Uterine Fibroids

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Background

What are fibroids?
Uterine fibroids are the most common, non-cancerous tumors in women of childbearing age. Commonly just called “fibroids,” they are tumors (lumps) made of muscle cells and other tissues that grow within the uterine walls.1

Fibroids may grow as a single tumor or in clusters, both of which can vary in size. A single fibroid can be less than one inch in size, or can grow to eight or more inches. Health care providers classify fibroids into three groups based on where they grow:

  • Submucosal fibroids grow just underneath the uterine lining;
  • Intramural fibroids grow in between the muscles of the uterus; and
  • Subserosal fibroids grow on the outside of the uterus.2

Why are fibroids a problem?

Fibroids are not associated with cancer and do not increase the risk of getting uterine cancer. They can cause other problems, however, that can either interfere with a woman’s quality of life or lead to more severe health issues. The most common symptoms are heavy bleeding during one’s period, anemia, abdominal pain or pressure, incontinence, and constipation.3 Other symptoms include painful periods, bleeding between periods, a feeling of “fullness” in the lower abdomen (sometimes called “pelvic pressure”), frequent urination, pain during intercourse, and lower back pain. Fibroids can also cause reproductive problems including infertility, multiple miscarriages, and early onset of labor during pregnancy.

What are the risk factors for developing uterine fibroids?

Fibroids are extremely common. About 30 percent of all women will get them by age 35, and about 70-80 percent of women will do so by age 50. For some reason, African American women are more likely to experience fibroids, and to do so at a younger age.4 As women age, fibroid growth rates decline for most women, but not for African American women.5 Other risk factors for fibroids include being having a Body Mass Index (BMI) above the “normal” range (e.g., a BMI indicating the individual is overweight or obese) and having ever given birth. The fact that it is unclear what causes fibroids, and that many cases have no symptoms, makes it difficult to decipher all the risk factors, however.

Treatment Options

Among women who ever have fibroids, only 30 percent experience symptoms severe enough to require intervention. Fibroids often shrink during the menopausal transition as estrogen levels decline. So, depending on the fibroid’s size, growth rate, and the discomfort caused, a woman may consider “watchful waiting” to see if her situation changes, before taking any other action. (For example, women who are approaching the menopausal transition may find that their fibroids shrink as their estrogen levels decline.) With watchful waiting, she would monitor the fibroids through her yearly pelvic exam.

But, if the fibroids are larger, growing rapidly, and/or causing discomfort, a woman may want to schedule more frequent exams, consider using ultrasounds to monitor their growth, and pursue one of the treatment options described below. When fibroids are associated with severe menstrual bleeding, the NWHN recommends that the woman have regular checkups to ensure there are no other, potentially more dangerous, sources for the bleeding.

In any case, women should work with their health care provider to evaluate the fibroid’s status and decide when, and if, intervention is desirable and/or necessary. Overall, a woman’s choices vary depending on the size and number of fibroids as well as her health, medical history, tolerance for specific treatments, and desire for pregnancy.

Self-Help Techniques

Some women try to reduce or prevent fibroids by avoiding processed foods such as commercial meat, dairy, and egg products, which may contain hormones that spur fibroid growth; there is no solid scientific evidence that this is effective against fibroids, however. Research suggests that green tea may help inhibit fibroids — at least in rats.6 Some research indicates that, at least for African American women, eating more dairy products may help reduce fibroids. Women need to experiment to determine the best diet for themselves.7

Some women find yoga or meditation can help ease the discomfort associated with fibroids. And, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, aspirin, and naproxen can help control cramps and bleeding.

Drug Therapy

Drug therapy can be used alone or in combination with surgery to treat fibroids. The main drug therapies are listed below.

  • Hormone-containing drugs like oral contraception or hormone therapy (HT) are sometimes used to control symptoms, especially if the woman experiences excessive or irregular bleeding. Researchers disagree about whether reproductive hormones affect the size and growth rate of fibroids, however. HT may shrink fibroids slightly, but is unlikely to eliminate them altogether.8 An NIH study found that the progesterone-blocking drug ulipristal acetate reduced fibroids’ size and bleeding caused by fibroids, and improved quality of life, when compared to a placebo drug.9
  • Anti-hormonal agents are often used to reduce the number and size of fibroids. Drugs such as progestin and danazol (which is related to testosterone) are used to create an environment rich in androgen and weak in estrogen, which reduces fibroids. A recent evidence-based review, however, indicates that the benefits gained from using these drugs do not outweigh the risks. The reviewers state: “various undesirable side effects have also been reported. These include acne, hirsutism (excess hair in females, with an adult male pattern of distribution), weight gain, irritability, musculoskeletal pain, hot flushes, and breast atrophy, which many women may not tolerate. The review found no evidence demonstrating that the benefits of danazol outweigh the risks in treating uterine fibroids.”10
  • Gonadotropin-releasing hormone (GnRH) agonists prevent the body from producing estrogen; since estrogen helps fibroids grow, the drug helps to shrink existing fibroids. GnRH agonists are also sometimes used to shrink fibroids before surgery and enable shorter, less complicated procedures.11 Some physicians prescribe the GnRH leuprolide acetate (Lupron) to curtail hormone production and shrink fibroids. Lupron has many negative side effects, however — including hot flashes, vaginal dryness, memory and concentration troubles, and bone thinning — and should not be used over the long-term.
  • The Mirena Interuterine Device (IUD) contains the progestogen hormone Levonorgestrel, and can reduce the heavy bleeding caused by fibroids. It does not impact the fibroids themselves, but may help women who are experiencing heavy bleeding to cope better.

Uterine Artery Embolization / Uterine Fibroid Embolization

Uterine Artery Embolization (UAE), also known as Uterine Fibroid Embolization (UFE), is a relatively new approach that cuts off fibroids’ blood supply and causes them to degenerate. With the patient under local anesthesia, a slim catheter is used to place tiny polyvinyl alcohol (PVA) particles next to the fibroids. The particles create a clot that blocks the blood flow to the uterus and fibroids. With their blood supply cut off, the fibroids shrink and die.

Although the Food and Drug Administration (FDA) has approved UAE / UFE to treat fibroids, the procedure can be a risky for women who want to get pregnant in the future. It has the advantage of having a shorter recovery time than other types of surgery, but does not completely eliminate the possible complications of surgery, which include severe pain,12 pulmonary embolism, necrosis (tissue death), sepsis, and death.13

Surgical Procedures

Hysterectomy, which used to be the standard treatment for fibroids, is less common today. Some surgical treatments keep the uterus intact, which many women prefer, while others remove the uterus. A disadvantage of uterine-sparing surgery is that fibroids return an estimated 10-50 percent of the time.14

Procedures that do not remove the uterus include:

  • Myomectomy: this procedure is less invasive than hysterectomy. (It’s also far less common than hysterectomy.) In myomectomy, the fibroids are removed while leaving the rest of the uterus intact; it may include additional surgery to repair the uterine walls. There are three different types of myomectomies that surgeons perform for fibroid removal. Vaginal myomectomy is used when women have relatively small fibroids inside the uterine cavity; it is most successful for fibroids that grow on a stalk. A miniature camera is inserted into the vagina and through the cervix into the uterus. The uterus is filled with a saline solution to expand its walls; then, using the camera to see, the doctor uses another tool to shave the fibroids down flush with the uterine wall. In the second process, laparoscopic myomectomy, the camera and tools are inserted in incisions made in the patient’s abdomen. Using a camera to see, and a second instrument to cut, the doctor chops the fibroids into very small pieces and removes them from the body. Finally, in abdominal (or “open”) myomectomy, also involves entering the body through a larger incision in the abdomen. The procedure allows the surgeon to have a greater field of vision and better ability to ensure the fibroids are removed. Myomectomy is still surgery, however, and — like all surgeries — carries risks. It may also make it harder to get pregnant, and 10 to 25 percent of patients have the fibroids return.15 Younger women are more likely to have their fibroids come back after myomectomy.
  • Myolysis uses energy, in combination with GnRH agonists, to shrink fibroids and kill their blood supply. Most typically conducted in combination with laparoscopic surgery, the process involves the doctor piercing the fibroids with a laser or electrified needle and uses radio-frequency electricity, lasers, supercooled cryoprobes, or focused ultrasound beams to reduce the fibroids’ size and minimize bleeding. More research is still needed on the efficacy and long-term effects of myolysis. In this procedure the fibroids are not removed, and the uterus is not cut into, but the procedure leaves the uterus too weak to carry a developing fetus.

When the uterus is removed, the procedure is called a hysterectomy.

A hysterectomy is “the surgical removal of the uterus; sometimes the cervix and/or ovaries and fallopian tubes are also removed.”16 The three most common types of hysterectomies are:

  • Supracervical hysterectomy, in which only the back portion of the uterus is removed;
  • Total hysterectomy, in which the uterus and the cervix are removed; and
  • Total abdominal hysterectomy, in which the uterus, cervix, both ovaries, and the fallopian tubes are all removed.

Hysterectomy is the second-most commonly performed surgery among reproductive-aged women in the U.S. The CDC’s most recent data indicate that, from 2000 to 2004, the conditions most frequently associated with hysterectomy were fibroids, endometriosis, and uterine prolapse. Hysterectomy rates are dropping, as is the rate of hysterectomy being performed for fibroids; the latter declined significantly from 44.2 percent of hysterectomies in 2000, to 38.7 percent in 2004. And, as with any surgery, hysterectomy carries risks. The NHWN believes that hysterectomy is over-prescribed and over-used, particularly when it comes to treating fibroids.17

The NWHN Position

The NWHN believes that women have been poorly served by a medical establishment that shows little interest in understanding why fibroids occur and how they can be prevented. We believe that the medical establishment too often treats the uterus as a disposable organ. We remain frustrated by the stubborn insistence of the many gynecologists who continue advising women to that all fibroids need to be removed and that hysterectomy is their only option.

The NHWN calls upon the research establishment to take fibroids seriously and devote meaningful resources to exploring their possible causes — and especially to explore why African American women have disproportionately high rates of fibroids. We also call upon the Ob-Gyn community to leave behind its old attitudes and offer women who have bothersome symptoms a range of treatment options.

The NHWN believes that women who experience fibroids should choose their own approach to addressing the condition. Women should assess the benefits of hysterectomy against other viable treatment options — including watchful waiting. We encourage all women to educate themselves about their bodies and the range of normal experience, including fibroids. We encourage women who have been told they have fibroids that need to be treated to first take time to learn about all of their options so they can make the decision that’s best for themselves. 

Resources

  • Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/WomensRH/Hysterectomy.htm
  • Center for Uterine Fibroids: http://www.fibroids.net
  • Fibroid Treatment Collective: http://www.fibroids.com
  • NIH Office on Women’s Health: http://www.nichd.nih.gov/health/topics/uterine/resources/Pages/patients-consumers.aspx
  • NWHN Health Information: (202) 682-2640, or at healthquestions@nwhn.org.
  • The Boston Women’s Health Collective, Our Bodies, Ourselves, New York: Touchstone. 2005.

Updated September 2013


References

1. National Institute of Child Health and Human Development (NICHD), Uterine Fibroids: Overview, Rockville MD: NICHD Public Information and Communications Branch, 2003. Updated 2013. Available online at: http://www.nichd.nih.gov/health/topics/uterine/Pages/default.aspx

2. Image from “Fibroid Tumor of Uterus,” Canstockphotos website, © Can Stock Photo, Inc. Available online at: http://www.canstockphoto.com/uterine-fibroid-eps8-12806770.html

3. Our Bodies, Ourselves Health Resource Center, “Unique to Women: Fibroids (Leiomyomas, Myomas),” Excerpted from Our Bodies, Ourselves, Boston: Boston Women's Health Book Collective, 2005. Available online at: http://www.ourbodiesourselves.org/book/excerpt.asp?id=36

4. Our Bodies, Ourselves Health Resource Center, “Unique to Women: Fibroids (Leiomyomas, Myomas),” Excerpted from Our Bodies, Ourselves, Boston: Boston Women's Health Book Collective, 2005. Excerpted from the 2011 Edition . Available online at: http://www.ourbodiesourselves.org/book/excerpt.asp?id=36

5. National Institute of Health (NIH), Fact Sheet: Uterine Fibroids, Rockville MD: NIH Office on Women’s Health, October 2010Available online at http://www.nichd.nih.gov/health/topics/uterine/resources/Pages/patients-... is this link more appropriate for that fact?? http://report.nih.gov/nihfactsheets/Pdfs/UterineFibroids%28NICHD%2cORWH%...

6. National Institute of Health (NIH), Fact Sheet: Uterine Fibroids, Rockville MD: NIH Office on Women’s Health, October 2010. Updated 2013. Available online at (same as #5) http://www.nichd.nih.gov/health/topics/uterine/resources/Pages/patients-...

7. National Institute of Health (NIH), Fact Sheet: Uterine Fibroids, Rockville MD: NIH Office on Women’s Health, October 2010. Updated 2013. Available online at (same as #5) http://www.nichd.nih.gov/health/topics/uterine/resources/Pages/patients-...

8. National Institute of Health, “Press Release: NICHD Study Shows Fibroid Tumors Unlikely To Respond To Conventional Hormone Treatments: Finding Suggests Strategies for New Treatments," Rockville, MD: NIH, October, 2004. Available online at: http://www.nih.gov/news/pr/oct2004/nichd-15.htm

9. National Institute of Health (NIH), Fact Sheet: Uterine Fibroids Research, Rockville MD: NIH Office on Women’s Health, October 2010. Updated 2013. Available online at http://www.nichd.nih.gov/health/topics/uterine/resources/Pages/patients-...

10. Lq K, Yang K, Li C-M, et al., “Danazol for treatment of women with symptoms caused by uterine fibroids,” Cochran Review, September 7, 2011. Published online at: http://summaries.cochrane.org/CD007692/danazol-for-treatment-of-women-wi...

11. National Institute of Health (NIH), Fact Sheet: Uterine Fibroids Research, Rockville MD: NIH Office on Women’s Health, October 2010. Updated 2013. Available online at http://www.nichd.nih.gov/health/topics/uterine/resources/Pages/patients-...

12. Soulen MC, Fairman RM, Baum R, “Embolization of the Internal Iliac Artery: Still More to Learn,” Journal of Vascular & Interventional Radiology 2000; 11 (5): 543–545. doi:10.1016/S1051-0443(07)61604-2; Common AA, Mocarski E, Kolin, “Leiomyosarcoma,” Journal of Vascular & Interventional Radiology 2001; 12: 1449–1452.

13. Schirf BE, Vogelzang RL, Chrisman HB, “Complications of Uterine Fibroid Embolization,”
Semin Intervent Radiol. 2006 June; 23(2): 143–149. doi:  10.1055/s-2006-941444.

14. Practice Committee of the American Society for Reproductive Medicine, Society of Reproductive Surgeons, “Myomas and reproductive function.” Fertility and Sterility 2008: 90(3): S125-S130.

15. Our Bodies, Ourselves Health Resource Center, “Unique to Women: Fibroids (Leiomyomas, Myomas),” Excerpted from Our Bodies, Ourselves, Boston: Boston Women's Health Book Collective, 2005. Available online at: http://www.ourbodiesourselves.org/book/excerpt.asp?id=36

16. Centers for Disease Control and Prevention (CDC), Women's Reproductive Health: Hysterectomy, Atlanta: CDC, 2011. Available online at: http://www.cdc.gov/reproductivehealth/WomensRH/Hysterectomy.htm

17. Centers for Disease Control and Prevention (CDC), Women's Reproductive Health: Hysterectomy, Atlanta: CDC, 2011. Available online at: http://www.cdc.gov/reproductivehealth/WomensRH/Hysterectomy.htm