What are fibroids?

Uterine fibroids are the most common benign (not cancerous) tumors, or growths, in women of childbearing age. They grow in and around the muscular wall of the uterus (womb). They can grow as a single tumor or there can be many. They can be as small as an apple seed or as big as a grapefruit. Fibroids can grow or stay about the same size over time. Another medical term for fibroids is leiomyoma or just “myoma”.

What are the symptoms of fibroids?

Fibroids do not always cause symptoms. People who have symptoms may find fibroids hard to live with. Symptoms of fibroids can include changes in menstruation (your period), heavy bleeding, vaginal bleeding between periods, painful periods, anemia (low red blood cell count, resulting from excessive bleeding), fullness or pressure in the lower abdominal area, frequent urination, pain the belly or lower back, and pain during sex. Fibroids can cause other reproductive problems, such as infertility, miscarriages, and obstetrical problems such as early labor and/or increased likelihood of Cesarean section.

What causes fibroids?

No one knows for sure what causes fibroids. Researchers think more than one factor could play a role. These factors include age, having a family member with fibroids, race/ethnic origin, being overweight or obese, having high blood pressure, and/or certain dietary factors and/or hormones.

How do I know if I have fibroids?

Unless you have symptoms, you might not know if you have fibroids. In some cases, a healthcare provider will find fibroids during a routine pelvic exam. Your provider may also order medical imaging like a pelvic ultrasound to see a picture of the fibroids. Imaging tests might include:

• Ultrasound – uses sound waves to make a picture; the ultrasound probe may be placed on the abdomen (belly) or inside the vagina
• Saline infusion sonohysterography (SIS or SHG) or saline ultrasound – uses a small amount of saline (salt solution) placed in the uterus (womb) to help “see” inside of the uterus on an ultrasound
• Magnetic resonance imaging (MRI) – uses magnets and radio waves to make a picture of the inside of your body
• Computed tomography (CT) or computer-assisted tomography (CAT) scan – scans the body with X-rays from many angles to form a more complete picture than a plain x-ray

Other tests your healthcare provider may order include:

• Complete blood count (CBC) – blood test to check for signs of anemia (low red blood cell count)
• Blood levels of iron - blood test to measure the iron levels and confirm if iron-deficiency anemia exists

Surgery (i.e. hysteroscopy) can confirm the ultrasound diagnosis of fibroids and provide additional information like the location of the fibroids.

How are fibroids treated?

If you have fibroids but do not have symptoms, you may not need medical intervention. If you have symptoms, there are medical treatments that may help. Talk with your healthcare provider about the best way to treat your fibroids. Your provider can check during regular exams and with imaging to see if your fibroids have grown.

Contact your healthcare provider if you have any of the following symptoms:

• Heavy bleeding or bleeding between periods
• Significant cramping or pain with periods
• A full or heavy feeling in or near your belly
• Frequent urination or difficulty with urination

If you have moderate or severe symptoms from your fibroids, your provider may recommend medical treatment, surgery or other interventional procedures depending on your symptoms and history. Medical treatments include hormonal medical treatments such as birth control pills, vaginal contraceptive rings, or intrauterine devices with hormone(s), which can help control heavy menstrual bleeding associated with fibroids. Newer medicines have been approved to manage heavy menstrual bleeding associated with fibroids in premenopausal women. Surgical options include removal of the fibroid(s) (myomectomy), destruction of the fibroid(s) without removal, or removal of the uterus (hysterectomy). These procedures can be performed using different methods, ranging from minimally invasive procedures to vaginal or open abdominal surgery. The type of surgery/procedure will depend on how many fibroids are present, where the fibroids are located and whether children are desired in the future.

Talk with your provider about all your medical treatment options and their risks and benefits. Your provider can answer all your questions and together you can decide which treatment is right for you.

Treatments for fibroids include the following:

• Medication-related treatments
• Hysterectomy
• Other treatments

Uterine fibroids can be treated with radiological and other methods. These can include endometrial ablation, uterine artery embolization, magnetic resonance imaging–guided focused ultrasound, and myomectomy.

These treatments are minimally invasive and typically involve a short hospital stay or can be done as an outpatient procedure. Before undergoing any treatment for uterine fibroids, you should discuss your options with your health care provider.

Your health care provider will consider several factors before recommending a treatment for your fibroids, including:

• Your age
• Your general health
• How severe your symptoms are
• Where your fibroids are located
• The type and size of the fibroids
• Whether you are pregnant now or want to get pregnant in the future

If you have uterine fibroids but have no symptoms or problems, you may not need treatment. You can ask your health care provider to continue to check the fibroids at your routine gynecological exams to see whether they have grown. If you are close to menopause, your health care provider may find that your fibroids are shrinking, which is common during and after menopause.

Depending on your symptoms, your health care provider may suggest medical treatments that can reduce the symptoms of fibroids or stop their growth. Certain medical treatments to reduce fibroid size and blood loss may be used in combination with other treatments.

Common medical treatments for fibroids include:

• Pain medicine. Over-the-counter or prescription medicine is often used for mild or occasional pain from fibroids.
• Birth control pills or other types of hormonal birth control. These medicines help control heavy bleeding and painful periods. However, this therapy can sometimes cause fibroids to grow larger.
• Progestin-releasing intrauterine device (IUD). The hormonal IUD, also called intrauterine contraception (IUC), reduces heavy and painful bleeding but does not treat the fibroids themselves. It is not recommended for women who have very large fibroids, which can block the uterine cavity.
• Gonadotropin-releasing hormone agonists (GnRHa). These medicines block the body from making the hormones that cause women to ovulate and have their periods. The medicines 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 medicines are used for a short time to reduce the size of fibroids before surgery or to treat anemia. If you need to take this treatment for a long time, the doctor may prescribe different medicine to put back the hormones that were blocked.
• Antihormonal agents or hormone modulators (such as selective progesterone receptor modulators). These drugs, which include ulipristal acetate, mifepristone, and letrozole, can slow or stop the growth of fibroids, reduce bleeding, and improve symptoms.

Medical treatments may give only temporary relief from the symptoms of fibroids. Once you stop the treatment, fibroids can grow back and symptoms can return.

Medicines 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.

Hysterectomy is the only sure way to cure uterine fibroids completely. Health care providers may recommend this option if you are near or past menopause and you have large fibroids or very heavy bleeding.

During a hysterectomy, the whole uterus or just part of it is removed.

There are several ways to perform 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. This type of hysterectomy requires a longer hospital stay and longer recovery time than others. 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 (3 to 4 weeks). Vaginal hysterectomy may not be an option if your fibroids are very large.
• Laparoscopic hysterectomy. Minimally invasive approaches include laparoscopic hysterectomy, laparoscopy-assisted vaginal hysterectomy, and 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 (3 to 4 weeks) 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. This process cannot be reversed, so be certain about your choice before having the surgery.

Endometrial ablation (pronounced ah-BLAY-shun) destroys the lining of the uterus. It is used to treat small fibroids inside the uterus. Ablations can be performed in a variety of ways, including using electric currents, using microwave energy, and freezing.

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.

Uterine artery embolization (pronounced em-bohl-ih-ZAY-shun), or UAE, is also called uterine fibroid embolization (UFE).

In this procedure, the doctor makes a small cut in the groin area, inserts a tube (called a catheter) into the large blood vessel there, and slides the tube until it reaches the arteries that supply blood to the uterus. He or she then injects tiny plastic or gel particles through the tube into the arteries. The particles block blood flow to the fibroids, so they eventually shrink and may relieve symptoms.

Some research has shown that UAE successfully treats fibroids but that about one-third of women who have UAE need treatment again within 5 years.

Because this procedure stops blood flow to parts of the uterus, it can affect how the uterus functions. It can also affect how the ovaries 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 by using high-intensity ultrasound. The health care provider uses an MRI scanner to see the fibroids and then directs focused 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. Studies show that although symptoms improve up to a year after having MRI-guided focused ultrasound, within 2 years, about one in three women will need another surgery or another procedure to treat fibroids. Because MRI-guided focused ultrasound is a relatively new kind of treatment, your health care provider may not offer it, or your health insurance company may not pay for it. It may also affect how ovaries function.

Myomectomy is a surgical procedure that removes only the fibroids and leaves the healthy areas of the uterus intact. It can preserve the ability to get pregnant.

Myomectomy can be performed in one of three ways, depending on the location and size of the fibroids:

• Hysteroscopy (pronounced hiss-tur-AH-skoh-pee). 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 fibroids.
• Laparotomy (pronounced lap-are-AH-toh-mee). The surgeon removes the fibroids through a cut in the abdomen.
• Laparoscopy (pronounced lap-are-AH-skoh-pee). 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% of women. The original fibroids do not regrow after surgery, but new fibroids may develop.

The following methods are not yet standard treatments, so your doctor may not offer them or health insurance may not cover them.

• Radiofrequency ablation uses heat to destroy fibroid tissue without harming surrounding normal uterine tissue. The fibroids remain inside the uterus but shrink in size. Most women go home the same day and can return to normal activities within a few days.
• Anti-hormonal drugs may provide symptom relief without bone-thinning side effects.

In most cases, fibroids stop growing or they shrink without treatment. Once a woman goes through menopause, fibroids often shrink, but this is not true for all women. Interestingly, each of a woman’s fibroids may grow or shrink at different times.

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.