Facts About Fibroids

Fibroids are noncancerous masses of muscular tissue and collagen that can develop within the wall of the uterus. They are the most common benign tumor in premenopausal women. By the time women are 50 years old, 80 percent will have fibroids, but only 20 percent of women with fibroids will have any symptoms.


You may hear your health care professional call fibroids by other terms including uterine leiomyomas, fibromyomas, fibromas, myofibromas and myomas. They can be small or quite large.
While fibroids can cause a variety of symptoms, they may not cause any symptoms at all—so you may not even know you have one. Heavy bleeding is the most common symptom associated with fibroids and the one that usually prompts a woman to make an appointment with her health care professional. You may learn you have one or more fibroids after having a pelvic exam.

Fibroids may cause a range of other symptoms, too, including pain, pressure in the pelvic region, abnormal bleeding, painful intercourse, frequent urination or infertility.

What actually causes fibroids to form isn't clear, but genetics and hormones are thought to play a big role. Your body may be predisposed to developing fibroids. They seem to grow or shrink depending on estrogen levels in your body, but researchers don't know why some women develop them while others don't.

Fibroids usually grow slowly during your reproductive years, but about 40 percent of fibroids increase in size with pregnancy.

At menopause, fibroids shrink because estrogen and progesterone levels decline. Using menopausal hormone therapy containing estrogen after menopause usually does not cause fibroids to grow. Growth of a fibroid after menopause is a reason to see your gynecologist to make sure nothing else is causing the growth.

Progesterone and growth hormone are other hormones that may stimulate a fibroid's growth once it has already formed.

A variety of treatments exist to remove fibroids and relieve symptoms. If you learn you have fibroids but aren't experiencing symptoms, you usually won't need treatment.

Who Is at Risk for Fibroids?
Your risk for developing fibroids increases with age. African-American women are more likely than Caucasian women to have them, and they are more likely to develop fibroids at a younger age. If women in your family have already been diagnosed with fibroids, you have an increased risk of developing them. You may also be at an increased risk if you are obese or have high blood pressure.

Types of Fibroids
Fibroids form in different parts of the uterus:

• Intramural fibroids are confined within the muscle wall of the uterus and are the most common fibroid type. They expand, which makes the uterus feel larger than normal. Symptoms of intramural fibroids may include heavy menstrual bleeding, pelvic pain, back pain, frequent urination and pressure in the pelvic region.
• Submucosal fibroids grow from the uterine wall into the uterine cavity. They can cause heavy menstrual bleeding with associated bad menstrual cramps and infertility.
• Subserosal fibroids grow from the uterine wall to the outside of the uterus. They can push on the bladder or bowel causing bloating, abdominal pressure, cramping and pain.
• Pedunculated fibroids grow on stalks out from the uterus or into the uterine cavity, like mushrooms. If these stalks twist, they can cause pain, nausea or fever, or extremely rarely can become infected. 

Diagnosis
More than half of women who have fibroids never experience symptoms. When fibroids are symptom-free, they generally don't require treatment. But even small fibroids can cause heavy or longer-than-normal menstrual bleeding and significant pain. Fibroids may also contribute to infertility.
The three most common symptoms caused by fibroids are:

• Abnormal uterine bleeding. The most common bleeding abnormality is heavy menstrual bleeding—menstrual bleeding that is excessively heavy or long. Normal menstrual periods last four to seven days. If you have abnormal bleeding from fibroids, your periods are likely to last longer or may be heavier. Instead of changing a pad or tampon every four to six hours, you may have to change one every hour and find that your periods greatly interfere with your daily activities. You may also experience breakthrough bleeding, or bleeding that occurs between periods.

• Pelvic pressure. You may experience pressure in the pelvic region. Many women with fibroids have an enlarged uterus. Pelvic pressure may be caused by either the increased size of your uterus or from the location of one fibroid in particular. Health care professionals usually describe the size of a uterus with fibroids in the same terms used for someone who is pregnant, such as a "12-week-size fibroid uterus."
  
  You may also experience pressure on areas near your pelvis, including your bowel or bladder. Pressure against these structures can lead to difficulty or pain with bowel movements and constipation or increased urinary frequency and incontinence. Conversely, you may not be able to empty your bladder because the fibroid is in the way or you may get recurrent urinary tract infections.

• Reproductive problems. Fibroids also are associated with reproductive problems, depending on the number of fibroids present in the uterus and on their size and specific location. While having fibroids can cause complications with pregnancy, most do not have any impact. Fibroids in a uterus do not create a high-risk pregnancy. The risks from fibroids may include a higher risk of miscarriage, infertility, premature labor and labor complications.

Symptoms caused by fibroids can be similar to a number of other symptoms caused by a variety of other conditions, including reproductive cancers, sexually transmitted infections and bowel and bladder disorders. So, if you are having any unusual symptoms, be sure to make an appointment to discuss them with your health care professional.

The first step in diagnosing fibroids is usually a pelvic exam and a comprehensive medical history performed by your health care professional. He or she may be able to feel the fibroids in your uterus during the exam, because fibroids can make the uterus feel enlarged or irregular. If the uterus is enlarged enough, it may also be felt abdominally above the pubic bone.
To confirm the diagnosis, even if nothing is felt, your health care professional may recommend one or more diagnostic tests.

Ultrasound is probably the most common option used to confirm the diagnosis. It is important to note that imaging may find very small fibroids that don't pose any medical problems, wouldn't be felt on physical examination and may not be causing symptoms.

If you have heavy or prolonged bleeding or have had multiple miscarriages, your health care professional may recommend a more involved examination of your uterine cavity to see if you have a submucous fibroid, which might go undetected on a regular ultrasound. The assessment can be performed in one of four ways:

• Magnetic resonance imaging (MRI). MRI uses a magnet (not x-ray) to make an image of the uterus. It is the most accurate way to determine the positions, sizes and number of fibroids you have.

• Hysteroscopy. The uterus is expanded with a liquid or gas, and a hysteroscope (a small telescope) is inserted directly into the uterus through the vagina and cervix enabling your health care professional to see your entire uterus. Fibroids within the uterine cavity can also be removed during this surgery.

• Saline-infused sonography. A saline solution is injected into your uterus, and ultrasound is used to visualize the uterine cavity. Also called hysterosonography, this test is most useful in women who have prolonged or heavy menstrual bleeding but normal ultrasound results.

• Hysterosalpingography (HSG). A dye that shows up on an X-ray is injected into your uterus, enabling your health care professional to evaluate the structure of your uterine cavity and look for any abnormalities in the uterus or fallopian tubes. This test may be recommended if you are trying to get pregnant to check if your tubes are open, but it is not very accurate when looking for fibroids..

Imaging tests, such as computed tomography (CT), may also be ordered but is not very accurate for the diagnosis of fibroids.
If you are experiencing abnormal vaginal bleeding as a result of fibroids, your health care professional may want to conduct other blood tests, including a complete blood count, to rule out other conditions.

Treatment
If you aren't experiencing symptoms caused by your fibroids, you usually do not need any treatment. And, if your symptoms aren't severe, you may decide you can put up with them. This may be especially true if you're close to menopause—a time when fibroids shrink and symptoms resolve. It's important to discuss all your options with your health care professional and consider his or her recommendations when weighing your treatment options.
You may want to try the "watch and wait approach," where your health care professional periodically evaluates the size of your fibroids during routine pelvic exams and discusses how much discomfort you're feeling or how the symptoms may be disrupting your lifestyle.
Fibroids that don't cause symptoms rarely need therapy unless they get big enough to affect other structures in the pelvic area, such as the kidneys or the ureter (the tube that drains the kidney to the bladder).
The need for treatment and the type of treatment you choose depends on the size and position of the fibroids, as well as any symptoms they're causing, your age and whether or not you want to have children in the future. Even with a variety of treatment options available, new fibroids may grow back to some degree in the years following most treatments. The need for repeat treatments ranges from 10 percent to 25 percent, depending on the number and sizes of the fibroids initially treated. No treatment—except hysterectomy—can guarantee that new fibroids won't grow. The more fibroids you have, the more likely you are to have a recurrence after treatment.
If bleeding is your major symptom, some women opt for managing this symptom with medication before surgery or as a way to delay surgery if they're close to menopause (because fibroids generally shrink and cause few or no problems after menopause).
Medical Treatment Options for Fibroids

• Oral contraceptives (OCs). While OCs do not treat fibroids, they may be recommended to manage heavy bleeding caused by fibroids or for women who experience irregular ovulation in addition to fibroids. OCs are the first treatment option for many women, often combined with a nonsteroidal anti-inflammatory such as ibuprofen. OCs do not make fibroids grow.
• Intrauterine device (IUD). The levonorgestrel intrauterine device (Mirena), which is usually prescribed for birth control, can help ease the heavy bleeding that accompanies some fibroids. The device won't shrink the fibroids, however, and depending on whether or not the fibroids have distorted the inside of the uterus, it may or may not provide effective birth control. Although the levonorgestrel IUD is FDA-approved for heavy menstrual bleeding, it isn't approved specifically for the treatment of fibroids, so if you are interested in this option, discuss it with your doctor.
  
• GnRH agonists. Gonadotropin-releasing hormone (GnRH) agonists, including leuprolide (Lupron), nafarelin nasal (Synarel) and goserelin (Zoladex), temporarily shrink fibroids by blocking estrogen and progesterone production; estrogen is thought to stimulate their growth. They are mainly used in women close to menopause or to shrink fibroids before removing them surgically or to correct anemia caused by heavy bleeding associated with fibroids. GnRH agonists are considered a short-term treatment because they block hormone production by the ovaries, thus triggering menopausal symptoms caused by estrogen depletion, such as hot flashes, vaginal dryness and bone loss. The usual course of treatment is three to six months, and it may be combined with estrogen and/or progesterone hormones to minimize menopausal symptoms. Once this medication is stopped, fibroids usually grow back to near pretreatment size or larger within several months.
  
• Antifibrinolytic medicines. Antifibrinolytic medicines are drugs that help slow menstrual bleeding by helping blood to clot. The drug tranexamic acid (Lysteda) is FDA-approved for heavy menstrual bleeding. Rare side effects include headaches, muscle cramps, or pain. Antifibrinolytic medicines do not affect your chances of becoming pregnant. They should not be taken with hormonal birth control without prior approval from a health care professional as the combination can cause blood clots. Antifibrinolytic therapies are relatively new and expensive—and often not covered by insurance. Check with your insurer if that is a concern.

Minimally Invasive Treatment Options

• Uterine artery embolization (UAE). UAE is a procedure that involves placing a small catheter (a thin tube) into an artery in the groin and guiding it via X-rays to the arteries in the uterus. Then, tiny particles similar in size to grains of sand are injected through the catheter and into the artery. As they move toward the uterus, they obstruct the blood supply to the fibroids. Without an adequate blood supply, the fibroids shrink. The uterus is spared, however, because an alternate blood supply develops to support it.
  
  UAE takes about one hour to perform and is typically performed by an interventional radiologist. It usually requires a one-night hospital stay. Most women are back to their normal activities in seven to 10 days.
  
  While this treatment option leaves your uterus intact, it's not recommended for women who wish to become pregnant in the future.
  
  Potential complications include fever, passage of small pieces of fibroid tissue through the vagina after the procedure, allergic reaction and hemorrhage. Complications can also occur if blood supply to the ovaries or other organs becomes compromised.

• Endometrial ablation. This technique is used to treat small fibroids within the uterus or heavy periods caused by fibroids. Endometrial ablation uses electrical energy, heat or cold to destroy the lining of the uterus. It is performed on an outpatient basis and is only offered as a treatment option to women who have finished childbearing. It is not recommended for women who wish to preserve fertility. However, using a reliable form of contraception after having ablation is important.

Surgical Options for Fibroids

• Hysterectomy. A hysterectomy offers the only real cure because it completely removes the uterus.
  
  However, hysterectomy is major surgery, requiring between two and eight weeks of recovery, depending on the type of surgery performed. Hospital stays and recovery times can vary based on the type of procedure used and the extent of the surgery performed. Because your uterus and, sometimes, your ovaries, are removed, it is not an option if you want to become pregnant. If your ovaries do not need to be removed, you may want to keep your ovaries to maintain estrogen production.
  
  If you and your health care professional decide that a hysterectomy is the best choice for you, you may have several options about how the procedure is performed:
  
  • Abdominal hysterectomy, in which the uterus is removed through an incision in the abdomen. It is generally used for large pelvic tumors or suspected cancer because this procedure allows the surgeon to see and manipulate the pelvic organs more easily.
  • Vaginal hysterectomy, in which the uterus is removed through the vagina.
    
  • Laparoscopically hysterectomy, in which a surgeon uses a laparoscope (a small telescope) inserted through the abdomen to see inside your pelvis. Laparoscopic hysterectomy is less invasive than an abdominal hysterectomy, but more invasive than a vaginal hysterectomy.
  • Robotic-assisted laparoscopic hysterectomy, in which a robotic system assists in removal of the uterus in a laparoscopic hysterectomy. It may be helpful with some patients because of the flexibility it allows, but it also adds to the time and cost of the procedure.

• Myomectomy. This procedure removes only the fibroids, leaving the uterus intact, which can preserve fertility. The procedure is performed through an incision in the abdomen (a laparotomy), which requires general anesthesia, or by laparoscopy, which uses a few small incisions to insert an operative camera and surgical instruments. Robotic myomectomy is a variation of laparoscopic myomectomy during which the surgical procedure is aided with a surgical robot. A full recovery from laparotomy can take up to six weeks and two weeks from laparoscopy. Your health care professional will recommend which procedure to use based on the size of the fibroids, as well as whether they are superficial or deep (which is too difficult for laparoscopy).
  
  A hysteroscopic myomectomy is performed through the vagina and requires no incision. It is appropriate only for women whose fibroids are in the endometrial cavity. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed through the vagina into the uterine cavity. A wire loop carrying electrical current is then used to shave off the fibroid.
  
  Blood loss may be slightly greater with a myomectomy than with hysterectomy, but surgeons use tourniquets and medications to control blood loss, so that transfusion rates are no greater than with hysterectomy.

Magnetic resonance guided focused ultrasound. A more recent fibroid treatment option, magnetic resonance guided focused ultrasound surgery (MRgFUS or FUS) is a noninvasive treatment that takes place inside an MRI machine. The machine guides the treatment, which consists of multiple waves of ultrasound energy that go through the abdominal wall and destroy the fibroid. The procedure requires sedation but is usually performed on an outpatient basis. In the weeks and months that follow, fibroids shrink and heavy menstrual flow decreases. Pregnancy isn't recommended after FUS, but it is possible to become pregnant following the procedure.

Radiofrequency ablation. Acessa is a new FDA-approved laparoscopic surgical procedure that uses radiofrequency energy to destroy fibroids. The energy heats the fibroid tissue and kills the cells, which are then reabsorbed by the lymphatic system, decreasing fibroid size and symptoms. The procedure is minimally invasive, performed under ultrasound guidance during an outpatient pelvic laparoscopy. The early results regarding the safety and effectiveness of Acessa are good. On average, women returned to normal activities in nine days. The long-term risk of fibroid recurrence has not yet been determined, though a 12-month follow-up in one study showed good results.

Prevention
Fibroids can't be prevented. If you are experiencing symptoms, such as heavy bleeding and pelvic pressure, contact your health care professional for an evaluation. If you have a family history of fibroids or have been treated for them in the past, you may want to be examined more frequently or investigate the various management strategies available to treat fibroids.