Uterine Fibroids

Uterine Fibroids Overview

Uterine fibroids (also called leiomyomas) are growths made up of the muscle and connective tissue from the wall of the uterus. These growths are usually not cancerous (benign). Your uterus is an upside down pear-shaped organ in your pelvis. The normal size of your uterus is similar to a lemon. It’s the place where a baby grows and develops during pregnancy.

Fibroids can grow as a single nodule (one growth) or in a cluster. These growths can develop within the wall of the uterus, inside the main cavity of the organ or even on the outer surface. Fibroids can vary in size, number and location within and on your uterus.

You may experience a variety of symptoms with uterine fibroids and these may not be the same symptoms that another woman with fibroids will experience. Because of how unique fibroids can be, your treatment plan will depend on your individual case.

Uterine Fibroids Types

There are for types of uterine fibroids.

Subserosal fibroids are located close to the uterine serosa, or outermost layer. They are less likely to cause significant symptoms because they grow more toward the uterine exterior. Typically, small asymptomatic subserosal fibroids do not necessitate treatment and can be monitored with periodic ultrasounds. Larger fibroids may manifest symptoms.

Submucosal fibroids extend into the uterine cavity as they grow toward the uterine mucosa. They tend to be symptomatic at smaller sizes, with heavy and irregular bleeding being the primary symptom. Submucous fibroids are also more likely to have a negative impact on fertility, both by making pregnancy difficult and by causing miscarriages.

Intramural fibroids are situated within the width of the uterine muscle or myometrium. They tend to behave similarly to subserous fibroids, but depending on their size and position, they can cause all the typical fibroids symptoms.

Pedunculated fibroids are considered a variation of subseroral or submucosal fibroids and not a distinct type. They grow on a stalk from the uterine wall, either externally (subserosal) or internally (submucosal). Unless they are extremely large, pedunculated subserosal fibroids typically cause only mild symptoms.

This classification of fibroid types is imperfect due to the fact that the majority of fibroids are large enough to fall into at least two and sometimes even three categories. It assists clinicians with diagnosis and treatment planning. Intramural fibroids with a significant submucosal component can be treated with hysteroscopy, whereas intramural/subserosal fibroids with no submucosal component must be removed via laparoscopy.

Uterine Fibroids Symptoms

Symptoms of uterine fibroids can develop slowly over years or rapidly over months. Most women with fibroids experience mild or no symptoms. Women with mild symptoms may never require medical care. Some women find the symptoms problematic. Pain and heavy menstrual bleeding are the most prevalent symptoms of menstruation. Many women discover they have fibroids when they experience difficulty becoming pregnant. Depending on where the fibroid is located in the uterus, women may experience a variety of symptoms.

Symptoms and complications of uterine fibroids include:

Heavy menstrual bleeding, caused by the enlarged uterus
Intermenstrual bleeding
Heavy, prolonged periods that can cause anemia
Painful periods
Abdominal, pelvic, or low back pain
Pain during sexual activity
Bloating and abdominal pressure
Frequent urination and urinary incontinence
Fertility issues and miscarriages
Complications or discomfort with bowel movements
Symptoms of pressure over nearby organs, most frequently the bladder (increased urinary frequency) and rectum (difficult motions/constipation).

Uterine Fibroids Causes

Doctors are uncertain as to the cause of fibroids. However, estrogen and progesterone appear to promote their growth. Your body produces the highest levels of these hormones during your menstrual cycle. After menopause, fibroids typically shrink and cease to cause symptoms. Some research also indicates that they originate from misplaced cells present in the body prior to birth. Endometriosis and pelvic inflammatory disease (PID) may also cause the formation of fibroids.

In addition to being of reproductive age, there are few known risk factors for uterine fibroids, such as race (black women are more likely than women of other racial groups to have fibroids and are more likely to have larger fibroids and more severe symptoms), genetics, starting menstruation at a young age; obesity; vitamin D deficiency; consuming more red meat; alcohol consumption.

Uterine Fibroids Diagnostics

In many cases, fibroids are first discovered during a regular exam with your doctor. They can be felt during a pelvic exam and can be found during a gynecologic exam or during prenatal care. Quite often your description of heavy bleeding and other related symptoms may alert your healthcare provider to consider fibroids as a part of the diagnosis. There are several tests that can be done to confirm fibroids and determine their size and location. These tests can include:

Ultrasonography: This non-invasive imaging test creates a picture of your internal organs with sound waves. Depending on the size of the uterus, the ultrasound may be performed by the transvaginal or transabdominal route.
Magnetic resonance imaging (MRI): This test creates detailed images of your internal organs by using magnets and radio waves.
Computed tomography (CT): A CT scan uses X-ray images to make a detailed image of your internal organs from several angles.
Hysteroscopy: During a hysteroscopy, your provider will use a device called a scope (a thin, flexible tube with a camera on the end) to look at fibroids inside your uterus. The scope is passed through your vagina and cervix and then moved into your uterus.
Hysterosalpingography (HSG): This a detailed X-ray where a contrast material is injected first and then X-rays of the uterus are taken. This is more often used in people who are also undergoing infertility evaluation.
Sonohysterography: In this imaging test, a small catheter is placed transvaginally and saline is injected via the catheter into the uterine cavity. This extra fluid helps to create a clearer image of your uterus than you would see during a standard ultrasound.
Laparoscopy: During this test, your provider will make a small cut (incision) in your lower abdomen. A thin and flexible tube with a camera on the end will be inserted to look closely at your internal organs.

Uterine Fibroids Complications

Despite the fact that uterine fibroids are typically harmless, they can cause discomfort and lead to complications such as a decrease in red blood cells (anemia), which causes fatigue, due to heavy blood loss. Rarely is a blood transfusion necessary due to blood loss. Fibroids typically do not interfere with conception. However, fibroids, particularly submucosal fibroids, could potentially cause infertility or pregnancy loss.

Fibroids may also increase the risk of placental abruption, fetal growth restriction, and premature delivery.

Uterine Fibroids Treatment

Treatment for uterine fibroids can vary depending on the size, number and location of the fibroids, as well as what symptoms they’re causing. If you aren’t experiencing any symptoms from your fibroids, you may not need treatment. Small fibroids can often be left alone. Some people never experience any symptoms or have any problems associated with fibroids. Your fibroids will be monitored closely over time, but there’s no need to take immediate action. Periodic pelvic exams and ultrasound may be recommend by your healthcare provider depending on the size or symptoms of your fibroid. If you are experiencing symptoms from your fibroids — including anemia from the excess bleeding, moderate to severe pain, infertility issues or urinary tract and bowel problems — treatment is usually needed to help. Treatment options for uterine fibroids can include:

Monitoring

Many women with uterine fibroids experience no symptoms or only mildly bothersome symptoms that can be tolerated. If this is the case, monitoring may be your best option.

Medications

Over-the-counter (OTC) pain medications: These medications can be used to manage discomforts and pain caused by the fibroids. OTC medications include acetaminophen and ibuprofen.
Iron supplements: If you have anemia from the excess bleeding, your provider may also suggest you take an iron supplement.
Birth control: Birth control can also be used to help with symptoms of fibroids — specifically heavy bleeding during and between periods and menstrual cramps. Birth control can be used to help control heavy menstrual bleeding. There are a variety of birth control options you can use, including oral contraceptive pills, intravaginal contraception, injections and intrauterine devices (IUDs).
Gonadotropin-releasing hormone (GnRH) agonists: These medications can be taken via a nasal spray or injection and they work by shrinking your fibroids. They’re sometimes used to shrink a fibroid before surgery, making it easier to remove the fibroid. However, these medications are temporary and if you stop taking them, the fibroids can grow back.

Fibroid surgery

There are several factors to consider when talking about the different types of surgery for fibroid removal. Not only can the size, location and number of fibroids influence the type of surgery, but your wishes for future pregnancies can also be an important factor when developing a treatment plan. Some surgical options preserve the uterus and allow you to become pregnant in the future, while other options can either damage or remove the uterus.

Myomectomy is a procedure that allows your provider to remove the fibroids without damaging the uterus. There are several types of myomectomy. The type of procedure that may work best for you will depend on where your fibroids are located, how big they are and the number of fibroids. The types of myomectomy procedure to remove fibroids can include:

Hysteroscopy: This procedure is done by inserting a scope (a thin, flexible tube-like tool) through the vagina and cervix and into the uterus. No incisions are made during this procedure. During the procedure, you provider will use the scope to cut away the fibroids. Your provider will then remove the fibroids.
Laparoscopy: In this procedure, your provider will use a scope to remove the fibroids. Unlike the hysteroscopy, this procedure involves placing a few small incisions in your abdomen. This is how the scope will enter and exist your body. This procedure can also be accomplished with the assistance of a robot.
Laparotomy: During this procedure, an incision is made in your abdomen and the fibroids are removed through this one larger cut.

If you aren’t planning future pregnancies, there are additional surgical options your healthcare provider may recommend. These options are not recommended if pregnancy is desired and there are surgical approaches that remove the uterus. These surgeries can be very effective, but they typically prevent future pregnancies. Surgeries to remove fibroids can include:

Hysterectomy: During this surgery, your uterus is removed. A hysterectomy is the only way to cure fibroids. By removing your uterus completely, the fibroids can’t come back and your symptoms should go away. If your uterus alone is removed — the ovaries are left in place — you will not go into menopause after a hysterectomy. This procedure might be recommended if you’re experiencing very heavy bleeding from your fibroids or if you have large fibroids. When recommended, the most minimally invasive procedure to perform hysteroscopy is advisable. Minimally invasive procedures include vaginal, laparoscopic or robotic approaches.
Uterine fibroid embolization (UFE): This procedure is performed by an interventional radiologist who works with your gynecologist. A small catheter is placed in the uterine artery or radial artery and small particles are used to block the flow of blood from the uterine artery to the fibroids. Loss of blood flow shrinks the fibroids — improving your symptoms.
Radiofrequency ablation (RFA): This is a safe and effective treatment for people with symptomatic uterine fibroids and can be delivered by laparoscopic, transvaginal or transcervical approaches.

There’s also a newer procedure called Magnetic resonance guided focused ultrasound (MRgFUS) that can be used to treat fibroids. This technique is actually done while you’re inside a MRI machine. You are placed inside the machine — which allows your provider to have a clear view of the fibroids — and then an ultrasound is used to send targeted sound waves at the fibroids. This damages the fibroids.