Women and Fibroids: Making the Best Decisions
Taken from the September/October 2006 issue of the Women's Health Activist Newsletter.
While this is a perfectly reasonable question, finding the answers often leads her to embark on a confusing journey in which she is likely to receive misleading information about treatment options and often becomes more anxious than she was before. The truth is that fibroids, while sometimes painful, are almost never a cause for worry. In the vast majority of cases, women can take the time needed to consider all of their options and find the treatment plan (if one is even necessary) that works best for them.
Fibroids (medically known as uterine leiomyomas) are benign lumps of muscle and tissue that grow in and around the uterus. Submucosal fibroids grow underneath the uterine lining; intramural fibroids grow between the muscles of the uterus; and subserosal fibroids are formed on the outside of the uterus. Fibroids are extremely common, potentially affecting three-quarters of all women of reproductive age. While fibroids have no known cause, African American women are three to five times more likely to develop them than are women of other racial and ethnic backgrounds.
Common Symptoms of Fibroids
The two main symptoms from which women usually seek relief are heavy bleeding and abdominal pain. Other possible symptoms of fibroids include anemia, a constant urge to urinate, constipation, pelvic pressure (a ‘full’ feeling in the lower abdomen), pain during intercourse, and lower back pain. While many women with fibroids have healthy and uneventful pregnancies, fibroids can contribute to reproductive problems such as early onset of labor, miscarriage, or difficulty conceiving.
Most women with fibroids have no symptoms and remain unaware of the condition until a gynecologist makes an identification during a routine pelvic exam. These women often find that fibroids do not affect their quality of life or physical health in any way. For other women, some of the symptoms of fibroids can significantly reduce their quality of life. These women often need to search for the best solution to their fibroid-related problems. Like many women’s health issues, there is no magic bullet for fibroids, and no ‘one size fits all’ treatment.
The Power of Language
Before delving into treatment options, it is worth exploring the intimidating (and often insensitive) language used to describe fibroids. Fibroids are, technically, tumors. But, telling a woman that she has a tumor in her uterus sounds misleadingly alarming, and is unlikely to alleviate her fears—even when a provider emphasizes that the tumor is benign. Instead, women should receive a proper explanation of fibroids, so that they understand what they are beyond just knowing that they are ‘tumors.’
A woman with fibroids may also be told that her uterus’ size is comparable to that of a pregnant woman’s uterus at a certain stage of pregnancy. A fibroid’s size is also often compared to different types of fruit, such as plums, oranges, or grapefruits. When a woman hears that her uterus is carrying the weight of a five-month fetus—or contains a grapefruit-sized tumor—her anxiety is bound to increase, making thoughtful decision-making more difficult.
Using different words or ways to describe fibroids will not stop a woman’s bleeding or make her pain go away, but it can impact the way she feels about the situation, and influence how she addresses her fibroid-related symptoms. Most importantly, avoiding unnecessarily frightening terms normalizes the situation. This may help the woman feel more in control of her health care which, in turn, increases the likelihood that she will make the best decision for herself from among her various options.
Watchful Waiting
The first thing many women with fibroids consider is whether they need to take any action at a given time. The term ‘watchful waiting’ describes an approach in which a woman tracks any symptoms and has regular pelvic exams to monitor her fibroids. This approach is ideal for asymptomatic women, as well as for women who can use pain management or other non-medical techniques to manage their symptoms. Women who are approaching menopause may also want to consider watchful waiting, as many fibroids shrink after the menopausal transition. Watchful waiting is an important option that, while not for everyone, should not be overlooked.
Heavy bleeding during menstruation (menorrhagia) can be intimidating, but it is fairly common among women with fibroids, and often needs no treatment. Many women who are near menopause experience an increase in blood flow that goes away after a month or two. Women are often able to manage this bleeding on their own without medical intervention. Interestingly, a Scottish study found that women who present with menstrual complaints tend to be diagnosed with menorrhagia or dysfunctional uterine bleeding—even if they did not report their bleeding as problematic. These diagnoses may, in turn, lead to inappropriate treatment, including hysterectomy.
If a woman’s menstrual bleeding is unmanageable and does not decrease on its own, however, a health care provider should be consulted to rule out endometrial cancer. For women who feel that their fibroids require medical intervention, there are several options, described below.
Treating Fibroids: Non-Surgical & Surgical Methods
Often, pain from fibroids can be eased with pain medications such as aspirin or ibuprofen, or with drugs called GnRH agonists which decrease the body’s production of estrogen, often shrinking the fibroids. Some women find that lifestyle changes, such as increasing exercise, discontinuing hormone use, and/or avoiding caffeine and alcohol help fibroid-related symptoms. Commonly, however, fibroids are treated with the following interventions, described from least to most invasive:
Uterine Artery Embolization
Uterine Artery Embolization (UAE), also sometimes called Uterine Fibroid Embolization, is a relatively new procedure introduced in the U.S. in 1997. UAE is designed to shrink fibroids by cutting off their blood supply. During UAE, a woman is put under conscious sedation and an incision is made in her groin. Using a catheter, small particles of polyvinyl alcohol (a type of plastic) are injected into the uterine arteries, the veins that provide blood to the uterus. The particles are then guided by the bloodstream and positioned next to the fibroids, thereby inhibiting the fibroids’ blood supply.
This procedure is the least invasive surgical procedure, but is not 100 percent effective, and some fibroid growth is still possible after UAE. While pregnancy after UAE is possible, there is a higher incidence of miscarriage and placenta problems in these pregnancies. For this reason, UAE is not recommended for women who want to preserve their fertility. Due to the lack of long-term data, UAE is not yet considered a standard of care, but interest in the procedure is rapidly growing.
Myomectomy
Myomectomy is a process by which the fibroids are surgically removed in small pieces and the uterus is left in place while the woman is under general anesthesia. It can be performed through a vaginal or abdominal incision, depending on the size and location of the fibroids.
Although the uterus is left intact, some women need additional surgeries to repair the uterine walls after the initial surgery. In addition, 20 percent of women who have had myomectomy find that their fibroids grow back after the surgery. This procedure is not performed very frequently in the United States, although it is more common in other countries, such as France. The procedure is recommended for women who want to become pregnant at a later date.
Hysterectomy
Hysterectomy is the surgical removal of the uterus. This procedure is performed while the woman is under general anesthesia, through either a vaginal or abdominal incision. It may or may not include the removal of the cervix, fallopian tubes, or ovaries. Hysterectomy is the procedure most often mentioned to women after they learn they have fibroids. In reality, however, a hysterectomy should be the last option a woman should consider. Although hysterectomy is the only sure way to completely remove fibroids, it is major surgery that comes with its own host of risks and considerations, including surgical complications, increased risk of heart attack, changes in sexual desire and function, and depression.
The majority of hysterectomies performed in this country are elective and the NWHN believes that most are medically unnecessary. Further, fibroids are the leading reason for which women are told they should have a hysterectomy. Women should explore other options before choosing to have a hysterectomy, although they may need to seek several opinions before finding a health care provider who is willing to discuss alternatives to the procedure.
How to Decide
The experiences of women with fibroids vary greatly, and it is really up to each woman to reflect on which of her symptoms needs addressing, and how she wants to do so. It is important to keep in mind that not all fibroids require surgery. Health care providers should be careful not to unnecessarily alarm women about having fibroids. Women, for their part, should feel actively involved in the process of monitoring and treating their fibroids. Once this occurs, much unnecessary over-treatment of fibroids can be avoided.
For more information about fibroids, visit NWHN’s website.
Electra Kaczorowski is the NWHN's Health Information Coordinator.
The continued availability of external resources is outside of the NWHN’s control. If the link you are looking for is broken, contact us at nwhn@nwhn.org to request more current citation information.
References
- National Institute of Child Health and Human Development (NICHD),National Institutes of Health, Department of Health and Human Services. Uterine Fibroids,Washington,DC: NICHD. 2005
- Warner, P, Critchley H, Lumsden M, et al. “Referral for Menstrual Problems: Cross Sectional Survey of Symptoms, Reasons for Referral, and Management.” BMJ 2001; 323:24-28.
- Skilling, Johanna. Fibroids: The Complete Guide to Taking Charge of Your Physical, Emotional, and Sexual Well-Being. New York: Marlow and Company. 2000.
Boston Women’s Health Book Collective, Our Bodies, Ourselves. New York: Touchstone. 2005. p. 637. - U.S. Department of Health and Human Services (HHS). “Hysterectomy: Frequently Asked Questions.” Washington DC: HHS, 2006. Posted on National Women’s Health Information Center Website; accessed October 6, 2006.