Uterine fibroids

Answer 1

Definition

Uterine fibroids are noncancerous (benign) tumors that develop in the uterus (womb), a female reproductive organ.

Alternative Names

Leiomyoma; Fibromyoma; Myoma; Fibroids

Causes, incidence, and risk factors

Uterine fibroids are the most common pelvic tumor. As many as 1 in 5 women may have fibroids during their childbearing years (the time after starting menstruation for the first time and before menopause).

Fibroids usually affect women over age 30. They are rare in women under 20, and often shrink and cause no symptoms in women who have gone through menopause. They are more common in African Americans than Caucasians.

The cause of uterine fibroid tumors is unknown. However, fibroid growth seems to depend on the hormone estrogen. As long as a woman with fibroids is menstruating, a fibroid will probably continue to grow, usually slowly.

Fibroids can be so tiny that you need a microscope to see them. However, they can grow very large. They may fill the entire uterus, and may weigh several pounds. Although it is possible for just one fibroid to develop, usually there are more than one.

Fibroids are often described by their location in the uterus:

• Myometrial -- in the muscle wall of the uterus
• Submucosal -- just under the surface of the uterine lining
• Subserosal -- just under the outside covering of the uterus
• Pendunculated -- occurring on a long stalk on the outside of the uterus or inside the cavity of the uterus

Symptoms

More common symptoms of uterine fibroids are:

• Abdominal fullness, gas, or constipation
• Bleeding between periods
• Increase in urinary frequency
• Heavy menstrual bleeding (menorrhagia), sometimes with the passage of blood clots
• Menstrual periods that may last longer than normal
• Pelvic cramping or pain with periods
• Sensation of fullness or pressure in lower abdomen
• Pain during intercourse

Note: There are often no symptoms.

Signs and tests

A pelvic examination may show an irregularly shaped, lumpy, or enlarged uterus. Frequently, this diagnosis is reliable. In some cases, it is difficult to diagnose fibroids, especially in obese women. Fibroid tumors have been mistaken for:

• Pregnancy
• Ovarian tumors
• Inflammation of the fallopian tubes
• Uterine adenomyosis (a condition in which the uterine lining grows into the muscle wall of the uterus)

A transvaginal ultrasound or pelvic ultrasound may be done to confirm the diagnosis of fibroids. Sometimes, a pelvic MRI is used to confirm the diagnosis.

An endometrial biopsy (biopsy of the uterine lining) or laparoscopy may be needed to rule out cancer.

Treatment

Treatment depends on various factors, including:

• Age
• General health
• Severity of symptoms
• Type of fibroids
• Whether you are pregnant
• If you want children in the future

Some women may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth.

Treatment for the symptoms of fibroids may include:

• Birth Control pills (oral contraceptives) to help control heavy periods
• Intrauterine devices (IUDs) that release the hormone progestin to help reduce heavy bleeding and pain
• Iron supplements to prevent or treat anemia due to heavy periods
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn for cramps or pain

Hormonal therapy (gonadotropin releasing hormone (GnRH) agonists or Depo Leuprolide injections) may be used to help shrink the fibroids. This therapy is used only for a short period of time, either before surgery to remove a fibroid or when a woman is expected to reach menopause soon. Side effects include hot flashes and vaginal dryness.

Surgery and procedures used to treat fibroids include:

• Hysteroscopic resection of fibroids: Women who have fibroids growing inside the uterine cavity may need this outpatient procedure. In this procedure, a small camera and instruments are inserted through the cervix into the uterus to remove the fibroid tumors.
• Uterine artery embolization: This procedure stops the blood supply to the fibroid, causing it to die and shrink. Uterine artery embolization is not used to treat large fibroids. Women who may want to become pregnant in the future should NOT have this procedure.
• Myomectomy: This surgery removes the fibroids. It is often the chosen treatment for women who want to have children, because it usually can preserve fertility. Another advantage of a myomectomy is that it controls pain or excessive bleeding that occurs in some women with uterine fibroids. More fibroids can develop after a myomectomy.
• Hysterectomy: This invasive surgery may be an option if medicines do not work and other surgeries and procedures are not an option.

Support Groups

National Uterine Fibroid Foundation - www.nuff.org

Expectations (prognosis)

Some women with fibroids have no symptoms and may not need treatment.

During a pregnancy, existing fibroids may grow due to the increased blood flow and estrogen levels. The fibroids usually return to their original size after the baby is delivered.

Complications

Fibroids may cause pregnancy complications, although the risk is thought to be small:

• Most women are able to carry their babies to term, but some end up delivering prematurely because there is not enough room in the uterus.
• Some pregnant women with fibroids may need a cesarean section because fibroids can occasionally block the birth canal or cause the baby to be positioned wrong.
• Some pregnant women with fibroids have heavy bleeding immediately after giving birth.

Other complications of fibroids include:

• Severe pain or excessively heavy bleeding that may require emergency surgery
• A pedunculated fibroid can become twisted and cause a kink in the blood vessels feeding the tumor (this type of fibroid may need surgery)
• Anemia (which may be severe if the bleeding is very heavy)
• Urinary tract infections, if pressure from the fibroid prevents the bladder from fully emptying
• Cancerous changes called leiomyosarcoma (in rare cases)
• Infertility (rarely)

Calling your health care provider

Call your health care provider if:

• You have gradual changes in your menstrual pattern, including a heavier flow, increased cramping, or bleeding between periods
• Fullness or heaviness develops in your lower abdomen

References

Katz VL. Benign gynecologic lesions: Vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 18.

Viswanathan M, Hartmann K, et al. Management of uterine fibroids: an update of the evidence. Evid Rep Technol Assess. 2007;154:1-122.

Van Voorhis B. A 41-year-old woman with menorrhagia, anemia, and fibroids: review of treatment of uterine fibroids. JAMA. 2009;301:82-93.

American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112:387-400.

Answer 2

Definition

Uterine fibroids are noncancerous (benign) tumors that develop in the womb (uterus), a female reproductive organ.

Alternative Names

Leiomyoma; Fibromyoma; Myoma; Fibroids

Causes, incidence, and risk factors

Uterine fibroids are common. As many as 1 in 5 women may have fibroids during their childbearing years (the time after starting menstruation for the first time and before menopause). Half of all women have fibroids by age 50.

Fibroids are rare in women under age 20. They are more common in African-Americans than Caucasians.

The cause of uterine fibroids is unknown. However, their growth has been linked to the hormone estrogen. As long as a woman with fibroids is menstruating, a fibroid will probably continue to grow, usually slowly.

Fibroids can be so tiny that you need a microscope to see them. However, they can grow very large. They may fill the entire uterus, and may weigh several pounds. Although it is possible for just one fibroid to develop, usually there are more than one.

Fibroids are often described by their location in the uterus:

• Myometrial -- in the muscle wall of the uterus
• Submucosal -- just under the surface of the uterine lining
• Subserosal -- just under the outside covering of the uterus
• Pendunculated -- occurring on a long stalk on the outside of the uterus or inside the cavity of the uterus

Symptoms

More common symptoms of uterine fibroids are:

• Bleeding between periods
• Heavy menstrual bleeding (menorrhagia), sometimes with the passage of blood clots
• Menstrual periods that may last longer than normal
• Need to urinate more often
• Pelvic cramping or pain with periods
• Sensation of fullness or pressure in lower abdomen
• Pain during intercourse

Note: There are often no symptoms. Your health care provider may find them during a physical exam or other test. Fibroids often shrink and cause no symptoms in women who have gone through menopause.

Signs and tests

The health care provider will perform a pelvic exam. This may show that you have a change in the shape of your womb (uterus).

It can be difficult to diagnose fibroids, especially if you are extremely overweight.

An ultrasound may be done to confirm the diagnosis of fibroids. Sometimes, a pelvic MRI is done.

An endometrial biopsy (biopsy of the uterine lining) or laparoscopy may be needed to rule out cancer.

Treatment

Treatment depends on several things, including:

• Your age
• General health
• Severity of symptoms
• Type of fibroids
• Whether you are pregnant
• If you want children in the future

Some women may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth.

Treatment for the symptoms of fibroids may include:

• Birth control pills (oral contraceptives) to help control heavy periods
• Intrauterine devices (IUDs) that release the hormone progestin to help reduce heavy bleeding and pain
• Iron supplements to prevent or treat anemia due to heavy periods
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn for cramps or pain
• Short-term hormonal therapy injections to help shrink the fibroids

Surgery and procedures used to treat fibroids include:

• Hysteroscopic resection of fibroids: Women who have fibroids growing inside the uterine cavity may need this outpatient procedure to remove the fibroid tumors.
• Uterine artery embolization: This procedure stops the blood supply to the fibroid, causing it to die and shrink. Women who may want to become pregnant in the future should discuss this procedure with their health care provider.
• Myomectomy: This surgery removes the fibroids. It is often the chosen treatment for women who want to have children, because it usually can preserve fertility. More fibroids can develop after a myomectomy.
• Hysterectomy: This invasive surgery may be an option if medicines do not work and other surgeries and procedures are not an option.

Support Groups

National Uterine Fibroid Foundation - www.nuff.org

Expectations (prognosis)

Some women with fibroids have no symptoms and may not need treatment.

During a pregnancy, existing fibroids may grow due to the increased blood flow and estrogen levels. The fibroids usually return to their original size after the baby is delivered.

Complications

Complications of fibroids include:

• Severe pain or excessively heavy bleeding that may require emergency surgery
• Twisting of the fibroid, which causes a blockage in nearby blood vessels feeding the tumor (surgery may be needed)
• Anemia (low red blood cell count) if the bleeding is very heavy
• Urinary tract infections, if pressure from the fibroid prevents the bladder from fully emptying
• Cancerous changes called leiomyosarcoma (rare)

In rare cases, fibroids may cause infertility. Fibroids may also cause complications if you become pregnant, although the risk is thought to be small:

• Some pregnant women with fibroids may deliver a premature baby because there is not enough room in the womb.
• A c-section may be needed if the fibroid blocks the birth canal or causes the baby to be in a dangerous position.
• Some pregnant women with fibroids have heavy bleeding immediately after giving birth.

Calling your health care provider

Call your health care provider if you have:

• Changes in your periods, including heavy bleeding, increased cramping, or bleeding between periods
• Fullness or heaviness in your lower belly area

References

Katz VL. Benign gynecologic lesions: Vulva, vagina, cervix, uterus, oviduct, ovary. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 18.

Rodriguez MI, Warden M, Darney PD. Intrauterine progestins, progesterone antagonists, and receptor modulators: a review of gynecologic applications. Am J Obstet Gynecol. 2010 May;202(5):420-8. Epub 2009 Dec 23. Review.

Moss J, Cooper K, Khaund A, et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG. 2011 Jul;118(8):936-944.

Peddada SD, Laughlin SK, Miner K, et al. Growth of uterine leiomyomata among premenopausal black and white women. Proc Natl Acad Sci USA. 2008 Dec 16;105(50):19887-92. Epub 2008 Dec 1.

Van Voorhis B. A 41-year-old woman with menorrhagia, anemia, and fibroids: review of treatment of uterine fibroids. JAMA. 2009;301:82-93.

American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112:387-400.

Reviewed By

Review Date: 07/25/2011

David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., and Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Bellevue, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine.