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 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.
How does the comprehensive approach work for specific illnesses?
Here are some examples:
A patient with allergies, for instance, who is taking conventional medicines to reduce acute symptoms, may also benefit from the elimination of certain trigger foods and the addition of specific nutritional or herbal medicines to balance the immune system.
A patient with fibromyalgia (an autoimmune condition involving chronic muscle pain and fatigue) may benefit from movement therapy to reduce discomfort. There are also often unsuspected underlying causes for pain that a detailed holistic evaluation can uncover.
A patient with irritable bowel syndrome may benefit from both conventional and botanical medicines as well as mindfulness meditation that all work together to relieve intestinal cramps and improve digestion.
A woman seeking menopause counseling may benefit from herbs and other appropriate therapies to ease hot flashes and also learn to modify her diet and exercise to prevent bone loss, heart disease and other postmenopausal conditions.
Can I come to the Institute if I already have a specialist?
Yes. In fact many patients with allergies, arthritis, irritable bowel syndrome and other chronic conditions are referred to us by their physician. We offer a perspective that augments the care that you’ve already received. Our aim is to help you feel better while adding value to your total patient care.
How can patients with cancer benefit from the Institute?
Our staff is trained in a wide range of supportive, complementary therapies that can help to sustain and strengthen the overall health of a person with cancer. Some therapies may help to enhance general immune function. Other therapies are very useful in reducing symptoms such as pain, nausea and anxiety. We incorporate mind/body therapies (including meditation, supportive psychotherapy, yoga and imagery work), nutritional counseling and diet modification, massage therapy, acupuncture and selected herbal and homeopathic medicines. We work closely with you and your doctor to find a program that is beneficial for you.