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Fibroids

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These materials are for your general information and are not a substitute for medical advice. You should contact your physician or other healthcare provider with any questions about your health, treatment, or care.

WHAT ARE FIBROIDS? — Fibroids are benign (that is, non-cancerous) tumors of the uterus, or womb. They are also called uterine leiomyomas, or simply myomas. They grow from the muscle cells of the uterus and may protrude from the inside or outside surface of the uterus or they may be contained within the muscular wall.

Fibroids are very common. About 25 percent of women in their childbearing years will have signs of fibroids that can be detected by a pelvic examination, although not all will experience symptoms.

WHAT CAUSES FIBROIDS? — Although the exact cause is unknown, the growth of fibroids seems to be related to the reproductive hormones estrogen and progesterone. When these hormone levels decrease at menopause, many of the symptoms of fibroids begin to resolve. However, it is not clear that the hormones actually cause the fibroids to occur. For example, women who have had high levels of both of these hormones as a result of pregnancy or birth control pills have a lower incidence of fibroids later in life.

Abnormalities in the blood vessels around the uterus may play a role in development of fibroids. Changes in chemicals in the body that cause tissue to grow may also be involved.

WHO IS AT RISK FOR GETTING FIBROIDS? — A number of factors have been associated with either an increased or decreased risk of developing fibroids. These include:

Number of pregnancies — Women with one or more pregnancies that extended beyond 5 months have a decreased risk of fibroid formation.

Use of birth control pills — Use of birth control pills can protect against fibroids, but use of the pill at an early age (between age 13 and 16) may be associated with an increased risk.

Smoking — Women who smoke appear to have a decreased risk of having fibroids. However, this apparent health benefit is clearly outweighed by the many serious health risks associated with cigarette smoking.

Diet — Significant consumption of beef, ham, or other red meats is associated with an increased risk, and consumption of green vegetables decreases risk. However, no study has shown that changes in diet lead directly to changes in the incidence or symptoms of fibroids.

Ethnic background — Fibroids are 2 to 3 times more common in African American women than in Caucasians. Among women undergoing hysterectomy (removal of the uterus), black women are significantly more likely to have fibroids, to be younger at the time of diagnosis and hysterectomy, and to have more severe problems associated with fibroids than their white counterparts.

WHAT SYMPTOMS ARE ASSOCIATED WITH FIBROIDS? — The majority of fibroids are small and do not cause any symptoms at all. But many women have significant problems that interfere with some aspect of their lives and want to be treated. The symptoms are related to the number, size, and location of the fibroids, and fall into three main groups: increased uterine bleeding, pelvic pressure and pain, and problems related to pregnancy and fertility. As noted above, the symptoms tend to decrease at the time of menopause, although women who take hormone replacements to treat the symptoms of menopause may not see this effect.

Increased uterine bleeding — Fibroids may cause an increase in blood flow during the menstrual period, or an increase in the length of the period. The presence and degree of uterine bleeding is determined mainly by the location of the fibroid. Women with fibroids that protrude into the uterus are more likely to have significant increases in bleeding, although women with all types of fibroids can have this problem. If the bleeding is very heavy, anemia (low red blood cell count) can occur.

Bleeding between periods is not a characteristic of fibroids and suggests another disease process.

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 pressure and fullness in the abdomen, similar to that caused by pregnancy. Fibroids of variable sizes can cause other symptoms depending on where they are located. For example, if the fibroid is pressing on the bladder, frequent urination can occur. A fibroid that pushes on the rectum can cause constipation, and one that puts pressure on the cervix can result in painful intercourse.

In rare cases, fibroids can cause acute pain because of breakdown or twisting of the tumor. Pain of this type may be associated with a mild fever, tenderness in the abdomen, and elevation in the white blood cell count. The pain usually resolves in a few days to a few weeks. Nonsteroidal antiinflammatory drugs, such as ibuprofen, can be used to treat the discomfort.

Problems with pregnancy and fertility — Some studies have suggested a slightly increased risk of certain problems during pregnancy in women with very large fibroids, including difficulties with labor, breech presentation of the fetus, premature rupture of membranes, and abruptio placenta (a condition in which the placenta separates from the uterine wall during the pregnancy). Nevertheless, almost all women with fibroids have completely normal pregnancies and deliver healthy babies with no complications.

The risk of miscarriage and infertility may increase with the type of fibroid that protrudes into the uterine cavity. However, the role that fibroids play in infertility is not completely clear. An infertile woman who has large or numerous fibroids without other identified reasons for the infertility can talk with her doctor about the possibility of having the fibroids removed.

HOW ARE FIBROIDS DIAGNOSED? — Often, doctors can feel the enlarged, irregular uterus typical of many fibroids during a routine pelvic exam. In certain cases, the doctor may wish to confirm the diagnosis and exclude the possibility of an ovarian tumor using procedures such as ultrasound in which sound waves are used to visualize the uterus. X-rays of the uterus and tubes after a dye is injected through the cervix make the inside of the uterus and tubes visible. This test (called a hysterosalpingogram) may be performed in women during fertility to diagnose the presence, size, and location of fibroids that may be protruding into the uterine cavity, and show tubal whether the tubes are patent (open). A sonohysterogram, which uses ultrasound and a salt solution instead of x-ray and dye, is usually preferred in women in whom fertility is not the main concern. Intracavitary fibroids can also be diagnosed and treated by hysteroscopy, which involves putting a thin, telescope-like device (hysteroscope) into the uterus via the vagina and cervix. This instrument allows the physician to see the contents of the uterus and possibly remove them.

In some cases, the fibroids are found during X-ray, MRI, or ultrasound procedures that are done for another reason.

HOW ARE FIBROIDS TREATED? — If there are no symptoms, treatment is usually not required. In women with significant symptoms, treatment may be medical or surgical.

Medical treatment — Medications called gonadotropin-releasing hormone (GnRH) analogs are the mainstay of medical treatment for fibroids. Most women taking these medicines have a cessation of the menstrual period and a significant reduction in uterine size. The lack of periods can help women correct anemia before surgery. However, iron alone has been shown to be successful in about 40 percent of women. The fibroids rapidly enlarge again after the medication is discontinued and these medicines have some significant side effects, including bone loss leading to osteoporosis after long term use. They are usually only given as a temporary measure, such as during the time a woman is preparing for surgery to remove the fibroids. In some cases, the side effects of GNRH analogs can be minimized with the use of additional hormones.

Danazol, an androgenic steroid, can sometimes be useful in stopping menstrual periods when uterine volume reduction is not necessary and the woman has contraindications to or significant symptoms from GnRH-agonists.

Surgical treatment — In some women, surgical treatment provides needed relief from symptoms. In other cases, surgical procedures are done in an attempt to treat infertility. A number of surgical treatments are available.

Uterine artery embolization — Uterine artery ablation appears to provide significant reduction in symptoms with few serious complications, although the longest reported follow-up is two years. The mean reduction in fibroid volume is comparable to that seen with GnRH-agonist treatment (40 to 60 percent).

It is common for submucous myomas to be expelled vaginally after treatment. This may overestimate the amount of shrinkage observed in women with intramural myomas since studies suggest that submucosal location of a fibroid is a strong predictor of volume reduction.

More than three-quarters of women responding to post operative surveys appear to be happy with their improvement in abnormal bleeding. Satisfaction with reduction in pressure symptoms appears to be high, as well, in most studies. However, in one series this, rather than abnormal bleeding, was the major reason women went on to have a hysterectomy after an uterine artery embolization procedure.

  Complications — Serious complications are rare. The rate of urgent hysterectomy is low, in the range of 1 percent, but may be higher in women with a single dominant fibroid. Post-procedure pain is usually moderate to severe with women typically requiring hospitalization and narcotics in the first 24 hours post-embolization. Pain with fever occurs in approximately one third of women and is called post-embolization syndrome. There also appears to be a 5 to 8 percent risk of amenorrhea post-procedure, which can be transient or permanent.

While normal pregnancies have occurred after uterine artery embolization has been done for postpartum hemorrhage, there are too few cases to be sure that the procedure is safe in women planning to become pregnant. Further studies are needed before the procedure can be offered as a treatment of fibroids in women who are considering future childbearing.

In deciding on the most appropriate surgical treatment for fibroids, a number of factors should be considered. Certainly one of the most critical is whether or not childbearing has been completed. Although hysterectomy provides excellent relief of symptoms, women who wish to become pregnant in the future may choose myomectomy, which allows future childbearing and may provide short-term relief, but is associated with a risk of recurrence. About 11 to 26 percent of women who have had myomectomy will require a second surgery. In addition, abdominal and laparoscopic myomectomy carry varying degrees of risk for uterine rupture during pregnancy or labor, although the risk in most cases is small.

Future directions — A number of new treatments are being investigated. Thermoablative techniques with magnetic resonance imaging-guided therapy including percutaneous laser ablation, cryomyomlysis and focused ultrasound treatment are all currently undergoing trials in women with leiomyomas. In addition, novel medical therapies including progesterone-receptor modulators and somatostatin analogues are being tested for as innovative medical therapies.

WHERE TO GET MORE INFORMATION — Your doctor is the best resource for finding out important information related to your particular case. Not all patients with fibroids are alike, and it is important that your situation is evaluated by someone who knows you as a whole person.

This discussion will be updated as needed every four months on our web site (http://www.uptodate.com). 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 other sites on the internet have information about fibroids. 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.

     (http://www.nlm.nih.gov/medlineplus)

      (http://www.acog.org/)