What are Uterine Fibroids?

Uterine fibroids (or leiomyomas) are noncancerous growths that develop from the muscle tissue of the uterus and often appear during the childbearing years. The size, shape and location of fibroids can vary greatly. They may be present inside the lining of the uterus, on its outer surface or within its wall. Women can have a single fibroid or many fibroids of varying sizes. Fibroids may remain very small for a long time, but they can also grow at different rates. Up to 80% of women will develop fibroids by age 50. However, not all fibroids cause symptoms, and not all fibroids need to be treated.

Fibroids and Infertility

Depending on their location and size, fibroids may cause infertility and pregnancy loss, although other causes of infertility are more common. Other factors should be explored before fibroids are considered the cause of a couple’s infertility. When fibroids are thought to be a cause, many women are able to become pregnant after they are treated.

Many women who have fibroids have no symptoms. For others, the symptoms are influenced by the fibroids' size, number and location. The symptoms may include:

  • Heavy or lengthy periods, which can lead to anemia
  • Abnormal bleeding between periods
  • Pelvic pain and pressure
  • Frequent urination
  • Low back pain
  • Pain during intercourse
  • Constipation
  • Abdominal swelling
  • Miscarriage
  • Infertility

Doctors categorize fibroids into groups based on where they grow:

  • Intramural fibroids grow within the wall of the uterus
  • Subserosal fibroids grow on the outside of the uterus
  • Submucosal fibroids grow in the inner lining of the uterus
  • Rarely, fibroids can grow separate from the uterus and are attached to other organs within the abdomen or pelvis

Fibroids may be diagnosed during your routine gynecologic physical exam if they are large enough for your provider to feel. If you have symptoms or signs of uterine fibroids, your provider may order imaging tests such as:

Ultrasound: Pelvic ultrasound is the most common imaging technique used to diagnose uterine fibroids. This exam usually consists of ultrasound images taken with a probe or transducer over your abdomen and from inside your vagina with a transvaginal approach.

Magnetic resonance imaging (MRI): This technique provides a better detail of the fibroids’ exact size and location. It also determines what the blood flow to the fibroids is like. This may allow your doctor to better tailor a treatment plan and is often helpful prior to a myomectomy (surgery to remove fibroids) or a uterine artery embolization.

Hysteroscopy: This approach allows your provider to evaluate the inside lining of your uterus. A small lighted camera (hysteroscope) is inserted inside your vagina and into the cervix. This allows your physician to see submucosal fibroids directly and possibly treat them.

Hysterosonography: With this technique, sterile water or saline solution is used to expand your uterine cavity while a transvaginal ultrasound is done at the same time. This allows for better identification of submucosal fibroids.

Lab tests: These can check for iron-deficiency anemia, which can result from heavy menstrual bleeding.

Medical Treatments

Since many fibroids cause minimal or no symptoms, your provider may suggest expectant management, also called "watchful waiting." Treatment will depend on your symptoms and your goals.

Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs may help reduce heavy menstrual bleeding and relieve pain related to fibroids.

Hormonal medication: Hormonal medication can reduce heavy menstrual bleeding (e.g., progestin-releasing intrauterine device (IUD), progestin-only pills, and combined estrogen and progesterone hormonal contraception pills/patch/ring).

Tranexamic acid: This is a nonhormonal medication taken only during your period. It helps decrease the number of days and total volume of your menses.

Gonadotropin-releasing hormone agonists/antagonists (GnRH): Designed to treat fibroids by lowering your estrogen and progesterone production, this medication is prescribed to stop or decrease menstruation. It may shrink fibroids prior to a planned surgery.

Surgical Treatments

Since many fibroids cause minimal or no symptoms, your provider may suggest expectant management, also called "watchful waiting." Treatment will depend on your symptoms and your goals.

Minimally invasive surgical techniques: Your doctor will be able to help guide you through the appropriateness of the options below based on the uniqueness of your fibroids and goals. Most patients are candidates for a minimally invasive surgical option. All minimally invasive techniques result in less blood loss, less pain, fewer complications and a quicker recovery than the traditional open abdominal approach (laparotomy) for myomectomy and hysterectomy.

Hysteroscopic myomectomy: First, your doctor inserts a long, thin telescope with a light through the vagina and cervix. A small electric loop or a mechanical device is used to cut away the fibroid. The uterus is left intact. Only submucosal fibroids can be removed by this method.

Laparoscopic hysterectomy or robotic-assisted laparoscopic hysterectomy: A hysterectomy is considered curative and is a definitive treatment for symptomatic fibroids. The uterus along with the fibroids are removed. Typically, the ovaries are left in place when healthy. This surgery is performed laparoscopically, using a tiny camera and small punctures in the abdomen. The surgeon can pass tools through the punctures. Sometimes, a robot is used to help control the tools at the surgeon’s discretion. The robot does not perform any part of the procedure by itself. It is always under the direct control of the surgeon.

Laparoscopic myomectomy or robotic-assisted laparoscopic myomectomy: Myomectomy is a surgery that removes only the fibroids, not the uterus. This surgery is performed using a tiny camera and instruments guided through a few small cuts in the abdomen. The fibroids are removed from the uterus, and the uterus is repaired with stitches (myomectomy). Sometimes, a surgeon will prefer to utilize a robot during the surgery. The robot does not perform any part of the procedure by itself. It is always under the direct control of the surgeon.

Radiofrequency ablation of fibroids (Acessa and Sonata®): This newer technology uses heat energy to treat the fibroid, which results in shrinkage over time and reduced menstrual flow. A radiofrequency probe is inserted into each fibroid while using ultrasound guidance, and the energy is delivered. This can be done via laparoscopy (using a camera and small cuts in the abdomen) known as the Acessa procedure, or through the vagina with a probe placed into the uterine cavity, which is called the Sonata procedure.

Traditional surgery (open surgery): Traditionally, larger abdominal incisions were used to remove fibroids (myomectomy) or remove the entire uterus (hysterectomy). In severe cases, despite the advances in minimally-invasive techniques, this may still be the best option for treatment. It is appropriate to seek a second opinion from a subspecialist in minimally invasive GYN surgery, given their additional training and expertise in these techniques to determine if open surgery can be avoided.

Uterine fibroid embolization/uterine artery embolization (UFE/UAE): UFE and UAE are minimally invasive procedures performed by an interventional radiologist, a doctor who specializes in using imaging techniques to perform procedures. The interventional radiologist inserts a thin tube (catheter) into the main artery of the thigh or wrist. The doctor guides the catheter into the uterine artery using X-ray guidance. Tiny permanent particles are inserted through the catheter into the uterine arteries, where they block the blood supply to the fibroids/uterus. Blocking the blood flow to the fibroids causes them to shrink and alleviates symptoms such as bulk and heavy menses over several months.