Janet Phoenix, MD, MPH, Anna Mazzucco, PhD, Elizabeth Eckel, and Diana Zuckerman, PhD
Uterine fibroids are benign growths or tumors that occur within the walls of the uterus (the area in a women’s body where a baby can grow). Fibroids can be as small as seeds or as large as a grapefruit. When the fibroids are large they increase the size of the uterus, so that the woman may look pregnant and feel pressure on her bladder as if she were pregnant.
How do I know if I have fibroids?
Most fibroids do not cause any symptoms, but some women with fibroids can have:
- Heavy bleeding or painful periods
- Bleeding between periods
- A feeling of fullness in the pelvic area (lower abdomen)
- Frequent urination
- Pain during sex
- Lower back pain
- Reproductive problems including: infertility, miscarriage, or early labor
How are uterine fibroids diagnosed?
There are several ways to diagnose uterine fibroids. During a manual abdominal or pelvic examination by a doctor, uterine fibroids can sometimes be felt. X-rays or CT scans can be used, but more commonly, fibroids are diagnosed with ultrasound, a device that uses sound waves to produce an image of the uterus. Magnetic resonance imaging (MRI) can also be used for diagnosing fibroids.
Are some women more likely to get fibroids than others?
Any woman can get uterine fibroids, but African-American women are more likely to get uterine fibroids and to suffer from them at a younger age, followed by white women. Asian women are less likely to suffer from fibroids than white or African-American women. Nobody is sure why this is. Genetic tests of women with fibroids have been done, but no differences between races have been found. Women who are overweight or obese are also more likely to develop uterine fibroids. Women who had their first period at an early age, or who have not had children or who had children later in life are also more likely to have fibroids, while having recently been pregnant reduces the chance of fibroids.1 A diet lower in meat and higher in fruits and vegetables may also reduce the chances of fibroids.2
Can uterine fibroids turn into cancer?
Although fibroids do not usually turn into cancer, cancer can be hidden inside the fibroid. Recent studies have found that women who have surgery to remove fibroids are at risk for having a hidden cancer spread if a surgical tool called a power morcellator is used.3 This is because the tool cuts the fibroid into very tiny pieces that can be spread throughout the pelvis and abdomen during surgery, causing the cancer to be a later stage and much more dangerous cancer than it was when it was inside the fibroid. The Food and Drug Administration (FDA) has estimated that 1 in 350 women who have fibroids surgically removed using morcellation are at risk for having a hidden cancer spread and therefore their lives endangered by the procedure. See surgery section below for more information.
What should I do about my fibroids?
Most doctors recommend no treatment for fibroids unless you are having symptoms. However, you might want to consider treatment if your fibroids are large, growing rapidly, could possibly interfere with your fertility, or if you have enough heavy bleeding to cause anemia (low iron).
What are the different treatment options?
If you and your doctor decide that your uterine fibroids need to be treated, medication is usually the first option. If you are experiencing pain, over-the-counter anti-inflammatory drugs, such as ibuprofen (Motrin) or other painkillers such as acetaminophen (Tylenol) may be recommended. Stronger painkillers can be prescribed if needed.
Oral contraceptives (birth control pills) or progestins can help control heavy bleeding resulting from fibroids but they do not reduce the size of the fibroids. For more information about different types of birth control pills, see our article here.
Drugs call gonadotroprin-releasing hormone agonists (GnRHa) can be prescribed to decrease the size of the fibroids, such as Lupron and Synarel. An injection lasts for six months and decreases the hormones estrogen and progesterone, which usually causes the fibroids to shrink but often also cause menstruation to stop. The potential side effects are typical of menopause: hot flashes, depression, insomnia, decreased sex drive, and joint pain. These medications are effective, but are generally only prescribed for one year because of possible risks. When the therapy is stopped, the fibroids often grow back. Sometimes these drugs are used prior to surgery to shrink the fibroids and make them easier to remove surgically.4,5
Androgens, the so-called male hormones, can relieve fibroid symptoms. Danazol, a synthetic drug similar to testosterone, can sometimes shrink fibroids. Like GnRHa, this treatment can also stop the menstrual cycle. Other possible side effects include weight gain, depression, anxiety, acne, headaches, unwanted hair growth, and a deepening voice.
Surgery is considered when symptoms or bleeding become more severe or when medical treatment stops working. There are many different kinds of surgery for uterine fibroids:
In a myomectomy, the surgeon removes just the fibroids without taking out the healthy uterine tissue (this is also called a fertility-sparing or uterus-sparing surgery). Myomectomies can be major or minor surgery depending upon the surgical technique used. An alternative to an incision through the abdomen is the use of slender instruments (laparascopes) that are inserted through smaller incisions, which is often called “minimally invasive surgery”. During laparascopic procedures, a small camera mounted on one of these allows the surgeon to see the area on a monitor. A hysteroscopic myomectomy is used when fibroids are contained inside the uterus and uses a long slender scope (hysteroscope) that is inserted through your vagina and cervix and into your uterus to remove the fibroids. While myomectomy is often recommended for women who may want to have children in the future, because it leaves the uterus in place, long-term studies on fertility after myomectomy have not been done. Also, because the uterus is left in place, it is possible for fibroids to return.
A hysterectomy removes the fibroids by removing the uterus, and sometimes the ovaries as well. Women who have had hysterectomies are no longer able to have children. If the ovaries are removed as well as the uterus, this will cause menopause. The incision to remove the uterus is made either through the abdomen or through the vagina. Recovery is usually faster if the surgery is through the vagina. There is no risk of recurrence of uterine fibroids after hysterectomy because there is no uterus.
For either a myomectomy or hysterectomy, if “minimally invasive surgery” is done (also called a laparascopic procedure), a device called a power morcellator could be used. Since April 2014, the FDA has recommended against their use for fibroid removal. The power morcellator cuts tissue into tiny pieces to allow it to be removed through smaller incisions. But recent studies have shown that if there is cancer hidden in the fibroid, these devices can spread the cancer dangerously when the device is used to remove fibroids. In the past, minimally invasive surgery has often been recommended to patients because it is a shorter, less invasive procedure with a quicker recovery time. However, because of the concerns over cancer that hasn’t been identified before surgery, the benefits of power morcellation do not outweigh the risks for most women. To read our testimony at an FDA meeting on morcellators, go here. To read about the FDA’s latest warning, read here.
There are several surgical procedures to destroy fibroids without actually removing them, but much more research is needed to know how safe and effective these procedures are:
- Myolysis. Using a laparoscope, an electric current can destroy the fibroids and shrink the blood vessels that are attached to them. Unfortunately, the safety, effectiveness, and risk of recurrence have not yet been determined. Women who are planning to have children should not have this procedure because it can increase the risk of uterine rupture, a serious emergency, during the birth of a baby.
- Cryomyolysis. Fibroids can be frozen using laparascopic probes that are cooled by liquid nitrogen. The safety, effectiveness, and risk of recurrence have not yet been determined for this procedure.
- Endometrial ablation. In this procedure, a hysteroscope uses heat to destroy the lining of the uterus. This can cause menopause or a reduction in menstrual flow. Endometrial ablation is not effective for fibroids outside the interior lining of the uterus.
Focused ultrasound surgery (FUS) is a treatment option that was approved by the FDA in 2004. FUS uses MRI so the doctor can see the fibroids and uses high-energy sound waves to destroy the fibroids. No incisions are made and the uterus is preserved. The advantage is that it does not cause menopause. However, the long-term effectiveness or the risk of recurrence is not yet known. This procedure is also not recommended for women who want to become pregnant.
Uterine fibroid artery embolization (UFE) and uterine artery ligation are surgical procedures that block the arteries that supply blood to the uterus. Cutting the blood flow causes the fibroids to shrink and also decreases heave menstrual bleeding. This procedure has a shorter recovery time than surgery, because no incision is made. However, interrupting the blood supply to your ovaries or to other organs can cause the ovaries to stop working for a short time or permanently. This can cause menopause or affect future fertility, and therefore it may not be a good choice for women who may want to have children in the future.
Pros and Cons of Hysterectomy
The advantage of a hysterectomy is that it is often effective at stopping the pain and uncontrolled bleeding, and can therefore improve the quality of life. However, it is an expensive procedure with the potential for serious complications. Many women report that after the surgery they feel less feminine and lose the urge to engage in sexual activity; this is probably more likely if their ovaries are also removed.
Although most women benefit from the lessening of pain and bleeding, one study found that 8 percent of women did not benefit from hysterectomy and some women developed new problems as a result. About 4 percent of the women were readmitted for a surgical complication during their first year.
How do I decide between the treatment options?
Most women do not need treatment for their uterine fibroids. If they have pain or bleeding, they should try medical treatment before trying surgery. Hysterectomy is the treatment that is proven most effective for reducing pain and bleeding, but many women do not need such radical surgery, and if they do, they probably do not need to have their ovaries removed. It is hoped that the newer surgical techniques will prove as effective as hysterectomies with fewer side effects, but more research is needed to determine how safe and effective they are and which patients are most likely to benefit.
Before making a decision about fibroid treatments, several tests can be done to learn more about your fibroids. Learning more about the size, shape and location of your fibroids can help you and your doctor decide which treatment is best for you. These tests can include a pelvic exam, imaging such as ultrasound and MRI (magnetic resonance imaging), a Pap smear and endometrial biopsy (which takes a sample from inside the uterus). Other imaging procedures to more closely examine the uterus and fallopian tubes (which connect the ovaries to the uterus) such as hysteroscopy may also be used. In this procedure, a small, lighted tube (called a hysteroscope) is inserted through the vagina into the uterus, allowing the doctor to see inside the uterus in more detail.
If you are considering any type of surgical procedure for fibroids, talk with your doctor about whether they plan to use morcellation. If you do not wish morcellation to be used, discuss all the other surgical options with your doctor and the risks and benefits of each. For more information about making informed decisions regarding medical devices, see this article here. It is also important to ask your doctor about how frequently they perform the surgery you plan to have. If they are not very comfortable with the procedure, consider looking for a doctor who performs them more regularly.
- Salman, T & Davis, C; Uterine fibroids, management, and effect on fertility, Current Opinion in Obstetrics and Gynecology, 22 (1) 295-303, 2010. ▲
- Office of Women’s Health, Health and Human Services, Fibroid Fact Sheet. ▲
- Seidman M, et al., PLOS, 2012. ▲
- Mayo Clinic. Uterine fibroids. href=”http://www.mayoclinic.com/health/uterine-fibroids/DS00078″>http://www.mayoclinic.com/health/uterine-fibroids/DS00078. ▲
- National Women’s Health Information Center. Uterine href=”http://www.4women.gov/faq/fibroids.htm”>http://www.4women.gov/faq/fibroids.htm. ▲