Uterine Fibroids: A Common But Rarely Discussed Condition

On behalf of the many women now suffering in silence, CARE About Fibroids is dedicated to taking uterine fibroids out of the shadows. This starts by raising awareness of this medical condition so women will recognize the signs and symptoms, know the risk factors, and know how to discuss fibroids with their gynecologist, family doctor, and other health care professionals. CARE About Fibroids believes that knowledge and awareness will help more women get an earlier diagnosis of uterine fibroids and choose an appropriate treatment that reflects their health situation.

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• Background
• Causes and Symptoms
• Diagnosing Fibroids
• Treatment Options

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Fibroids 101

Far too often, women are unaware that uterine fibroids are the cause of severe bleeding, intense pain, bladder problems, and painful intercourse. Fibroids also account for a one-third of all hysterectomies performed in the U.S.

Fibroids consist of lumps made of muscle cells and other tissues that grow in or around the wall of a woman’s uterus, which is also called her womb. Fibroids are the most common growth in women that is not a cancer. Between the ages of 25 and 44, 30 percent of American women have fibroids. One study in a large urban health system estimated that by age 50, 80 percent of African American women in the study and nearly 70 percent of white women will have the condition.

For many women, their fibroids are not a problem – the growths are small and do not cause uncomfortable symptoms.  But studies find that nearly 50 percent of women experience symptoms and for some, symptoms of their fibroids can be severe. Women can experience pain, severe bleeding, and difficulty urinating, as well as frequent urination and constipation. Additionally, when fibroids cause severe symptoms, the condition can be disabling and lead to anemia, urinary tract infections, and kidney damage.
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Depending on the type of fibroid and where it is located, the growth can keep women from getting pregnant and increase the complications of pregnancy, such as miscarriages and early labor. Further, this condition can produce emotional stress, causing anxiety about sexual function and the ability to accomplish everyday activities.

Uterine Fibroids Defined

Uterine fibroids go by several names: fibromyomas, leiomyomas and myomas as well as uterine fibroids or simply fibroids. These growths develop from the muscle tissue of the uterus (or the womb), the reproductive organ where a baby grows during pregnancy. In some cases, a woman will only have one fibroid; in other cases, a woman will have many, which may be grouped in clusters.

Fibroids also differ in size. They can be as small as an apple seed or as big as a grapefruit – or bigger! When fibroids grow in clusters or are large in size, they can cause heavy bleeding, frequent urination, constipation, bloating and pain. However, the location of the fibroid can be the reason a woman experiences symptoms. For example, a small fibroid located on the inside of the uterus can cause severe bleeding and anemia.

Fibroid Fact
Studies show that women who start their periods at a younger age are more likely to develop fibroids.

Fibroid Fact
If fibroids become very large, they can expand the uterus to the size of a pregnancy during the second trimester (in its 4th, 5th or 6th month).

Not All Fibroids Are the Same

Fibroids occur inside the uterus, on its outer surface, or within the wall of the uterus, and they can be attached to the uterus by a stem-like structure. There are four types of fibroids depending on their location, and a woman can have more than one type of fibroid at a time. 

• Intramural fibroids – they are the most common and are located in the wall of the uterus. 
• Subserosal fibroids – these fibroids grow on the outside of the uterus and can cause pain due to their size and the pressure they put on nearby organs. 
• Submucosal fibroids – these growths are found underneath the lining of the inside of the uterus and can crowd into the uterus itself. This can lead to heavy bleeding and more serious complications.
• Pedunculated fibroids – they grow inside or outside the uterus on small stalks that might look like mushrooms.

A note about cancerous fibroids: It is very rare for a woman to be diagnosed with a cancerous fibroid (called leiomyosarcoma). There is a less than one in 1,000 chance for a woman to have a cancerous fibroid and existing fibroids cannot become cancerous. Furthermore, there is no linkage between a leiomyosarcoma and a woman being diagnosed with another form of cancer.

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What Causes Fibroids?

The simple answer to this question is no one knows. However, research has indicated that the female hormones estrogen and progesterone play a role and that fibroids may be inherited. In essence, this means that if your mother or sister has or had fibroids, you may be at a higher risk for developing them.

Who Is Most Likely to Have Fibroids?

​Uterine fibroids are common in women and can occur at an early age. However, a number of factors put some women at higher risk.

• Having a family member with fibroids increases the risk.
• If a woman’s mother had fibroids, the risk is 3 times higher than average.

• Fibroids are most  common when women are in their 30s and 40s.
• After menopause, fibroids tend to shrink.

• For very heavy women, fibroid risk is 2-3 higher.
• Eating red meat and ham often increases the risk; plenty of green vegetables are protective.

What Are the Symptoms?

Not all women with fibroids have symptoms. But millions of women with severe symptoms go undiagnosed and untreated, often because they don’t realize that the pain, heavy bleeding during their periods, and other medical problems are caused by fibroids. According to some studies, women with “symptomatic” fibroids wait, on average, more than three years before going to see a doctor and almost a third wait up to 5 years.

To help women get the care they need, CARE About Fibroids created a simple tool called the Fibroid MAP so women can identify the major signs and symptoms:

Fibroid Map
File Size:	822 kb
File Type:	pdf

Download File

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When to Seek Medical Care

Even when women know the signs of fibroids, many believe their symptoms are normal and delay getting medical help. For this reason, the American College of Obstetricians and Gynecologists (ACOG) and other experts encourage women to see a doctor if they experience any of the following problems:

• Heavy or painful menstrual periods that cause anemia or that disrupt a woman’s normal activities
• A change in the length of your period over three to six cycles or months
• Bleeding between periods
• New and steady pain or heaviness in lower abdomen or pelvis
• Frequent urination or not being able to control the flow of urine
• Difficulties getting pregnant

How Are Fibroids Diagnosed?

In many cases, the doctor will feel moderate or large fibroids during an ordinary pelvic exam or the condition is revealed during tests for other problems. However, to confirm the diagnosis, doctors will often order imaging tests and other procedures to show the size and location of the growth(s). 
The most common imaging tests for fibroids are:

• Ultrasound – This painless test uses sound waves to create a picture of the uterus and pelvic organs. [6]
• Hysterosalpingography – This is a special X-ray test to detect changes in the size and shape of the uterus and fallopian tubes.
• Sonohysterography – In this test, fluid is injected into the uterus through the cervix while ultrasound images are taken of the inside of the uterus. The fluid provides a clear picture of the uterine lining. [6]​

Less often, an accurate diagnosis requires a surgical procedure. There are two options for this purpose:

• Hysteroscopy – This procedure involves inserting a slender device (the hysteroscope) through the vagina and cervix (opening of the uterus). This permits the doctor to see fibroids inside the uterus.
• Laparoscopy – This procedure inserts a slender device (the laparoscope) through a small cut just below or through the belly button to help the doctor see fibroids on the outside of the uterus.

What to Ask Your Doctor

Once you have been tested for fibroids, the U.S. Department of Health and Human Services’ Office on Women’s Health (OWH) created this list of questions to ask your doctor about your fibroid diagnosis:             

Seven Questions to Ask Your Doctor

1. How many fibroids do I have?
2. What size is (are) my fibroid(s)?
3. Where is (are) my fibroid(s) located in my body?
4. Can I expect the fibroid(s) to grow larger?
5. What problems can the fibroid(s) cause me?
6. What tests are best to keep track of the growth of my fibroid(s)?
7. What are my treatment options? 

​Besides asking these questions, make sure to talk to your doctor about these factors, which will help determine the best course of treatment:

• Your symptoms, how bad they are, and whether they interfere with your daily activities
• Whether you want to become pregnant in the future
• Your age and how close you are to menopause

 You should get a second opinion if you still have questions or want the advice of a specialist who understands all the available treatment options. ​

Treatment Options

Deciding on how to treat uterine fibroids depends on how serious the symptoms are, where the fibroids are located, and each woman’s plans for having children. Based on these factors, women can choose from:

1. A wait and see approach
2. Drug therapy
3. A variety of procedures that remove only the fibroid(s)
4. Surgery that removes the fibroid or the entire uterus

Below is a short primer that describes these treatment options.
 
1. Watchful Waiting
For women diagnosed with fibroids who either don’t have symptoms or the symptoms are mild, doctors will often recommend “watchful waiting,” an approach that postpones treatment while keeping an eye on the fibroid(s) to see if the symptoms get worse or the fibroids get substantially bigger. This method is often suggested when women with mild symptoms are close to menopause, when fibroids tend to shrink and symptoms lessen.

2. Drug Therapy
​For women with mild to moderate symptoms, medications are used to reduce the heavy bleeding and painful periods that fibroids may cause. In some cases, medications are prescribed to shrink the fibroids prior to surgery. Drug treatment for fibroids includes the following options:

• Over-the-counter (OTC) pain medications – OTC drugs, such as acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, can help relieve menstrual cramping. [15]
• Birth control pills and other types of birth control methods – Because birth control pills manage levels of estrogen and progesterone, these drugs are often are used to control heavy bleeding and painful periods. Other birth control methods that may lessen fibroid symptoms include progestin injections and intrauterine devices (IUDs). None of these methods are FDA-approved for treatment of uterine fibroids.
• Gonadotropin-releasing hormone (GnRH) agonists – These drugs offer temporary relief from fibroid symptoms by stopping the periods and shrinking fibroids temporarily. Sometimes they are used before surgery to reduce the risk of bleeding during surgery. However, GnRH agonists have many side effects and are only used for less than six months. After a woman stops taking a GnRH agonist, her fibroids usually return to their previous size.

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3. Procedures to Remove Fibroids
​A number of fibroid removal techniques using small incisions have been developed as alternatives to traditional surgery options. These procedures are:

• ​Endometrial ablation – This is a type of minor surgery usually performed as an outpatient where the lining of the uterus is removed or destroyed to control very heavy bleeding. It is used to treat women with small fibroids. However, pregnancy is not likely to occur after this procedure.
• Hysteroscopic removal – This is an outpatient surgical procedure without any incisions and involves inserting a small instrument (hysteroscope) passed through the cervix and the inside of the uterine cavity to destroy the fibroids with electricity or a laser beam. It is used only if fibroids are within or bulging into the uterine cavity (submucosal). 
• Magnetic resonance imaging (MRI)-guided ultrasound surgery – This approach uses high-intensity ultrasound waves to destroy fibroids without the risk of damaging the uterus. The waves are directed at the fibroids through the abdominal wall with the help of an MRI scanner.

• Uterine artery embolization (UAE) – In this procedure, tiny particles (about the size of grains of sand) are injected into the blood vessels that lead to the uterus. The particles block the blood flow to the fibroid and cause it to shrink. UAE can be performed as an outpatient procedure in most cases.
• Laparoscopic Radiofrequency Ablation (Lap-RFA) – This procedure, under ultrasound, treats each fibroid individually by applying heat through small needle arrays. The surrounding tissue is not damaged. Over time, the treated fibroids shrink and may become completely reabsorbed by the body. This is a minimally invasive treatment option and patients return to normal activity on an average of 3-5 days.

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4. Fibroid Surgery
There are two types of fibroid surgery, a myomectomy and a hysterectomy. Because there are major differences between these two options, it is important to know what each surgery involves.

• Myomectomy – This operation removes the fibroids but doesn’t remove the uterus. It is suitable for women who wish to have children or wish to keep their uterus for other reasons. Depending on the size, number and location of the fibroids, the procedure may require major abdominal surgery. This is often the case when the fibroids are large, numerous or are deep within the uterus. It may be possible to do the myomectomy with less invasive laparoscopy or hysteroscopy. All forms of myomectomy are effective but the fibroids may still grow back or new ones develop. In fact, research shows that the younger the woman and the more fibroids she has at the time of myomectomy, the more likely she is to develop fibroids again in the future. 
• Hysterectomy – Considered the sure way to cure uterine fibroids, hysterectomy is a surgery to remove the uterus. This means the woman will no longer be able to bear children. However, because the ovaries do not have to be removed, this spares the woman from having hot flashes and other symptoms of the menopause.

If the fibroids are large, a woman may need an abdominal hysterectomy that involves cutting into the abdomen to remove the uterus. If the fibroids are smaller, the doctor may be able to remove the uterus through her vagina using a laparoscope. Abdominal hysterectomy carries a higher risk of complications and longer recovery. Abdominal hysterectomy is most often used when other treatments have not worked or the fibroids are very large.
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A Caution About ​Power Morcellation
​In 2014, the Food and Drug Administration  (FDA) issued a warning against using an instrument called a “laparoscopic power morcellator” in fibroid removal surgery. This device cuts the fibroids into small pieces during surgery so the tissue can be removed through a small incision.  FDA took this step because a few women undergoing this surgery have an undiagnosed cancer in the fibroid and power morcellation increases the risk of spreading the cancerous tissue. While not banning power morcellation, FDA recommends other forms of surgery for most women with uterine fibroids. 

References

• Agency for Healthcare Research and Quality (AHRQ). (2007). Management of uterine fibroids: An update of the evidence (AHRQ Publication No. 07-E011). Retrieved December 8, 2011. Accessible at:  https://archive.ahrq.gov/downloads/pub/evidence/pdf/uterupdate/uterup.pdf
• National Women’s Health Network. Uterine Fibroids Fact Sheet 2015. Accessible at:  https://www.nwhn.org/uterine-fibroids/
• Hartmann, K. E., Birnbaum, H., Ben-Hamadi, R., Wu, E. Q., Farrell, M. H., Spalding, J., et al. (2006). Annual costs associated with diagnosis of uterine leiomyomata. Obstetrics and Gynecology, 108, 930–937. 
• Baird, D. D., Dunson, D. B., Hill, M. C., Cousins, D., & Schectman, J. M. (2003). High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. American Journal of Obstetrics and Gynecology, 188, 100–107
• Divakar H. Asymptomatic Uterine Fibroids. Best Pract Res Clin Obstet Gynaecol. 2008 Aug;22(4):643-54
• American College of Obstetricians and Gynecologists (ACOG). Uterine Fibroids. FAQ074. May 2011. Accessible at: https://www.acog.org/Patients/FAQs/Uterine-Fibroids#are
• New York Times. Fibroids In-Depth Report. Accessible at: http://www.nytimes.com/health/guides/disease/uterine-fibroids/print.html
• Office on Women’s Health. Department of Health & Human Services (HHS). Uterine Fibroids. Accessible at: https://www.womenshealth.gov/a-z-topics/uterine-fibroids
• Stewart EA, Nicholson WK, Bradley L, et al. The Burden of Uterine Fibroids for African-American Women: Results of a National Survey. J Womens Health (Larchmt). 2013 Oct; 22(10): 807–816
• Ghant MS, Sengoba KS, Vogelzang R, et al. An Altered Perception of Normal: Understanding Causes for Treatment Delay in Women with Symptomatic Uterine Fibroids. Journal of Women's Health. August 2016, 25(8): 846-852
• Borah BJ, Nicholson WK, Bradly L, et al. The Impact of Uterine Fibroids: A National Survey of Affected Women. Am J Obstet Gynecol. 2013 Oct;209(4):319.e1-319.e20
• ​​University of Michigan Medicine Von Voigtlander Women’s Hospital. Uterine Fibroids & Abnormal Bleeding. Accessible at umwomenshealth.org/conditions-treatments/abnormal-bleeding-uterine-fibroids. 
• ​Singh SS, Belland L. Contemporary Management of Uterine Fibroids: Focus on Emerging Medical Treatments. Curr Med Res Opin. 2015 Jan:31(1):1-12
• WebMD. Slideshow. A Visual Guide to Uterine Fibroids. Accessible at: https://www.webmd.com/women/uterine-fibroids/ss/slideshow-fibroid-overview
• University of California San Francisco (UCSF) Medical Center. Myomectomy. Accessible at: https://www.ucsfhealth.org/treatments/myomectomy/