Jefferson University Hospitals

Frequently Asked Questions

What are the treatment options and which one is best for me?

While up to 75 percent of reproductive aged women in certain populations may have uterine fibroids during their lifetime, the percentage of women who experience symptoms are fewer — about 25 percent. For these women with symptoms, there are several treatment options. Which of these treatments is best depends on each woman's unique clinical situation and desires. Factors such as a desire for future pregnancy, size, location of the fibroids, and age are the major considerations.

Treatments for symptomatic fibroids range from medications like pain relievers and hormones, such as oral contraceptives, to minimally invasive procedures like uterine artery embolization, to surgeries such as myomectomy and hysterectomy.

What is expectant management?

Expectant management, the wait and see approach, is an option for women who do not have symptoms related to their fibroids. With expectant management, patients are monitored, but not treated, by their physician. Periodic exams may be scheduled to check for enlargement of the fibroids. If the patient remains asymptomatic, however, there is probably no benefit in checking for growth, other than for curiosity’s sake. An ultrasound may be obtained to use as a basis for comparison and to confirm that the pelvic mass is a fibroid uterus and not an ovarian mass.

Fibroids do tend to increase in size until menopause. Unless this enlargement is accompanied by symptoms, however, expectant management may be continued.

What is medical treatment?

Medical treatment may offer control of symptoms and pain related to fibroids. Medications may be used alone, or as an adjunct to surgery. The medications most commonly used to treat fibroids are pain and hormonal medications.

  • Pain medications: Women with painful symptoms may be prescribed pain medications. These range from over-the-counter medicines, such as NSAIDs and ibuprofen, to potent drugs, such as narcotics. Most often these medications are only necessary during menses.
  • Hormonal agents: Heavy, painful, or prolonged menstrual bleeding, may also be managed with hormonal agents. Oral contraceptive pills, progestins such as Provera® or Depo-Provera®, may improve symptoms and control bleeding by decreasing proliferation of the uterine lining.
  • Progesterone IUD: This IUD imbedded with progesterone is placed into the uterine cavity in the patient office. It may be left in place for up to 5 years at a time. It works by inducing atrophy of the endometrium. 80% reduction in menstrual blood loss has been reported at three months. There is a very low rate of complications or side effects. This IUD also provides effective contraception.
  • Gonadotropin releasing hormone agonists (GnRH): Gonadotropin releasing hormone (GnRH) agonists, such as Lupron®, induce low estrogen states, or temporary menopause-like states, improve symptoms by causing fibroids to temporarily decrease in size. In addition to reducing tumor bulk and improving mass-related symptoms, including pelvic pressure, these agents usually improve bleeding symptoms. This may allow anemic patients to temporarily improve their blood counts. Side effects of GnRH agonists include menopausal symptoms, such as hot flashes, vaginal dryness, decreased sex drive, bone loss, and depression. Therapeutic courses are usually limited to three to six months, often prior to surgery. These medications are also very expensive. After discontinuation of GnRH agonist therapy, fibroids begin growing again, enlarging to their original size within three months.
  • SPRMs: Selective Progesterone Receptor Modulators (SPRMs) are a promising category of designer medications for the treatment of uterine fibroids. These orally available medications act at the level of the fibroids, rather than centrally on the brain. Thus, they have less systemic side effects compared to GNRH agonists (Lupron ®). Preliminary studies have demonstrated significant reduction in fibroid volume and uterine bleeding. They are currently only available by participating in scientific trials.

What is High Intensity Frequency Ultrasound (HIFUS)?

HIFUS is a treatment for symptomatic fibroids recently approved by the FDA. Thermal lesions are created within target fibroids using an MRI-guided focused ultrasound system. Seventy-nine percent of treated patients reported improvement at 6 months, with only a 13 percent mean reduction in fibroid volume. Limited data is available for this treatment, with only 108 patients included in the study gaining FDA approval. Most insurers consider HIFUS experimental and do not cover it.

What are uterine fibroids?

Uterine leiomyomas, or fibroids, are non-cancerous, smooth muscle tumors. Fibroids grow within the uterus, and may occur as solitary or multiple tumors. Fibroids may range in size from microscopic to over twelve inches.

Physicians classify fibroids on the basis of their appearance and location within the uterus. Submucosal fibroids grow just underneath the interior lining of the uterine cavity. Intramural fibroids grow within the intermediate, muscular layer of the uterus. Subserosal fibroids grow just underneath the uterus’s outer lining. A subset of fibroids that grow on stalks are considered pedunculated, and are seen both within the uterine cavity and on the outside of the uterus. Most fibroids are intramural or subserosal.

Up to 25% of reproductive aged women in the United States have clinically symptomatic fibroids, and up to 75% have fibroids overall. Many women have multiple fibroids in their uterus. Fibroids are seen two to five times more often in black women, with overweight women also having a higher incidence of the tumors. Fibroids are detected in most women during their 30’s or 40’s.

What are the signs and symptoms of fibroids?

As many as 25% of women experience symptoms related to uterine fibroids. Irregular menstrual cycles are the most common. This may present as menorrhagia, menometrorrhagia or dysmenorrhea. Menorrhagia means heavy menses. Menometrorrhagia means heavy, prolonged and irregular vaginal bleeding. Dysmenorrhea means painful menses. Because large fibroids also enlarge the uterus, many women experience a sensation of lower abdominal fullness or pelvic pressure. This pressure may also affect adjacent pelvic structures, leading to more specific symptoms like frequent urination, incontinence, constipation, or pain during sex. Some women may notice low back pain.

Fibroids are associated with a number of reproductive problems, which relate in part to the tumor’s volume and distortion of the uterine cavity. These may include infertility, miscarriage, recurrent pregnancy loss, preterm (early) delivery, fetal malpresentation (breech), and complications during labor (obstructed labor, hemorrhage, …).

How are fibroids diagnosed?

Clinicians are able to diagnose fibroids by appreciating an enlarged or irregularly shaped uterus. This may be done manually through a pelvic examination or through imaging studies such as an ultrasound, MRI or CT. Sometimes, tests like hysterosalpingography (HSG) and sonohysterography (SHG), which use both fluid and imaging to better visualize the uterine cavity, may provide additional information. Direct visualization of the uterine cavity is sometimes necessary and may be achieved with hysteroscopy, a technique that involves insertion of a small camera into the uterus through the vagina. Visualization of the outside of the uterus is similarly enabled by laparoscopy, a procedure in which a small camera is introduced into the abdominal cavity through an incision in the umbilicus.

What causes fibroids to grow?

Current research links fibroid growth to a number of hormones. Estrogen and progesterone have long been accepted as major factors influencing fibroid growth. Newer research now suggests that growth factors and other hormones may also play a role in promoting cell growth in already established fibroid tumors.

High levels of estrogen and progesterone have been shown to independently enhance fibroid growth. Interestingly, fibroids express higher levels of estrogen and progesterone receptors than normal uterine tissue, suggesting enhanced sensitivity and responsiveness to these hormones. Absence of estrogen and/or progesterone correlates with decreased fibroid size.

From a clinical and therapeutic perspective, these findings support observations that fibroids expand in high estrogen and progesterone states such as pregnancy and generally throughout the reproductive years. Conversely, fibroids decrease in size when levels of these hormones drop, such as during menopause and with certain drug therapies.

Will my fibroids continue to grow?

Because fibroid growth is linked to the levels of female hormones in the body, mainly estrogen and progesterone, fibroids usually will continue to increase in size in women who are pre-menopausal.

Will my fibroids shrink when I enter menopause?

Most, but not all, women experience an improvement in fibroid-related symptoms after menopause. This change is thought to be secondary to the decreased estrogen and progesterone levels that accompany menopause. While fibroids often stop growing and decrease in size at this time, women who take hormone replacement therapy (HRT) may not have the same degree of regression of their fibroids.

Do fibroids become cancerous?

No. Most uterine leiomyomas or fibroids are not cancerous. They are usually considered benign (non-cancerous) tumors and pose almost no increased risk of future uterine cancer. One study of hysterectomies performed for suspicious fibroids found only a 1/400 incidence of cancerous fibroids (leiomyosarcoma).

How can the Jefferson Fibroid Center help me?

The Jefferson Fibroid Center is here to aid in the diagnosis, treatment, and follow-up of your fibroids. We are available to discuss treatment options, and to help you decide which one is right for you. We offer a full range of therapies, from expectant management to medical therapy to all surgical treatments to uterine artery embolization. We offer full follow-up care, both short and long-term, with the goal of helping you to obtain the greatest improvement in your fibroid-related symptoms. Our physicians are nationally and internationally recognized experts in the treatment of fibroids, with multiple publications and presentations at national and international meetings. Unique amongst fibroid treatment centers, our physicians include obstetrician gynecologists, infertility specialists, and interventional radiologists.

What are the treatment options and which one is best for me?

While up to 75 percent of reproductive aged women in certain populations may have uterine fibroids during their lifetime, the percentage of women who experience symptoms are fewer — about 25 percent. For these women with symptoms, there are several treatment options. Which of these treatments is best depends on each woman's unique clinical situation and desires. Factors such as a desire for future pregnancy, size, location of the fibroids, and age are the major considerations.

Treatments for symptomatic fibroids range from medications like pain relievers and hormones, such as oral contraceptives, to minimally invasive procedures like uterine artery embolization, to surgeries such as myomectomy and hysterectomy.

What is expectant management?

Expectant management, the wait and see approach, is an option for women who do not have symptoms related to their fibroids. With expectant management, patients are monitored, but not treated, by their physician. Periodic exams may be scheduled to check for enlargement of the fibroids. If the patient remains asymptomatic, however, there is probably no benefit in checking for growth, other than for curiosity's sake. An ultrasound may be obtained to use as a basis for comparison and to confirm that the pelvic mass is a fibroid uterus and not an ovarian mass.

Fibroids do tend to increase in size until menopause. Unless this enlargement is accompanied by symptoms, however, expectant management may be continued.

What surgical treatments exist?

Surgical therapy includes myomectomy, in which fibroids, but not the entire uterus, are removed. This procedure allows a woman to keep her uterus, also potentially preserving future fertility. Approaches in this method may be hysteroscopic, placing a camera and instruments through the vagina into the uterus to guide submucosal fibroid resection, or laparoscopic, which uses a small camera directly within the abdominal cavity to aid removal of the fibroid(s). Most commonly, an open procedure, or laparotomy, is used to remove the fibroids through an incision in the abdomen.

Endometrial ablation is a new technique that has recently been approved to treat women with fibroids suffering from irregular bleeding. In this minimally-invasive outpatient treatment, the endometrial lining is destroyed with microwaves in a procedure lasting less than five minutes. Inital data reports improved bleeding in over 90% of patients.

Another surgical option is hysterectomy, in which the uterus is removed along with the fibroids. While hysterectomy is the only definitive treatment for fibroids, it also eliminates a woman’s ability to bear children. Hysterectomy may be performed by either a vaginal or abdominal approach, and may be assisted by a camera laparoscopically assisted vaginal hysterectomy (LAVH).

What is myomectomy?

Myomectomy is a surgical procedure in which only fibroids, but not the uterus, are removed. This preserves childbearing potential. Myomectomy can be performed in different ways depending on the location of fibroids within the uterus. The most common approach is abdominal myomectomy, which allows the surgeon to directly visualize the uterus and fibroids through an abdominal incision. In some circumstances, other approaches to myomectomy may be used. Submucosal fibroids may be reached by hysteroscopic myomectomy. This approach uses a camera inserted in the uterus through the vagina to enable resection of the fibroid. Subserosal fibroids, just beneath the outer covering of the uterus, may be best approached by laparoscopic myomectomy, which uses a small camera inserted into the abdominal cavity to identify and aid in removing the fibroid.

EWhile the procedure offers symptomatic reduction and decreases heavy, prolonged menstrual bleeding in most women, there is a small risk of symptomatic fibroid recurrence. Up to 10% of women may require additional operations due to future growth of new fibroids.

What is laparoscopic myomectomy?

Subserosal fibroids, which are just beneath the outer covering of the uterus, may be best approached by laparoscopic myomectomy. This approach removes fibroids from the uterus using a small camera and thin surgical instruments inserted into the abdominal cavity through multiple, small incisions. This procedure is technically more difficult and may have limitations in terms of the number, size, and location of fibroids to be removed. The main benefits of laparoscopic myomectomy are a quicker recovery and shorter hospital stay.

What is hysteroscopic myomectomy?

For submucosal fibroids, those within the cavity of the uterus, hysteroscopic myomectomy may be an option. This approach uses a camera, or hysteroscope, inserted in the uterus through the vagina to enable resection of the fibroid. The procedure is typically done on an outpatient basis, with patients often returning to work the next day. Limitations of this procedure include the size of the fibroid to be resected and co-existing fibroids that also need to be treated.

What is endometrial ablation?

Several techniques of endometrial ablation have been approved to treat women with fibroids suffering from irregular bleeding. In this minimally-invasive outpatient treatment, the endometrial lining is destroyed by a probe inserted into the uterine cavity through the vagina emitting energy from its tip, in a procedure lasting less than five minutes. Initial data reports improved bleeding in over 80% of patients, with up to 40% of patients never bleeding again.

What is abdominal myomectomy?

The most common method to remove fibroids from the uterus is abdominal myomectomy. Unless the uterus is massively enlarged, it is performed through a low transverse (bikini cut) incision. This surgical procedure allows for direct visualization of the uterus and fibroids through an abdominal incision. This procedure typically requires a two day hospital stay, with full recovery in four to six weeks.

What is hysterectomy?

Hysterectomy is a surgical treatment for symptomatic fibroids that removes the uterus along with the fibroids. Hysterectomy is the only definitive treatment for fibroids. Women electing to have a hysterectomy must be aware that removal of the uterus eliminates a woman’s ability to bear children.

Hysterectomy may be performed in different ways depending on the size of the uterus, scar tissue from previous surgeries, uterine mobility from prior vaginal deliveries, and skill of the surgeon. Abdominal hysterectomy, the most common technique, uses an abdominal incision to remove the uterus. Vaginal hysterectomy uses a vaginal approach to remove the uterus, without cutting through the abdomen. Laparoscopically assisted vaginal hysterectomy starts the hysterectomy through small abdominal incisions, then completes it with a vaginal approach. Laparoscopic hysterectomy uses a small camera inserted through the abdomen. Depending on a patient’s wishes, the ovaries and fallopian tubes may be removed as well.

Each year, 30% of all hysterectomies are performed for symptomatic fibroids—nearly 200,000 operations in the United States alone.

What is abdominal hysterectomy?

Abdominal hysterectomy removes the uterus along with all fibroids through an abdominal incision. This is considered definitive treatment for fibroids.

A variation of this procedure, supracervical hysterectomy, leaves the cervix intact. Potential advantages of supracervical hysterectomy include shorter operative time, decreased complication rate, decreased risk of vaginal vault prolapse later on, and preserved sexual function. Women at risk for cervical cancer or with abnormal Pap smears are not candidates for supracervical hysterectomy. Patients should expect to be hospitalized for a two days following abdominal hysterectomy, with full recovery within four to six weeks.

What is vaginal hysterectomy?

Vaginal hysterectomy removes the uterus and fibroids through the vagina, without need for an abdominal incision. The three limitations to vaginal hysterectomy are size, scarring, and prolapse. Most surgeons, unless they are skilled in the surgical techniques of morcellation, will only attempt vaginal hysterectomy is the uterus is smaller than 12-14 weeks gestational size. Additionally, if there is a history of prior abdominal surgery or a lack of uterine mobility, the vaginal approach may not be an option. The hospitalization is usually just overnight. Most patients are back to work within two to three weeks. If possible, the vaginal approach is preferable over the abdominal approach.

How long will it take to recover from surgery?

The length of time it takes to recover from surgery depends on the type of procedure used to treat the fibroids. Patients typically recover from hysteroscopic and laparoscopic procedures more quickly (within a week) than vaginal (two to three weeks) or open abdominal procedures (four to six weeks). The definition of recovery will also differ based on a patient's motivation, general health, and the requirements of their job.

Will I be able to have a baby?

Fibroids can contribute to a number of reproductive problems, ranging from infertility, recurrent pregnancy loss, preterm (early) delivery, fetal malpresentation (breech), to complications in labor. By treating symptomatic fibroids, the chances of being able to have a baby may improve. Many women with fibroids, however, have no difficulty in conceiving and go on to have normal pregnancies, even without treatment.

The therapies available for treating symptomatic fibroids do have risks and side effects. Some medical treatments temporarily interfere with fertility by disrupting normal hormonal balance. Surgical and minimally invasive treatments have led to many normal pregnancies, but success rates vary with the type of therapy used. The type of fibroids present in the uterus, as well as the number of procedures completed also influence the chances of being able to have a baby.

Many factors weigh into predicting the chances of a successful pregnancy and delivery. Every woman with fibroids desiring future fertility should consult an obstetrician to discuss their unique situation and the therapies that will lead to the best outcome.

What are uterine artery embolization (UAE) and uterine fibroid embolization (UFE)?

Uterine artery embolization (UAE) or uterine fibroid embolization (UFE) are interchangeably used names for a non-surgical, radiologic procedure for treating single or multiple symptomatic fibroids. This procedure removes neither the uterus nor the fibroids. UAE offers improvement in fibroid-related symptoms by blocking the blood supply to fibroids, inducing shrinkage. The technique was first reported in 1995 as a primary treatment to treat fibroid tumors. It had been previously used for over 20 years, however, in other causes of excessive pelvic bleeding.

UFE is performed by an interventional radiologist, who is specially trained in the procedure. This minimally invasive procedure introduces a thin tube or catheter into the femoral artery in the right groin and guides it through the arterial vasculature to the left and right uterine arteries under x-ray visualization or fluoroscopy. Once in the uterine arteries, the main suppliers of blood for fibroids and the uterus, tiny particles are released to induce arterial blockage. With decreased blood supply, fibroids begin to shrink, bringing improvement in fibroid-related symptoms within weeks to months.

UAE takes approximately one hour. The procedure is usually done on an outpatient basis or with a one night stay at most. Light activity can be resumed after a few days, with full recovery usually in about one week.

Upwards of 90 percent of women may experience some degree of relief from fibroid-related symptoms with UAE. Most women do not experience recurrence of symptoms or regrowth of tumors, although there are no follow-up studies longer than five years.

The desire for future fertility is a relative contraindication to UFE. While there is little data in regarding pregnancy outcomes, the best studies to date, which were published by Jefferson physicians, found higher pregnancy complications in women who had previously undergone UFE compared to the general population and patients who previously underwent myomectomy. Myomectomy remains the gold standard treatment in women desiring future fertility with symptomatic fibroids requiring treatment. More studies are needed to assess the long-term outcomes of UFE and its effects on the ability to conceive and future pregnancies before it can be routine recommended for these women.