by Laurie Wertich and Dr. C.H. Weaver M.D. updated 7/2020
You have probably heard the term uterine fibroids, but if you are like many women, you might not really understand what they are, your risk, or treatment options. This is despite the fact that fibroids are fairly common among women during their reproductive years. Uterine fibroids, also called leiomyomas, are estrogen and progesterone-dependent non-cancerous tumors of the uterus and are the most common type of benign tumor in women of reproductive age. Fibroids affect up to 70% women by age 50. Traditionally, uterine fibroids have been primarily managed by surgery and are the leading reason that hysterectomies are performed in the U.S. In June 2020 the United States Food and Drug Administration approved the first oral medication for the treatment of Uterine fibroids which gives women a non surgical treatment option. (4,5)
“As a women’s health issue, fibroids don’t get the attention they deserve, considering their prevalence,” says Vanessa Jacoby, MD, MAS, an assistant professor at the University of California, San Francisco (UCSF) School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences and a faculty member at the UCSF Comprehensive Fibroid Center. But, she explains, fibroids can have a significant impact on a woman’s health and overall quality of life, making them an essential part of our healthcare conversations.
Marisa R. Adelman, MD, a women’s health doctor at the University of Utah Center of Excellence in Women’s Health, describes a uterine fibroid as a “benign tumor of the uterus.” They grow in different parts of the muscle tissue of the uterus, as single or multiple growths, and can range in size from very small to very large.
Also called leiomyomas and myomas, fibroids can cause a variety of symptoms, depending on their size and location. These include bleeding between periods; heavy bleeding during menstruation, sometimes with blood clots; periods that may last longer than normal; needing to urinate more often; pelvic cramping or pain with periods; feeling fullness or pressure in the lower belly; pelvic pressure; and pain during intercourse.
Despite these well-recognized symptoms, not all women with fibroids have such symptoms. According to Dr. Jacoby, about 25 percent of premenopausal women with fibroids have symptoms. “Many more have fibroids,” she explains, “but not symptoms.”
Dr. Adelman adds that because fibroids can be present and not cause symptoms, you might learn that you have fibroids during a physical exam or other gynecological test but not experience any signs.
Who Is At Risk?
Fibroids tend to develop in women during their reproductive years and are most common in women in their thirties and forties. They are rare in women younger than 20 and tend to stop growing or shrink after menopause, but they can occur at any age. (2)
We don’t know exactly what causes uterine fibroids, but given their tendency to develop during reproductive years, hormones seem to be at work. They also appear to run in families, and African-American women tend to develop them more often than do White women.
What Women Want— and Need—To Know
According to Dr. Jacoby, patient concerns about fibroids range from how the condition might affect their health and daily life to their ability to become pregnant. These worries, she says, are valid, as fibroids can have some significant consequences. “For many women it’s a hidden condition that can have a severe impact on their health,” she explains.
Dr. Jacoby says that patients are initially concerned about the impact that uterine fibroids can have on their quality of life, including their ability to work and fulfill daily responsibilities. On the more severe end of the scale, fibroids can cause very heavy periods— so heavy that a woman bleeds through her clothes. When bleeding is hard to control, even with frequently changing sanitary products, it can be hard to go about your normal day, whether you are at work, traveling, or caring for your family. Bleeding caused by fibroids can be so severe that a woman might need a transfusion to replace lost blood. She can also be at risk for severe anemia, where red blood cell levels become very low and cause fatigue and weakness.
There is also an emotional component to fibroid symptoms, particularly heavy bleeding, pain with intercourse, and other issues affecting sexuality. Dr. Jacoby says that some women worry about how this will affect their relationships and ability to enjoy intimacy.
Even with these concerns, Dr. Jacoby says that women can also be hesitant about treatment for fibroids. “They may worry about the impact of treatment because it can require major surgery, such as myomectomy or hysterectomy.” Many women also have trouble finding time for a surgery that requires a recovery phase amid work and family responsibilities.
Some women with fibroids worry about their ability to get pregnant and carry out a healthy pregnancy, but Dr. Jacoby says that this does not tend to be a leading concern. “Fibroids are more common among women in their forties,” she explains, “so many are done having children when they’re diagnosed.” She explains, however, that there is an exception for African-American women: because this population tends to develop fibroids earlier in life, they may still want to have children after diagnosis and treatment.
Treatment: You Have Options
Fibroids are treated only when they cause symptoms. They tend to grow a little each year—though in some women they do not grow at all, and they may actually shrink in others. In most cases, however, fibroids do grow and cause symptoms once they reach a certain size. There is currently no way to prevent fibroids from developing or growing, so treatment once they are symptomatic is the only course of action.
If you have fibroids that were discovered during a medical examination but have not caused symptoms, you do not need treatment yet. In fact, if they never cause a problem, you may never need therapy.
When fibroids do create problems and discomfort that interfere with your quality of life and daily activities, treatment options range from medication and minimally invasive procedures to surgery with myomectomy or hysterectomy. The choice of therapy will depend on the size and location of the fibroids within the uterus and whether you want to preserve fertility or keep your uterus.
“Hysterectomy is a common treatment for fibroids—and many women are happy with how they feel after hysterectomy—but there are many other treatment options to consider,” Dr. Jacoby explains. This surgical removal of the uterus is used to treat such symptoms as pelvic pressure, urinary tract involvement, and other problematic issues, but there are nonsurgical and minimally invasive options (discussed later). Once your uterus is removed, you can no longer become pregnant.
You may also have the option of surgery to remove the fibroids only, leaving the uterus intact, meaning you may still be able to become pregnant. This procedure is known as myomectomy. After the fibroids are removed during surgery, the walls of the uterus are stitched back together. There is a risk that fibroids can grow back after myomectomy, but this risk decreases for women closer to menopause.
Laparoscopic radiofrequency ablation (Acessa™)
Another surgical option to treat fibroids is Acessa. According to Dr. Jacoby, Acessa is considered “minor surgery” because it uses a laparoscope—a thin, lighted tube—that requires only a small incision to view the fibroids. A small probe is then inserted into the uterus and delivers radiofrequency energy to heat and destroy the fibroid. This newer procedure preserves the uterus, but Dr. Jacoby says there are unknowns about future fertility. “We’re still early in our understanding of the impact of Acessa on pregnancy and fertility,” she explains.(3)
If your only fibroid complication is heavy bleeding, you may be able to manage this symptom with medication and avoid any type of surgery. This type of management does not destroy or shrink fibroids but is often an effective way to lessen the inconvenience and emotional toll of heavy periods.
The U.S. Food and Drug Administration (FDA) approved Oriahnn™ (elagolix) with a treatment duration of up to 24 months as the first FDA-approved non-surgical, oral medication option for the management of heavy menstrual bleeding associated with uterine fibroids in pre-menopausal women. Oriahnn is an oral combination of elagolix and E2/NETA (estradiol/norethindrone acetate) to help achieve a balance between the reduction of heavy bleeding and associated hypoestrogenic side effects. (4,5)
In two clinical trials called ELARIS UF-I and ELARIS UF-II, Oriahnn was directly compared to a placebo and in order to determine if a clinically meaningful reduction in bleeding could be achieved. In the direct comparison studies found that seven out of 10 women no longer experiencing heavy menstrual bleeding with Oriahnn compared to only one out of 10 women receiving placebo. Oriahnn also reduced heavy menstrual bleeding due to uterine fibroids by 50 percent within the first month of use. (9) The results from these studies were recently published in The New England Journal of Medicine.
Other medications to manage heavy bleeding include birth control pills—“anything with combined estrogen/progesterone,” Dr. Adelman explains—as well as nonhormone options such as Lysteda® (tranexamic acid).
GnRH [gonadotropin-releasing hormone] agonists, such as Lupron® (leuprolide), can also be used to stop heavy bleeding by blocking production of the female hormone estrogen; but because they can cause unpleasant menopause-like side effects, they are recommended only for very specific cases. And, says Dr. Adelman, “GnRH agonists are not a long-term solution because fibroids will grow when they’re exposed to estrogen again.” They can, however, be helpful in shrinking fibroids before surgery.
Placement of an intrauterine device (IUD) is an additional option, and an alternative to medication and surgery, to manage bleeding. These devices, such as Mirena® (levonorgestrel-releasing intrauterine system), are inserted into the uterus, where they release progestin to decrease heavy bleeding. (3)
Uterine artery embolization and magnetic resonance (MR)–guided focused ultrasound.
There are a couple procedures that are aimed at shrinking the fibroids without surgery: These approaches do not remove or destroy the fibroids but rather control symptoms by making the fibroids smaller. In uterine artery embolization, a radiologist cuts off the blood supply to the fibroids by blocking the arteries that feed them. This is done through a catheter placed in an artery in the groin. In MR-guided focused ultrasound, tightly focused ultrasound waves generate heat that damages fibroids, with the goal of shrinking them. An MRI (magnetic resonance imaging) machine is used to visualize the fibroids and guide the ultrasound, making this procedure noninvasive. (3)
Most Important, You Have Options
The foremost message—and a very encouraging one at that—in uterine fibroid management these days is that you have options. They can be individualized according to your medical needs (your symptoms and the size and location of the fibroids) and your goals with regard to time off work and future pregnancy. Know that these potential solutions exist and that hysterectomy is no longer the only recourse. The key to an outcome you are happy with, says Dr. Jacoby, is “informed choices about treatment options.”
- Uterine Fibroids. MedlinePlus website. Available here. Accessed January 2, 2015.
- Uterine Fibroids. American Congress of Obstetricians and Gynecologists website. Available here. Accessed January 2, 2014.
- Fibroid Treatments. University of California, San Francisco website. Available here. Accessed January 2, 2014
- ORIAHNN™ (elagolix, estradiol and norethindrone acetate capsules co-formulated) [Package Insert]. North Chicago, Ill.: AbbVie Inc.
- Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids
Beyond Hysterectomy: A Patient Pushes For Options and Enjoys A Great Outcome
Though Joan Little of San Diego, California, was suffering from a slew of life-altering fibroid symptoms, she says she balked at her gynecologist’s first suggestion of hysterectomy. Determined to avoid major surgery to remove her uterus, Joan, a retired attorney, began exploring alternatives.
“I did my own research and knew there were other options,” she says. “So I made my way to a fibroid specialist and gynecological surgeon, who went over all options, surgical and nonsurgical, with me at length.” With detailed input and guidance from her doctor, Joan chose laparoscopic myomectomy as well as hysteroscopic myomectomy (performed through the vagina) to remove fibroids in different locations, plus endometrial ablation, a procedure that cauterizes the uterine lining.
Joan says that prior to treatment she suffered from heavy bleeding, anemia, urinary frequency, pelvic and low-back pain, and more. “I couldn’t sleep well, as I would wake up in the middle of the night with lower-back and pelvic discomfort and would need to walk around,” she explains.
Today Joan describes her health as significantly improved: “I feel so much better! I’m very relieved to have the heavy bleeding behind me and very glad I researched my options and found a good doctor to go over all options and who provided me with the treatment options I wanted.”
As part of her research, Joan connected online with other women who were undergoing or had had fibroid treatment. She encourages others to do the same: “Avail yourself of online forums to connect with other women who have had fibroids to get advice and suggestions on treatment options and doctors.” The National Uterine Fibroids Foundation (nuff.org) provides information about fibroids and hosts an online Yahoo Group fibroid forum, where women can connect with other fibroid sufferers and share research, personal stories, and support.