Understanding Fibroids

iStock 000006387424SmallWhat are fibroids?

Fibroids (also known as "leiomyoma") are benign tumors in the uterus, composed of smooth muscle tissue. They are fairly common, about 30 to 50% of women between ages 30 and 50 have at least one small one. Usually they are not of any concern.

Sometimes fibroids can get to be large, or their locations within your uterus cause problems.

What types of fibroids are there?

The size, shape, and location of fibroids can vary greatly. They may be present inside the uterus, on its outer surface or within its wall, or attached to it by a stem-like structure.

Fibroids can range in size from small, pea-sized growths to large, round ones that may be more than 5–6 inches wide. As they grow, they can distort the inside as well as the outside of the uterus. Sometimes fibroids grow large enough to completely fill the pelvis or abdomen.

A woman may have only one fibroid or she might have several that are different sizes and shapes. Whether fibroids will occur singly or in groups is hard to predict. They may remain very small for a long time, suddenly grow rapidly, or grow slowly over a number of years.

After menopause, they shrink by about 10% but they don't go away.

Typically fibroids grow quickly under the influence of estrogen, especially if it is not balanced with an adequate amount of progesterone.

A diagram showing the various types of fibroids

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How do I know if I have fibroids?

A pelvic exam done by one of our providers can usually detect a uterus that is enlarged, but it cannot diagnose fibroids specifically. An ultrasound or MRI can detect fibroids and provide detail as to exactly where they are located and how large they are.

What symptoms could fibroids cause?

(Note: Many of these symptoms could be signs of other problems besides fibroids, so if you have them, you should see your gynecologist)

  • Changes in menstruation
    • Longer, more frequent, or heavy menstrual periods
    • Menstrual pain (cramps)
    • Vaginal bleeding at times other than menstruation
    • Anemia (from blood loss)
  • Pain
    • In the abdomen or lower back (often dull, heavy and aching, but may be sharp)
    • During sex
  • Pressure
    • Difficulty urinating or frequent urination
    • Constipation, rectal pain, or difficult bowel movements
    • Abdominal cramps
  • Enlarged uterus and abdomen
  • Miscarriages
  • Infertility

What kind of complications do fibroids cause?

Complications are not common, but do happen from time to time. Sometimes they grow rapidly and outgrow their blood supply. When this happens, the cells in the middle of the fibroid die off, and can cause pain. Sometimes they twist on their stem, and severe pain and nausea can result. They can get so big that they can fill most of the abdomen, cause the abdomen to swell and be the size of a full term pregnancy. (Dr. Ravasia has removed fibroids over 15 pounds in her career). Sometimes they can obstruct the tube between the kidney and the bladder.

They can increase the surface area of the inside of the uterus, especially if they are located near the inner surface of the uterus. This increases the amount of tissue that sheds and bleeds every month. They also make it harder for the uterus to contract down and "shut off" the bleeding at the end of your period.

If they are located inside your uterus, they may cause recurrent miscarriages or infertility.

They can distort the uterine muscle and make the uterus contract in an uncomfortable and painful way and cause discomfort during sex. They can obstruct the path of bowel movements and urination, and can press on the bladder causing urinary frequency.

Do they ever turn into cancer?

In a word, "no". They are benign tumors and don't "convert" into cancer. However, sometimes rare cancerous tumor can look a lot like a fibroid in the early stages. Typically these grow much more rapidly than fibroids. There is no simple way to biopsy or test the fibroid to see if it is cancerous, but cancer is extremely rare when fibroids have the classic ultrasound appearance.

How are fibroids diagnosed?

Fibroids are usually suspected when the uterus feels enlarged on a pelvic exam.

Further tests that may be used for diagnosis include:

Pelvic Ultrasound +/- Pelvic MRI - Pelvic ultrasound uses sound waves to create a picture of the uterus and is one of the most accurate and cost effective ways to view the uterus. Pelvic MRI uses magnetic fields to create a picture of the uterus. It is a little more precise, but much more expensive that pelvic ultrasound. It is mostly used when the ultrasound picture is not entirely clear.

Saline Sonography is a test in which fluid is put into the uterus through the cervix. Ultrasonography is then used to show the inside of the uterus. The fluid provides a clear picture of the uterine lining.

Hysteroscopy uses a slender device (the hysteroscope) to see the inside of the uterus. It is inserted through the vagina and cervix (opening of the uterus). This permits the doctor to see fibroids inside the uterine cavity and occasionally to remove them (if they are on a slender stock).

Laparoscopy uses a slender device (the laparoscope) to help the doctor see the inside of the abdomen. It is inserted through a small cut just below or through the navel. This allows the surgeon to see fibroids on the outside of the uterus with the laparoscope, and occasionally remove them.

Do fibroids have to be treated? When should I consider treatment?

Fibroids do not need to be treated unless they are causing medical problems for you. These might include:

  • Heavy or painful menstrual periods that cause anemia or that disrupt a woman’s normal activities
  • Bleeding between periods
  • Uncertainty whether the growth is a fibroid or another type of tumor, such as an ovarian tumor
  • Rapid increase in growth of the fibroid
  • Infertility or recurrent pregnancy loss
  • Pelvic pain or pain with intercourse

What treatments are available?

Treatment options depend on how much the symptom is causing problems for you and on the size and location of the fibroid and on your lifestyle. It is a personal decision that you make with our gynecologists.

Treatment options include:

Medications

Medications and hormones can be an option to control the heavy bleeding and pain related to heavy periods. They don't reduce the size fibroids themselves, and/or are just temporary measures.

  • Oral Contraceptive Pills: These are often used to control heavy bleeding and painful periods. They may cause the fibroids to increase slightly in size. For some women, the benefits of hormonal contraception outweigh the risk of this side effect. Not everyone is a candidate.
  • Hormone balancing: Because fibroids grow under the influence of too much estrogen and not enough real progesterone, balancing estrogen and progesterone by decreasing estrogen levels and increasing progesterone may help slow down growth. It requires time and patience and doesn't make the fibroids get smaller, but can help with the symptoms they cause.
  • GnRH Agonists (Lupron): These are monthly injections that "shut down" the ovaries and make you temporarily menopausal. They cause bone loss, hot flashes and fatigue, and so their use is limited to about 6 months. They do make fibroids smaller, but as soon as you stop, they quickly go back to their original size. The FDA has recently required Lupron to carry a Black Box warning about increased risk of heart disease.
  • Mirena IUD contains a synthetic form of progestin which may decrease bleeding, but doesn't treat the fibroids themselves.

Myomectomy (removing the fibroids, but leaving the uterus itself in)

This sounds simpler than a hysterectomy, and occasionally it is, but much of the time it is actually a more difficult and complicated surgery, with more risks, more scarring and more blood loss. It depends on where the fibroids are located.

If the fibroid is on a thin stalk, it can indeed be done fairly simply through a hysteroscopy or laparoscopy. If the fibroids are embedded in the uterus, it is usually much simpler to remove the whole body of the uterus (because the surgeon stops can occlude the uterine artery), than to try to remove fibroids individually. The only good reason to do a myomectomy in this circumstance is to try to preserve fertility.

Myomectomy looks after the fibroids that are currently present. It may need to be done more than once because new ones can form.

Uterine artery embolization

Uterine artery embolization (UAE) is a procedure in which the blood vessels to the uterus are blocked, stopping the blood flow that allows fibroids to grow.

Usually UAE is performed by a specially trained radiologist. Epidural anesthesia is often needed as the cramping that follows this procedure can be uncomfortable. Several hours in hospital are usually required for pain control and observation. In some cases, it is done as an outpatient procedure. In other cases, you may need to spend a night in the hospital.

A small incision is made in your groin area on both sides. A tube called a catheter is passed through the large artery there until it reaches the small arteries that supply the uterus with blood. Tiny particles (about the size of grains of sand) are injected through the catheter into these arteries. The particles cut off the blood flow to the fibroid and cause it to shrink. The procedure helps even if you have more than one fibroid. It reduces the size of fibroids but doesn't make them disappear.

Many women have cramping for a few hours after the procedure. Some women have nausea or fever. Medicine often can help treat these symptoms.

Complications are not common and include infection and uterine injury. Most women will resume regular menstrual periods shortly after the procedure. In about 40% of women older than 50 years who have UAE, menstrual periods do not return. UAE does not prevent new fibroids from forming in the future.

The effect of UAE on future pregnancies is not clear. Women who have had UAE may be at greater risk for placenta problems during pregnancy. Women who want to have children may want to consider other forms of treatment.

Endometrial ablation

Women's Health Connection uses Novasure ablation as treatment options for heavy crampy periods that can result from fibroids. This is an option so long as the fibroids are not distorting the inside of the uterus too much. They are done in the office procedure room, and you go home from the office within an hour after the procedure and usually return to normal activities the next day. Most women find their periods either stop or are greatly reduced after ablation. Ablations don't treat the fibroids themselves though. You should have permanent birth control in place before doing an ablation.

Laparoscopic supracervical hysterectomy

Laparoscopic supracervical hysterectomy (LaSH) is our preferred method of definitively treating fibroids that are causing problems in women that are done having babies, in most situations. It is an outpatient procedure, done under general anesthetic. It removes only the body of the uterus, including the fibroids, but leaves the cervix and ovaries behind. It is done through tiny incisions and the hospital stay is typically only a few hours. Post-op pain is fairly minimal (we feel it is less than uterine artery embolization, UAE, based on our observation). We are of the opinion this is simpler, less painful and more definitive treatment than UAE.

Vaginal hysterectomy

Sometimes used if there is a compelling reason to remove the cervix and hysterectomy is desired and recommended. Usually the uterus needs to be less than the size of a 16 week pregnancy as a result of the fibroids in order to easily be removed through the vagina.

Traditional abdominal hysterectomy

Reserved for very large fibroids, or ones that are in awkward or unsafe positions to remove any other way. Typically this requires a 6-8 week recovery and a hospital stay of a few days.

For more information about fibroids, see ACOG's Patient Brochure on Uterine Fibroids.