Fibroids
Signs and Symptoms
Fibroids are non-cancerous or benign growths that develop within the uterus. As many as 30 percent of women have fibroids. Some women have one fibroid. Other women have many. Fibroids range in size from as small as a pea to as large as a melon. Most women with fibroids have no symptoms and don't need treatment. When symptoms occur, women should seek medical attention.
At UCSF, the Comprehensive Fibroid Center offers a wide range of treatments, depending on the size and location of the fibroid.
Symptoms of fibroids may include:
Heavy Vaginal Bleeding — Some women experience excessively heavy or prolonged menstrual bleeding. Not uncommonly, women describe soaking through sanitary protection in less than an hour, passing blood clots and being unable to leave the house during the heaviest day of flow. As a result of the blood loss, some women develop anemia, or a low blood count, which can cause fatigue or lightheadedness.
Pelvic Pressure or Discomfort — Women with large fibroids may have a sense of heaviness or pressure in the lower abdomen or pelvis. This discomfort is similar to pregnancy when the enlarging uterus presses against surrounding structures.
Bladder Changes — The most frequent bladder symptom is the need to urinate more frequently. Women may awaken several times during the night in order to urinate. Occasionally, women experience an inability to urinate despite a full bladder. Bladder symptoms are caused by the uterine fibroids pressing against the bladder thereby reducing its capacity for holding urine or allowing urine to pass.
Pelvic Pain — A less common symptom of fibroids is acute, severe pain. This type of pain occurs when a fibroid goes through a process called degeneration, usually because it has outgrown its blood supply. The pain is usually localized to a specific spot and improves on it own within two to four weeks.
Low Back Pain — Fibroids that press against the muscles and nerves of the lower back can cause back pain. It is important to look for other causes of back pain before attributing the pain to the fibroids.
Rectal Pressure — Fibroids also can press against the rectum and cause a sense of rectal fullness, difficulty having a bowel movement or pain with bowel movements. Occasionally, fibroids can lead to the development of a hemorrhoid.
See Fibroid FAQs and UCSF Comprehensive Fibroid Center.
Diagnosis
Fibroids can be diagnosed in a number of ways including:
Pelvic Examination -- During a routine gynecologic exam, a physician is able to feel the size and shape of the uterus. If the uterus is enlarged or irregularly shaped, then fibroids may be present. Several tests can be performed to confirm the diagnosis.
Ultrasonography -- Sound waves are used to create an image of the uterus and ovaries.
Saline Hysterosonography -- Also called water ultrasound. Fluid is placed inside the uterus and an ultrasound is performed. This test is very useful for identifying fibroids within the uterine cavity.
Magnetic Resonance Imaging (MRI) -- A large magnet is used to create very detailed images of the uterus and other pelvic structures. This expensive test is reserved for special circumstances when the precise location of fibroids is needed.
Hysteroscopy -- A slender "telescope" is inserted through the vagina and cervix into the uterine cavity to allow a physician to see fibroids inside the uterus.
See Fibroid FAQs and UCSF Comprehensive Fibroid Center.
Treatment
Treatment options for fibroids can range from no treatment at all to surgery. Unless fibroids are causing excessive bleeding, discomfort or bladder problems, treatment usually isn't necessary.
Women with fibroids should be evaluated periodically by their health care provider to review symptoms, follow the fibroid size and conduct abdominal and pelvic examinations to assess uterine size.
The following are treatment options for fibroids:
Medical Therapy
Medical treatments currently available for fibroids may improve certain symptoms, but do not make fibroids go away. Medical treatment may be recommended for women with heavy bleeding caused by fibroids before they decide to have a surgical procedure. Women with pressure symptoms caused by large fibroids will not benefit from any medicines currently available. Several promising new drugs that will treat the fibroids themselves and not just the symptoms are currently being developed and tested in clinical trials.
Oral Contraceptive Pills and Progestational Agents (Provera, medroxyprogesterone acetate)
Women with heavy menstrual periods and fibroids are often prescribed hormonal medications to try to reduce bleeding and regulate their menstrual cycle. The medications will not cause fibroids to shrink nor will it cause them to grow at a faster rate. If the medication has not improved your bleeding after three months, consult your doctor. Women over the age of 35 who smoke should not use oral contraceptive pills.
GnRH Agonists (Lupron)
GnRH agonists are a class of medications that temporarily shrinks fibroids and stops heavy bleeding by blocking production of the female hormone, estrogen. Lupron is the most well known of these drugs. Although Lupron can improve fibroid symptoms, it causes unpleasant, menopausal symptoms such as hot flashes and with long-term use, leads to bone loss.
Lupron is recommended only for very specific cases. For example, a woman with very heavy bleeding and serious anemia will likely need a blood transfusion at the time of fibroid surgery. However, if she takes Lupron for two to three months before surgery to make her periods temporarily stop, along with an iron supplement, her anemia will improve and she may not need a blood transfusion. In rare instances, Lupron may be recommended to women with very large fibroids -- greater than 10-12 centimeters -- prior to fibroid surgery. It is important to note that Lupron should not be used solely for the purpose of shrinking fibroids unless surgery is planned because fibroids will re-grow to their original size and symptoms will return as soon as a woman stops taking Lupron.
Intrauterine Devices (IUD)
Although intrauterine devices (IUD) are typically used to prevent pregnancy, they have non-contraceptive benefits as well. An IUD that releases a small amount of hormone into the uterine cavity has been shown to decrease bleeding caused by fibroids. An IUD can be inserted during a routine office appointment. Ask you doctor for more information about this treatment option.
Myomectomy
This procedure involves removing the fibroids while preserving the uterus. For women with problematic fibroids who want to have children, myomectomy is the best treatment option. The procedure can be performed several different ways depending on the size, number and location of the fibroids. For example, fibroids located within the uterine cavity can be removed using a hysteroscope, called a hysteroscopic myomectomy. Some fibroids can be removed via several small incisions through which a viewing instrument called a laparoscope and several miniature surgical instruments are used. A laparoscopic myomectomy involves removing fibroids located on the outer aspect of the uterus. Most myomectomies are performed by making an incision across the lower abdomen during an abdominal myomectomy. This allows for the removal of all types and sizes of fibroids and for the reconstruction of the uterus to its former size and contour.
Myomectomy is very effective treatment, but fibroids can re-grow. The younger a woman is at the time of myomectomy and the more fibroids she had, the more likely she is to develop fibroids in the future. Women nearing menopause are the least likely to have problems from recurring fibroids.
Hysterectomy
Hysterectomy is a major surgical procedure in which the uterus is removed. Many women choose hysterectomy to definitively resolve their fibroid symptoms. After hysterectomy, menstrual bleeding stops, pelvic pressure is relieved, frequent urination improves and new fibroids cannot grow. A woman can no longer become pregnant after a hysterectomy.
There are several different surgical approaches. A vaginal hysterectomy involves removing the uterus through an incision in the vagina. An abdominal hysterectomy is performed through an incision on the lower abdomen. A laparoscopic hysterectomy is accomplished through four tiny incisions on the abdomen. The type of hysterectomy will depend on the size of the uterus and several other factors.
The ovaries are not necessarily removed during a hysterectomy. Women should discuss the pros and cons of ovarian removal with their physicians.
Uterine artery embolization (UAE)
This relatively new treatment is an alternative to open surgery for fibroids. Embolization is a technique that blocks the blood flow to the fibroids, causing them to shrink and die. This also often decreases menstrual bleeding and symptoms of pain, pressure, urinary frequency or constipation.
UAE is performed in a radiology suite rather than an operating room. A substance is released into the blood vessels leading to the fibroids, blocking the blood flow. Women receive pain medicine but are not completely asleep. After the procedure, patients experience pain for one to three days but are able to return to work and full activities in one week. Ninety percent of women report improvement in both pelvic pressure and heavy bleeding. However, UAE has been performed for only five years, so there is little information about long-term results. Since the procedure is still quite new, we discourage its use for women who have not completed childbearing.
See Fibroid FAQs and UCSF Comprehensive Fibroid Center.
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