What are fibroids?

Uterine fibroids are non-cancerous growths of the uterus or womb. They are also called fibroids, uterine leiomyomas or myomas. They can be undetectable, or the size of different fruits (Ex: from a grape to a melon). Fibroids can push up against other organs and/or become a heavy mass in the abdomen sometimes reaching as high as the rib cage.

Signs and Symptoms

If you have fibroids, you may or may not experience symptoms. Many women are not aware they have fibroids until a provider finds them in a routine physical exam or are randomly found on an imaging test (hyperlink to diagnostic tests). Other women experience significant discomfort or pain as a result of their fibroids. Everyone is different.

Some common symptoms may include:

• • Heavy Menstrual Bleeding (HMB)
• • Blood Clots
• • Anemia
• • Abdominal Cramping
• • Pelvic Pain
• • Back Pain
• • Leg Pain
• • Bulk Symptoms
• • Pain with sexual intercourse (known as dyspareunia)

Heavy Menstrual Bleeding (HMB)

The most common bleeding symptom associated with fibroids is heavy menstrual bleeding (HMB). HMB is usually defined as an excessive amount of blood flow during your period. Defining what “excessive” means is difficult because women have different perceptions of a heavy flow. However, HMB could be but is not limited to:

• • Bleeding that soaks through one or more pads/tampons every hour for
  several hours in a row.
• • Needing to wear more than one pad/tampon at once to control blood
  flow.
• • Waking up to change pads/tampons during the night.
• • Consistently lasts more than 7 days; or
• • Soils your clothes and seats.

Diagonising Uterine Fibroids.

Uterine fibroids are frequently found during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus, suggesting the presence of fibroids. You may suspect the presence of uterine fibroids based on symptoms that you are experiencing.
Fibroids can be diagnosed using various tests such as

Ultrasound

It uses soundwaves to create a picture of the uterus and other pelvic organs. A doctor or technician moves the ultrasound device over your abdomen (transabdominal) or places it inside your vagina (transvaginal) to get images of your pelvic organs including your uterus. An ultrasound is the most frequent test utilized to diagnose fibroids, however, it does not always provide a comprehensive picture the pictures or information needed of your uterus. More detailed tests are MRI and hysteroscopy.

Magnetic resonance imaging (MRI)

This imaging test can show in more detail the size and location of fibroids, identify different types of tumors and help determine appropriate treatment options. We recommend MRI is recommended since it shows the fibroid as well as the blood supply to the fibroid. This more comprehensive imaging is important for surgical planning.

Hysteroscopy

Uses a slender device (the hysteroscope) to see the inside of the uterus. It is inserted through the vagina and cervix (opening of the uterus). This allows your healthcare professional to see fibroids inside the uterine cavity.

Lab Tests

If you have abnormal menstrual bleeding, your doctor may order other tests to investigate potential causes. These might include a complete blood count (CBC) to determine if you have anemia because of chronic blood loss and other blood tests to rule out bleeding disorders or thyroid problems.

Less frequently used imaging methods are:

Hysterosalpingography:

This is a special X-ray test. It may detect abnormal changes in the size and shape of the uterus and fallopian tubes.

Sono hysterography:

A test in which fluid is put into the uterus through the cervix. Ultrasonography is then used to show the inside of the uterus. The fluid provides a clear picture of the uterine lining.

Laparoscopy:

Uses a slender device (the laparoscope) to help your health care professional see the inside of the abdomen. It is inserted through a small cut just below or through the navel. Fibroids on the outside of the uterus can be seen with the laparoscope. Imaging tests, such as magnetic resonance imaging and computed tomography scans, may be used but are rarely needed. Some of these tests may be used to track the growth of fibroids over time.

Menorrhagia + Anemia

Why am I passing clots?

Unfortunately, clots with fibroids is very common because fibroids can cause changes in the way that your blood vessels and clotting mechanisms work during your period. The causes of HMB in UF are not well known, abnormal development of the inner layer of your uterus called endometrium and altered clotting mechanisms may be a factor.

Learn more. Are there risk factors?

Some women have specific genes that may predispose them, and their families, to fibroids; and lifestyle and reproductive factors influence fibroids. Some fibroids grow with time and others shrink. Fibroids can also have growth spurts where they grow quickly over a short period of time.

What happens next?

Don’t wait to seek treatment because symptoms could get worse.

What questions should I ask my doctor?

1. How many fibroids do I have?
2. What size is my fibroid(s)?
3. Where is my fibroid(s) located (outer surface, inner surface, or in the wall of the uterus)?
4. Can I expect the fibroid(s) to grow larger?
5. How rapidly have they grown (if they were known about already)?
6. How will I know if the fibroid(s) is growing larger
7. What problems can the fibroid(s) cause
8. What tests or imaging studies are best for keeping track of the growth of my fibroids?
9. What are my treatment options if my fibroid(s) becomes a problem?
10. What fibroid surgery options do you specialize in?
11. May I speak with a patient who has had the same surgery that you are recommending for me?
12. What happens to fibroids when you get to menopause?

A second opinion is always a good idea if your doctor has not answered your questions completely or does not seem to be meeting your needs.

What should my doctor ask me?

• • How are you feeling?
• • What symptoms are most troublesome?

Can you rank your goals for treatment? Ex: eliminate pain, stop heavy menstrual bleeding, relief from pain during intercourse, desire to conceive

Why is treatment important for me?

Treatment is important because it may alleviate your symptoms. The sooner you can get effective treatment, the better outcomes you may be able to achieve. In some cases, fibroid symptoms worsen over time. It is better to address symptoms early and avoid having to make treatment decisions quickly if you are not feeling well.
Like many women, you have heard from your care provider that you have fibroids. Depending upon how heavy your menstrual periods are or how much pain you are feeling, you may have different goals for therapy. Fortunately, you have many options to treat your symptoms, and it is important for you to consider all of your options before making the best decision for you.

For most of these options, you can try one and switch to another, so when in doubt, choose the option that is best for you. Before your doctor’s visit, make a list of your symptoms, and rank them in order of importance. Each patients goals for treatment are very personal. Your physician should address each concern.

Treatment considerations may be different if you’re recently diagnosed, near menopause, or if you wish to become pregnant soon. There are many potential options, and each have their benefits and drawbacks. Understanding YOUR medical and surgical management options will help you select the best option(s) to achieve your treatment goals.

Therapies directed at your symptoms

Watchful Waiting

If you know you have fibroids, but your symptoms are manageable at home without involving medicine or surgery, it is reasonable to check in with your care provider regularly and otherwise continue to manage your symptoms as you have been doing. It is possible that your symptoms will get worse over time, so regular re-assessment is important to be sure that your fibroids are not disrupting your life.

Birth Control Pills

Birth control pills are often prescribed for women who have heavy periods in order to decrease the amount of bleeding associated with their periods. While this therapy does decrease normal menstrual bleeding, unfortunately it does not treat the fibroids, and symptoms may start to worsen over time despite using birth control pills. This therapy does not treat the fibroids, so they may continue to grow, and any pain or pressure that you feel will not be treated either.

Other Hormonal Therapies

Hormone-releasing IUDs, pills that only contain progesterone-like compounds, implants, and other hormonal methods will have a similar effect on bleeding, but do not treat the fibroid directly. As a result, while menstrual bleeding may improve initially, your fibroids also may worsen over time. Also, pain and pressure will not be treated.

Tranexamic Acid

This medicine regulates the way that blood clots, and can lower the amount of blood that is lost from the normal menstrual period and from fibroids. It does not treat the fibroid directly, however, and will not address pain and pressure.

Endometrial Ablation

This out-patient surgery essentially destroys the part of the womb that is involved with menstruation. The procedure is quick and requires a few visits, but it can be expensive and does not cure the fibroids. As a result, additional treatment in the future may be required. Also, if you plan on having children in the future, this is not an option to consider, since it destroys the tissue required for pregnancy.

Therapies that treat fibroids

GnRH Analogues

There are two types of medicines that block the impact of hormones on fibroids: gonadotrophin-releasing hormone (GnRH) agonists and antagonists. In the United States, currently only GnRH-agonists and antagonists are available for fibroid treatment. These therapies may decrease fibroid size and heavy menstrual bleeding. Currently, the approved treatment timeframe for a GnRH agonist is 3-6 months which is used prior to fibroid surgery. The approved treatment timeframe for a GnRH antagonist is up to 2 years. Consult with your health care provider to determine which medical therapy is best for you.

Selective Progesterone Receptor Modulators

Progesterone receptor modulators are drugs that bind to the progesterone receptor modifying the uterine tissue response to progesterone. By modifying the response of the uterine muscle (called myometrium) these drugs help decrease fibroid size and heavy menstrual bleeding.

Uterine Artery Embolization

Under X-ray guidance, a small tube is placed near the fibroid, and small beads are released into the nearby blood vessels to block blood flow to the fibroids. This causes the fibroids to shrink, and improves symptoms. However, surrounding tissue may be impacted, and as a result this option may not be best for women who want to have children in the future.²

MRI-Guided High Frequency Ultrasound:

This therapy uses a focused ultrasound to heat up the fibroids an MRI machine to monitor the spread of the heat so that surrounding tissues (such as blood vessels, nerves, and normal uterine tissue) are protected. No incisions are needed. Specialized equipment and training are required, however, and may not be available locally. Finally, this therapy may not be covered by insurance, so be sure to check before proceeding with this option.

Radiofrequency Ablation

A probe is placed into the fibroid either during a surgical procedure or using local anesthesia and going through the normal skin. The tip of the probe is then heated up to destroy normal myometrial tissue. While the tip is monitored, potential damage to surrounding tissues may be difficult to detect and prevent.

Myomectomy

The surgical procedure where the fibroids are removed from the uterus, leaving the uterus inside of you. It may be performed inside the uterus (called a hysteroscopic myomectomy), or through the abdomen as a laparoscopic surgery, a robotic surgery, or a laparotomy (where a larger incision is used to make the uterus more accessible. Robotic surgery has certain benefits to the surgeon, but typically the quality of the surgery is not better than either a laparoscopic surgery or surgery by laparotomy.

Hysterectomy

This is the surgical removal of the uterus, with all fibroids. While curative, it also eliminates the possibility of future child-bearing, and may result in other long-term side-effects such as inability to hold urine when coughing or sneezing, and potentially bulging of tissues out of the vagina. Given the wide array of alternatives, hysterectomy should be the last option once all other options are either not right for you or have failed.