your health care provider.
- Uterine Artery Embolization (UAE)
- Magnetic Resonance Imaging (MRI)-Guided Ultrasound
Uterine artery embolization (UAE)
Uterine artery embolization, or UAE, is also called uterine fibroid embolization (UFE). This procedure cuts off the blood supply to the fibroids, causing them to shrink and be reabsorbed by your body.
In this procedure, the doctor makes a small cut in the groin area and inserts a tube (called a catheter) into the large blood vessel there. The doctor slides the tube until it reaches the arteries that supply blood to the uterus and then injects tiny particles through the tube into the arteries. The particles block blood flow to the fibroids. Blocking the blood flow eventually shrinks the fibroids and may relieve symptoms.
Recovery from UAE takes less time than does recovery from a hysterectomy. Some research has shown that UAE successfully treats them, but that about one-third of women who have UAE need treatment again within five years.
Because this procedure stops blood flow to parts of the uterus, it can affect how the uterus functions. It can also affect future ovarian function if the inserted particles drift into other areas of the pelvis such as the ovarian artery. Its effect on pregnancy is not clear, but an increased risk of miscarriage has been reported. For this reason, most health care providers do not recommend UAE for women who want to have children.
This treatment destroys fibroids using high-intensity ultrasound. The health care provider uses an MRI scanner to see the fibroids, then directs ultrasound waves through the skin to destroy the fibroids. This option is usually recommended for women who have only a few large fibroids.
Scientists are still studying the long-term effects of this procedure. Current research shows that up to 25% of women who have MRI-guided ultrasound need a second procedure after one year. Because MRI-guided ultrasound is new, your health care provider may not offer it or your health insurance company may not pay for it. It may also affect ovarian function.
Emotional support for living with fibroids
Emotional support may be just as important as medical treatment for dealing with the chronic symptoms and potential reproductive problems associated with fibroids. Many women find that joining a support group and talking to other women who have fibroids helps them come to terms with their condition.
Hospitals and health clinics may offer support groups for women and families affected by fibroids. Your health care provider may be able to refer you to a support group. You may also find it helpful to work with a “professional listener,” such as a social worker, a psychologist, a psychiatrist or another mental health professional.
This article was adapted from information provided by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Office of Research on Women’s Health. Illustrations thanks to the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Fibroids take psychological, not just physical, toll
Fibroids may be considered benign tumors — but that doesn’t mean they’re completely harmless.
Uterine fibroids take a considerable psychological toll
Scientists from Northwestern University presented research at the 70th Annual Meeting of the American Society for Reproductive Medicine that explored the considerable psychological toll that uterine fibroids take on patients.
The researchers recruited 48 women suffering from symptomatic uterine fibroids to explore the emotional and psychological toll the disease takes on patients. Their reactions included general worry, fear, sadness, anxiety and depression.
Over half the women felt helpless, believing they had no control over the fibroids, or the unpredictable, sometimes heavy, menstrual flow which the fibroids can trigger. Only two of the 48 women reported they were getting care from a mental health professional.
There was also a racial dimension to the experience of fibroid patients. Nearly all the women, regardless of race, expressed concerns about the treatment options that were presented to them. African American women were more likely to express an aversion to surgery and were more likely to report a difficult recovery following surgery.
“The mental health toll of uterine fibroids is important, but, up to now, has been poorly understood,” says Kurt Barnhart, MD, President of the Society for Reproductive Endocrinology and Infertility. “This study will help us better meet the needs of our patients.”
Information provided by the ASRM Office of Public Affairs. Studies referenced: P-329 MS Ghant et al, “Beyond the Physical: A Qualitative Assessment of the Emotional Burden of Symptomatic Uterine Fibroids on Women’s Mental Health” and P-450 MS Ghant et al, “Great Expectations: A Qualitative Assessment of Racial/Ethnic Differences in Women’s Treatment Experiences with Symptomatic Uterine Fibroids.”
Quality of life goes way up after uterine fibroid treatment
Women who received one of three treatments for uterine fibroids at Brigham and Women’s Hospital in Boston said their symptoms diminished and their quality of life significantly increased, according to a study from 2011.
Quality of life after fibroid treatment
Uterine fibroids are benign pelvic tumors that occur in as many as one in five women during their childbearing years. Although not all fibroids cause symptoms, some women experience heavy bleeding, pain and infertility.
Treatment options include hysterectomy, minimally invasive uterine artery embolization (UAE) and a noninvasive MR-guided focused ultrasound (MRgFUS) procedure.
“When discussing treatment options for women with uterine fibroids, the pros and cons of each treatment option need to be outlined,” said the study’s lead author, Fiona M Fennessy, MD, PhD, assistant professor of radiology at Harvard Medical School. “But until now, we haven’t been able to evaluate all of the options with health-related quality-of-life measures, assessing symptom relief as well as the pain, anxiety or recovery time associated with the treatment itself.”
The fibroid study
In the study, researchers surveyed a total of 197 women who underwent hysterectomy (62), UAE (74) and MRgFUS (61) for symptomatic uterine fibroids between 2004 and 2006. The mean ages of the women in three groups were 47, 44 and 47, respectively.
A utility weight (a single unit of measure that encompasses all the different quality-of-life benefits from a health care intervention) was obtained for each of the fibroid treatment options, allowing comparisons of quality of life before and after treatment.
In addition, short-term utility weights for the actual treatments the women underwent were compared, allowing comparison of the actual treatment experiences among the options. To do this, the researchers used the waiting trade-off (WTO) method, which is based on the fact that people tend to wait longer to avoid unpleasant tests or procedures. Analysis by the WTO method provides short-term quality-of-life tolls in terms of quality-adjusted life-weeks.
“Quality of life significantly increased following each of the fibroid treatment options,” Dr Fennessy said. “But patients rated the non- or minimally invasive treatments — UAE and MRgFUS — more favorably.”
Patients who underwent a hysterectomy reported that they would wait 21 weeks in order to avoid the procedure, while patients in the other two groups said they would put off their procedures by only 14 weeks.
The minimally invasive UAE procedure, which is increasingly used as an alternative to the surgical removal of the uterus (hysterectomy), requires only a small nick in the skin, through which a catheter is inserted to deliver particles that block blood flow to the fibroids. UAE may be associated with a number of days of pain and cramping.
The MRgFUS procedure, which was approved by the US Food and Drug Administration in 2004 as a treatment option for uterine fibroids, is noninvasive: it uses ultrasound energy to ablate the fibroids. MRgFUS is quick and painless for many, and symptom relief has been shown to occur by 12 weeks.
“Quality-of-Life Assessment of Fibroid Treatment Options and Outcomes” was published in the May 2011 issue of Radiology. Collaborating with Dr Fennessy were Chung Yin Kong, PhD, Clare M Tempany, MD, and J Shannon Swan, MD.