A significant portion of women diagnosed with fibroids do not require surgery. For a fibroid that does not cause symptoms, an ultrasound check once or twice a year is usually sufficient. When surgery is necessary, the decision is not made solely by looking at the size.
The most common question asked during an examination is, "At what size is it removed?" It is not possible to give a single answer to this question. A 6 cm fibroid located on the outer surface of the uterus can be monitored for years without being touched. Conversely, a 1.5 cm fibroid growing into the uterine cavity may cause severe bleeding and require removal.
What is a fibroid, and who gets it?
A fibroid (medically known as a leiomyoma) is a benign tumor that develops from the uterine muscle. It is very common in women of reproductive age. A large portion of women reaching age 50 have at least one fibroid, even if most have gone unnoticed. A family history of fibroids, early onset of menstruation, being overweight, and never having given birth increase the likelihood of developing fibroids.
Fibroids grow in response to hormones. Therefore, they usually become prominent in the 30s and 40s and shrink after menopause. During pregnancy, they can sometimes grow rapidly.
The location of the fibroid tells more than its size
Fibroids are classified according to their position in the uterine wall. The terms "submucosal," "intramural," or "subserosal" in your ultrasound report describe this location.
| Type | Where? | Common Condition |
|---|---|---|
| Submucosal (intrauterine) | Just below the uterine lining, towards the uterine cavity | Heavy and prolonged menstrual bleeding, difficulty conceiving, miscarriage |
| Intramural (within the wall) | Inside the uterine muscle | Increased bleeding and uterine enlargement as it grows. Often asymptomatic if small. |
| Subserosal (outer surface) | On the outer surface of the uterus, towards the abdominal cavity | Rarely affects bleeding. When large, it puts pressure on the bladder and bowel. |
| Pedunculated (can be inside or outside) | Attached to the uterus by a thin stalk | Rarely causes sudden and severe pain by twisting on its stalk. |
Physicians use the FIGO classification to make this distinction in more detail. In this classification, fibroids are numbered from 0 to 8. If you see an expression like "type 0" or "type 2" in your report, smaller numbers indicate that the fibroid is closer to the uterine cavity.
Which symptoms are caused by fibroids?
- Heavy menstrual bleeding: Changing pads every hour, bleeding with clots, periods lasting longer than 8 days, and associated iron deficiency anemia are the most common complaints.
- Pressure symptoms: Frequent urination, feeling of incomplete bladder emptying, constipation, fullness in the lower abdomen.
- Pain: Fibroids are usually painless. However, a fibroid with compromised blood supply (especially during pregnancy) or a pedunculated fibroid twisting on its stalk can cause sudden and severe pain.
- Pregnancy-related issues: Fibroids that distort the uterine cavity can make it difficult for the embryo to implant and may increase the risk of miscarriage.
Not every heavy bleeding is caused by a fibroid. Polyps, hormonal imbalances, or other issues in the uterine lining can lead to the same picture. Therefore, during the examination, we look not only at the fibroid but also at changes in your menstrual cycle.
When is monitoring sufficient?
For fibroids that do not cause symptoms, do not distort the uterine cavity, and do not grow significantly in a short time, medication or surgery is not required. After the initial diagnosis, a follow-up ultrasound is usually performed within 3–6 months to see the growth rate. If the fibroid remains stable, check-ups are reduced to once or twice a year.
Waiting is often a reasonable option for a woman approaching menopause. Since the fibroid will shrink on its own when hormones decrease, managing symptoms with medication for a few years may be more logical than surgery.
When does surgery come into question?
In practice, we discuss surgery in the following cases:
- Heavy bleeding that continues despite medication and leads to anemia
- Pressure symptoms that affect daily life
- A fibroid detected in a woman planning pregnancy that distorts the uterine cavity
- Fibroids detected inside the uterus after recurrent miscarriages or failed IVF attempts
- Fibroids that grow after menopause or have a suspicious appearance on ultrasound
In the past, it was recommended to remove all fibroids above a certain size. Today, this approach has changed. The decision for surgery for a large, asymptomatic fibroid is made by evaluating the growth rate, its effect on neighboring organs, and the patient's preference together.
Non-surgical treatment options
Surgery is not the only option. Especially in women whose complaint is bleeding, medications are tried first:
- Medications used only during menstrual days that reduce bleeding (such as tranexamic acid)
- Birth control pills or progesterone-only medications. They can reduce bleeding but do not shrink the fibroid.
- Hormonal IUD placed in the uterus. It can significantly reduce bleeding in fibroids that do not distort the uterine cavity.
- Medications that temporarily shrink the fibroid by suppressing hormones. They can be used to correct anemia before surgery or to buy time until menopause.
- Blocking the vessels feeding the fibroid by entering through the groin (uterine artery embolization). It is performed in centers with an interventional radiology unit and is an option for women who do not plan pregnancy and want to avoid surgery.
The effect of hormone-suppressing drugs wears off when the medication is stopped, and the fibroid may grow again. New generation oral medications can be used for longer periods with additional hormones that prevent bone loss. You can discuss with your physician whether these medications are suitable for you.
Which surgery for whom?
The surgical method is chosen according to the location, number, size of the fibroid, and whether the uterus is to be preserved:
- Hysteroscopic myomectomy: Submucosal fibroids are removed with a thin camera inserted through the vagina, without any abdominal incision. The patient often returns home the same day.
- Laparoscopic myomectomy: Intramural and subserosal fibroids are removed through a few small holes in the abdomen. The uterus is sutured and preserved.
- Open myomectomy: May be preferred for numerous or very large fibroids.
- Hysterectomy (removal of the uterus): It is a permanent solution for women who do not plan pregnancy and whose symptoms cannot be controlled by other methods. The ovaries can often be preserved.
Do fibroids prevent pregnancy?
Fibroids on the outer surface of the uterus generally do not affect the chance of pregnancy. Submucosal fibroids growing towards the uterine cavity can make embryo implantation difficult, and their removal can increase the chance of pregnancy. The effect of intramural fibroids is controversial depending on their size and proximity to the uterine cavity.
After a fibroid surgery involving the uterine wall, pregnancy is usually postponed for 3–6 months for the stitches to heal. Depending on the scope of the surgery, it may be recommended that the subsequent delivery be performed by cesarean section. Be sure to share this information with the physician following your pregnancy.
Do fibroids turn into cancer?
This is one of the biggest concerns of women. A fibroid is a benign formation and is not expected to turn into cancer. Cancer developing from the uterine muscle (leiomyosarcoma) is a very rare and separate disease. It is not always possible to distinguish these two conditions definitively with ultrasound before surgery. Therefore, fibroids that continue to grow, especially after menopause, are evaluated separately, and the surgical technique is planned accordingly.
What is looked for during the examination?
The number, size, and relationship of the fibroids with the uterine cavity are determined by vaginal ultrasound. If necessary, a blood count is checked for anemia, and a hysteroscopy is planned to see the inside of the uterus. Treatment options and follow-up plans are determined together by discussing your pregnancy desire and expectations.
You can make an appointment from our Department of Obstetrics and Gynecology for fibroids and other gynecological issues. If a cyst is also seen in the ovary on ultrasound, whether the cyst requires follow-up or treatment is evaluated in the same examination. The medical content of the article has been reviewed by Obstetrician and Gynecologist Op. Dr. Ömer Altun.
Disclaimer: The content on this page is for informational purposes only. Please consult your physician for diagnosis and treatment.
