Fibroids

Fibroids, otherwise known as myomas or leiomyomas, are benign tumors which commonly grow in the wall of the uterus, or womb. Fibroids are extremely common, and seem to start growing relatively early in a woman’s life. Over time, most women will grow fibroids, though many are so small that they may never be detected or cause problems. Fibroids can grow to be extremely large; one weighing 140 pounds has been reported!

It is not known why some women grow large, troublesome fibroids while others don’t. African-American women are definitely at higher risk: Women of color grow fibroids earlier in life, grow larger fibroids, and more frequently require major surgery for their treatment. In many women, there is a familial tendency: When we interview patients with symptomatic fibroids, many tell us that their mother had similar issues.

A change in the fibroid’s DNA seems to be, at least in some cases, the root cause of their growth. Other factors can also affect the growth of fibroids: Fibroids do respond to female hormones like estrogen, and can sometimes grow in high-hormone states like pregnancy. Birth control pills can also sometimes cause fibroids to grow, even while helping to control their symptoms. Cellular changes in fibroids may affect the way the cells process hormones, and make them more susceptible to hormonally-stimulated growth.

Fibroids tend to shrink after menopause, probably because hormone levels fall at this stage of life. While it is unlikely that a large fibroid will disappear completely, most of the symptoms caused by fibroids are more problematic prior to menopause. It is unusual for women to require treatment of fibroids after menopause.

Symptoms of Fibroids

Fibroids can be completely asymptomatic, or can cause severe, life-altering bleeding and pain. By far, the most common symptoms of fibroids is heavy bleeding with menstrual periods: About half of women with fibroids report heavy bleeding, which sometimes results in anemia. Fibroids can also cause pain, ranging from pain occurring only with menstrual cramps to severe pelvic pain all month long; 7% of women with fibroids report moderate-to-severe pain. When fibroids grow to be large, they can cause “mass” or “bulk” symptoms: Women may be aware of a growing abdominal mass which gives them a protruding belly, makes their clothes too tight, or puts pressure on their bladder, causing them to urinate frequently.

The symptoms caused by fibroids depend largely on the size and location of the fibroids. Tiny fibroids—and even some large ones—may cause no symptoms at all. You should not be concerned if a fibroid is incidentally found during physical examination or ultrasound assessment: Small fibroids which cause no symptoms generally do not require therapy, though we may ask you about symptoms and recommend that you monitor the growth of your fibroids periodically.

The uterus or womb is a hollow organ, roughly the same size and shape as a pear. The function of the uterus is to carry a baby during pregnancy, and to bleed every month with your menses. Fibroids located on the inside of the womb are called submucous fibroids. Submucous fibroids typically will cause problems with bleeding, even if they are quite small: A submucous myoma the size of a marble can result in prolonged menstrual periods with flooding, clots, frequent pad changes, and bleeding in between cycles. Because the womb is designed to push things out (it pushes out your period; it pushes out your baby), it may naturally try to expel a fibroid growing on the inside. As such, some women with submucous myomas will have a sensation of menstrual cramps, even when they don’t have their period.

Women with fibroids in the wall of the uterus have intramural myomas (intra=within, mural=wall). Intramural myomas can also cause heavy periods, but generally not until they are at least a few centimeters in size. Larger or numerous intramural myomas can cause severe cramps with periods, month-long pelvic pain, or pain with intercourse. When the womb gets significantly enlarged with fibroids, women may complain of mass symptoms: They may notice, for example, that their belly looks bloated, or that they need to urinate frequently because of pressure on the bladder. They also may have symptoms of constipation as a result of a large fibroid uterus blocking the effective evacuation of stool.

Like intramural myomas, fibroids growing on the outside of the uterus (“subserous” myomas) generally only cause symptoms when their size is significant. These fibroids may grow off the surface of the uterus on a stalk—a so-called pedunculated myoma.

Again, the significance of fibroids in these circumstances will depend mostly on their location and their size. Fibroids growing on the inside of the uterus distort the chamber in which the fetus grows; these fibroids are frequently associated with difficulty conceiving and carrying a pregnancy. Fibroids located within the wall or on the outside of the uterus are probably less important unless quite large. Larger fibroids have been associated with an increased risk of miscarriage, premature labor, early rupture of the membranes, and low birthweight; women with large fibroids are more likely to require cesarean section and blood transfusion at delivery due to hemorrhage. Fibroids can also sometimes grow rapidly in pregnancy—so rapidly in fact that they outgrow their blood supply and begin to die, or degenerate. A degenerating myoma typically causes localized pain, and is sometimes associated with a painful lump and preterm contractions.

In addition to size and location, other factors will influence the behavior of fibroids and the symptoms they cause.

Is it Cancer?

Fibroids, by definition, are not cancerous: They are benign tumors which tend to grow slowly throughout a woman’s reproductive life. However, in rare cases a mass which is thought to be a fibroid is discovered at surgery to be a more serious tumor. Usually, the diagnosis in this case is leiomyosarcoma, a cancerous tumor arising from the muscle cells of the womb.

There is no absolutely reliable test to distinguish a benign fibroid from a leiomyosarcoma until it is removed. While many women find this troubling, the risk of leiomyosarcoma is extremely small: In one large series, only 3 leiomyosarcomas were discovered among 1297 surgeries for presumed fibroids.

Gynecologists are usually taught to be suspicious of fibroids which are rapidly growing. There is no agreement, however, on what constitutes a “rapidly growing” fibroid, since their natural history is so variable. Moreover, one study found that the risk of finding a leiomyosarcoma in a “rapidly growing” fibroid was similar to the risk of finding leiomyosarcoma in fibroids operated on for other reasons…about 1 in 400.

How are Fibroids Treated?

Because fibroids are so common, many will never even be detected and most will not require treatment. When treatment is required, a variety of options are available. Generally, treatment is dictated by the symptoms of fibroids (bleeding, pain, mass symptoms) or by reproductive consequences.

Birth Control Pills

Birth control pills can often control heavy periods and cramps associated with fibroids, even though the hormones in “the pill” can actually stimulate fibroid growth. Oral contraceptives will only continue to work as long as they are taken, so treatment of fibroids using birth control pills requires a long-term commitment. Some women are uncomfortable with the idea of staying on the pill for many years; other women may not be ideal candidates for birth control pills because of age, excess weight, diabetes, high blood pressure, and cholesterol problems. Finally, one has to consider the costs of treatment with each month of pills costing anywhere from $30 to $85 out-of-pocket. The long-term costs of birth control for a 35-year old woman could amount to thousands of dollars.

The Levonorgestrel IUD (“Mirena”)

The levonorgestrel IUD (“Mirena”) has a small amount of hormone in it which generally causes light periods; in many women who use this device, periods disappear altogether. This effect can be exploited in women who have heavy bleeding associated with fibroids. Most women will have some disorganized bleeding in the first 3 to 6 months after having a Mirena inserted; this bleeding is usually not heavy, but can consist of unexpected spotting or persistent staining. Evidence suggests that women with fibroids are more likely to expel an IUD, however, meaning that an IUD will occasionally not stay in place in a uterus distorted by fibroids. The Mirena IUD has to be replaced every 5 years, an in-office procedure which may cause some discomfort. While the levonorgestrel IUD may be effective in controlling bleeding associated with fibroids, it will not control other symptoms such as pain or mass effects.

Uterine Artery Embolization

Uterine artery embolization is occasionally used to treat women with symptomatic fibroids. In this procedure, a catheter is snaked from the artery in the groin up to the artery which feeds the fibroids. A “plug” is then deposited which will obstruct blood flow to the fibroid. Although it is a minimally-invasive procedure, embolization is quite painful; women are generally admitted to the hospital to manage the pain associated with dying fibroid tissue. Embolization resolves symptoms in most, but not all, women with fibroids. A significant proportion of women—most studies suggest about one third, overall—will ultimately require surgical intervention because of return of symptoms. Also, there is some evidence that embolization may compromise the blood supply to the ovaries, leading to earlier menopause.

Endometrial Ablation

Many women with fibroid-related heavy bleeding will be candidates for endometrial ablation. This highly effective same-day procedure reduces menstrual bleeding dramatically by destroying the inner lining of the uterus (the endometrium). The procedure typically takes just 10 minutes to perform under anesthesia, and allows women to return to their usual activities the following day. Because the inner lining of the womb is permanently inactivated by ablation procedures, this option should only be considered by women who have already completed their families. Women with large fibroids or fibroids which significantly distort the inner cavity of the uterus are generally not ideal candidates for endometrial ablation.

Remove the Fibroids

For some women, the best treatment option is simply to remove the fibroids, a procedure known as myomectomy. Traditionally, this has been performed with an “open” surgical procedure, usually with a bikini-type incision. In our practice, we now perform most myomectomies using a minimally-invasive laparoscopic approach. In this procedure, tiny incisions are made which allow us to pass a telescope and long, slender instruments into the abdomen. Fibroids can be dissected from the surrounding uterus, and then removed through the small incisions. Women generally are discharged a few hours after laparoscopic myomectomy, and can return to work after 7-10 days.

Laparoscopic Myomectomy

Laparoscopic myomectomy does a good job of treating symptoms related to fibroids. Because it is technically challenging, most gynecologic surgeons in our area do not offer this option. Women with very large or very numerous fibroids may not be candidates for the procedure. Also, because women can continue to develop new fibroids, some treated women will develop new symptoms years later, and some may require additional treatment.

Hysterectomy

The definitive treatment for women with fibroid-related symptoms is hysterectomy, or removal of the uterus. While many women are fearful of this option, the uterus is only a muscle, and serves only two functions-to produce a regular monthly period, and to carry a baby in pregnancy. For women who have completed their families, removal of the uterus may be an attractive option. In our practice, we almost always perform hysterectomy using a minimally-invasive laparoscopic approach: Women generally are discharged on the day of surgery, and can return to work in one to two weeks. Because the ovaries are not removed in most women who have a hysterectomy, they do not experience menopausal symptoms after hysterectomy, even though they have no periods. In properly selected women, hysterectomy vastly improves quality of life.

More Information on Fibroids

We have Fibroid frequently asked questions (FAQs) to help our patients. In addition, you can submit additional fibroid questions using the form below.