Fibroids
Author
Elizabeth A Stewart, MD Section Editor
Robert L Barbieri, MD Deputy Editor
Leah K Moynihan, RNC, MSN
Sandy J Falk, MD
FIBROIDS OVERVIEW — Fibroids are growths of the uterus, or womb (show figure 1
Fibroids are very common. At least 25 percent of women have signs of fibroids that can be detected by a pelvic examination or ultrasound; not all of these women have symptoms of their fibroids.
FIBROID CAUSES — Although the exact cause of fibroids is unknown, fibroid growth seems to be related to the hormones estrogen and progesterone. When these hormone levels decline at menopause, many fibroid-related symptoms begin to resolve. However, it is not clear that hormones actually cause the fibroids. As an example, women who have had high levels of both of these hormones during pregnancy or from taking birth control pills have a lower incidence of fibroids later in life. (See “Epidemiology; clinical manifestations; diagnosis; and natural history of uterine leiomyomas”)
FIBROID SYMPTOMS — The majority of fibroids are small and do not cause any symptoms at all. However, many women with fibroids have significant bleeding and/or pelvic pain that interfere with some aspect of their lives.
The severity of symptoms is related to the number, size, and location of the fibroids. Fibroid symptoms fall into three main groups: increased uterine bleeding, pelvic pressure and pain, and problems related to pregnancy and fertility. Fibroid symptoms tend to decrease at the time of menopause.
Increased uterine bleeding — Fibroids can increase the amount and duration of menstrual bleeding. If the bleeding is very heavy, anemia (low red blood cell count) can occur.
Bleeding irregularly (between periods) is not typically a result of fibroids but may indicate another problem. Women with irregular bleeding should speak with their healthcare provider.
Pelvic pressure and pain — Fibroids can range in size from microscopic to the size of a grapefruit or even larger. Larger fibroids may cause a sense of pelvic pressure or fullness in the abdomen, similar to that caused by pregnancy.
Fibroids can also cause other symptoms, depending upon where they are located within the uterus. As an example, if the fibroid is pressing on the bladder, frequent urination or difficulty emptying the bladder can occur. A fibroid near the rectum may cause constipation, and cervical fibroids can cause pain during sexual intercourse.
In rare cases, fibroids can cause sudden and severe pain if the fibroid begins to break down (degenerate) or twist on a stalk (show figure 2
Problems with pregnancy and fertility — Most women with fibroids have completely normal pregnancies without complications. However, some studies have suggested a slightly increased risk of problems during pregnancy (such as preterm labor) in women with very large fibroids. In addition, women with large fibroids are at risk of requiring a cesarean delivery. (See “Management of pregnant women with leiomyomas”).
There is some risk of miscarriage and infertility associated with fibroids that distort the inside the uterus, known as submucosal or intramural fibroids. These fibroids can be removed with a surgical procedure if necessary. (see “Myomectomy” below).
It is not completely clear what role that fibroids play in infertility. An infertile woman who has large or numerous subserosal or intramural fibroids should talk with her doctor. In most cases, couples are counseled to initially try to become pregnant without treating the fibroid. If the couple has difficulty becoming pregnant, all other causes of infertility should be eliminated first. (See “Patient information: Evaluation of the infertile couple” and see “Reproductive issues in women with uterine leiomyomas”).
FIBROID DIAGNOSIS — Fibroids are often diagnosed during a routine pelvic exam. A pelvic ultrasound may be recommended to confirm the diagnosis.
Hysterosalpingogram — A hysterosalpingogram (also called HSG or tubogram) may be recommended for a woman who is trying to become pregnant. During this test, an x-ray of the uterus and tubes is taken after dye is inserted through the cervix. The dye outlines the shape of the inside of the uterus and fallopian tubes. This test can diagnose the presence, size, and location of fibroids in the uterine cavity, and can show if the fallopian tubes are patent (open) (show picture 1
Sonohysterogram — A sonohysterogram (also called SHG or saline-infusion sonogram), uses ultrasound and a water solution, which is inserted through the cervix, to view the inside of the uterus. This test is most useful in a woman with a normal pelvic ultrasound who has heavy or prolonged menstrual bleeding. A fibroid or endometrial polyp can cause heavy bleeding and not be visible with traditional ultrasound (show picture 2
In some cases, fibroids are found during an X-ray, MRI, or ultrasound procedure that is done for another reason.
FIBROID TREATMENT — Women who have no symptoms from their fibroids do not usually require treatment. Women with significant symptoms may try medical or surgical treatment. (See “Overview of treatment of uterine leiomyomas”).
Medical fibroid treatment — Medical treatment includes the use of medications to treat the symptoms of fibroid-related bleeding and pain.
Birth control pills — Birth control pills can be helpful in decreasing heavy menstrual bleeding associated with fibroids. The birth control pill does not shrink the fibroid, thus it is not an effective treatment for women with fibroids who have pelvic pressure, pain, or infertility. More information about birth control pills is available separately. (See “Patient information: Hormonal methods of birth control”).
Levonorgestrel intrauterine device — The levonorgestrel intrauterine device (IUD), available in the United States as Mirena®, is another possible option for women with fibroids who have heavy menstrual bleeding. Similar to the birth control pill, the Ievonorgestrel IUD does not shrink the fibroids, although it can significantly reduce menstrual bleeding and provide an effective long-term (up to 5 years) form of birth control.
In some cases, the shape of the inside of the uterus can be distorted by fibroids, which may decrease the effectiveness of the IUD as a birth control method. Women should discuss this possibility and the need for a second form of birth control (eg, condoms) with their healthcare provider.
More information about IUDs is available separately. (See “Patient information: Long-term methods of birth control”).
Progestin implants, injections, or pills — Progestin is a hormone that works to decrease the thickness of the uterine lining, thereby decreasing menstrual bleeding. It can be taken as a daily pill, an injection given every 12 weeks, or as an implant that is inserted and left under the skin for up to 3 years. Progestin treatments do not decrease the size of fibroids but can decrease fibroid-associated heavy bleeding.
More information about progestin is available separately. (See “Patient information: Hormonal methods of birth control”).
Gonadotropin releasing hormone (GnRH) agonists — Gonadotropin-releasing hormone (GnRH) agonists are the most common medical treatment for fibroids. Leuprolide (Lupron Depot®) is an example of a GnRH agonist.
Most women who use GnRH agonists temporarily stop having menstrual periods and have a significant reduction in the size of their fibroid(s). Reducing or eliminating menstrual bleeding can improve anemia. Common side effects of GnRH agonists include hot flashes and night sweats, similar to symptoms experienced by menopausal women. A low dose of estrogen can minimize these side effects without increasing the risk of bleeding or fibroid growth.
However, fibroids rapidly enlarge after GnRH agonists are discontinued. In addition, there are some potentially serious side effects (eg, thinning bones) if GnRH agonists are used for more than 12 months in a row. GnRH medications are usually given as a temporary fibroid treatment (for three to six months) while a woman is preparing for surgical fibroid treatment.
Antifibrinolytic medications — Antifibrinolytic medications are not intended to treat fibroids, although they can reduce menstrual bleeding by 30 to 55 percent. They are taken by mouth on the days when menstrual bleeding occurs and do not interfere with fertility. Examples of antifibrinolytic medications include tranexamic acid and aminocaproic acid; these medications are not currently available in the United States but are widely available elsewhere.
Danazol — Danazol is a steroid hormone that may be recommended to temporarily stop menstrual bleeding. However, Danazol is not a popular fibroid treatment due to bothersome side effects, including weight gain and mood changes.
Surgical fibroid treatment — Surgical fibroid treatment may be recommended for longer-term relief of fibroid symptoms such as bleeding and pain. In other cases, surgical fibroid procedures are done in an attempt to treat infertility. A number of surgical fibroid treatments are available.
Hysterectomy — Hysterectomy is the surgical removal of the uterus through the abdomen or vagina. It may be the treatment of choice for women who have completed childbearing, those who are not interested in other surgical treatments, and those with severe symptoms or recurrent symptoms after less invasive surgery. Removal of the ovaries and cervix is not required to relieve symptoms. More information about hysterectomy is available separately. (See “Patient information: Abdominal hysterectomy”).
Myomectomy — Myomectomy is the surgical removal of a fibroid. It may be done by making an incision in the abdomen and removing the fibroids (called abdominal myomectomy) or by making multiple small incisions in the abdomen and using a thin narrow tube with a camera (laparoscope) to remove the fibroids (called laparoscopic myomectomy). If the fibroids are inside the uterus, a procedure called hysteroscopic myomectomy may be recommended. (See “Myomectomy”).
Myomectomy preserves the chance of future childbearing and may provide short-term relief of heavy bleeding. However, there is a significant risk that fibroids will recur after myomectomy; between 10 and 25 percent of women who have myomectomy will require a second fibroid surgery. Laparoscopic myomectomy slightly increases the risk of uterine rupture during pregnancy or labor; the risk for most women is small.
Endometrial ablation — In this procedure, the lining of the uterus is destroyed with heat by inserting a scope through the vagina and cervix and into the uterus. It can be done in combination with other treatments, such as hysteroscopic myomectomy or myolysis (explained below). Endometrial ablation does not shrink the fibroid(s), but can help to decrease heavy menstrual bleeding caused by fibroids.
Pregnancy is possible, although not recommended, after endometrial ablation; some form of birth control is strongly recommended after ablation.
Uterine artery embolization — In uterine artery embolization (UAE or UFE), a small catheter is inserted into a large blood vessel in the groin and threaded up to blood vessels near a fibroid (show figure 3A-3B
* Post-procedure — Complications of UAE are similar to that of other fibroid surgeries. Post-procedure pain is generally moderate to severe; most women stay in the hospital overnight and are given intravenous pain medication after their procedure.
In the short term, approximately 95 percent of women report significant improvement in symptoms and quality of life after UAE. Long term studies show that approximately 75 percent of women reported normal or improved uterine bleeding five or more years after UAE. A small percentage of women (5 to 8 percent) stop having menstrual periods after UAE, which can be temporary or permanent. This change is more likely in women older than 50 years.
* Pregnancy after UAE — Pregnancy is not usually recommended for women who have undergone UAE, although normal pregnancies have occurred.
Myolysis — In this procedure, the fibroid tissue is destroyed with heat or cold using a device inserted laparoscopically into the abdomen. Myolysis can be combined with endometrial ablation; combining these procedures is more effective than either procedure alone.
Focused Ultrasound Surgery — MRI-guided focused ultrasound surgery (MRgFUS) involves destroying fibroid tissue with high intensity, focused ultrasound heat energy. The treatment takes place in an MRI machine, allowing for progress to be monitored while the procedure is done. The treatment is not widely available since it is expensive, time consuming, and requires special equipment.
Choosing a fibroid treatment — A number of factors should be considered before deciding upon the best surgical treatment for fibroids. One of the most critical factors is whether or not childbearing has been completed.
* Although hysterectomy provides excellent relief of symptoms, a woman who wishes to become pregnant in the future should consider myomectomy.
* A woman who is done with childbearing but who is not interested in hysterectomy may consider uterine artery embolization, myolysis, endometrial ablation, or a combination of the above.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
* National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
* US Department of Health and Human Services
(www.4woman.gov)
* Society of Interventional Radiology
(www.sirweb.org, search for “uterine fibroids”)
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