Fast Facts for Your Health: Uterine Fibroids

Fibroid Basics

As many as three out of four women have uterine fibroids, growths that originate in the wall or lining of the uterus. Although fibroids are sometimes referred to as "tumors," they are noncancerous. Most women with fibroids aren't even aware they have them. Fibroids can cause symptoms such as pain or bleeding, but it's usually only when they have grown in size and/or number. These symptoms may be mild, moderate or severe.

What causes fibroids is unknown, although the hormone estrogen is known to influence their growth. That's why fibroids tend to develop during the childbearing years and then subside with menopause. Your risk for developing fibroids is greatest if you are in your 30s or 40s, if you are African-American, and/or if you have a family history of fibroids.

Types & Symptoms of Fibroids

Fibroids are mostly muscle cells that grow as a single lump or cluster of lumps attached to the uterine wall. They can range in size from less than one inch in diameter to the size of a grapefruit. Fibroids are classified according to their location in the uterus. Their symptoms can vary:

• Submucosal: These grow just under the uterine lining into the uterine cavity. They can cause bleeding, pain and infertility.
  
• Intramural: This most common type of fibroid grows between the muscles of the uterine wall. These fibroids usually cause feelings of pressure and, less often, heavy menstruation.
  
• Subserosal: These grow from the uterine wall to the outside of the uterus. They can push on other organs, such as the bladder, bowel or intestine, causing abdominal bloating, pressure, cramps or pain.
  

Some fibroids grow on "stalks" or "pedicles" sticking out from the uterus or into the uterine cavity. If the stalks twist, they can cause pain and nausea as the tissue degenerates, or fever, if they become infected.

Other possible symptoms include frequent urination, constipation, pain during sex and lower back pain. Fibroids also increase the risk of miscarriage and complications during pregnancy.

Many of these symptoms also can occur with more serious conditions, such as gynecologic cancers, so it is important to have your symptoms evaluated promptly.

Diagnosing Fibroids

Your health care professional may be able to feel fibroids during your routine pelvic exam, which all women should have yearly. If the fibroids are not causing any problems, however, they do not require treatment.

If you are experiencing symptoms possibly caused by your fibroids, your health care professional may order tests to better understand why and for more information about how to best treat them. Diagnostic tests could include ultrasound, CT and MRI scans that display images of the inside of your uterus. Hysterosalpingography, a test that uses dye to create x-ray images of your uterus, also may be recommended.

Your health care professional also may need to examine the inside of the uterus directly. There are several techniques available. Hysteroscopy is a technique that uses a small telescope, inserted through the vagina and cervix, to view the uterus after it has been expanded with a liquid or gas. Hysterosonography uses an ultrasound probe to obtain images inside the uterus. And laparoscopy uses a camera on a fiber-optic device, threaded through a small abdominal incision, to view the uterus, ovaries and fallopian tubes.

To look for other causes of abnormal bleeding, such as uterine cancer, your doctor may remove a sample of cells from the lining of your uterus for laboratory analysis.

Treatment Options for Fibroids

If you are diagnosed with fibroids, your choice of treatment likely will depend on how severe your symptoms are, your age, whether or not you wish to preserve your ability to have children and your concern about treatment side effects.

You may choose to follow a "watch and wait" approach, especially if your symptoms are mild to moderate and/or you are nearing menopause, when fibroid-related symptoms tend to subside. Your health care professional would monitor the fibroids' growth during regular office visits. Many women choose this option.

Mild pain caused by fibroids often can be treated with over-the-counter anti-inflammatory drugs such as ibuprofen (Advil or Motrin), other painkillers such as acetaminophen (Tylenol) or even a prescription painkiller. If your symptoms affect your quality of life, however, there are other treatment options.

Other options include medications and surgery.

Medications
Hormone-blocking medications may help relieve symptoms but are considered only a temporary treatment. These include:

• Gonadotropin-releasing hormone (GnRH agonists) is a class of hormones that temporarily shrink fibroids by blocking estrogen production that stimulates their growth. GnRH agonists such as leuprolide (Lupron), nafarelin nasal (Synarel) and goserelin (Zoladex) may be suggested as treatment options. This type of medication is mainly used in women close to menopause or to shrink fibroids before surgery, thus making them easier to remove.
  

  GnRH agonists are considered a short-term treatment because by blocking estrogen production, the therapy triggers menopausal changes caused by low estrogen levels. These symptoms can include hot flashes, vaginal dryness and temporary bone loss. The usual course of treatment is three to six months.
  

Hormone therapy—low doses of estrogen and progesterone—are typically combined with GnRH agonists to lengthen therapy and to alleviate symptoms. Once the GnRH agonists are discontinued, fibroids usually grow back to near pre-treatment size or larger within several months.

• Mifepristone, a progesterone-blocking agent, and raloxifene, an estrogen-blocking agent, have shown promise in shrinking fibroids, but further studies are needed to evaluate their effectiveness.
  
• Oral contraceptives (OCs) can help to control heavy bleeding sometimes caused by fibroids, but OCs cannot shrink fibroids.
  

Surgeries & Procedures

• Hysterectomy. In the past, the most common treatment for fibroids was hysterectomy, which is the surgical removal of the uterus. Today, it's estimated that more than one-third of the 600,000 hysterectomies performed in the U.S. each year are done to treat fibroids.
  

  While hysterectomy is the only proven permanent solution, it also has some drawbacks. After hysterectomy, you no longer can have children. It is invasive surgery that requires from two to six weeks of recovery depending on the type of surgery performed. Though major complications from hysterectomy are considered rare, other side effects ranging from urinary tract infections to changes in sexual desire are possible; they may be only temporary concerns or longer-lasting health issues.

• Myomectomy. This surgical procedure removes just the fibroids, leaving the uterus intact. It's a good option if you want to maintain your fertility, but the fibroids may eventually recur.
  

  A myomectomy can be performed through a long abdominal incision, laparoscopically (through tiny incisions in the abdomen) or hysteroscopically (through the cervix with no incision). The form of surgery depends on the size and location of your fibroids, your medical history and your surgeon's preference. Risks involve those of any surgery, such as infection or complications from anesthesia. Post-operative adhesions—scar tissue—also are a risk. They may involve the bowel adhering to the uterus or may involve tubes and ovaries, which could cause pain, impair fertility or both. Robotically assisted laparoscopic myomectomy holds promise for better results in the future.
  

Other treatment strategies:

• Uterine artery embolization (UAE): One of the newest, non-surgical methods of treating fibroids, UAE works by cutting the blood supply to the arteries that feed the fibroids. Although this procedure has proven successful for many women, it can affect a woman's ability to have more children. In some cases, it may also help women achieve pregnancy, however. Risks include a slight risk of early menopause, particularly among perimenopausal women, and infection that could require emergency surgery.
  
• Myolysis: Another experimental procedure still under study, myolysis is a laparoscopic procedure that involves using lasers, electrical current or freezing (cryomyolysis) to destroy fibroids. It is only recommended for fibroids of a certain size and generally is not used for women who want to have children in the future.
  

Ask your health care professional to explain all your treatment options with your age and personal medical history in mind. Be sure to ask about the benefits and risks of any option he or she recommends. (See "Questions to Ask about Uterine Fibroids" for more things to discuss.)

Questions to Ask Your Health Care Professional

1. Are fibroids always noncancerous? How can you be sure?
   
2. Do fibroids always need to be treated? What happens if I just leave them alone?
   
3. Why are you recommending treatment for my fibroids?
   
4. What are my treatment options, and what are their potential advantages and disadvantages?
   
5. What can I expect after treatment, now and in the future?
   
6. Will I still be able to have children after this treatment?
   
7. How long is the recovery period for the treatment you're recommending?
   
8. Will my insurance cover this treatment?
   
9. Will the fibroids be removed permanently or can they return after this treatment - how fast will they return?
   
10. Can you perform the treatment you're recommending or will you refer me to a specialist?

Resources

National Uterine Fibroids Foundation
1-800-874-7247
www.nuff.org
Non-profit foundation provides education on the care and treatment of women with fibroids and related conditions.

Your Guide to Uterine Health
National Women's Health Resource Center
1-877-986-9472
www.healthywomen.org
An online overview of uterine health, including fibroids. Also available in print.

Uterine Fibroids Health Decision Guide
www.mayoclinic.com
An online tool from the Mayo Clinic

Hysterectomy Educational Resources and Services (HERS) Foundation
1-888-750-4377
610-667-7757
www.hersfoundation.com
Independent, non-profit international organization provides information about hysterectomies and alternative treatments.

Scott Goodwin, MD, and Michael Broder, MD. What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies—Including Breakthrough Alternatives to Hysterectomy. Warner Books, 2003.

Sources Consulted

The National Women's Health Information Center, "Uterine Fibroids," www.4woman.gov. Last update September 2004, accessed Sept. 9, 2005.

"Diagnosing and Treating Uterine Fibroids," in M. Sara Rosenthal, PhD, The Gynecological Sourcebook, 4th edition, McGraw-Hill, 2003, pages 229-40.

Mayo Clinic, "Uterine Fibroids Health Decision Guide," www.mayoclinic.com;
Last date updated: June 2005

Leon Baginski, MD, "Uterine Fibroids," www.medicinenet.com. Last updated April 5, 2002.

Serena Gordon, "Embolization Bests Surgery for Fibroid Treatment," HealthDay News, March 26, 2004, www.hon.ch.

Society of Interventional Radiology, "Uterine Fibroid Embolization," www.sirweb.org.

"Uterine Fibroids," The Merck Manual of Diagnosis and Therapy, 17th edition, 1999. pages 1959-60.

For more information about fibroids, visit "Questions to Ask about Uterine Fibroids" and "Fibroids."