Fibroids: When They’re a Problem and When They’re Not
Fibroids are mysterious in their size, shape, and symptoms. Let me try to demystify them a bit.
Fibroids (or leiomyomas, or myomas) are benign tumors of the uterus. Fibroids are very common – as many as 80% of women have them (1). They often run in families and are slightly more common in Black women (2). Fibroids can be on the surface of the uterus (subserosal), within the muscular wall (intramural), or bulging into the cavity of the uterus (submucosal).
Most women with fibroids do not have symptoms and do not need any treatment at all (3). It may be reasonable to have a yearly pelvic exam &/or ultrasound to track possible growth of the fibroid(s). Having said that, while only about a quarter of women with fibroids have symptoms, these symptoms may significantly impact quality of life. Symptoms are most influenced by size and location and fall into four general categories:
- Heavy or prolonged menstrual bleeding (menorrhagia)
- Pain, including painful menses (dysmenorrhea) or nonmenstrual pain
- Size-related symptoms, such as bowel or bladder problems, pelvic pressure, pain with intercourse, or abdominal fullness
- Fertility and pregnancy-related problems
Whether you need treatment for fibroids depends mostly on your symptoms and your desire for future pregnancies (4):
- For most women, especially if they need contraception, combined estrogen-progestin contraceptives (birth control pills) work really well in controlling the heavy menstrual bleeding and pain associated with fibroids, while also providing excellent contraception and other health benefits as well. They are considered first-line treatment for fibroids (4). If you do not want to or cannot take typical birth control pills, then progestin-releasing intrauterine devices (IUDs)also control pain and bleeding well. Do be aware, though, that if you have submucosal fibroids, there’s a greater chance of spontaneous IUD For many women, progestin injections (e.g., Depo-Provera) are also effective, but sometimes the side effect of unexpected bleeding is an unwanted or even difficult issue to control.
- If your only symptom is pain during your period (dysmenorrhea), then over-the-counter non-steroidal pain medications such as naproxen or ibuprofen may be enough. Be sure to start the pain medication with the very first twinge of menstrual pain. The medication is much less effective if the pain is already severe.
- If you have heavy bleeding during your period, there are several considerations. You may need an iron supplement to keep you from acquiring or reversing anemia – you should also have your blood count checked periodically to monitor that. In addition, tranexamic acid (4) is a non-hormonal oral medication that can be taken during menses or during the heavy days of menses to control bleeding. Gonadotropin Releasing Hormone (GNRH) analogs can also control bleeding, but they cause menopausal symptoms, such as hot flashes and vaginal dryness, along with possible bone loss. They are most often used prior to surgery to temporarily shrink the fibroid(s) in order to minimize blood loss during the operation (4).
Fibroids & Pregnancy
While most women with fibroids have no pregnancy-related problems, that is not always the case, especially if there are fibroids that distort the endometrial cavity. Infertility, pregnancy loss, and premature deliveries are all possible. Surgical treatment (hysteroscopic myomectomy) is often very effective in removing submucosal fibroids.
Having said that, for the vast majority of women who want to become pregnant, experts to not recommend the removal of asymptomatic or minimally symptomatic fibroids before pregnancy has been attempted. The reason is that fibroids often do not affect pregnancy; what is more, even after fibroids are removed, there’s a large chance of new fibroid formation. Also, surgery has its own risks in itself and for causing future fertility and pregnancy problems (4).
When to Do More
If you have fibroids with moderate or severe symptoms, an interventional procedure may be the best way to treat them. There are many options (4, 5), including:
- Hysterectomy (removal of the uterus)
- Myomectomy (removal of a fibroid)
- Endometrial ablation (removal or destruction of the uterine lining)
- Uterine artery embolization (blocking the blood supply to a fibroid to make it shrink)
These procedures differ in terms of risks, benefits, fertility prevention, invasiveness, and other factors. Particularly if you are considering pregnancy in the future, I highly recommend a consultation with a fertility specialist.
Getting Older Can Be a Good Thing!
If you are close to the age of menopause, I have good news for you. Fibroids, and their symptoms, usually regress when women reach menopause, so hang in there (6)! Of course, if there is fibroid-associated bleeding or growth, be sure to see your physician right away.
As you can see, fibroids are complicated, and so is their treatment! Find a doctor who is expert in this area and who is willing to work in partnership with you, taking into account your priorities. Feel free to email me any time (firstname.lastname@example.org). Since I’m not your doctor, I can’t answer your specific concerns, but I’ll try to steer you in the right direction.
(1)Baird DD et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003; 188(1):100-7.
doi: 10.1067/mob.2003.99. PMID: 12548202.
(2) Giuliani E et al. Epidemiology and management of uterine fibroids. Int J Gynaecol Obstet. 2020;149(1):3-9.
doi: 10.1002/ijgo.13102. Epub 2020 Feb 17. PMID: 31960950.
(3) Wise LA, Laughlin-Tommaso SK. Epidemiology of Uterine Fibroids: From Menarche to Menopause. Clin Obstet Gynecol. 2016;59(1):2-24.
doi: 10.1097/GRF.0000000000000164. PMID: 26744813; PMCID: PMC4733579.
(4) Stewart EA. UpToDate 2021.
(6) Ulin M et al. Uterine fibroids in menopause and perimenopause. Menopause. 2020; 27(2):238-242.
doi: 10.1097/GME.0000000000001438. PMID: 31834160; PMCID: PMC6994343.