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Fibroid locations

Uterine fibroids are noncancerous growths of the uterus that often appear during your childbearing years. Also called fibromyomas, leiomyomas or myomas, uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer.

As many as 3 out of 4 women have uterine fibroids sometime during their lives, but most are unaware of them because they often cause no symptoms. Your doctor may discover them incidentally during a pelvic exam or prenatal ultrasound.

In general, uterine fibroids cause no problems and seldom require treatment. Medical therapy and surgical procedures can shrink or remove fibroids if you have discomfort or troublesome symptoms. Rarely, fibroids can require emergency treatment if they cause sudden, sharp pelvic pain or profuse menstrual bleeding.

In women who have symptoms, the most common symptoms of uterine fibroids include:

• Heavy menstrual bleeding
• Prolonged menstrual periods — seven days or more of menstrual bleeding
• Pelvic pressure or pain
• Frequent urination
• Difficulty emptying your bladder
• Constipation
• Backache or leg pains

Rarely, a fibroid can cause acute pain when it outgrows its blood supply. Deprived of nutrients, the fibroid begins to die. Byproducts from a degenerating fibroid can seep into surrounding tissue, causing pain and fever. A fibroid that hangs by a stalk inside or outside the uterus (pedunculated fibroid) can trigger pain by twisting on its stalk and cutting off its blood supply.

Fibroid location influences your signs and symptoms:

• Submucosal fibroids. Fibroids that grow into the inner cavity of the uterus (submucosal fibroids) are thought to be primarily responsible for prolonged, heavy menstrual bleeding and are a problem for women attempting pregnancy.
• Subserosal fibroids. Fibroids that project to the outside of the uterus (subserosal fibroids) can sometimes press on your bladder, causing you to experience urinary symptoms. If fibroids bulge from the back of your uterus, they occasionally can press either on your rectum, causing constipation, or on your spinal nerves, causing backache.

When to see a doctor
See your doctor if you have:

• Pelvic pain that doesn't go away
• Overly heavy or painful periods
• Spotting or bleeding between periods
• Pain with intercourse
• Difficulty emptying your bladder
• Difficulty moving your bowels

Seek prompt medical care if you have severe vaginal bleeding or sharp pelvic pain that comes on suddenly.

Uterine fibroids develop from the smooth muscular tissue of the uterus (myometrium). A single cell reproduces repeatedly, eventually creating a pale, firm, rubbery mass distinct from neighboring tissue.

Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. They can be single or multiple, in extreme cases expanding the uterus so much that it reaches the rib cage.

Doctors don't know the cause of uterine fibroids, but research and clinical experience point to several factors:

• Genetic alterations. Many fibroids contain alterations in genes that code for uterine muscle cells.
• Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and estrogen receptors than do normal uterine muscle cells.
• Other chemicals. Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.

There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Other factors include:

• Heredity. If your mother or sister had fibroids, you're at increased risk of also developing them.
• Race. Black women are more likely to have fibroids than are women of other racial groups. In addition, black women have fibroids at younger ages, and they're also likely to have more or larger fibroids.

Areas of research
Research examining other potential risk factors continues in these areas:

• Obesity. Some studies have suggested that obese women are at higher risk of fibroids, but other studies have not shown a link.
• Oral contraceptives. So far, strong data exist showing that women who take oral contraceptives have a lower risk of fibroids. This is generally true for all women, except those who start oral contraceptives between ages 13 and 16.
• Pregnancy and childbirth. Researchers have also looked at whether pregnancy and giving birth may have a protective effect, and so far pregnancy and childbirth seem to have a protective effect.

Although uterine fibroids usually aren't dangerous, they can cause discomfort and may lead to complications such as anemia from heavy blood loss. In rare instances, fibroid tumors can grow out of your uterus on a stalk-like projection. If the fibroid twists on this stalk, you may develop a sudden, sharp, severe pain in your lower abdomen. If so, seek medical care right away. You may need surgery.

Pregnancy and fibroids
Because uterine fibroids typically develop during the childbearing years, women with fibroids are often concerned about their chances of a successful pregnancy.

Fibroids usually don't interfere with conception and pregnancy. However, they can rarely distort or block your fallopian tubes, or interfere with the passage of sperm from your cervix to your fallopian tubes. Submucosal fibroids may prevent implantation and growth of an embryo.

Research indicates that pregnant women with fibroids are at slightly increased risk of miscarriage, premature labor and delivery, abnormal fetal position, and separation of the placenta from the uterine wall. But not all studies confirm these associations. Furthermore, complications vary based on the number, size and location of fibroids. Multiple fibroids and large submucosal fibroids that distort the uterine cavity are the type most likely to cause problems. A more common complication of fibroids in pregnancy is localized pain, typically between the first and second trimesters. This is usually easily treated with pain relievers.

In most cases, fibroids don't interfere with pregnancy, and treatment isn't necessary. It was once believed that fibroids grew faster during pregnancy, but multiple studies suggest otherwise. Most fibroids remain stable in size, although some may increase or decrease slightly, usually in the first trimester.

If you have fibroids and you've experienced repeated pregnancy losses, your doctor may recommend removing one or more fibroids to improve your chances of carrying a baby to term, especially if no other causes of miscarriage can be found and if your fibroids distort the shape of your uterine cavity.

Doctors usually don't remove fibroids in conjunction with a cesarean section because of the greater risk of excessive bleeding.

Your first appointment will likely be with either your primary care provider or a gynecologist.

Because appointments can be brief, and it can be difficult to remember everything you want to discuss, it's a good idea to prepare in advance of your appointment.

What you can do

• Write down any symptoms you're experiencing. Include all of your symptoms, even if you don't think they're related.
• Make a list of any medications and vitamin supplements you take. Write down doses and how often you take them.
• Have a family member or close friend accompany you, if possible. You may be given a lot of information at your visit, and it can be difficult to remember everything.
• Take a notebook or notepad with you. Use it to write down important information during your visit.
• Prepare a list of questions to ask your doctor. List your most important questions first, in case time runs out.

For uterine fibroids, some basic questions to ask include:

• How many fibroids do I have? How big are they?
• Are the fibroids located on the inside or outside of my uterus?
• Will they keep getting bigger?
• What kinds of tests might I need?
• How much experience do you have in diagnosing and treating uterine fibroids?
• What medications are available to treat uterine fibroids? Is there a certain medication that can improve my symptoms?
• What side effects can I expect from medication use?
• Under what circumstances do you recommend surgery?
• Will I need a medication before or after surgery?
• What kind of problems can fibroids cause?
• Will uterine fibroids affect my ability to become pregnant?
• Can treatment of uterine fibroids improve my fertility?
• Can you recommend any alternative treatments I might try?

Make sure that you understand completely everything that your doctor tells you. Don't hesitate to ask your doctor to repeat information or to ask follow-up questions for clarification.

What to expect from your doctor
Some potential questions your doctor might ask include:

• How often do you experience these symptoms?
• How long have you been experiencing symptoms?
• How severe are your symptoms?
• Do your symptoms seem to be related to your menstrual cycle?
• Does anything improve your symptoms?
• Does anything make your symptoms worse?
• Do you have a family history of uterine fibroids?

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Pelvic examination

Uterine fibroids are frequently found incidentally during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus through your abdomen, suggesting the presence of fibroids.

Ultrasound
If confirmation is needed, your doctor may obtain an ultrasound — a painless exam that uses sound waves to obtain a picture of your uterus — to confirm the diagnosis and to map and measure fibroids. A doctor or technician moves the ultrasound device (transducer) over your abdomen (transabdominal) or places it inside your vagina (transvaginal) to obtain images of your uterus.

Transvaginal ultrasound provides more detail because the probe is closer to the uterus. Transabdominal ultrasound visualizes a larger anatomic area. Sometimes, fibroids are discovered during an ultrasound conducted for a different purpose, such as during a prenatal ultrasound.

Other imaging tests
If traditional ultrasound doesn't provide enough information, your doctor may order other imaging studies, such as:

• Hysterosonography. This ultrasound variation uses sterile saline to expand the uterine cavity, making it easier to obtain interior images of the uterus. This test may be useful if you have heavy menstrual bleeding despite normal results from traditional ultrasound.
• Hysterosalpingography. This technique uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Your doctor may recommend it if infertility is a concern. In addition to revealing fibroids, it can help your doctor determine if your fallopian tubes are open.
• Hysteroscopy. Your doctor inserts a small, lighted telescope called a hysteroscope through your cervix into your uterus. Your doctor injects (instills) saline into your uterus expanding the uterine cavity and allowing your doctor to examine the walls of your uterus and the openings of your fallopian tubes. A hysteroscopy can be performed in your doctor's office.

Imaging techniques that may occasionally be necessary include computerized tomography (CT) and magnetic resonance imaging (MRI).

Other tests
If you're experiencing abnormal vaginal bleeding, your doctor may want to conduct other tests to investigate potential causes. He or she may order a complete blood count (CBC) to determine if you have iron deficiency anemia because of chronic blood loss. Your doctor may also order blood tests to rule out bleeding disorders and to determine the levels of reproductive hormones produced by your ovaries.

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Using embolic agents to stop blood flow

There's no single best approach to uterine fibroid treatment. Many treatment options exist. In most cases, the best action to take after discovering fibroids is simply to be aware they are there.

Watchful waiting
If you're like most women with uterine fibroids, you have no signs or symptoms. In your case, watchful waiting (expectant management) could be the best course. Fibroids aren't cancerous. They rarely interfere with pregnancy. They usually grow slowly and tend to shrink after menopause when levels of reproductive hormones drop. This is the best treatment option for a large majority of women with uterine fibroids.

Medications
Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don't eliminate fibroids, but may shrink them. Medications include:

• Gonadotropin-releasing hormone (Gn-RH) agonists. To trigger a new menstrual cycle, a control center in your brain called the hypothalamus manufactures gonadotropin-releasing hormone (Gn-RH). The substance travels to your pituitary gland, a tiny gland also located at the base of your brain, and sets in motion events that stimulate your ovaries to produce estrogen and progesterone.

  Medications called Gn-RH agonists (Lupron, Synarel, others) act at the same sites that Gn-RH does. But when taken as therapy, a Gn-RH agonist produces the opposite effect to that of your natural hormone. Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves.

• Progestin-releasing intrauterine device (IUD). If you have fibroids that don't distort your inner uterus, a progestin-releasing IUD can relieve heavy bleeding and pain caused by the fibroids. A progestin-releasing IUD provides symptom relief only and doesn't shrink fibroids or make them disappear.

• Androgens. Your ovaries and your adrenal glands, located above your kidneys, produce androgens, the so-called male hormones. Given as medical therapy, androgens can relieve fibroid symptoms.

  Danazol, a synthetic drug similar to testosterone, may effectively stop menstruation, correct anemia and even shrink fibroid tumors and reduce uterine size. However, occasional unpleasant side effects, such as weight gain, dysphoria (feeling depressed, anxious or uneasy), acne, headaches, unwanted hair growth and a deeper voice, make many women reluctant to take this drug.

• Other medications. Oral contraceptives or progestins can help control menstrual bleeding, but they don't reduce fibroid size. Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, are effective for heavy vaginal bleeding unrelated to fibroids, but they don't reduce bleeding caused by fibroids.

Hysterectomy
This operation — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. It ends your ability to bear children, and if you elect to have your ovaries removed also, it brings on menopause and the question of whether you'll take hormone replacement therapy. Most women with uterine fibroids can choose to keep their ovaries.

Myomectomy
In this surgical procedure, your surgeon removes the fibroids, leaving the uterus in place. If you want to bear children, you might choose this option. With myomectomy, as opposed to a hysterectomy, there is a risk of fibroid recurrence. There are several ways a myomectomy can be done:

• Abdominal myomectomy. If you have multiple fibroids, very large or very deep fibroids, your doctor may use an open abdominal surgical procedure to remove the fibroids.
• Laparoscopic myomectomy. If the fibroids are small and few in number, you and your doctor may opt for a laparoscopic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. Your doctor views your abdominal area on a remote monitor via a small camera attached to one of the instruments. Use of a surgical robot now allows for removal of more fibroids or larger fibroids.
• Hysteroscopic myomectomy. This procedure may be an option if the fibroids are contained inside the uterus (submucosal). A long, slender scope (hysteroscope) is passed through your vagina and cervix and into your uterus. Your doctor can see and remove the fibroids through the scope. This procedure is best performed by a doctor experienced in this technique.

Other procedures to shrink or destroy fibroids
Certain procedures can destroy uterine fibroids without actually removing them through surgery. They include:

• Myolysis. In this laparoscopic procedure, an electric current or laser destroys the fibroids and shrinks the blood vessels that feed them. A similar procedure called cryomyolysis uses liquid nitrogen to freeze the fibroids. The safety, effectiveness and associated risk of fibroid recurrence of myolysis and cryomyolysis have yet to be determined.
• Endometrial ablation. This treatment, performed with a specialized instrument inserted into your uterus uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow. Endometrial ablation is effective in stopping abnormal bleeding, but doesn't affect fibroids outside the interior lining of the uterus.
• Uterine artery embolization. Small particles (embolic agents) injected into the arteries supplying the uterus cut off blood flow to fibroids, causing them to shrink. This technique, performed by an interventional radiologist, is proving effective in shrinking fibroids and relieving the symptoms they can cause. Advantages over surgery include no incision and a shorter recovery time. Complications may occur if the blood supply to your ovaries or other organs is compromised.

Focused ultrasound surgery
MRI-guided focused ultrasound surgery (FUS) is a noninvasive treatment option for uterine fibroids that preserves your uterus.

This procedure is performed while you're inside of a specially crafted MRI scanner that allows doctors to visualize your anatomy, and then locate and destroy (ablate) fibroids inside your uterus without making an incision. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids. A single treatment session is done in an on- and off-again fashion, sometimes spanning several hours. Initial results with this technology are promising, but its long-term effectiveness is not yet known.

Before you decide
Because fibroids aren't cancerous and usually grow slowly, you have time to gather information before making a decision about if and how to proceed with treatment. The option that's right for you depends on a number of factors, including the severity of your signs and symptoms, your plans for childbearing, how close you are to menopause, and your feelings about surgery.

Before making a decision, consider the pros and cons of all available treatment options in relation to your particular situation. Remember, most women don't need any treatment for uterine fibroids.

You may have seen on the Internet, or in books focusing on women's health, alternative treatments, such as certain dietary recommendations, enzymes, hormone creams or homeopathy, which combine stress reduction techniques and herbal preparations.

More research is necessary to determine whether dietary practices or other methods can help prevent or treat fibroids. So far, there's no scientific evidence to support the effectiveness of these techniques.

Although researchers continue to study the causes of fibroid tumors, little scientific advice is available on how to prevent them. Preventing uterine fibroids may not be possible, but you can take comfort in the fact that only a small percentage of these tumors require treatment.