Fibroids are common and usually cause no symptoms. However, they can sometimes cause heavy periods, tummy (abdominal) swelling and urinary problems.
What are fibroids?
A fibroid is a non-cancerous (benign) growth of the womb (uterus). They are also called uterine myomas, fibromyomas or leiomyomas. Their size can vary. Some are the same size as a pea and some can be as big as a melon. Fibroids can increase in size, decrease in size or even go away with time. They can occur anywhere in the womb and are named according to where they grow:
- Intramural fibroids grow within the muscle tissue of the womb. This is the most common place for fibroids to form.
- Subserous fibroids grow from the outside wall of the womb into the pelvis.
- Submucous fibroids grow from the inner wall into the cavity of the womb.
- Pedunculated fibroids grow from the wall of the womb and are attached to it by a narrow stalk.
What do fibroids look like?
How common are fibroids?
They are common. It is difficult to know exactly how common they are as many women won't have any symptoms, and so may not know they have fibroids. Probably at least 1 in 2 women develop one or more fibroids in their lifetime, and probably more. They usually develop in women aged 30-50 and can sometimes run in families. It is common to have several fibroids of various sizes, although some women just have one. Fibroids are more common in women from Afro-Caribbean origin. They also tend to be larger, occur at an earlier age and are more likely to cause symptoms in Afro-Caribbean women.
Fibroids are also more common in women who weigh over 70 kg (11 stones). This is thought to be due to the higher levels of oestrogen hormone that occur in obese and overweight women.
Are fibroids cancerous? Can fibroids cause miscarriages or infertility? How are fibroids removed? Do fibroids shrink after menopause? All your questions answered.
What causes fibroids?
A fibroid is an overgrowth of smooth muscle cells, and other cells from the lining of the womb (uterus). The womb is mainly made of smooth muscle. It is not clear why fibroids develop. Fibroids are sensitive to oestrogen and progesterone, the female hormones that are made in the ovary. Fibroids tend to swell when levels of female hormones are high - for example, during pregnancy. They also shrink when levels are low - after the menopause. This shrinkage of the fibroids after the menopause may be delayed if you take hormone replacement therapy (HRT).
Most women who have fibroids are not aware that they have them as they do not have any symptoms. Sometimes one is found during a routine examination by a doctor or by chance during a scan which you may have for another reason. Symptoms may include:
Heavy or more painful periods
Fibroids do not disturb the menstrual cycle but bleeding is often heavier than usual, sometimes with more pain. This can lead to low iron levels and to anaemia which will be diagnosed by a blood test. This is easily treated with iron tablets.
Bloating or swelling
If a fibroid is large you may have discomfort or swelling in the lower tummy (abdomen). Some women experience lower back pain due to their fibroids.
Bladder or bowel symptoms
Occasionally, a fibroid may press on the bladder which lies in front of the womb (uterus). You may then pass urine more often than usual. Rarely, pressure on the bowel (which lies behind the womb) may cause constipation.
Pain during sexual intercourse
If the fibroids grow near to the vagina or neck of the womb (cervix) then this can cause discomfort during sexual intercourse.
Miscarriage or infertility
If the fibroids grow into the cavity of the womb they can sometimes block the Fallopian tubes or interfere with implantation. This can cause problems conceiving, although this is not common. Very rarely, fibroids can be a cause of miscarriages.
Problems during pregnancy
Having one or more fibroids does not cause any problems in the vast majority of women when they are pregnant. Occasionally, you may have pain or discomfort from your fibroid. This may be caused by the fibroid growing too large for its blood supply or twisting, if the fibroid has a stalk (also called pedunculated).
However, fibroids can be associated with an increased risk of having a caesarean section, the baby lying bottom-first rather than head-first (breech) and early labour. Your doctor will advise you further if you are pregnant and have fibroids.
How are fibroids diagnosed?
Some fibroids can be felt during an internal (vaginal) examination by a doctor. Usually an ultrasound scan is done to confirm the diagnosis and to rule out other causes of any symptoms. If periods are heavy, a blood test would usually be done to check you are not anaemic.
If your fibroids are not causing any symptoms then treatment is not usually needed. Many women choose not to have treatment if they have symptoms that are not too bad. After the menopause, fibroids often shrink and symptoms tend to go or ease. You can change your mind and consider treatment if symptoms become worse. Your doctor may advise you to have a repeat scan to assess the growth and size of your fibroids.
Medication to improve symptoms
The following medicines are used to treat heavy periods whatever the cause, including heavy periods that are caused by fibroids. These medicines may not work so well if your fibroids are large. However, one or more of the following may be worth a try if your periods are heavy and the fibroids are small:
- Tranexamic acid is taken 3-4 times a day, for the duration of each period. It works by reducing the breakdown of blood clots in the womb (uterus).
- Anti-inflammatory medicines such as ibuprofen and mefenamic acid. These also help to ease period pain. They are taken for a few days at the time of your period. They work by reducing the high level of a chemical (prostaglandin) in the lining of the womb. Prostaglandin seems to contribute to heavy and painful periods.
- The combined oral contraceptive (COC) pill may help you to have lighter periods and can often help with period pain too. If you are unable to take this, the progestogen-only contraceptive pill (POP) may help. Although there is little evidence for the POP, it seems to help, especially if it makes your periods lighter or stops them altogether.
- The levonorgestrel intrauterine system (LNG-IUS) is a plastic device that sits inside the womb, originally used as a contraceptive. It is inserted into the womb and slowly releases a regular small amount of progestogen hormone called levonorgestrel. It works by making the lining of the womb very thin, so bleeding is lighter. However, it can sometimes be difficult to insert into the womb in women with fibroids.
- Progestogen tablets at certain times in your cycle or the progestogen-only injection. The injection, usually used for contraception, tends to reduce or stop periods.
Medication to shrink the fibroids
Some women are given a gonadotrophin-releasing hormone (GnRH) analogue. This is a hormone medicine that causes you to have a very low level of oestrogen in your body. Fibroids shrink if the level of oestrogen falls. This can ease heavy periods and pressure symptoms due to fibroids. However, a low oestrogen level can cause symptoms similar to going through the menopause (hot flushes, etc). It may also increase the risk of 'thinning' of the bones (osteoporosis). Therefore, this treatment is given for a maximum of six months.
GnRH analogues, such as goserelin or leuprorelin acetate, are often prescribed for three to four months before having an operation. This will make it easier to remove fibroids. Sometimes a low dose of HRT is also given to reduce the incidence of menopausal side-effects.
A medicine called ulipristal acetate (UPA) works by blocking the effects of the hormone progesterone. Progesterone is thought to play a role in fibroid development, so (by blocking progesterone) this medicine shrinks fibroids. Clinical trials have shown that this is a good treatment option as an alternative to GnRH analogues (above) used before surgery for fibroids. It has been used intermittently (up to four courses) for women who have moderate-to-severe problems from their fibroids. However, currently this is not to be used while a safety review is taking place as some women were found to develop liver problems while using it.
Surgery and other operative treatments
There are several different operations available to remove and treat fibroids.
Hysterectomy: this is the traditional and most common treatment for fibroids which cause symptoms. Hysterectomy is the removal of the womb. This can be done by making a bikini line scar in the lower tummy (abdomen). Or, if the fibroids are small enough, the womb can be removed through keyhole (laparoscopic) surgery in the tummy, or through the vagina so there are no scars. A hysterectomy may be a good option for women who have completed their family. See separate leaflet called Hysterectomy.
Myomectomy: this is a possible alternative, especially in women who may wish to have children in the future. In this operation, the fibroids are removed and the womb is left. This procedure is not always possible. This operation can be done through a cut (incision) in the abdomen, via keyhole surgery (laparoscopically) or through the vagina (hysteroscopically). The type of operation depends on the size, number and position of the fibroids. It is fairly common for a fibroid to occur again (recur) after a myomectomy. There is a risk of very heavy bleeding with this operation. Your surgeon should advise you that a hysterectomy may be needed if that situation arises.
Uterine artery embolisation: this procedure is done by a specially trained X-ray doctor (radiologist) rather than a surgeon. It involves putting a thin flexible tube (a catheter) into a blood vessel (artery) in the leg. It is guided, using X-ray pictures, to an artery in the womb that supplies the fibroid. Once there, a substance that blocks the artery is injected through the catheter. As the artery supplying the fibroid becomes blocked it means the fibroid loses its blood supply and so the fibroid shrinks. The complete process of fibroid shrinkage takes about 6-9 months but most women notice a marked improvement in their symptoms within three months. There is a good chance of success with this procedure but nearly one in three women will need further treatment.
Myolysis: this means shrinking the fibroids in some way surgically. There are a number of ways of achieving this, including the following:
- Endometrial ablation: this procedure involves removing the lining of the womb. This can be done by different methods - for example, using laser energy, a heated wire loop or by microwave heating. This method is usually only recommended for fibroids close to the inner lining of the womb. Treatment can be done either through a tube passed through the vagina, or can be guided through the skin by MRI scan.
- MRI-guided focused ultrasound: this treatment sends pulses of high-power ultrasound through the skin of the lower abdomen. It is targeted at the fibroid, using the MRI scanner. It is effective but there is no research yet on the long-term outcome for women trying to conceive.
- Ultrasound-guided high-intensity focused ultrasound: this treatment is guided by ultrasound.
Further reading and references
; NICE CKS, June 2017 (UK access only)
; NICE Interventional Procedures Guidance, November 2010
; NICE Interventional Procedures Guidance, November 2011
; Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med. 2012 Feb 2366(5):421-32. doi: 10.1056/NEJMoa1103180.
; Preoperative medical therapy before surgery for uterine fibroids. Cochrane Database Syst Rev. 2017 Nov 1511:CD000547. doi: 10.1002/14651858.CD000547.pub2.
; Selective progesterone receptor modulators (SPRMs) for uterine fibroids. Cochrane Database Syst Rev. 2017 Apr 264:CD010770. doi: 10.1002/14651858.CD010770.pub2.
; Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2014 Dec 2612:CD005073. doi: 10.1002/14651858.CD005073.pub4.
; NICE Clinical Guideline (August 2016)
; Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Womens Health. 2012 Mar 2612:6. doi: 10.1186/1472-6874-12-6.
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