Pinky Ronen, M.D.
Fibroids are growths of the uterus, or womb . They are also called uterine leiomyomas or myomas. The uterus is made of muscle, and fibroids grow from the muscle. Fibroids can bulge from the inside or outside of the uterus. Fibroids are not cancerous and are not thought to be able to become cancerous.
Fibroids are very common. Approximately 80 percent of women have fibroids, although not all of these women have bothersome fibroid symptoms. Treatments are available for women who have fibroid-related problems like heavy menstrual bleeding, pain or pressure in the pelvis, or problems with pregnancy or infertility.
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The cause of fibroids is unknown. Fibroids seem to respond to the female hormones estrogen and progesterone; some women have specific genes that may predispose them, and their families, to fibroids, and lifestyle and reproductive factors influence fibroids. Some fibroids grow with time and others shrink. Fibroids can also have growth spurts where they grow quickly over a short period of time.
Fibroids can range in size from microscopic to the size of a grapefruit or even larger. The majority of fibroids are small and do not cause any symptoms at all. However, some women with fibroids have very heavy or long menstrual periods or pelvic pressure or pain that interferes with their life.
Fibroids are more likely to cause symptoms if the fibroids are large, if there are many fibroids, or if the fibroid is located in certain places in the uterus. Fibroid symptoms tend to get better when a woman no longer has menstrual periods, at menopause.
Most women with fibroids have a completely normal pregnancy without complications. However, women with a large fibroid (greater than 5 to 6 cm) might have an increased risk of specific pregnancy complications.
A doctor or nurse may suspect fibroids if your uterus is enlarged or has an irregular shape. A pelvic ultrasound is needed to confirm that fibroids are present. Ultrasound uses sound waves to create a picture of the uterus.
Women who have no symptoms from their fibroids do not need to have treatment. Women with significant symptoms may try medical or surgical treatment. The best treatment depends on which symptom is most bothersome. The size, number and locations of fibroids also factor into most treatment decisions.
MEDICAL FIBROID TREATMENT
Medical treatments are those that use a medicine to reduce the heavy menstrual bleeding, which is common in women with fibroids. Medical treatments are often recommended before surgical treatments.
There are a number of medical treatments available, including some that use hormones and some that do not.
Hormonal birth control — Hormonal methods of birth control include the pill, skin patch, vaginal ring, shot, hormonal IUD, and implant. These treatments reduce bleeding, cramps, and pain during your menstrual period. It might take three months for bleeding to improve after you start taking hormonal birth control.
Nonsteroidal antiinflammatory drugs (NSAIDs)
Nonsteroidal antiinflammatory drugs, such as ibuprofen (sold as Motrin® or Advil®) and naproxen (sold as Naprosyn or Alleve®), can help reduce menstrual cramps. You can buy some NSAIDs (including ibuprofen) without a prescription.
NSAIDs are not expensive, have few side effects, reduce pain, and you only need to take them during your menstrual period. You can take NSAIDs in combination with any of the medical treatments discussed here. However, NSAIDs do not reduce bleeding as well other medical treatments do. For women do not get relief with non-prescription NSAIDs, there are other similar medications available by prescription that may be helpful for some women.
Gonadotropin-releasing hormone agonists
Gonadotropin-releasing hormone (GnRH) agonists are a medicine given by injection once every one to three months that can be used to temporarily shrink uterine fibroids and temporarily stop menstrual bleeding. GnRH agonists work by "turning off" the ovaries, causing a temporary and reversible menopause. If you are scheduled to have your fibroids removed surgically, your doctor might recommend that you first use GnRH agonists for 3 to 6 months to shrink the fibroids, which can make them easier to remove. This treatment is not routinely recommended for longer than six months in a row due to the risk of thinning bones when used for long periods of time. However, once the medication shrinks the fibroids, the medicine can be continued long-term, as long as low doses of estrogen and progestin are added to protect the bones. GnRH agonists do not work immediately. They first cause an increase in ovarian hormones that can cause an increase in symptoms for the first few weeks. This “flare” can be a problem for women with heavy bleeding who are severely anemic.
Iron and vitamins
For women who are anemic, the combination of iron supplements and a multivitamin, which will help the body effectively use the iron, is a an effective treatment option.
Your doctor might recommend a surgical treatment for fibroids if:
Myomectomy is a surgery done to remove fibroids which can reduce both bleeding and size related symptoms. Most women who have myomectomy are able to have children afterwards. However, there is a risk that fibroids will come back after myomectomy; between 10 and 25 percent of women who have myomectomy will need a second fibroid surgery. For this reason, myomectomy is not the best choice for women who do not want future pregnancies.
There are several ways to perform myomectomy; the "best" way depends on where your fibroids are located and the size and number of fibroids .
Endometrial ablation destroys the lining of the uterus. The treatment does not shrink the fibroid(s) but can help to decrease heavy menstrual bleeding caused by fibroids. In fact, some women who have endometrial ablation stop having menstrual periods.
Ablation can be done in the office or as a day surgery. It can be done in combination with other treatments, such as myomectomy. Endometrial ablation is not a form of birth control, but pregnancy is not recommended after treatment. You will need to use some form of birth control to prevent pregnancy after ablation. Women who do get pregnant following ablation are more likely to have an abnormal pregnancy outside the uterus.
Uterine artery embolization
Uterine artery embolization (also called UAE or uterine fibroid embolization, UFE) is a treatment that blocks the blood supply to fibroids. This causes the fibroid to shrink within weeks to several months after the treatment.
The treatment is performed in the hospital after you are given light anesthesia or sedation. A doctor will insert a small tube into a large blood vessel in the inner thigh. The tube is threaded up to blood vessels near a fibroid (figure 3A-B). The doctor injects tiny particles into the blood vessel, which stops blood flow to the fibroid.
To minimize pain after the treatment, most women stay in the hospital overnight. Pregnancy is not usually recommended after uterine artery embolization, although it is possible to become pregnant. Some form of birth control is recommended if you do not want to become pregnant.
Magnetic resonance guided focused ultrasound
Magnetic resonance guided focused ultrasound surgery (MRgFUS or FUS) (eg, ExAblate® 2000) is a more recent fibroid treatment option. This noninvasive treatment takes place in a MRI machine which guides the treatment. Multiple waves of ultrasound energy go through the abdominal wall and converge on a small volume of tissue, which leads to thermal destruction of the fibroid. Women do receive sedation during the procedure and it can be performed as an outpatient procedure. Pregnancy is not usually recommended following FUS, although it is possible to become pregnant following treatment.
Hysterectomy is a surgery that removes the uterus. The ovaries and cervix are sometimes removed, along with the uterus.
Hysterectomy is a permanent treatment that cures heavy menstrual bleeding and the bulk related symptoms of fibroids. However, it is major surgery, and you will need up to six weeks to fully recover.
There are many treatments for fibroids, and it can be hard to decide which one is right. You should choose a treatment based upon your fibroid-related symptoms.
If you are bothered by heavy menstrual bleeding, you can first try the medical treatments. Hormonal birth control, nonsteroidal antiinflammatory drugs (NSAIDs), or antifibrinolytic medicines work better than other medical treatments.
Some women who no longer want future pregnancies can also be treated with endometrial ablation to reduce bleeding.
If medical treatment or endometrial ablation are not good options for you, or you also have symptoms related to the size of the fibroids, you can consider uterine fibroid embolization, myomectomy, hysterectomy or focused ultrasound surgery.
If you are having trouble getting pregnant and fibroids could be the cause, myomectomy is the standard surgical option. Talk to your doctor to be sure that other possible causes of infertility have been addressed before you have fibroid surgery