UNC Fibroid Care Clinic

The purpose of UNC Hospitals Fibroid Care Clinic is to provide up-to-date, comprehensive medical information and care for the treatment of uterine fibroids. We offer the full range of diagnostic tests and treatments as well as the benefit of collaboration among gynecology, reproductive endocrinology, and radiology to help coordinate your care. By streamlining the process of diagnosis and treatment, the Fibroid Care Clinic will make it easier for you to make fully informed decisions about treatment for your fibroids. Our Fibroid Care Clinic team is dedicated to answering your questions and providing you with the highest quality medical care.

Learn more about fibroids:

What are uterine fibroids?

What are signs and symptoms of fibroids?

What causes fibroids?

How common are fibroids and who is at risk for fibroids?

How are fibroids diagnosed?

What are available treatments for fibroids?

What effects do fibroids have on pregnancy?

What effects do fibroids have on fertility?

Could my fibroid be a cancer?

What other treatments for fibroids are available or may be available in the future?

What is the UNC Hospital Fibroid Care Clinic?

What are uterine fibroids:

Uterine fibroids are benign (non-cancerous) tumors that grow in or around the wall of the uterus. Fibroids are the most common non-cancerous tumors in women. Fibroids are also known as myomas or leiomyomas. The size of a fibroid can vary from the size of a pea to larger than a cantaloupe. Fibroids are very responsive to the hormones estrogen and progesterone. For instance, the increase of hormones during pregnancy tends to make fibroids grow, and the decrease in hormones during menopause tends to shrink fibroids. Fibroids vary in size, shape and location and often change the shape of the uterus.

The location of a fibroid can be defined as intramural (within the muscle wall of the uterus), submucosal (underlying the lining of the uterine cavity), or subserosal (just beneath the outer covering layer of the uterus). Sometimes a fibroid grows on a stalk (pedunculated) inside or outside the uterus. Fibroids can occur on any part of the uterus, including the lower part or cervix.

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What are possible signs and symptoms of fibroids?

One quarter to one half of women with fibroids have symptoms from them. The most common symptoms include:

• Heavy, prolonged menstrual bleeding
• Severe pain or cramping during menstrual periods
• Pelvic pain or pressure
• Urinary frequency
• Back pain
• Pain during sexual intercourse
• Complications with pregnancy (infertility or miscarriage)

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What causes fibroids?

To date, we do not know what causes fibroids to develop. It is thought that each fibroid arises from a single muscle cell in the uterus that experiences a mutation allowing uncontrolled growth. Studies have shown that tumor growth is encouraged by growth signals and hormones such as estrogen and progesterone. During the childbearing years, a woman’s ovaries are producing more estrogen and progesterone, and fibroids tend to grow. After menopause, fibroids tend to shrink. Current research is looking at links between fibroid development and genetic abnormalities. The exact triggers of these abnormalities are unknown. Most likely, many different factors interact to make fibroids develop and grow.

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How common are fibroids and who is at risk for developing them?

Fibroids are very common and are found in more than one third of women who are child bearing age. They may effect up to 80% of all women, but are less likely to be symptomatic or diagnosed in menopausal women. African-American women are 2-3 times more likely to develop fibroids than Caucasian women. Up to one half of all hysterectomies are performed for symptoms related to fibroids.

Factors that may be associated with fibroids include:

• African-American race (compared to Caucasian)
• Obesity
• Family history of fibroids
• Having never been pregnant (nulliparity)
• Early first period (at less than 10 years of age)
• Birth control pills at an early age (13-16 years of age)
• Heavy alcohol use

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How are fibroids diagnosed?

Fibroids are usually first found on pelvic exam or suspected based on symptoms. More definitive ways to diagnose fibroids include the following:

	Transvaginal ultrasound uses high-frequency sound waves to provide images of structures in the body, such as the uterus, fibroids, ovaries, and other organs.
Sonohysterogram (also known as hydrosonogram) is an ultrasound technique in which sterile water is inserted into the uterus to better see the inside shape of the uterus. This test is helpful for diagnosing and planning treatment for a submuscosal fibroid or polyp.
	Magnetic Resonance Imaging (MRI) uses powerful magnets to produce images of both internal organs and soft tissues of the body. MRI is helpful for locating and measuring uterine fibroids and provides a more detailed image than ultrasound. MRI is commonly used to help determine the treatment plan, especially when the surgical intervention being considered is a myomectomy.
Hysterosalpingogram (HSG) is a special x-ray of the uterus and fallopian tubes after dye is injected into the uterus. HSG can reveal abnormal structures of the uterus and tubes, and is commonly used as a diagnostic tool in an infertility workup.
	Hysteroscopy is a surgical procedure that uses a narrow, lighted telescope-like instrument (hysteroscope) to examine the inside of the uterus. During this procedure, the hysteroscope is passed through the cervix, and a liquid or gas is released to expand the inside of the uterus for better visualization. Hysteroscopy is a minor surgical outpatient procedure that requires IV sedation or light anesthesia. This technique is used to diagnose and treat abnormalities of the uterine cavity (inside of the uterus), such as fibroids, polyps, or scarring.

Endometrial biopsy is a test used to look for abnormal gland cells in the lining of the uterus (the endometrium). The biopsy is done in clinic and requires a thin flexible tube that is passed through the cervix to collect a small piece of endometrium. Endometrial biopsy may be helpful in diagnosing causes of abnormal vaginal bleeding. Mild spotting or cramping may occur during or after the biopsy.

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What are available treatments for fibroids?

Because the vast majority of fibroids are benign, “watchful waiting” is an option for many women who do not have symptoms or pressure on nearby organs. Fibroid growth may be monitored periodically by ultrasound. For women with symptoms who require treatment, there are many options to consider. The most common treatment options for fibroids include: medical management of symptoms, Uterine Artery Embolization (UAE), and surgical treatment. Additional treatments are being researched or are newly available.

Medical Management of fibroid symptoms may include:

• Nonsteroidal Anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used to treat pain associated with fibroids. Besides providing pain relief, NSAIDs limit the uterus’s production of prostaglandins (natural chemicals that cause uterine cramping).
• Oral contraceptive pills (OCPs) or other hormonal contraceptive methods may control pain and bleeding associated with fibroids by making menstrual periods lighter or less frequent. OCPs are not thought to increase fibroid size.
• Progesterone is an hormone made by the ovaries and also available in pill form, (Provera®, Aygestin®, or Megace®), as an injection (Depo Provera®), and in the Mirena® IUD. Progesterone thins the glandular lining of the uterus and can decrease fibroid-related bleeding during treatment. High-dose progesterone is usually avoided as a long-term treatment for fibroids because the effect on fibroid growth is unclear.
• Mirena® intrauterine device (IUD) is a small plastic T-shaped device that is inserted into the uterus to release progesterone hormone locally. The Mirena® IUD is typically used to prevent pregnancy. However, it also decreases menstrual bleeding and therefore has recently been used as a treatment for fibroid-related bleeding. The Mirena® IUD is not thought to increase the size of fibroids.
• Leuprolide or Lupron® (a gonadatropin releasing hormone agonist) is a medication that decreases the body’s production of estrogen and progesterone hormone. Without estrogen and progesterone, fibroids shrink temporarily during treatment. Low estrogen levels may cause menopause-like symptoms such as hot flushes, vaginal dryness, and mood changes. Long-term use may lead to serious bone loss (osteoporosis). Once Lupron® has been discontinued, the hormone levels return to normal and the menopause-like side effects disappear. If the fibroids have not been removed, they rapidly return to previous size. Giving Lupron® or a similar drug for several months before surgery may allow a smaller incision and may also reduce blood loss during surgery in certain situations.

*The role of other medical treatments, such as anti-progestins (mifepristone), selective estrogen-receptor modulators (SERMs) (raloxifene), and androgens (male hormones) such as danacrine (Danazol®), for fibroids is still being investigated. There is currently insufficient scientific data to support the effectiveness of herbal remedies, acupuncture, and other complementary medicine for the treatment of fibroids

Uterine Artery Embolization (UAE)

Uterine artery embolization (UAE) is a radiology-guided procedure that blocks the blood supply to uterine fibroids. This causes fibroids to shrink and reduces symptoms of bleeding and pain or pressure in 60-90% of patients. Fibroids usually decrease by approximately 35-60% in volume. As an example, a treated fibroid that is 10 cm in diameter, after maximum shrinkage, may be expected to be no smaller than 7.4 cm in diameter.

UAE is usually performed under sedation and takes about 1.5 to 2 hours. A radiologist inserts a catheter through a small incision (1⁄4 inch) in the groin area. Using fluoroscopic (x-ray) guidance, the catheter is threaded into the uterine artery. Tiny round particles, the size of grains of sand, are injected into the blood vessels feeding the fibroid. Hospital stay is usually one night and time to full recovery is about 2-3 weeks.

Most women feel some pain and cramping following a UAE. Other symptoms such as nausea, fever, and muscle aches can occur, a condition known as “post-embolization syndrome”. Less common complications include passage of the embolized fibroid through the vagina, vaginal discharge, loss of ovarian function, or severe infection.

UAE offers the advantages of preserving the uterus, a short hospital stay, minimal blood loss, and a fast return to work. UAE does not completely eliminate the fibroid(s) and is appropriate only for certain patients with certain fibroid characteristics. Approximately 5% of patients who have a UAE will sometime later require additional surgical treatment for new or recurrent symptoms. Additional research is required before UAE can be recommended for women who still hope to become pregnant.

To discuss the option of UAE at UNC Hospitals, you can make an appointment with Interventional Radiology at (919) 966-4645.

Surgical Treatment

Myomectomy

Myomectomy is the surgical removal of uterine fibroids without the removal of the uterus. There are several techniques that may be used, and the choice of the technique depends on the location and size of the fibroids as well as the characteristics of the woman. It is sometimes impossible to remove all the fibroids, and new fibroids may grow after a myomectomy. Though myomectomy is the only accepted procedure for fibroids in a woman who wants to maintain fertility, a myomectomy may lead to scarring that can negatively affect future fertility. Following a myomectomy, cesarean delivery is frequently recommended to prevent the myomectomy scar from breaking open during labor. Types of myomectomies include:

• Abdominal myomectomy
• Laparoscopic or Robot-assisted laparoscopic myomectomy
• Hysteroscopic myomectomy

Hysterectomy

Hysterectomy is a surgery to remove the uterus. It prevents future pregnancy and eliminates fibroid-related bleeding and pressure symptoms. A hysterectomy is the surgical treatment of choice for women with symptomatic fibroids who have completed childbearing.

There are two categories of hysterectomy:

• Total hysterectomy is removal of the entire uterus, including the cervix (the lower part of the uterus).

• Supra-cervical hysterectomy is removal of the upper part of the uterus, but not the cervix. This type of surgery is not recommended for women with a history of an abnormal Pap smear or certain types of pelvic pain. Up to 5-10% of women may continue to have chronic cyclic bleeding after surgery, similar to a period. It was previously thought that a supra-cervical hysterectomy would preserve sexual function better than a total hysterectomy, but research does not support this theory. Benefits to supra-cervical hysterectomy include slightly faster surgery and shorter recovery time.

Possible complications of hysterectomy include: bleeding, infection, injury to surrounding organs, blood vessels, and nerves. After laparoscopic surgery, pain may be felt in the shoulders which is often due to irritation from the gas used to inflate the abdomen prior to surgery.

Depending on factors such as a uterus size, previous surgery or scarring, and obesity, a hysterectomy can be performed by one of the following techniques:

• Abdominal hysterectomy
• Vaginal hysterectomy
• Laparoscopic or Robot-assisted laparoscopic hysterectomy

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What effects do fibroids have on pregnancy?

Most women with fibroids have uncomplicated pregnancies. However, some women may have trouble conceiving or may experience early pregnancy loss, vaginal bleeding, preterm delivery, breech birth (baby emerges buttocks or feet first), or other complications of pregnancy. These complications generally occur in the setting of submucosal fibroids or those fibroids that change the shape of the uterine cavity. Large fibroids may block the opening of the uterus enough to prevent a baby from delivering head-first, leading to a cesarean delivery. Additionally, during pregnancy estrogen and progesterone hormones increase, which causes some fibroids to grow quickly. Other fibroids shrink or stay the same size. Some fibroids may outgrow their blood supply and degenerate (deteriorate), which can cause pain. Surgery for fibroids is rarely performed during pregnancy.

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What effects do fibroids have on fertility?

Couples who are experiencing infertility in the setting of a woman’s fibroids may need additional workup to determine whether there are other causes of infertility besides the fibroid. This evaluation may include:

• Semen analysis
• Blood tests to determine the function of the ovaries and the levels of hormones important to pregnancy
• Tests for blockage of the fallopian tubes (Hysterosalpingogram or HSG)

If all other factors are favorable, removal of some fibroids (myomectomy) can help improve the chances of pregnancy and may be recommended. During a myomectomy, incisions are made in the wall of the uterus. These healed incisions may rupture under the stress of labor, and a cesarean delivery is often recommended for future pregnancies. Additionally, healing of the uterus after a myomectomy may result in scarring between the uterus, ovaries, fallopian tubes, and bowel. This scarring may decrease chances for pregnancy or make future surgery difficult.

Many available treatments used to manage the symptoms of fibroids, either delay pregnancy or are not recommended if a woman desires future pregnancy. Some of these medications or treatments include:

• Leuprolide or Lupron® (a gonadatropin releasing hormone agonist) is a drug used to temporarily shrink fibroids or to control bleeding, but it also prevents pregnancy when using it.
• Endometrial ablation is a technique that uses heat or electricity to destroy the lining of the uterus to reduce the amount of menstrual bleeding. It is not recommended for women who wish to get pregnant.
• Uterine artery embolization (UAE) is not recommended for women who want to become pregnant because the decreased blood supply to the uterus may interfere with normal fetal growth and development. Rarely, UAE may lead to an early menopause.

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Could my fibroid be a cancer?

Fibroids are rarely malignant (cancer). In fact, over 99% of uterine tumors that appear to be fibroids on imaging (ultrasound or MRI) are benign (not cancer). If a fibroid has a worrisome appearance on imaging, the woman may be recommended to have a hysterectomy instead of a myomectomy. Other worrisome findings include a fibroid that grows very rapidly, particularly in a woman who has experienced menopause.

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What other treatments for fibroids are available or may be available in the future?

A number of other treatments have been explored for fibroids. One of the newest treatments to be approved is ultrasound ablation of fibroids (Magnetic Resonance-guided Ultrasound Surgery for Fibroids (MRgFUS), ExAblate 2000®, InSightec.) This technique uses ultrasound waves to heat and destroy fibroid cells (a process called thermoablation). The procedure is performed under MRI-guidance while the woman is awake but sedated and generally takes several hours. Large studies are not yet available on this technique. In those women studied, more than half have experienced a decrease in symptoms, and complications have been few. MRgFUS is currently available only in certain states. More information can be found at www.uterine-fibroids.org.

Other treatments for fibroids exist and are supported by small studies. These treatments include myolysis (destruction of fibroid tissue using heat or cold) and laparoscopic uterine artery ligation (tying off the main blood supply to the uterus to shrink the fibroid). These treatments are not widely performed and it is best to speak directly with a doctor about the details of their availability and safety.

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What is the UNC Hospital Fibroid Care Clinic?

The University of North Carolina Fibroid Care Clinic is a new treatment model designed to provide up-to-date, comprehensive medical information and care for the treatment of women with uterine fibroids. We offer the full range of diagnostic test and treatments including minimally-invasive treatments such as laparoscopic (and robotic) myomectomy and hysterectomy, hysteroscopic myomectomy, and uterine artery embolization. The Fibroid Care Clinic also offers the benefit of close collaboration between gynecology, reproductive endocrinology, and radiology to help coordinate your care. By streamlining the process of diagnosis and treatment, the Fibroid Care Clinic hopes to reduce the strain you experience associated with having fibroids and getting them treated. Our Fibroid Care Clinic staff is dedicated to answering your questions and providing you with the highest quality medical care. We look forward to serving you. Below is our staff and contact information.

Dr. John Steege, Division Chief, Fibroid Care Clinic Director

Dr. Charles Burke - Department of Radiology, Division of Vascular Interventional

Dr. Robert Dixon - Department of Radiology, Division of Vascular Interventional

Dr. Marc Fritz, Division Chief - Department of OB/GYN, Division of Reproductive Endocrinology & Infertility

Jaclyn Green, ACNP - Department of Radiology, Division of Vascular Interventional

Dr. Matthew Mauro - Department of Radiology, Division of Vascular Interventional

Dr. Cameron Mouro - Department of OB/GYN, Division of Women's Primary Healthcare

Dr. Joseph Stavas, Section Chief - Department of Radiology, Division of Vascular Interventional

Dr. Anne Steiner - Department of OB/GYN, Division of Reproductive Endocrinology & Infertility

Dr. Steve Young - Department of OB/GYN, Division of Reproductive Endocrinology & Infertility

Dr. Denniz Zolnoun - Department of OB/GYN, Division of Advanced Laparoscopy & Pelvic Pain

Other websites for additional information:
www.medlineplus.gov
Medline Plus is a service of the US National Library of Medicine and the National Institutes of Health. This information is also available in Spanish.
www.womenshealth.gov
The Federal Government Source for Women’s Health Information.
www.sirweb.org
Society for Interventional Radiology.
www.nuff.org
National Uterine Fibroids Foundation

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