A fibroid is a noncancerous tumor composed of muscle and fibrous tissue.

• Fibroids can cause pain, vaginal bleeding, constipation, repeated miscarriages, and an urge to urinate frequently or urgently.
• Doctors do a pelvic examination and usually ultrasonography to confirm the diagnosis.
• Treatment is necessary only if fibroids cause problems.
• Usually, surgery or procedures to destroy the fibroids are needed to relieve symptoms or to make childbirth possible.

Fibroids

Fibroids are also called fibromyomas, fibromas, myofibromas, leiomyomas, and myomas.

Fibroids in the uterus are the most common noncancerous tumor of the female reproductive tract. By age 45, about 70% of women develop a fibroid. Many fibroids are small and cause no symptoms. But about one fourth of white women and one half of black women have fibroids that cause symptoms. Fibroids are more common among women who are overweight.

Did You Know... By age 45, about 7 out of 10 women develop fibroids of the uterus.

What causes fibroids to grow in the uterus is unknown. High estrogen and progesteroneSome Trade Names
CRINONE ENDOMETRIN
levels seem to stimulate their growth. Thus, fibroids often grow larger during pregnancy and, to a lesser extent, before menopause, and they shrink after menopause. If fibroids grow too large, they may not be able to get enough blood. As a result, they begin to degenerate.

Fibroids may be microscopic or as large as a basketball. They may grow in different parts of the uterus, usually in the wall (which has three layers):

• Within the wall of the uterus (intramural fibroids)
• Just under the inside layer (lining or endometrium) of the uterus (submucosal fibroids)
• On the outside of the uterus (subserous fibroids)

Some fibroids grow from a stalk (called pedunculated fibroids). Fibroids that grow in the wall or just under the endometrium can distort the shape of the interior of the uterus. Usually, more than one fibroid is present.

Fibroids can grow in the wall of the uterus, into the interior of the uterus (sometimes from a stalk), under the lining of the uterus, or on the outside of the uterus.

Symptoms

Symptoms depend on the number of fibroids present, their size, and their location in the uterus. Many fibroids, even large ones, do not cause symptoms. Fibroids, particularly those just under the lining, commonly make menstrual bleeding heavier or last longer than usual. Anemia may result from the loss of blood. Less often, fibroids cause bleeding between menstrual periods, after sexual intercourse, or after menopause.

Large fibroids, particularly those that grow in the wall of the uterus, may cause pain, pressure, or a feeling of heaviness in the pelvic area during or between menstrual periods. Fibroids may press on the bladder, making a woman need to urinate more frequently or more urgently. They may press on the rectum, causing discomfort and constipation. Large fibroids may cause the abdomen to enlarge. A fibroid growing from a stalk inside the uterus may twist and cause severe pain. Fibroids that are growing or degenerating usually cause pressure or pain. Pain due to degenerating fibroids can last as long as they continue to degenerate.

Fibroids that cause no symptoms before pregnancy may cause problems during pregnancy. Problems include miscarriage, early (preterm) labor, abnormal positioning (presentation) of the baby before delivery, and excessive blood loss after delivery (postpartum hemorrhage).

Rarely, fibroids cause infertility by blocking the fallopian tubes or by distorting the shape of the uterus, making attachment to the lining of the uterus (implantation) of a fertilized egg difficult or impossible.

Diagnosis

Doctors can often detect fibroids during a pelvic examination. Doctors also use other procedures to examine the uterus and confirm the diagnosis:

• Transvaginal ultrasonography: An ultrasound device is inserted into the vagina.
• Saline infusion sonohysterography: Ultrasonography is done after a small amount of fluid is infused into the uterus to outline its interior.

Sometimes magnetic resonance imaging (MRI) is also done. Occasionally, additional tests are necessary.

If bleeding (other than menstrual) has occurred, doctors may want to exclude cancer of the uterus. So they may do a Papanicolaou (Pap) test, biopsy of the uterine lining (endometrial biopsy), ultrasonography, sonohysterography, or hysteroscopy. For hysteroscopy, a flexible viewing tube is inserted through the vagina and cervix into the uterus. A local, regional, or general anesthetic is used.

Treatment

For most women who have fibroids but no bothersome symptoms or other problems, treatment is not required. They are reexamined every 6 to 12 months to determine whether fibroids are growing.

Several treatment options, including drugs and surgery, are available if bleeding or other symptoms worsen or if fibroids enlarge substantially.

Drugs: A few drugs may be used to relieve symptoms or to shrink fibroids, but their effects are only temporary. No drug can permanently shrink a fibroid.

Synthetic forms of a hormone produced by the body called gonadotropin-releasing hormone (GnRH) are most commonly used. These drugs are called GnRH agonists (see Endometriosis: Drugs). LeuprolideSome Trade Names
LUPRON
and goserelinSome Trade Names
ZOLADEX
are most commonly used. They can shrink fibroids and reduce bleeding by causing the body to produce less estrogen (and progesteroneSome Trade Names
CRINONE ENDOMETRIN
). Because they shrink the fibroids and reduce bleeding, doctors may give GnRH agonists before surgery to make removal of fibroids easier, reduce blood loss, and thus reduce the risks of surgery. The drugs are injected once a month, used as a nasal spray, or implanted as a pellet under the skin. If taken for a long time, they may reduce bone density and increase the risk of osteoporosis. Estrogen may be given in low doses with GnRH agonists to help prevent these side effects.

Hormonal contraceptives, usually progestins (see Family Planning: Hormonal Methods), can control bleeding in some women. However, when women stop taking contraceptives, abnormal bleeding and pain tend to recur. Also, when some women are treated with contraceptives, the fibroids grow.

RaloxifeneSome Trade Names
EVISTA
and related drugs (such as some selective estrogen receptor modulators, or SERMs) reverse some of estrogen's effects and can reduce fibroid growth.

Surgery: Surgery is usually considered for women who have any of the following:

• Symptoms, such as pain and bleeding, that remain severe enough to interfere with daily activities after other treatments have been tried
• Large fibroids that women can feel and that are bothersome
• For women who want to conceive, fibroids that have caused infertility or repeated miscarriages

Surgery traditionally involves one of the following:

• Hysterectomy: The entire uterus is removed, but the ovaries are not. Hysterectomy is the only permanent solution to fibroids. However, after hysterectomy, women cannot have children. Thus, hysterectomy is done only when women do not wish to become pregnant.
• Myomectomy: Only the fibroid or fibroids are removed. Unlike hysterectomy, most women who have a myomectomy can have children. Also, some women feel psychologically better if they keep their uterus. However, after myomectomy, new fibroids may grow, and about 25% of women need a hysterectomy about 4 to 8 years later.

For hysterectomy, surgeons may use one of the following methods:

• Laparotomy: They may make an incision that is several inches long in the abdomen.
• Laparoscopy: They may make one or a few small incisions just below the navel, then insert a viewing tube with surgical attachments through the incision. This procedure can be used to remove the entire uterus. Or the main body of the uterus is removed, leaving the cervix in place (a procedure called laparoscopic supracervical hysterectomy).
• Vaginal hysterectomy: The entire uterus is removed through the vagina. An abdominal incision is not needed.

For myomectomy, surgeons may use laparotomy, laparoscopy (used to remove fibroids on the outer part of the uterus), or hysteroscopy. For hysteroscopy, they insert a telescope-like lighted device through the vagina into the uterus. This device can cut tissue and remove fibroids on the inside of the uterus. Which method is used depends on the size, number, and location of fibroids. Laparoscopy and hysteroscopy are outpatient procedures, and recovery is faster than recovery after an abdominal incision. However, laparoscopy often cannot be used to remove large fibroids, and the risk of complications after laparoscopy can be higher.

Other Treatments: Other treatments can be used to destroy rather than remove fibroids.

For uterine artery embolization, doctors use an anesthetic to numb a small area of the thigh and make a small puncture hole or incision there. Then, they insert a thin, flexible tube (catheter) through the incision into the main artery of the thigh (femoral artery). The catheter is threaded to the arteries that supply blood to the fibroid, and small synthetic particles are injected. The particles travel to the small arteries supplying the fibroid and block them. As a result, the fibroid dies, then shrinks. Most of the rest of the uterus appears to be unaffected. However, whether the fibroid will regrow (because blocked arteries reopen or new arteries form) and whether the woman can become pregnant are unknown. The most common problems after this procedure are pain and infection.

Other procedures to destroy fibroids involve heat (high-intensity focused ultrasonography or radiofrequency ablation) or cold (cryoablation) via needle insertion, ultrasonography, or both. In myolysis, a needle that transmits an electrical current or heat is inserted into the fibroid and used to destroy the core of the fibroid. In cryomyolysis (a type of cryoablation), a similar procedure, a cold probe is used to destroy the fibroid. Whether women who have one of these procedures can become pregnant is unknown.

After these treatments, fibroids may grow back. In such cases, another treatment or a hysterectomy may be done.

Last full review/revision December 2008 by Bryan D. Cowan, MD