Uterine Fibroids

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
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What are uterine fibroids?

Uterine fibroids are lumps that grow on your uterus. You can have fibroids on the inside , on the outside , or in the wall of your uterus.

Your doctor may call them fibroid tumors, leiomyomas, or myomas. But fibroids are not cancer. You do not need to do anything about them unless they are causing problems.

Fibroids are very common in women in their 30s and 40s. By the time they are 50, about 80 women out of 100 have fibroids. But fibroids usually do not cause problems. Many women never even know they have them.

What causes uterine fibroids?

Doctors are not sure what causes fibroids. But the female hormones estrogen and progesterone seem to make them grow. Your body makes the highest levels of these hormones during the years when you have periods.

Your body makes less of these hormones after you stop having periods (menopause). Fibroids usually shrink after menopause and stop causing symptoms.

What are the symptoms?

Often, fibroids do not cause symptoms. Or the symptoms may be mild, like periods that are a little heavier than normal. If the fibroids bleed or press on your organs, the symptoms may make it hard for you to enjoy life. Fibroids make some women have:

• Long, gushing periods and cramping.
• Fullness or pressure in their belly.
• Low back pain.
• Pain during sex.
• An urge to urinate often.

Heavy bleeding during your periods can lead to anemia. Anemia can make you feel weak and tired.

Sometimes, fibroids can make it harder to get pregnant. Or they may cause problems during pregnancy, such as going into early labor or losing the baby (miscarriage).

How are uterine fibroids diagnosed?

To find out if you have fibroids, your doctor will ask you about your symptoms. He or she will do a pelvic exam to check the size of your uterus.

Your doctor may send you to have an ultrasound or another type of test that shows pictures of your uterus. These help your doctor see how large your fibroids are and where they are growing.

Your doctor may also do blood tests to look for anemia or other problems.

How are they treated?

If your fibroids are not bothering you, you do not need to do anything about them. Your doctor will check them during your regular visits to see if they have gotten bigger.

If your main symptoms are pain and heavy bleeding, try an over-the-counter pain medicine like ibuprofen, and ask your doctor about birth control pills. These can help you feel better and make your periods lighter. If you have anemia, take iron pills and eat foods that are high in iron, like meats, beans, and leafy green vegetables.

If your symptoms bother you a lot, you may want to think about surgery. Most of the time fibroids grow slowly, so you can take time to consider your choices.

There are two main types of surgery for fibroids. Which is better for you depends on how big your fibroids are, where they are, and whether you want to have children.

• Surgery to take out the fibroids is called myomectomy. Your doctor may suggest it if you hope to get pregnant or just want to keep your uterus. It may improve your chances of having a baby. But it only works if your fibroids are small, and they may grow back.
• Surgery to take out your uterus is called hysterectomy. This is the most common surgery for fibroids. And it is the only way to make sure that fibroids will not come back. Your symptoms will go away, but you will not be able to get pregnant.

It is normal to have mixed feelings about hysterectomy. Some women are sad to lose part of what makes them a woman. Other women just want their symptoms to go away. If you are thinking about hysterectomy, learn all you can about it. This will help you make the choice that is right for you.

There are a number of other ways to treat fibroids. One newer treatment is called uterine fibroid embolization. It can shrink fibroids. It may be a choice if you do not want to have children but want to keep your uterus. It is not a surgery, so you feel better soon. But fibroids may grow back.

If you are near menopause, you might try medicines to treat your symptoms. Heavy periods will stop after menopause.

Frequently Asked Questions

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	Should I have surgery to treat uterine fibroids?
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	Should I use GnRH-a therapy to treat uterine fibroids?

The exact cause of uterine fibroids is not known. Fibroids begin when cells overgrow in the muscular wall of the uterus.

Once a fibroid develops, the hormones estrogen and progesterone appear to influence its growth. A woman's body produces the highest levels of these hormones during her childbearing years. After menopause, when hormone levels decline, fibroids usually shrink or disappear.

Estrogen is thought to play a major role in fibroid growth because fibroids:

• Tend to grow larger when a woman's body produces more estrogen (during pregnancy).
• Usually shrink when a woman's body produces less estrogen (after menopause).

Progesterone also seems to stimulate fibroid growth, even when estrogen is not present.¹

Uterine fibroid symptoms can develop slowly over several years or rapidly over several months. Most women with uterine fibroids have mild symptoms or none at all and never need treatment.

For some women, uterine fibroid symptoms become a problem. Pain and heavy menstrual bleeding are the most common symptoms. In some cases, difficulty becoming pregnant is the first sign of fibroids.

Uterine fibroid symptoms and problems include:

• Abnormal menstrual bleeding. Up to 30% of women with fibroids have menstrual period changes, such as:^{2, 3}
  • Heavier, prolonged periods that can cause anemia.
  • Painful periods.
  • Spotting before or after periods.
  • Bleeding between periods.
• Pelvic pain and pressure, such as:
  • Pain in the abdomen, pelvis, or low back.
  • Pain during sexual intercourse.
  • Bloating and feelings of abdominal pressure.
• Urinary problems, such as:
  • Frequent urination.
  • Leakage of urine (urinary incontinence).
  • Kidney blockage following ureter blockage (rare).
• Other symptoms, such as:
  • Difficulty or pain with bowel movements.
  • Infertility. Sometimes, fibroids make it difficult to become pregnant.
  • Problems with pregnancy, such as placental abruption and premature labor.
  • Miscarriage.

Uterine fibroids can grow on the inside wall of the uterus , within the muscle wall of the uterus , or on the outer wall of the uterus . They can alter the shape of the uterus as they grow. Over time, the size, shape, location, and symptoms of fibroids can change. See an illustration of the female pelvic organs .

As women age, they are more likely to have uterine fibroids, especially from their 30s and 40s through menopause (around age 50). About 80% of women have uterine fibroids by the time they reach age 50.⁴ Uterine fibroids can stay the same for years with few or no symptoms, or you can have a sudden, rapid growth of fibroids.^{5, 2}

Fibroids do not grow before the start of menstrual periods (puberty). They sometimes grow larger during pregnancy, and they usually shrink after menopause. The use of estrogen replacement therapy (ERT) can cause fibroids to grow after menopause.

Complications of uterine fibroids are not common. They include:

• Anemia from heavy bleeding.
• Blockage of the urinary tract or bowels, if a fibroid presses on them.
• Infertility, if the fibroids change the shape of the uterus or the location of the fallopian tubes.
• Ongoing low back pain or a feeling of pressure in the lower abdomen (pelvic pressure).
• Infection or a breakdown of uterine fibroid tissue.

Fibroids can cause problems during pregnancy, such as:

• Miscarriage.
• Pain during the second and third trimesters.
• An abnormal fetal position, such as breech position, at birth.
• Premature labor.
• The need for a cesarean section delivery.

Factors that increase a woman's risk of developing uterine fibroids include:^{6, 4}

• Age. Fibroids become more common as women age, especially from the 30s and 40s through menopause. About 80% of women develop uterine fibroids by the time they reach age 50. After menopause, fibroids usually shrink.
• Family history. Having a family member with fibroids increases your risk.
• Ethnic origin. Black women are more likely to develop fibroids than white women.
• Obesity.⁷

Call to make an appointment if you have possible symptoms of a problem from a uterine fibroid, including:

• Heavy menstrual bleeding.
• Periods that have changed from relatively pain-free to painful over the past 3 to 6 months.
• Frequent painful urination, blood in the urine, or an inability to control the flow of urine.
• A change in the length of your menstrual cycle over 3 to 6 menstrual cycles.
• New persistent pain or heaviness in the lower abdomen or pelvis.

Watchful Waiting

Unless you develop bothersome or severe symptoms, you will probably only need to have a fibroid checked during your yearly gynecological exam.

During a pregnancy, your health professional will check for changes in fibroid size and position.

Who To See

Uterine fibroids can be diagnosed and treated by any of the following health professionals:

• Family medicine physician
• Gynecologist
• Internist
• Nurse practitioner
• Physician assistant

You may need to see a gynecologist for further testing or treatment.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Your health professional may suspect that you have a uterine fibroid problem based on:

• The results of a pelvic exam.
• The history of your symptoms and your menstrual periods.

You will probably also have a pelvic ultrasound or hysterosonogram to confirm that you have one or more uterine fibroids. A hysterosonogram is done by filling the uterus with sterile saline during a transvaginal pelvic ultrasound.

If you have had heavy menstrual bleeding, you may have a complete blood count (CBC) to check for anemia.

Laparoscopy may be used to confirm and locate fibroids on the outer surface of the uterus before removal (myomectomy).

Additional testing

If you have severe pain, bleeding, or pelvic pressure or have had repeat miscarriages or trouble becoming pregnant, you will probably have other tests to look for other possible causes of your symptoms.

Additional tests for specific symptoms, such as urinary or bowel problems, may be needed to diagnose the problem or develop a treatment plan.

Most uterine fibroids are harmless, do not cause symptoms, and shrink with menopause. However, some fibroids are painful, press on other internal organs, bleed and cause anemia, or cause pregnancy problems. If you have a fibroid problem, there are several treatments to consider. Fibroids can be surgically removed, the entire uterus can be removed, or medicine can temporarily shrink fibroids. Your choice will depend on whether you have severe symptoms and whether you want to preserve your fertility.

Watchful waiting for minimal fibroid symptoms or when nearing menopause

If you have uterine fibroids but you have few or no symptoms, you do not need treatment. Instead, your health professional will recommend watchful waiting. This means that you will have regular pelvic exams to check on fibroid growth and symptoms. Talk with your health professional about how often you will need a checkup.

If you are nearing menopause, watchful waiting may be an option for you, depending on how tolerable your symptoms are. After menopause, your estrogen and progesterone levels will drop, which causes most fibroids to shrink and symptoms to subside.

For heavy menstrual bleeding or pain

If you have pain or heavy menstrual bleeding, it may be from a bleeding uterine fibroid. However, it may also be linked to a simple menstrual cycle problem or other problems. (For more information, see the topic Dysfunctional Uterine Bleeding.) Since the only proven medicine for shrinking fibroids has troublesome side effects and can only be used short-term, consider first trying one or both of the following for menstrual pain or heavy bleeding. Combining the two often improves their effectiveness:⁸

• Nonsteroidal anti-inflammatory drug (NSAID) therapy improves menstrual cramping and greatly reduces bleeding for many women.⁸ However, there is no evidence that NSAIDs relieve pain or bleeding specifically caused by fibroids.⁷
• Birth control pills (oral contraceptives) lighten menstrual bleeding and pain while preventing pregnancy. However, they do not shrink the size of uterine fibroids; nor, in general, do they make fibroids grow larger.⁹

Iron supplement therapy and an iron-rich diet improve anemia caused by blood loss.

NSAID use during conception or early pregnancy may cause miscarriage.¹⁰ If you are trying to get pregnant, talk to your health professional about whether you can use NSAID therapy.

For infertility and pregnancy problems

Experts have yet to learn exactly how fibroids cause pregnancy problems. Experts know that fibroids can prevent a fertilized egg from implanting in the uterus, can sometimes increase miscarriage risk, and make in vitro fertilization less likely to be successful.¹¹ If you have fibroids, there is no way of knowing for certain whether they are affecting fertility.

Surgical fibroid removal, called myomectomy, is the only proven fibroid treatment that improves your chances of having a baby.¹² However, because fibroids can grow again, it is best to try to become pregnant as soon as possible after a myomectomy. Of women who have a myomectomy for infertility (and who have no other known cause of infertility), 60% then become pregnant.¹¹ Experts think that myomectomy may also lower the risk of miscarriages among women with fibroids.¹²

For severe fibroid symptoms

If you have fibroid-related pain, heavy bleeding, or a large fibroid that is pressing on other organs, you can consider shrinking the fibroid, removing the fibroid (myomectomy) , or removing the entire uterus (hysterectomy). After all treatments except hysterectomy, fibroids may grow back. Only myomectomy is recommended for women who have future childbearing plans.

To shrink a fibroid for a short time, hormone therapy with a gonadotropin-releasing hormone analogue (GnRH-a) puts the body in a state like menopause. This shrinks both the uterus and the fibroids. Fibroids grow back after GnRH-a therapy. GnRH-a therapy can help to:

• Shrink a fibroid before it is surgically removed. This lowers your risk of heavy blood loss and scar tissue from the surgery.
• Provide short-term relief as a "bridge therapy" if you are nearing menopause. (Fibroids naturally shrink after menopause.)

GnRH-a therapy can be used for only a few months because it weakens the bones. It also may cause unpleasant menopausal symptoms.

To shrink or destroy fibroids without surgery, uterine fibroid embolization (UFE) can be used to stop the blood supply to the fibroid. Tiny particles are injected into two arteries that supply blood to the fibroid, which closes them off and blocks blood flow. The fibroid then shrinks and sometimes breaks down. Although there are reports of pregnancy after UFE, these pregnancies have a higher rate of complications than normal. Up to 14% of women have early ovarian failure and sterility after UFE, and other serious complications are possible. UFE is not recommended for women who hope to become pregnant.¹³

To surgically remove fibroids, myomectomy can often be done through one or more small incisions using laparoscopy or through the vagina (hysteroscopy). Sometimes, a larger abdominal incision is needed. Myomectomy preserves the uterus.

To surgically remove the entire uterus, hysterectomy is available to women with long-lasting or severe symptoms who have no future pregnancy plans. Hysterectomy has both positive and negative long-term effects. For more information, see the topic Hysterectomy.

Should I take prescription medicines to treat uterine fibroids?

Should I have surgery to treat uterine fibroids?

Should I have uterine fibroid embolization for uterine fibroids?

What To Think About

There are several new ways of removing fibroids or killing fibroid tissue using extreme cold (cryomyolysis), laser (myolysis), or high-frequency focused ultrasound (ExAblate). However, they are still new enough that risks and long-term benefits are not yet fully known.¹⁴ If your doctor offers one of these procedures, ask how many of the procedures he or she has done, how successful they have been, and what kinds of problems can result. These treatments are not recommended for women who are trying to become pregnant.¹²

There is no evidence that progestin therapy improves fibroids.⁷ Some experts think that progestin therapy, which is used to treat heavy menstrual bleeding, might feed fibroid growth.

Danazol is a medicine that increases androgen levels and stops the menstrual cycle. It is not very useful for the treatment of fibroids, except as a treatment option for controlling blood loss.¹²

Uterine fibroids cannot be prevented.

Preventing recurrence after treatment

It is common for fibroids to grow back after treatment. The only treatment that absolutely prevents regrowth of fibroids is removal of the entire uterus, called hysterectomy. After hysterectomy, you cannot carry a pregnancy. While many women report an improved quality of life after hysterectomy, there are also possible long-term side effects to consider. For more information, see the topic Hysterectomy.

Home treatment can ease menstrual period pain and anemia that may be linked to uterine fibroids.

Tips for relieving menstrual pain

Painful menstrual periods (dysmenorrhea) are one of the most common symptoms of fibroids.

Why fibroids cause pain is not known. Forceful menstrual contractions may be an attempt to push the fibroids out of the uterus. Try one or more of the following tips to help relieve your menstrual pain:

• Apply heat to the lower abdomen by using a heating pad or hot water bottle or taking a warm bath. Heat improves blood flow and may improve pelvic pain.
• Lie down and elevate your legs by putting a pillow under your knees. This may help relieve pain.
• Lie on your side and bring your knees up to your chest. This will help relieve back pressure.
• Use sanitary napkins instead of tampons.
• Get exercise, which improves blood flow and may decrease pain.

Tips for preventing anemia

Anemia occurs when your body cannot produce blood as fast as it is being lost. As a result, you have fewer red blood cells in the blood. A test called a complete blood count (CBC) can tell you whether you have anemia. Take the following steps to prevent anemia:

• Increase the amount of iron in your diet. Your body needs iron to make new blood cells, and your diet is the best source. Get 18 mg to 20 mg of iron per day. Red meats, shellfish, eggs, beans, leafy green vegetables, and iron-enriched breads and cereals are the best sources of iron.
• Cook in iron cookware to add small amounts of iron to your food.
• Eat a well-balanced diet. If you are not able to meet your need for iron through diet alone, consider taking a nonprescription iron supplement (such as ferrous sulfate) or a multivitamin. You may become constipated when you are taking an iron supplement. To avoid constipation, eat more fiber, eat plenty of fruits and vegetables, and drink at least 2 to 4 extra glasses of water per day.
• Be sure your diet includes 250 mg of vitamin C per day. Vitamin C helps your body absorb iron more effectively.
• For more information about getting enough iron, see the U.S. National Institutes of Health Web page at http://www.ods.od.nih.gov//factsheets/iron.asp#h4.

For more information on how to prevent constipation, see healthy bowel habits to prevent constipation.

Medicine can be used to help relieve uterine fibroid problems. The goals of medicine treatment are to:

• Relieve severe pain or other symptoms caused by fibroids.
• Correct anemia caused by heavy bleeding.
• Shrink fibroids before fibroid removal (myomectomy) or uterus removal (hysterectomy).
• Avoid hysterectomy.

When treatment is stopped, symptoms usually return.

Medication Choices

The following medicines are used to relieve heavy menstrual bleeding, anemia, or painful periods; they do not shrink fibroids:

• Nonsteroidal anti-inflammatory drug (NSAID) therapy relieves menstrual cramping and greatly lessens heavy menstrual bleeding for many women.⁸ However, there are no studies that show that NSAIDs decrease fibroid pain or bleeding.⁷
• Birth control pills (oral contraceptives) lessen heavy menstrual periods and pain while preventing pregnancy. However, they usually do not affect the size of uterine fibroids.⁹
• Iron supplements, available without a prescription, are an important part of correcting anemia caused by fibroid blood loss.

The following medicine is used to shrink fibroids before surgery and to temporarily relieve symptoms:

• Gonadotropin-releasing hormone analogue (GnRH-a) therapy puts the body in a menopause-like state, which shrinks the uterus and fibroids. GnRH-a therapy can be used for only a few months because it weakens the bones. It may also cause unpleasant menopausal symptoms. Fibroids grow back after GnRH-a therapy is stopped.

Should I take prescription medicines to treat uterine fibroids?

What To Think About

If you have pain or heavy menstrual bleeding, it may be from a bleeding uterine fibroid. However, it may also be linked to a menstrual cycle problem that can be improved with birth control pills and/or NSAID therapy. (For more information, see the topic Dysfunctional Uterine Bleeding.) Using the two together often maximizes their effectiveness.⁸

GnRH-a therapy is sometimes used to stop bleeding and improve anemia. However, taking iron supplements can also improve anemia and does not cause the troublesome side effects and bone weakening of GnRH-a therapy.

NSAID use during conception or early pregnancy may increase the risk of miscarriage.¹⁰ If you are trying to get pregnant, talk to your health professional about whether you can use NSAID therapy.

There is no evidence that progestin therapy improves fibroids.⁷ Some experts think that progestin therapy, which is used to treat heavy menstrual bleeding, might feed fibroid growth.

Danazol, a medicine that increases androgen levels and stops the menstrual cycle, is not recommended for treatment of fibroids.¹²

Research to develop the ideal medicine for uterine fibroids continues. The antiprogestin medicine called mifepristone improves fibroids, but it causes precancerous changes in the uterus (endometrial hyperplasia).¹⁵ The selective estrogen receptor modulator (SERM) called raloxifene, which is used for breast cancer, is also under investigation.

To treat uterine fibroids, surgery can be used to remove fibroids only (myomectomy) or to remove the entire uterus (hysterectomy).

Surgery is a reasonable treatment option when:¹⁴

• Heavy uterine bleeding and/or anemia has continued after several months of therapy with birth control pills and a nonsteroidal anti-inflammatory drug (NSAID).
• Fibroids grow after menopause.
• The uterus is misshapen by fibroids and you have had repeat miscarriages or trouble getting pregnant.
• Fibroid pain or pressure affects your quality of life.
• You have urinary or bowel problems (from a fibroid pressing on your bladder, ureter, or bowel).
• There is a possibility that cancer is present.
• Fibroids are a possible cause of your trouble getting pregnant.

Surgery Choices

Surgical treatment options include:

• Myomectomy, or fibroid removal. This is the only fibroid treatment that improves the chances of having a baby.¹²
• Hysterectomy, or uterus removal. This is only recommended for women who have no future pregnancy plans. Hysterectomy is the only fibroid treatment that prevents regrowth of fibroids. It improves quality of life for many women, but it can also have negative long-term effects, such as pelvic organ prolapse. For more information, see the topic Hysterectomy.

Myomectomy or hysterectomy can be done through one or more small incisions using laparoscopy, through the vagina, or through a larger abdominal cut (incision). The method depends on your condition, including where, how big, and what type of fibroid is growing in the uterus and whether you hope to become pregnant.

Should I have surgery to treat uterine fibroids?

Uterine fibroid embolization (UFE) is a nonsurgical option that shrinks or destroys a fibroid by cutting off its blood supply. For more information, see the Other Treatment section of this topic.

What To Think About

If you are hoping for a future pregnancy, myomectomy is your one surgical option. An abdominal myomectomy may be safer than a laparoscopic one—there is limited research about pregnancy safety after laparoscopic myomectomy.¹²

Heavy, prolonged, and painful periods caused by uterine fibroids will stop naturally after you reach menopause. If you are nearing menopause and your symptoms are tolerable, consider controlling symptoms with home treatment and medicine until menopause. Uterine fibroid embolization (UFE) may also be a reasonable option for you, although it has some risks.

Uterine fibroid embolization (UFE) is a recent addition to the list of uterine fibroid treatment options. It is a nonsurgical alternative to hysterectomy or myomectomy. UFE has not yet been extensively researched, and it is still considered experimental by some health professionals. It relieves fibroid symptoms for most women, but on rare occasions, it can also lead to serious infection, early menopause, and infertility. UFE may be a reasonable treatment option when:

• You have no future childbearing plans (pregnancy is possible but not likely after UFE, and the risks to pregnancy after UFE are not fully known¹¹).
• Heavy uterine bleeding and/or anemia has continued after several months of therapy with birth control pills and a nonsteroidal anti-inflammatory drug (NSAID).
• You have fibroid pain or pelvic pressure that affects your quality of life.
• You have urinary or bowel problems (from a fibroid that is pressing on your bladder, ureter, or bowel).
• You do not wish to have a hysterectomy or myomectomy.
• You have a disease or disorder that makes surgery with general anesthesia dangerous.

Should I have uterine fibroid embolization for uterine fibroids?

What to Think About

Pregnancy is possible after uterine fibroid embolization. Whenever you need to prevent pregnancy after UFE, be sure to use a dependable form of birth control.

Heavy, prolonged, and painful periods caused by uterine fibroids will stop naturally when you reach menopause. If you are nearing menopause and your symptoms are tolerable with home treatment or medicines, then the risks of UFE may not outweigh the benefits.

There are several new ways of removing fibroids or killing fibroid tissue, including using extreme cold (cryomyolysis), laser (myolysis), or high-frequency focused ultrasound (ExAblate). However, they are still new enough that risks and long-term benefits are not yet fully known.¹⁴ If your doctor offers one of these procedures, ask how many of the procedures he or she has done, how successful they have been, and what kinds of problems can result. These treatments are not recommended for women who are trying to become pregnant.¹²

Organizations

• Cervical Polyps

Citations

1. Eldar-Geva T, Jealy DL (1998). Other medical management of uterine fibroids. Bailliere's Clinical Obstetrics and Gynaecology, 12(2): 269–288.

2. Memarzadeh S, et al. (2003). Benign disorders of the uterine corpus. In AH DeCherney, L Nathan, eds., Current Obstetric and Gynecologic Diagnosis and Treatment, 9th ed., pp. 693–704. New York: McGraw-Hill.

3. American College of Obstetricians and Gynecologists (2000). Surgical alternatives to hysterectomy in the management of leiomyomas. ACOG Technical Bulletin No. 16. Obstetrics and Gynecology, 95(5): 1–9.

4. Day Baird D, et al. (2003). Highly cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. American Journal of Obstetrics and Gynecology, 188(1): 100–107.

5. Lumsden MA, Wallace EM (1998). Clinical presentation of uterine fibroids. Bailliere's Clinical Obstetrics and Gynaecology, 12(2): 177–195.

6. Spellacy WN (1999). Uterine leiomyoma. In JR Scott et al., eds., Danforth's Obstetrics and Gynecology, 8th ed., pp. 857–864. Philadelphia: Lippincott Williams and Wilkins.

7. Lethaby A, Vollenhoven B (2004). Fibroids (uterine myomatosis, leiomyomas). Clinical Evidence (11): 2406–2426.

8. Mishell DR Jr, et al. (2001). Abnormal uterine bleeding. In MA Stenchever et al., eds., Comprehensive Gynecology, 4th ed., pp. 1079–1097. St. Louis: Mosby.

9. Haney, AF (2003). Leiomyomata. In JR Scott et al., eds., Danforth's Obstetrics and Gynecology, 9th ed., pp. 869–887.

10. Li D, et al. (2003). Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: Population-based cohort study. BMJ, 327(7411): 368–372.

11. Hart R (2003). Unexplained infertility, endometriosis, and fibroids. BMJ, 327(7417): 721–724.

12. Practice Committee of the American Society for Reproductive Medicine (2004). Myomas and reproductive function. Fertility and Sterility, 82(Suppl 1): S111–S116.

13. American College of Obstetricians and Gynecologists (2004). Uterine artery embolization. ACOG Committee Opinion No. 293. Obstetrics and Gynecology, 103(2): 403–404.

14. Wallach E, Vlahos NF (2004). Uterine myomas: An overview of development, clinical features, and management. Obstetrics and Gynecology, 104(2): 393–406.

15. Steinauer J, et al. (2004). Systematic review of mifepristone for the treatment of uterine leiomyomata. Obstetrics and Gynecology, 103(6): 1331–1336.

Other Works Consulted

• Hindley J, et al. (2004). MRI guidance of focused ultrasound therapy of uterine fibroids: Early results. AJR, 183(6): 1713–1719.

Author:	Kathe Gallagher, MSW Lila Havens	Last Updated August 24, 2005
Medical Review:	Joy Melnikow, MD, MPH - Family Medicine Kathleen Romito, MD - Family Medicine R. Hugh Gorwill, MD - Obstetrics and Gynecology
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