Patient education: Uterine fibroids (Beyond the Basics)

FIBROIDS OVERVIEW — Fibroids are growths of the uterus (figure 1). 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 (figure 2). Fibroids are not cancerous and are not thought to be able to become cancerous. However, it can sometimes be difficult to determine if a mass in the uterus is a common fibroid or a rare cancerous tumor.

Fibroids are very common. Approximately 80 percent of females will have fibroids in their lifetime, although not everyone has bothersome symptoms. Treatments are available for fibroid-related problems like heavy menstrual bleeding, pain or pressure in the pelvis, or problems with pregnancy or infertility.

For reasons that experts do not fully understand, fibroids are more common, more severe, and occur at an earlier age for people of African descent.

FIBROID RISK FACTORS — The cause of fibroids is unknown. However, fibroids seem to respond to the female hormones estrogen and progesterone, and experts have identified several factors (such as age at first menstruation, specific genes, lifestyle, and number of pregnancies) that might influence a person's risk.

However, it is possible for a person without any known or theoretical risk factors to develop fibroids.

FIBROID SYMPTOMS — 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 people with fibroids have very heavy or long menstrual periods (more than eight days a month) 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 person stops having menstrual periods (at menopause).

Increased menstrual bleeding — Fibroids can increase the amount and/or the number of days of menstrual bleeding. If you are regularly soaking through a pad or a tampon in less than an hour or having bleeding for more than seven days, this is abnormal and you should contact your health care provider. People who have excessive menstrual bleeding are at risk of losing too much iron (iron deficiency anemia).

Pelvic pressure and pain — Larger fibroids can cause a sense of pelvic pressure or fullness in the abdomen, similar to the feeling of being pregnant. Sometimes the presence of fibroids can even make a person look pregnant when they are not.

Fibroids can also cause other symptoms, depending on the size and where they are located in the uterus. As an example, if a fibroid is pressing on your bladder, you may feel like you need to urinate frequently. Similarly, a fibroid pressing on the rectum can cause constipation.

Problems with fertility and pregnancy — Most people with fibroids are able to get pregnant without a problem. However, if your fibroids are distorting (affecting the shape of) the inside of your uterus, this may make it more difficult to get pregnant. Fibroids in the outer part of the uterus may have a mild effect on decreasing fertility, but surgically removing these fibroids does not appear to decrease the risk.

Studies show that, while people with fibroids may be more likely to have miscarriages (pregnancy loss) than people without fibroids, the increased risk of miscarriage is related to increasing age and not the fibroids.

If you have fibroids and are trying to get pregnant without success, talk with your health care provider. They, or another specialist, can evaluate you to better understand whether the fibroids are responsible for the problem.

Most people with fibroids who do get pregnant have a completely normal pregnancy without complications. However, people with a large fibroid (greater than 5 to 6 cm) or many fibroids might have an increased risk of specific pregnancy complications.

FIBROID DIAGNOSIS — A doctor or other health care provider may suspect fibroids if your uterus is enlarged or has an irregular shape. They will ask you about your symptoms and do an abdominal and pelvic examination to feel for a mass. A pelvic ultrasound can confirm the presence of fibroids; this is often done by inserting a probe inside the vagina. Ultrasound uses sound waves to create a picture of the uterus.

FIBROID TREATMENT — If your fibroids are not causing bothersome symptoms, you can choose not to have treatment. If you do have symptoms, your options include medication or surgical treatment. The best treatment depends on which symptom(s) is most bothersome to you. The size, number, and locations of fibroids, as well as whether or not you might want to get pregnant in the future, also factor into most treatment decisions.

Medications for fibroid symptoms — Most medications aim to reduce the heavy menstrual bleeding that is common in people with fibroids. A few also shrink the fibroid, and some are focused on reducing pain or correcting anemia. Medications are often recommended before surgical treatments.

Iron and vitamins — If you have anemia, your doctor will likely recommend a combination of iron supplements and a multivitamin (which will help your body effectively use the iron). If you think you might have iron deficiency, talk to your health care provider before you take any supplements. They can order blood tests to confirm you need extra iron and make sure you get the right dose. (See "Patient education: Anemia caused by low iron in adults (Beyond the Basics)".)

Nonsteroidal anti-inflammatory drugs (NSAIDs) — Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand names: Aleve, Naprosyn), can help reduce menstrual cramps and decrease menstrual flow in some cases.

NSAIDs are not expensive, have few side effects, and reduce pain, and you only need to take them during your menstrual period. You can take NSAIDs in combination with any of the other medications discussed here. However, NSAIDs do not reduce bleeding as well as most other medications do.

If nonprescription NSAIDs do not relieve your pain, there are other similar medications available by prescription that may be helpful.

Hormonal birth control — Hormonal methods of birth control include the pill, skin patch, vaginal ring, shot, hormonal IUD, and implant. These methods reduce bleeding, cramps, and pain during your menstrual period and can correct anemia. It might take three months for bleeding to improve after you start taking hormonal birth control.

More detailed information about hormonal birth control is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

Hormonal methods include:

●Pills, patch, vaginal ring – Most forms of hormonal birth control, including the pill, skin patch, and vaginal ring, are designed to be used for three weeks in a row, followed by one week off. During the fourth week, you will have menstrual bleeding. It might take three months for bleeding to improve after you start taking hormonal birth control.

Some health care providers advise people with heavy menstrual periods to take hormonal birth control continuously, without a break week. This will allow you to skip your period. This strategy is called "continuous dosing."

●Hormonal intrauterine device – There are several intrauterine devices (IUDs) that slowly release a form of a progesterone-like hormone called a progestin into the uterus. There is no estrogen in the IUDs. The 52 mg levonorgestrel-releasing IUD (brand names: Liletta, Mirena) has been studied the most for the treatment of heavy menstrual bleeding, although other progestin IUDs are also expected to decrease bleeding. This IUD prevents pregnancy and reduces menstrual bleeding for up to eight years. A doctor or nurse places the IUD inside the uterus. IUDs are best for people who do not have plans to become pregnant within the next 6 to 12 months. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)", section on 'Intrauterine device'.)

●Implant – There is an implant (brand name: Nexplanon) that slowly releases a progestin into your bloodstream. It prevents pregnancy and reduces menstrual bleeding for up to three years. A doctor or nurse places the implant (which is about the size of a match stick) under the skin in the upper inner arm. This treatment is best for people who do not have plans to become pregnant within the next 6 to 12 months. The most common side effect of the progestin implant is irregular menstrual bleeding.

●Shot – Depot medroxyprogesterone acetate is a long-acting form of a progesterone-like hormone called a progestin. It is a shot given once every three months. This treatment prevents pregnancy and can reduce heavy menstrual bleeding. The shot is best for people who do not have plans to become pregnant in the next 6 to 12 months. In contrast to the implant and IUD, the shot has to wear off naturally and cannot be undone if you change your mind about an earlier pregnancy.

The most common side effect of medroxyprogesterone acetate is bleeding and spotting, particularly during the first few months. Many people completely stop having menstrual periods after using this treatment for one year.

Antifibrinolytic medications — These medications do not contain hormones and can help to slow menstrual bleeding quickly. They work by helping blood to clot. Antifibrinolytic medications do not shrink fibroids or correct anemia. Tranexamic acid (brand name: Cyklokapron) is used worldwide and is also approved by the US Food and Drug Administration for treating heavy menstrual bleeding.

The advantages of antifibrinolytic medications over other medications are that:

●They slow bleeding quickly (within two to three hours)

●You need to take the medication only during your period or only during the times when your period is heavy

●They do not affect your chances of becoming pregnant

Side effects can include headache and muscle cramps or pain. You should not take antifibrinolytic medications with hormonal birth control unless your doctor or nurse approves; there may be an increased risk of blood clots, stroke, and heart attack when taken together.

Gonadotropin-releasing hormone analogues — Gonadotropin-releasing hormone (GnRH) analogues include GnRH "antagonists" and GnRH "agonists." Both types of medication cause the ovaries to temporarily stop producing estrogen and progesterone and can reduce heavy menstrual bleeding.

●GnRH antagonists – These medications can be taken orally (as pills or tablets) and are taken along with hormone therapy in order to limit the estrogen-reducing side effects of GnRH antagonists, like thinning of the bones or hot flashes. The GnRH antagonists elagolix and relugolix are sold in combination with the hormones estradiol (an estrogen) and norethindrone acetate (a progestin) and are approved for continuous use for up to two years. They stop periods in most people and also can act to decrease pain and result in a small amount of uterine shrinkage.

●GnRH agonists – In addition to reducing heavy menstrual bleeding, these medications can also temporarily shrink fibroids substantially. They are given as an injection every one to three months and are primarily used as preoperative therapy for people who are planning surgery to remove their fibroids (see 'Surgical or interventional fibroid treatment' below) or transitioning into menopause naturally.

If you are scheduled for surgery to remove your fibroids, your doctor might recommend that you first use GnRH agonists for three to six 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, it 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 people with heavy bleeding who are severely anemic.

Surgical or interventional fibroid treatment — Your doctor might recommend a surgical or interventional treatment for fibroids if:

●You have fibroid-related heavy menstrual bleeding, pain, or pressure that does not get better with medication

●You are trying to get pregnant and fibroids appear to be interfering

●The size of the fibroid is causing symptoms

Myomectomy — Myomectomy is a surgery done to remove fibroids, which can reduce both bleeding and size-related symptoms. Most people 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 people who have myomectomy will need a second fibroid surgery. Myomectomy is often a good choice for people who might want to get pregnant in the future.

There are several ways to perform myomectomy; the "best" way depends on where your fibroids are located and the size and number of fibroids.

●Abdominal myomectomy – This surgery requires an incision (cut) in the lower belly to remove the fibroids.

●Laparoscopic or robotic myomectomy – This surgery uses several small incisions in the stomach. A doctor uses thin instruments and a camera (laparoscope) to remove the fibroids. The fibroid can then be removed through a bigger incision or broken into smaller pieces for removal ("morcellation"). Robotic myomectomy is a variation of laparoscopic myomectomy where the surgical procedure is aided by a surgical robot.

●Hysteroscopic myomectomy – If the fibroids are inside the uterus, a doctor can insert instruments through the cervix to remove them. This approach might not be recommended if you have very large fibroids.

Uterine artery embolization — Uterine artery embolization (UAE), also called 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 and decreases other fibroid symptoms including heavy menstrual bleeding.

The treatment is performed in the hospital. A doctor will insert a small tube into a large blood vessel in the inner thigh. The tube is threaded up to the uterine blood vessels (figure 3A-B). The doctor injects tiny particles into the blood vessel, which stops blood flow to the fibroid.

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) is also a fibroid treatment option. This noninvasive treatment takes place in an 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. Sedation is used during the procedure, and it can be performed as an outpatient procedure. Fibroids shrink over the weeks and months following treatment, and heavy menstrual bleeding is also decreased. Pregnancy is possible following treatment.

Ultrasound-guided radiofrequency ablation — There are two ultrasound-guided radiofrequency ablation techniques available: one is laparoscopic (eg, Acessa) and one is transcervical (eg, Sonata). Using information from the ultrasound during the procedure, the ablation device is inserted into the fibroids causing tissue destruction. Fibroids shrink over the weeks to months after the procedure. Pregnancy is not usually recommended following this procedure, although it is possible to become pregnant following treatment.

Endometrial ablation — 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 people who have endometrial ablation stop having menstrual periods altogether.

Ablation can be done in the office or as a day surgery. It can be done in combination with other treatments, such as hysteroscopic myomectomy. Endometrial ablation is not a form of birth control, but pregnancy is not recommended after treatment and often not possible. You will need to use some form of birth control to prevent pregnancy after ablation. People who do get pregnant following ablation are more likely to have an abnormal pregnancy outside the uterus.

Hysterectomy — Hysterectomy is a surgery that removes the uterus. The ovaries and cervix may be left in place when the hysterectomy is for uterine fibroids.

Hysterectomy is a permanent treatment that cures heavy menstrual bleeding and the bulk of related symptoms of fibroids. However, it is major surgery, and you will need up to six weeks to fully recover. Additionally, research shows there may be long-term risks to hysterectomy, such as increased risk of heart disease later in life. More detailed information about hysterectomy is available separately. (See "Patient education: Abdominal hysterectomy (Beyond the Basics)" and "Patient education: Vaginal hysterectomy (Beyond the Basics)".)

WHICH TREATMENT IS RIGHT FOR ME? — 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 and whether or not you might want to get pregnant in the future.

●If you are bothered by heavy menstrual bleeding, you can first try treatment with medication. Hormonal birth control, nonsteroidal anti-inflammatory drugs (NSAIDs), or antifibrinolytic medicines work better than other medications.

If medication is not a good option for you, or you also have symptoms related to the size of the fibroids, you can consider uterine fibroid embolization, focused ultrasound surgery, radiofrequency ablation, endometrial ablation, myomectomy, or hysterectomy.

●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.

Your health care provider can talk to you about the risks and benefits of each treatment option and help you make the decision that is best for you.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Uterine fibroids (The Basics)
Patient education: Heavy periods (The Basics)
Patient education: Painful periods (The Basics)
Patient education: Repeat pregnancy loss (The Basics)
Patient education: Uterine artery embolization (The Basics)
Patient education: Endometrial ablation (The Basics)
Patient education: Uterine adenomyosis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Patient education: Abdominal hysterectomy (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Overview of endometrial ablation
Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history
Uterine fibroids (leiomyomas): Hysteroscopic myomectomy
Uterine fibroids (leiomyomas): Issues in pregnancy
Uterine fibroids (leiomyomas): Prolapsed fibroids
Uterine fibroids (leiomyomas): Treatment overview
Uterine fibroids (leiomyomas): Treatment with uterine artery embolization
Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure

The following organizations also provide reliable health information.

●National Library of Medicine

(https://medlineplus.gov/uterinefibroids.html)

●United States Department of Health and Human Services

(www.womenshealth.gov/a-z-topics/uterine-fibroids)