What are uterine fibroids?

Uterine fibroids are benign tumors that originate in the uterus (womb). Although they are composed of the same
smooth muscle fibers as the uterine wall (myometrium), they are many times denser than normal myometrium.
Uterine fibroids are usually round or semi-round in shape.

Uterine fibroids are often described based upon their location within the uterus. Subserosal fibroids are located
beneath the serosa (the lining membrane on the outside of the organ). These often appear localized on the outside
surface of the uterus or may be attached to the outside surface by a pedicle. Submucosal (submucous) fibroids are
located inside the uterine cavity beneath the lining of the uterus. Intramural fibroids are located within the muscular
wall of the uterus.

What causes uterine fibroids and how common are they?

We do not know exactly why women develop these tumors. Genetic abnormalities, alterations in growth factor
(proteins formed in the body that direct the rate and extent of cell proliferation) expression, abnormalities in the
vascular (blood vessel) system, and tissue response to injury have all been suggested to play a role in the
development of fibroids.

Family history is a key factor, since there is often a history of fibroids developing in women of the same family. Race
also appears to play a role. Women of African descent are two to three times more likely to develop fibroids than
women of other races. Women of African ancestry also develop fibroids at a younger age and may have symptoms
from fibroids in their 20s, in contrast to Caucasian women with fibroids, in whom symptoms typically occur during the
30s and 40s. Pregnancy and taking oral contraceptives both decrease the likelihood that fibroids will develop.
Fibroids have not been observed in girls who have not reached puberty, but adolescent girls may rarely develop
fibroids. Other factors that researchers have associated with an increased risk of developing fibroids include having
the first menstrual period (menarche) prior to age 10, consumption of alcohol (particularly beer), uterine infections,
and elevated blood pressure (hypertension).

Estrogen tends to stimulate the growth of fibroids in many cases. During the first trimester of pregnancy, up to 30% of
fibroids will enlarge and then shrink after the birth. In general, fibroids tend to shrink after menopause, but
postmenopausal hormone therapy may cause symptoms to persist.

Overall, these tumors are fairly common and occur in up to 50% of all women. Most of the time, uterine fibroids do not
cause symptoms or problems, and a woman with a fibroid is usually unaware of its presence.

What are the symptoms of uterine fibroids?

Most women with uterine fibroids have no symptoms.

However, abnormal uterine bleeding is the most common symptom of a fibroid. If the tumors are near the uterine
lining, or interfere with the blood flow to the lining, they can cause heavy periods, painful periods, prolonged periods
or spotting between menses. Women with excessive bleeding due to fibroids may develop iron deficiency anemia.
Uterine fibroids that are deteriorating can sometimes cause severe, localized pain.

Fibroids can also cause a number of symptoms depending on their size, location within the uterus, and how close
they are to adjacent pelvic organs. Large fibroids can cause:

 pressure,

 pelvic pain,

 pressure on the bladder with frequent or even obstructed urination, and

 pressure on the rectum with pain during defecation.

While fibroids do not interfere with ovulation, some studies suggest that they may impair fertility and lead to poorer
pregnancy outcomes. In particular, submucosal fibroids that deform the inner uterine cavity are most strongly
associated with decreases in fertility.

Do untreated uterine fibroids pose a risk?

For the most part, uterine fibroids that do not cause a problem for the woman can be left untreated. In some cases,
even fibroids that are not causing symptoms require removal or at least close observation. Rapid growth is a reason
to watch more carefully, since a rare cancerous form of fibroid (referred to as a leiomyosarcoma) is usually a fast-
growing tumor, and it cannot be differentiated from a benign fibroid by ultrasound, MRI , or other imaging studies.
However, this type of tumor occurs in less than 1% of uterine fibroids.

Another risk of leaving these tumors alone is that they sometimes grow to a size that eventually cause significant
symptoms, thus requiring removal. If fibroids grow large enough, the surgery to remove them can become more
difficult and risky. Occasionally, fibroids are the cause of recurrent miscarriages. If they are not removed in these
cases, the woman may not be able to sustain a pregnancy.

What are the usual ways of diagnosing uterine fibroids?

Uterine fibroids are diagnosed by pelvic exam and even more commonly by ultrasound. Often, a pelvic mass cannot
be determined to be a fibroid on pelvic exam alone, and ultrasound is very helpful in differentiating it from other
conditions such as ovarian tumors. MRI and CT scans can also play a role in diagnosing fibroids, but ultrasound is
the simplest, cheapest, and almost without question the best technique for imaging the pelvis. Occasionally, when
trying to determine if a fibroid is present in the uterine cavity (endometrial cavity), a hysterosalpingogram (HSG) is
done. In this procedure, an ultrasound exam is done while contrast fluid is injected into the uterus from the cervix.
The fluid within is visualized in the endometrial cavity and can outline any masses that are inside, such as
submucosal fibroids.

What is the treatment for uterine fibroids?

Surgical treatments

There are many ways of managing uterine fibroids. Surgical methods are the mainstay of treatment when treatment is
necessary. Possible surgical interventions include hysterectomy, or removal of the uterus (and the fibroids with it).
Myomectomy is the selective removal of just the fibroids within the uterus. Myomectomy can be done through a
laparoscope or with the standard open incision on the abdominal wall. Some treatments have involved boring holes
into the fibroid with laser fibers, freezing probes (cryosurgery), and other destructive techniques that do not actually
remove the tissue but try to destroy it in place. Surgery is necessary if there is suspicion of malignancy in any case of
leiomyoma or uterine mass.

Another technique for treating fibroids is known as uterine artery embolization (UAE). This technique uses small
beads of a compound called polyvinyl alcohol, which are injected through a catheter into the arteries that feed the
fibroid. These beads obstruct the blood supply to the fibroid and starve it of blood and oxygen. While this technique
has not been in use long enough to evaluate long-term effects of UAE versus surgery, it is known that women
undergoing UAE for fibroids have a shorter hospital stay than those having surgery but a greater risk of complications
and readmissions to the hospital. Studies are underway to evaluate the long-term outcomes of UAE as opposed to
surgical treatment. Uterine artery occlusion (UAO), which involves clamping the involved uterine arteries as opposed
to injecting the polyvinyl alcohol beads, is currently under investigation as a potential alternative to UAE.

Medical treatments

Non-surgical techniques are usually hormonal in nature and include the use of drugs that turn off the production of
estrogen from the ovaries (GnRH analogs). These medications are given for three to six months and induce a
hypoestrogenic (low estrogen) state. When successful, they can shrink the fibroids by as much as 50%. Side effects
of these drugs are similar to the symptoms of the perimenopause and can include hot flashes, sleep disturbance,
vaginal dryness, and mood changes. Bone loss leading to osteoporosis after long-term (12+ months) use is the most
serious complication. These drugs may also be used as preoperative treatment prior to undergoing surgical treatment
of leiomyoma.

Mifepristone (RU-486) is an antiprogestin drug that can shrink fibroids to an extent comparable to treatment with the
GnRH analogs. This drug, sometimes known as the "morning-after pill" is also used to terminate early pregnancy.
Treatment with mifepristone also reduced the bleeding associated with fibroids, but this treatment can be associated
with adverse side effects such as overgrowth (hyperplasia) of the endometrium (uterine lining). Mifepristone is not
approved by the US Food and Drug Administration (FDA) for the treatment of uterine leiomyomas, and the required
dosages (different from those used for termination of early pregnancy) have not been determined.

Danazol (Danocrine) is an androgenic steroid hormone that has been used to reduce bleeding in women with fibroids,
since this drug causes menstruation to cease. However, danazol does not appear to shrink the size of fibroids.
Danazol is also associated with significant side effects, including weight gain, muscle cramps, decreased breast size,
acne, hirsutism (inappropriate hair growth), oily skin, mood changes, depression, decreased high density lipoprotein
(HDL or 'good cholesterol') levels, and increased liver enzyme levels.

The administration of raloxifene (Evista) (a drug used to prevent and treat osteoporosis in postmenopausal women)
has been shown to decrease the size of fibroids in postmenopausal women, but results with this therapy in
premenopausal women have been conflicting.

Low dose formulations of oral contraceptives are also sometimes given to treat the abnormal bleeding associated
with fibroids, but these do not shrink the fibroids themselves. Use of oral contraceptive pills has been associated with
a decreased risk of developing fibroids, so some women may benefit from their use for this purpose.

What are the risks of uterine fibroids during pregnancy?

Uterine Fibroids At A Glance

 Uterine fibroids are benign tumors that originate in the uterus (womb).

 It is not known exactly why women develop uterine fibroids.

 Most women with uterine fibroids have no symptoms. However, fibroids can cause a number of symptoms
depending on their size, location within the uterus, and how close they are to adjacent pelvic organs.

 Uterine fibroids are diagnosed by pelvic exam and even more commonly by ultrasound.

 If treatment for uterine fibroids is required, both surgical and medical treatment options are available.