Fibroids

DEFINITION — Fibroids are growths of the uterus, or womb (show figure 1). They are also called uterine leiomyomas or myomas. They grow from the muscle cells of the uterus and may protrude from the inside or outside surface of the uterus. Fibroids may also be found within the muscular wall (show figure 2). Fibroids are not cancerous or pre-cancerous.

Fibroids are very common. At least 25 percent of women have signs of fibroids that can be detected by a pelvic examination, although not all women have symptoms.

CAUSES — Although the exact cause of fibroids is unknown, their growth seems to be related to the hormones estrogen and progesterone. When these hormone levels decrease at menopause, many of the symptoms of fibroids begin to resolve. However, it is not clear that hormones actually cause the fibroids. For example, women who have had high levels of both of these hormones as a result of pregnancy or birth control pills have a lower incidence of fibroids later in life.

RISK FACTORS — A number of factors influence the risk of developing fibroids. These include:

Ethnic background — Fibroids are three times more common in black women as compared to white, non-Hispanic women. In studies of women undergoing hysterectomy (removal of the uterus), black women were significantly more likely to have fibroids, were younger at the time of diagnosis and hysterectomy, and had more severe problems associated with fibroids as compared to white women.

Number of pregnancies — Women with one or more pregnancies that extended beyond 5 months have a decreased risk of fibroid formation.

Use of birth control — Women who use birth control pills have a lower risk of developing fibroids, although women who use the pill at an early age (between age 13 and 16) may have an increased risk. Similar to the birth control pill, women who use using continuous progestin contraceptives (for example, Depo Provera®) have a lower risk of fibroids. (See "Patient information: Contraception").

Smoking — Women who smoke appear to have a decreased risk of fibroids in some studies. However, any small benefit is clearly outweighed by the many serious health risks associated with cigarette smoking.

Diet — Significant consumption of beef, ham, or other red meats is associated with an increased risk of fibroids, while consumption of green vegetables decreases risk. However, no study has shown that changes in diet influence changes in the incidence or symptoms of fibroids. Women who consume alcohol, especially beer, have an increased risk of developing fibroids.

SYMPTOMS — The majority of fibroids are small and do not cause any symptoms at all. However, many women with fibroids have significant bleeding and/or pain that interfere with some aspect of their lives. The severity of symptoms is related to the number, size, and location of the fibroids, and fall into three main groups: increased uterine bleeding, pelvic pressure and pain, and problems related to pregnancy and fertility. As noted above, the symptoms tend to decrease at the time of menopause, although women who take hormone replacement may not see this effect.

Increased uterine bleeding — Fibroids can cause an increase in the amount of blood flow and length of a woman's menstrual period. The presence and amount of uterine bleeding is determined mainly by the location and size of the fibroid. Women with fibroids that protrude into the uterus are more likely to have significant increases in bleeding, although women with all types of fibroids can have this problem. If the bleeding is very heavy, anemia (low red blood cell count) can occur.

Bleeding irregularly (between periods) is not a characteristic of fibroids and may indicate another problem. Women with irregular bleeding should speak with their healthcare provider.

Pelvic pressure and pain — Fibroids can range in size from microscopic to the size of a grapefruit or even larger. Larger fibroids may cause a sense of pressure and fullness in the abdomen, similar to that caused by pregnancy. Fibroids of variable sizes can cause other symptoms, depending upon where they are located within the uterus. As an example, if the fibroid is pressing on the bladder, frequent urination or difficulty emptying the bladder can occur. A fibroid near the rectum may cause constipation, and cervical fibroids can cause pain during sexual intercourse.

In rare cases, fibroids can cause sudden and severe pain if the fibroid begins to break down (degenerate) or twist. Pain of this type may be associated with a mild fever, tenderness in the abdomen, and elevation in the white blood cell count. The pain usually resolves in a few days to weeks. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, can be used to treat the discomfort.

Problems with pregnancy and fertility — Some studies have suggested a slightly increased risk of problems during pregnancy in women with very large fibroids, including breech presentation, premature rupture of membranes, premature labor, and placental abruption (a condition in which the placenta separates prematurely from the uterine wall). In addition, women with very large fibroids are at a high risk of cesarean delivery. These problems are more likely if the placenta is implanted over the area of the large fibroid. Nevertheless, nearly all women with fibroids have completely normal pregnancies without complications. (See "Patient information: Cesarean delivery" and see "Patient information: Preterm labor").

The risk of miscarriage and infertility is associated with a type of fibroid that protrudes into the uterine cavity. Typically these fibroids can be easily removed using a hysteroscope (a small telescope-like device inserted through the cervix into the uterus), which reduces this risk.

However, it is not completely clear what role that fibroids play in infertility. An infertile woman who has large or numerous fibroids may want to talk with her doctor about having the fibroids removed, although all other causes of infertility should first be eliminated. (See "Patient information: Evaluation of the infertile couple").

DIAGNOSIS — Fibroids are often diagnosed during a routine pelvic exam. A clinician may feel the enlarged, irregular outline of the uterus through the abdomen. In certain cases, the clinician may wish to confirm the diagnosis of fibroids and exclude other types of masses. Ultrasound is generally preferred, and uses sound waves to visualize the uterus.

Hysterosalpingogram — A hysterosalpingogram (also called HSG or tubogram) may be recommended for a woman who is trying to become pregnant. During this test, an x-ray of the uterus and tubes is taken after dye is inserted through the cervix. The dye outlines the shape of the inside of the uterus and fallopian tubes. This test can diagnose the presence, size, and location of fibroids that may be protruding into the uterine cavity, and shows if the fallopian tubes are patent (open) (show picture 1).

Sonohysterogram — A sonohysterogram (also called SHG or saline-infusion sonogram), uses ultrasound to view the inside of the uterus while a saline solution is inserted through the cervix. This test is most useful in a woman with heavy or long periods who has had a normal pelvic ultrasound. It is possible for a fibroid or endometrial polyp to cause heavy bleeding, but not be visible with traditional ultrasound (show picture 2).

In some cases, the fibroids are found during X-ray, MRI, or ultrasound procedures that are done for another reason.

TREATMENT — In women who have no symptoms from their fibroids, treatment is usually not required. In women with significant symptoms, treatment may be medical or surgical.

Medical treatment — Medical treatment includes the use of medications to treat the symptoms of fibroid-related bleeding and pain. Gonadotropin-releasing hormone (GnRH) agonists are the most common medical treatment for fibroids. Leuprolide (Lupron Depot®) is an example of a GnRH agonist. Most women who use GnRH agonists temporarily stop having menstrual periods and have a significant reduction in the size of their fibroid(s). Reducing or eliminating menstrual bleeding can improve anemia.

However, fibroids rapidly enlarge after GnRH agonists are discontinued. In addition, there are some significant side effects after long-term use, including bone loss leading to osteoporosis. GnRH medications are usually given as a temporary measure (usually no longer than six months), such as while a woman is preparing for surgical treatment. In some cases, using a small dose of estrogen can minimize the side effects of GnRH agonists.

Danazol is an androgenic steroid, and may be used to stop menstrual bleeding. Danazol may be used when it is not necessary to shrink the size of the uterus or for women who cannot take GnRH-agonists. Use of Danazol is generally limited due to bothersome side effects, including weight gain and mood changes.

Surgical treatment — In most women, surgical treatment is used to provide relief from fibroid symptoms. In other cases, surgical procedures are done in an attempt to treat infertility. A number of surgical treatments are available.

Hysterectomy — Hysterectomy is surgical removal of the uterus through the abdomen or vagina. It may be the treatment of choice for some women who have completed childbearing, are not interested in other surgical treatments, and who have severe symptoms. Removal of the ovaries and cervix is not necessary for symptom relief. (See "Patient information: Abdominal hysterectomy").

Abdominal myomectomy — Myomectomy is surgical removal of a fibroid. In an abdominal myomectomy, an incision is made through the abdomen to expose the uterus, and the fibroids are excised from the uterine muscle. It is done in women who do not want to have a hysterectomy, and who have multiple fibroids or significant enlargement of the uterus. Blood loss, time off from work, and complications are similar to that seen with hysterectomy.

Myomectomy preserves the chance of future childbearing and may provide short-term relief of heavy bleeding, but is associated with a significant risk of recurrence. Between 10 and 25 percent of women who have myomectomy will require a second surgery. In addition, abdominal and laparoscopic myomectomy slightly increase the risk of uterine rupture during pregnancy or labor; the risk for most women is small.

Laparoscopic myomectomy — In this procedure, fibroids are removed through a laparoscope, a thin tube inserted through a small incision in the abdomen. A surgeon uses the laparoscope to visualize and remove the fibroids. Laparoscopic myomectomy requires a physician who is skilled in performing this technique, and is usually reserved for women with one or two small fibroids located on the outer surface of the uterus.

Hysteroscopic myomectomy — In this procedure, a telescope-like instrument (hysteroscope) is placed into the vagina, through the cervix and into the uterus. Fibroids may be seen through the hysteroscope and removed. This procedure can only be done on fibroids that are on the inside of the uterus, and it requires a physician who is skilled in performing this technique. This approach decreases menstrual bleeding with little reduction in uterine size.

Endometrial ablation — In this procedure, the lining of the uterus is destroyed with heat by a scope inserted into the vagina through the cervix and into the uterus. It can be done alone, or in combination with other treatments such as hysteroscopic myomectomy or myolysis (explained below). Pregnancy is possible, though not recommended after endometrial ablation; contraception is strongly recommended since a woman continues to ovulate. Endometrial ablation decreases bleeding without affecting uterine size.

Uterine artery embolization — In uterine artery embolization (UAE or UFE), a small catheter is inserted in a large blood vessel and threaded up to blood vessels near a fibroid (show figure 3A-3B). Tiny particles are injected into the blood vessel, which stops blood flow to the fibroid (show figure 4). This causes the fibroid to rapidly decrease in size within days to weeks after UAE.

The procedure appears to provide significant reduction in symptoms with few serious complications, although follow up data is limited to five years. The mean reduction in fibroid volume is comparable to that seen with GnRH-agonist treatment (30 to 40 percent). Post-procedure — Serious complications of UAE are rare, and similar to complications of other fibroid surgeries. Post-procedure pain is generally moderate to severe; most women stay in the hospital and receive intravenous pain medication after their procedure. Fever occurs in approximately one third of women, but is not usually related to infection. A small percentage of women (5 to 8 percent) stop having menstrual periods after UAE, which can be temporary or permanent. This change is more likely in women greater than 50 years of age; 40 percent of these women have no menstrual periods following UAE. Approximately 95 percent of women report significant improvement in symptoms and quality of life after UAE. Pregnancy after UAE — Pregnancy is not recommended for women who have undergone UAE, although normal pregnancies have occurred. UAE can affect ovarian function, potentially increasing the chances of infertility after treatment. Additionally, there is an increased risk of placental abnormalities in pregnancy following UAE. Myolysis — In this procedure, the fibroid tissue is destroyed through a laparoscope inserted in the abdomen. Myolysis can be combined with endometrial ablation, which is more effective than either procedure alone. Focused Ultrasound Surgery — MRI-guided focused ultrasound surgery (MRgFUS) is a new, FDA-approved treatment for fibroids. It involves destroying fibroid tissue with high intensity, focused ultrasound heat energy. The treatment takes place in an MRI machine, which gives live, "real-time" images of the uterus, allowing for progress to be monitored while the procedure is done. Only short-term outcome data is available, but MRgFUS appears to provide good symptom relief without incisions. In addition, it can be done on an outpatient basis. The treatment is not widely available since it is expensive, time consuming, and requires special equipment.

Choosing a treatment — In deciding on the best surgical treatment for fibroids, a number of factors should be considered. One of the most critical is whether or not childbearing has been completed. Although hysterectomy provides excellent relief of symptoms, a woman who wishes to become pregnant in the future may choose myomectomy. A woman who is done with childbearing but who is not interested in hysterectomy may consider uterine artery embolization, myolysis, endometrial ablation, or a combination of the above.

SUMMARY Fibroids are growths of the uterus (womb) (show figure 1 and show figure 2). Fibroids are not cancerous or pre-cancerous. The exact cause of fibroids is unknown (see "Risk factors" above). Most fibroids are small and do not cause any problems. Women with several small fibroids or one large fibroid often have heavy bleeding and/or pain during their menstrual period. This pain and bleeding can cause a woman to miss work or school (see "Symptoms" above). Fibroids may be diagnosed with a pelvic exam or ultrasound test (see "Diagnosis" above). Fibroids may need to be treated if the woman has heavy bleeding or pain. Women who do not have heavy bleeding or pain usually do not need any treatment. A medicine or surgery may be used to shrink the fibroid. Surgery to remove the fibroid or entire uterus is another option (see "Surgical treatment" above). The best type of treatment depends upon whether the woman wants to become pregnant in the future. Some treatments prevent pregnancy (see "Choosing a treatment" above).

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
U.S. Department of Health and Human Services

(www.4woman.gov)
Society of Interventional Radiology

(www.sirweb.org, search for "uterine fibroids")
The Cochrane Collaboration

(www.cochrane.org, search for "uterine fibroids")


[1-9]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Cramer, SF, Patel, A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990; 94:435.
2. Parazzini, R, La Vecchia, C, Negri, E, et al. Epidemiologic characteristics of women with uterine fibroids: a case-control study. Obstet Gynecol 1988; 72:853.
3. Stewart, EA, Nowak, RA. New concepts in the treatment of uterine leiomyomas. Obstet Gynecol 1998; 92:624.
4. American College of Obstetricians and Gynecologists. Surgical alternatives to hysterectomy in the management of leiomyomas. ACOG practice bulletin #16, American College of Obstetricians and Gynecologists, Washington, DC 2000.
5. Iverson, RE Jr, Chelmow, D, Strohbehn, K, et al Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996; 88:415.
6. Spies, JB, Spector, A, Roth, AR, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002; 100:873.
7. Pron, G, Bennett, J, Common, A, Wal,l J, Asch M, Sniderman K. The Ontario uterine fibroid embolization trial part 2. Uterine fibroid reduction and sympton relief after uterine artery embolization for fibroids. Fertil Steril 2003; 79:120.
8. Marshall, LM, Spiegelman D, Goldman, MB, Manson JE, Colditz GA, Barbieri RL, et al. A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata. Fertil Steril 1998; 70:432.
9. ACOG Committee Opinion. Uterine artery embolization. Obstet Gynecol 2004; 103:403.

Fibroids

DEFINITION — Fibroids are growths of the uterus, or womb (show figure 1). They are also called uterine leiomyomas or myomas. They grow from the muscle cells of the uterus and may protrude from the inside or outside surface of the uterus. Fibroids may also be found within the muscular wall (show figure 2). Fibroids are not cancerous or pre-cancerous.

Fibroids are very common. At least 25 percent of women have signs of fibroids that can be detected by a pelvic examination, although not all women have symptoms.

CAUSES — Although the exact cause of fibroids is unknown, their growth seems to be related to the hormones estrogen and progesterone. When these hormone levels decrease at menopause, many of the symptoms of fibroids begin to resolve. However, it is not clear that hormones actually cause the fibroids. For example, women who have had high levels of both of these hormones as a result of pregnancy or birth control pills have a lower incidence of fibroids later in life.

RISK FACTORS — A number of factors influence the risk of developing fibroids. These include:

Ethnic background — Fibroids are three times more common in black women as compared to white, non-Hispanic women. In studies of women undergoing hysterectomy (removal of the uterus), black women were significantly more likely to have fibroids, were younger at the time of diagnosis and hysterectomy, and had more severe problems associated with fibroids as compared to white women.

Number of pregnancies — Women with one or more pregnancies that extended beyond 5 months have a decreased risk of fibroid formation.

Use of birth control — Women who use birth control pills have a lower risk of developing fibroids, although women who use the pill at an early age (between age 13 and 16) may have an increased risk. Similar to the birth control pill, women who use using continuous progestin contraceptives (for example, Depo Provera®) have a lower risk of fibroids. (See "Patient information: Contraception").

Smoking — Women who smoke appear to have a decreased risk of fibroids in some studies. However, any small benefit is clearly outweighed by the many serious health risks associated with cigarette smoking.

Diet — Significant consumption of beef, ham, or other red meats is associated with an increased risk of fibroids, while consumption of green vegetables decreases risk. However, no study has shown that changes in diet influence changes in the incidence or symptoms of fibroids. Women who consume alcohol, especially beer, have an increased risk of developing fibroids.

SYMPTOMS — The majority of fibroids are small and do not cause any symptoms at all. However, many women with fibroids have significant bleeding and/or pain that interfere with some aspect of their lives. The severity of symptoms is related to the number, size, and location of the fibroids, and fall into three main groups: increased uterine bleeding, pelvic pressure and pain, and problems related to pregnancy and fertility. As noted above, the symptoms tend to decrease at the time of menopause, although women who take hormone replacement may not see this effect.

Increased uterine bleeding — Fibroids can cause an increase in the amount of blood flow and length of a woman's menstrual period. The presence and amount of uterine bleeding is determined mainly by the location and size of the fibroid. Women with fibroids that protrude into the uterus are more likely to have significant increases in bleeding, although women with all types of fibroids can have this problem. If the bleeding is very heavy, anemia (low red blood cell count) can occur.

Bleeding irregularly (between periods) is not a characteristic of fibroids and may indicate another problem. Women with irregular bleeding should speak with their healthcare provider.

Pelvic pressure and pain — Fibroids can range in size from microscopic to the size of a grapefruit or even larger. Larger fibroids may cause a sense of pressure and fullness in the abdomen, similar to that caused by pregnancy. Fibroids of variable sizes can cause other symptoms, depending upon where they are located within the uterus. As an example, if the fibroid is pressing on the bladder, frequent urination or difficulty emptying the bladder can occur. A fibroid near the rectum may cause constipation, and cervical fibroids can cause pain during sexual intercourse.

In rare cases, fibroids can cause sudden and severe pain if the fibroid begins to break down (degenerate) or twist. Pain of this type may be associated with a mild fever, tenderness in the abdomen, and elevation in the white blood cell count. The pain usually resolves in a few days to weeks. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, can be used to treat the discomfort.

Problems with pregnancy and fertility — Some studies have suggested a slightly increased risk of problems during pregnancy in women with very large fibroids, including breech presentation, premature rupture of membranes, premature labor, and placental abruption (a condition in which the placenta separates prematurely from the uterine wall). In addition, women with very large fibroids are at a high risk of cesarean delivery. These problems are more likely if the placenta is implanted over the area of the large fibroid. Nevertheless, nearly all women with fibroids have completely normal pregnancies without complications. (See "Patient information: Cesarean delivery" and see "Patient information: Preterm labor").

The risk of miscarriage and infertility is associated with a type of fibroid that protrudes into the uterine cavity. Typically these fibroids can be easily removed using a hysteroscope (a small telescope-like device inserted through the cervix into the uterus), which reduces this risk.

However, it is not completely clear what role that fibroids play in infertility. An infertile woman who has large or numerous fibroids may want to talk with her doctor about having the fibroids removed, although all other causes of infertility should first be eliminated. (See "Patient information: Evaluation of the infertile couple").

DIAGNOSIS — Fibroids are often diagnosed during a routine pelvic exam. A clinician may feel the enlarged, irregular outline of the uterus through the abdomen. In certain cases, the clinician may wish to confirm the diagnosis of fibroids and exclude other types of masses. Ultrasound is generally preferred, and uses sound waves to visualize the uterus.

Hysterosalpingogram — A hysterosalpingogram (also called HSG or tubogram) may be recommended for a woman who is trying to become pregnant. During this test, an x-ray of the uterus and tubes is taken after dye is inserted through the cervix. The dye outlines the shape of the inside of the uterus and fallopian tubes. This test can diagnose the presence, size, and location of fibroids that may be protruding into the uterine cavity, and shows if the fallopian tubes are patent (open) (show picture 1).

Sonohysterogram — A sonohysterogram (also called SHG or saline-infusion sonogram), uses ultrasound to view the inside of the uterus while a saline solution is inserted through the cervix. This test is most useful in a woman with heavy or long periods who has had a normal pelvic ultrasound. It is possible for a fibroid or endometrial polyp to cause heavy bleeding, but not be visible with traditional ultrasound (show picture 2).

In some cases, the fibroids are found during X-ray, MRI, or ultrasound procedures that are done for another reason.

TREATMENT — In women who have no symptoms from their fibroids, treatment is usually not required. In women with significant symptoms, treatment may be medical or surgical.

Medical treatment — Medical treatment includes the use of medications to treat the symptoms of fibroid-related bleeding and pain. Gonadotropin-releasing hormone (GnRH) agonists are the most common medical treatment for fibroids. Leuprolide (Lupron Depot®) is an example of a GnRH agonist. Most women who use GnRH agonists temporarily stop having menstrual periods and have a significant reduction in the size of their fibroid(s). Reducing or eliminating menstrual bleeding can improve anemia.

However, fibroids rapidly enlarge after GnRH agonists are discontinued. In addition, there are some significant side effects after long-term use, including bone loss leading to osteoporosis. GnRH medications are usually given as a temporary measure (usually no longer than six months), such as while a woman is preparing for surgical treatment. In some cases, using a small dose of estrogen can minimize the side effects of GnRH agonists.

Danazol is an androgenic steroid, and may be used to stop menstrual bleeding. Danazol may be used when it is not necessary to shrink the size of the uterus or for women who cannot take GnRH-agonists. Use of Danazol is generally limited due to bothersome side effects, including weight gain and mood changes.

Surgical treatment — In most women, surgical treatment is used to provide relief from fibroid symptoms. In other cases, surgical procedures are done in an attempt to treat infertility. A number of surgical treatments are available.

Hysterectomy — Hysterectomy is surgical removal of the uterus through the abdomen or vagina. It may be the treatment of choice for some women who have completed childbearing, are not interested in other surgical treatments, and who have severe symptoms. Removal of the ovaries and cervix is not necessary for symptom relief. (See "Patient information: Abdominal hysterectomy").

Abdominal myomectomy — Myomectomy is surgical removal of a fibroid. In an abdominal myomectomy, an incision is made through the abdomen to expose the uterus, and the fibroids are excised from the uterine muscle. It is done in women who do not want to have a hysterectomy, and who have multiple fibroids or significant enlargement of the uterus. Blood loss, time off from work, and complications are similar to that seen with hysterectomy.

Myomectomy preserves the chance of future childbearing and may provide short-term relief of heavy bleeding, but is associated with a significant risk of recurrence. Between 10 and 25 percent of women who have myomectomy will require a second surgery. In addition, abdominal and laparoscopic myomectomy slightly increase the risk of uterine rupture during pregnancy or labor; the risk for most women is small.

Laparoscopic myomectomy — In this procedure, fibroids are removed through a laparoscope, a thin tube inserted through a small incision in the abdomen. A surgeon uses the laparoscope to visualize and remove the fibroids. Laparoscopic myomectomy requires a physician who is skilled in performing this technique, and is usually reserved for women with one or two small fibroids located on the outer surface of the uterus.

Hysteroscopic myomectomy — In this procedure, a telescope-like instrument (hysteroscope) is placed into the vagina, through the cervix and into the uterus. Fibroids may be seen through the hysteroscope and removed. This procedure can only be done on fibroids that are on the inside of the uterus, and it requires a physician who is skilled in performing this technique. This approach decreases menstrual bleeding with little reduction in uterine size.

Endometrial ablation — In this procedure, the lining of the uterus is destroyed with heat by a scope inserted into the vagina through the cervix and into the uterus. It can be done alone, or in combination with other treatments such as hysteroscopic myomectomy or myolysis (explained below). Pregnancy is possible, though not recommended after endometrial ablation; contraception is strongly recommended since a woman continues to ovulate. Endometrial ablation decreases bleeding without affecting uterine size.

Uterine artery embolization — In uterine artery embolization (UAE or UFE), a small catheter is inserted in a large blood vessel and threaded up to blood vessels near a fibroid (show figure 3A-3B). Tiny particles are injected into the blood vessel, which stops blood flow to the fibroid (show figure 4). This causes the fibroid to rapidly decrease in size within days to weeks after UAE.

The procedure appears to provide significant reduction in symptoms with few serious complications, although follow up data is limited to five years. The mean reduction in fibroid volume is comparable to that seen with GnRH-agonist treatment (30 to 40 percent). Post-procedure — Serious complications of UAE are rare, and similar to complications of other fibroid surgeries. Post-procedure pain is generally moderate to severe; most women stay in the hospital and receive intravenous pain medication after their procedure. Fever occurs in approximately one third of women, but is not usually related to infection. A small percentage of women (5 to 8 percent) stop having menstrual periods after UAE, which can be temporary or permanent. This change is more likely in women greater than 50 years of age; 40 percent of these women have no menstrual periods following UAE. Approximately 95 percent of women report significant improvement in symptoms and quality of life after UAE. Pregnancy after UAE — Pregnancy is not recommended for women who have undergone UAE, although normal pregnancies have occurred. UAE can affect ovarian function, potentially increasing the chances of infertility after treatment. Additionally, there is an increased risk of placental abnormalities in pregnancy following UAE. Myolysis — In this procedure, the fibroid tissue is destroyed through a laparoscope inserted in the abdomen. Myolysis can be combined with endometrial ablation, which is more effective than either procedure alone. Focused Ultrasound Surgery — MRI-guided focused ultrasound surgery (MRgFUS) is a new, FDA-approved treatment for fibroids. It involves destroying fibroid tissue with high intensity, focused ultrasound heat energy. The treatment takes place in an MRI machine, which gives live, "real-time" images of the uterus, allowing for progress to be monitored while the procedure is done. Only short-term outcome data is available, but MRgFUS appears to provide good symptom relief without incisions. In addition, it can be done on an outpatient basis. The treatment is not widely available since it is expensive, time consuming, and requires special equipment.

Choosing a treatment — In deciding on the best surgical treatment for fibroids, a number of factors should be considered. One of the most critical is whether or not childbearing has been completed. Although hysterectomy provides excellent relief of symptoms, a woman who wishes to become pregnant in the future may choose myomectomy. A woman who is done with childbearing but who is not interested in hysterectomy may consider uterine artery embolization, myolysis, endometrial ablation, or a combination of the above.

SUMMARY Fibroids are growths of the uterus (womb) (show figure 1 and show figure 2). Fibroids are not cancerous or pre-cancerous. The exact cause of fibroids is unknown (see "Risk factors" above). Most fibroids are small and do not cause any problems. Women with several small fibroids or one large fibroid often have heavy bleeding and/or pain during their menstrual period. This pain and bleeding can cause a woman to miss work or school (see "Symptoms" above). Fibroids may be diagnosed with a pelvic exam or ultrasound test (see "Diagnosis" above). Fibroids may need to be treated if the woman has heavy bleeding or pain. Women who do not have heavy bleeding or pain usually do not need any treatment. A medicine or surgery may be used to shrink the fibroid. Surgery to remove the fibroid or entire uterus is another option (see "Surgical treatment" above). The best type of treatment depends upon whether the woman wants to become pregnant in the future. Some treatments prevent pregnancy (see "Choosing a treatment" above).

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
U.S. Department of Health and Human Services

(www.4woman.gov)
Society of Interventional Radiology

(www.sirweb.org, search for "uterine fibroids")
The Cochrane Collaboration

(www.cochrane.org, search for "uterine fibroids")


[1-9]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Cramer, SF, Patel, A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990; 94:435.
2. Parazzini, R, La Vecchia, C, Negri, E, et al. Epidemiologic characteristics of women with uterine fibroids: a case-control study. Obstet Gynecol 1988; 72:853.
3. Stewart, EA, Nowak, RA. New concepts in the treatment of uterine leiomyomas. Obstet Gynecol 1998; 92:624.
4. American College of Obstetricians and Gynecologists. Surgical alternatives to hysterectomy in the management of leiomyomas. ACOG practice bulletin #16, American College of Obstetricians and Gynecologists, Washington, DC 2000.
5. Iverson, RE Jr, Chelmow, D, Strohbehn, K, et al Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996; 88:415.
6. Spies, JB, Spector, A, Roth, AR, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002; 100:873.
7. Pron, G, Bennett, J, Common, A, Wal,l J, Asch M, Sniderman K. The Ontario uterine fibroid embolization trial part 2. Uterine fibroid reduction and sympton relief after uterine artery embolization for fibroids. Fertil Steril 2003; 79:120.
8. Marshall, LM, Spiegelman D, Goldman, MB, Manson JE, Colditz GA, Barbieri RL, et al. A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata. Fertil Steril 1998; 70:432.
9. ACOG Committee Opinion. Uterine artery embolization. Obstet Gynecol 2004; 103:403.

Endometriosis

INTRODUCTION — The normal tissue that lines the uterus and bleeds during the menstrual period is called the endometrium (show figure 1). Endometriosis is a noncancerous disorder in which tissue that is similar to the endometrium develops outside of the uterus. Typically this occurs in the pelvis, but it may occur in virtually any part of the body.

The most common locations for endometriosis are: the outer surface of the ovaries, peritoneum (the tissue that lines the abdomen) and peritoneal structures (the area behind the uterus and the various ligaments that hold the uterus in place), uterus, fallopian tubes, bowel, and bladder. Most women have endometriosis in more than one location.

RISK FACTORS — It is not known how many women are affected by endometriosis; the disease can only be diagnosed with a biopsy of lesions seen during surgery. Therefore, women who have no symptoms and never have surgery may not know that they are affected. Studies in small groups of women have shown that endometriosis is present in at least 5 percent of all women of reproductive age.

Endometriosis is rarely diagnosed before menarche (the first menstrual period of a woman's life) and new cases are seldom diagnosed after menopause (the last menstrual period of a woman's life). The growth and function of endometriosis depends upon stimulation from estrogen and progesterone, which are produced by the ovaries in women who menstruate. The condition is most common among women 25 to 29 years old and least common in women over age 44.

Risk factors for developing endometriosis include: No pregnancies resulting in the birth of an infant Endometriosis in a woman's mother (7 percent chance) Short menstrual cycles (<27>8 days) (2 percent chance) Partial or complete obstruction of normal menstrual flow (eg, from uterine abnormalities such as a tight cervical opening or vaginal septa [band of tissue] blocking the flow of menses) White or Asian race

Conditions that decrease the amount or frequency of menstrual bleeding lower the risk of endometriosis. Some examples are amenorrhea (absent menstrual periods), pregnancy, and prolonged use of birth control pills.

CAUSES — The cause of endometriosis is not known, but several theories have been suggested. Retrograde menstruation is a theory that menstrual blood and tissue flows backwards from the uterus, through the fallopian tubes and into the pelvis (show figure 1). This theory was proposed because women with a partial or complete obstruction of the uterus or cervix that prevents normal menstrual flow are more likely to have endometriosis. This is presumably because menstrual blood and tissue are more likely to flow backwards. Retrograde menstruation has been observed during surgery. The endometrial tissue shed during a menstrual period is able to grow when "planted" in the pelvis. Endometrial tissue from the uterus may be transported through blood and lymphatic vessels to sites elsewhere in the body, including the pelvis. Changes in the immune system allow endometrial tissue outside of the uterus to grow and develop. Coelomic metaplasia is the concept that the cells from lining of the abdomen and surface of the ovaries can change into endometrial tissue with certain stimuli, such as irritation from retrograde menstruation or infection.

SYMPTOMS AND SIGNS — For many women, severe pelvic pain is the main symptom of endometriosis. Pelvic pain usually occurs just before or during menses or during or after sex. Other symptoms may include pain during bowel movements, spotting before the menstrual period, frequent or heavy uterine bleeding, and pain during urination. Painful periods cause mild to severe discomfort (often cramps) in the lower abdomen; this may worsen over a period of years. Some women have constant pelvic soreness or pain in the lower back and legs that is aggravated during menses or intercourse. (See "Patient information: Chronic pelvic pain in women").

Pelvic pain is probably the result of bleeding from areas of endometriosis and release of substances that cause pain (eg, prostaglandins). Endometriosis implants respond to the hormonal changes that occur during the menstrual cycle, similar to the normal endometrium. Thus, at the end of the menstrual cycle, small amounts of endometrial tissue are shed and bleeding occurs (show figure 2).

Endometriomas are areas of endometriosis that are large enough to be considered a mass or tumor. They are usually filled with old blood that resembles chocolate syrup; thus, they are sometimes called chocolate cysts. Endometriomas may be seen as a mass on the ovary during a pelvic ultrasound, although only surgery can confirm that the mass is an endometrioma.

DIAGNOSIS — The diagnosis of endometriosis is one possibility for women who develop pelvic pain, problems with fertility, or have an abnormal pelvic examination or ultrasound. The disease may have no signs or symptoms and the intensity of the symptoms (eg, amount of pain and bleeding) does not always correlate with the severity or amount of endometriosis. For example, it is possible to have mild endometriosis with severe pelvic pain.

Pelvic examination — During a pelvic examination, a healthcare provider may feel thickening of, or nodules on, pelvic structures, an adnexal mass (a mass in the area of the ovary), or fixed or distorted pelvic organs, which suggests the presence of endometriosis. However, since these signs and symptoms are present in a variety of disorders, the diagnosis and stage (severity) of endometriosis can only be made with certainty by viewing the implants (small areas of endometriosis) during surgery, with either laparoscopy or laparotomy.

There are no blood tests or x-ray examinations that can make a definitive diagnosis, but a mildly elevated CA-125 blood level or growth near the ovaries on ultrasonography may suggest the disease.

Surgical evaluation — Laparoscopy and laparotomy are surgical procedures that are commonly used to diagnose and treat endometriosis. Both procedures are usually done in an operating room after the woman has received general anesthesia to induce sleep and prevent pain. After laparoscopy most women go home the same day. After laparotomy most women go home after spending one to three nights in the hospital.

At surgery, endometriosis appears as small (< 1/4 inch) blue, purple, or red implants. Scar tissue (adhesions) and/or an ovarian cyst may also be noted. A biopsy (removal of a small piece of tissue) can be done to confirm the diagnosis.

Staging — Surgery is also helpful for staging (determining the volume and location of disease) and treating the disorder. To stage the disease, the surgeon assigns points based upon size, depth, and location of implants (show figure 3). Endometriosis is classified as minimal (stage I, 1 to 5 points) if there are isolated superficial implants; mild (stage ll, 6 to 15 points) if there are several small, superficial implants and no more than a few small adhesions. Endometriosis is moderate (stage lll, 16 to 40 points) if the implants are superficial and deep with prominent adhesions. Endometriosis is severe (stage lV, over 40 points) when there are multiple superficial and deep implants with large endometriomas and prominent adhesions.

TREATMENT — There are several treatment options for women with endometriosis: No therapy Pain medication Birth control pills Other forms of hormonal therapy Surgery A combination of therapies

The treatment strategy depends upon whether the woman's major concern is pain, infertility, or a pelvic mass.

Women with minimal disease or who are near menopause and have no troubling symptoms may choose to have no treatment of endometriosis. Young women with minimal disease may consider taking birth control pills to protect against unplanned pregnancy and to prevent progression of disease. Near menopause, endometriosis may regress without treatment because the ovaries produce lower levels of estrogen, which decreases stimulation of the implants.

Endometriosis progresses slowly, over years, and resolves after menopause. Most women with endometriosis will get relief of pain from taking medication, after a pregnancy, or after menopause; some women will be helped only by surgery. Removal of the ovaries almost always provides excellent pain relief, making this an option for women who do not wish to have children.

Some women with endometriosis will have difficulty becoming pregnant, especially those who have severe disease and extensive adhesions. However, most women can achieve pregnancy after medical or surgical therapy or with fertility enhancing drugs or procedures (eg, in vitro fertilization). Rarely, endometriosis causes other problems such as blockage of the intestines or urinary tract or disease in the chest. ( See "Patient information: Evaluation of the infertile couple" and see "Patient information: Infertility treatment with clomiphene (Clomid® or Serophene®)").

Pelvic pain — When a laparoscopy is performed to diagnose endometriosis, endometrial implants and scar tissue are usually removed, which may relieve pain temporarily. However, the disease and pain tend to recur unless the uterus and ovaries are removed.

Recurrent or persistent pain after surgery is usually treated with medication. Studies have not determined the best medical therapy for treating pelvic pain, and no medical therapy has been proven to improve the chance of becoming pregnant in the future.

One advantages of medical therapy is that surgery can be avoided. Pelvic surgery has potential risks, some of which include damage to pelvic organs and formation of scar tissue. Another advantage is that medical therapy treats all implants, not just those seen during surgery. Disadvantages of medical therapy include the inability to treat existing adhesions or endometriomas. Medications may have side effects, including prevention of pregnancy (if drugs suppressing ovulation are used), and pain often recurs when medical therapy is stopped. Nonsteroidal antiinflammatory drugs — Nonsteroidal antiinflammatory drugs (NSAIDs, eg, ibuprofen, naproxen sodium) may be useful in relieving mild pain. NSAIDs inhibit prostaglandins, one of the main chemicals responsible for pain during menses. NSAIDs do not shrink or prevent the growth of implants, and pain often returns when medication is stopped.

The recommended dose of ibuprofen 400 to 600 mg by mouth every six hours, taken when pain starts or is expected. Other NSAIDs may also be used (show table 1).

Serious side effects from NSAIDs, although uncommon, include gastrointestinal pain and bleeding, kidney problems, and worsening high blood pressure. Oral contraceptive pills — Oral contraceptive pills (OCPs or birth control pills) contain both estrogen and progestin and cause the endometrial lining and endometriosis implants to shrink. There is no effect on scar tissue or endometriomas. OCPs are usually less effective than GnRH agonists and danazol (see below) for women with moderate or severe disease, but are a good choice for women with minimal or mild symptoms. OCPs prevent pregnancy and generally have tolerable side effects.

Birth control pills work by reducing the number of menstrual cycles and volume of bleeding. For most patients with only mild pain, this results in less painful periods and may also slow progression of endometriosis. The side effects of OCPs include nausea, breast tenderness, and decreased libido, although most side effects improve after being on the pill for several months. Serious side effects (eg, blood clots, stroke, heart attack) are rare in women who do not smoke and have no underlying blood vessel disease.

Continuous use of OCPs can be effective in relieving painful periods. Traditional birth control pill packs can be used in continuous dosing. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This regimen can be continued for as long as desired.

Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not indicate an increased risk of pill failure (unless pills are forgotten). Gonadotropin releasing hormone agonists — Gonadotropin releasing hormone (GnRH) agonists (eg, nafarelin, leuprolide, goserelin) work by turning off ovarian production of estrogen, thereby causing a temporary type of menopause. The lack of estrogen causes the endometriosis implants to shrink and reduces pain in over 80 percent of patients. The drugs may be given as a nasal spray, implant, or injection.

The full dose of a GnRH agonist is usually taken for up to six months; they are not usually taken for longer due to the risk of bone thinning. Side effects of GnRH agonists include headaches in 20 percent of women, especially in patients with a history of migraine, and the signs and symptoms of menopause: lack of menstrual bleeding, hot flashes, vaginal dryness, decreased libido, insomnia, and loss of bone density (on average a 2 to 7 percent loss). Bone strength recovers substantially after the drug is stopped.

Many of these side effects can be minimized by giving estrogen or a bone strengthening drug along with the GnRH agonist. Five years after completing GnRH agonist treatment, many women will again have pain (37 of women with mild disease and 74 percent of women with severe disease).

Alternate dosing regimens that use lower doses of the GnRH agonist for longer than five years may be considered for some women; this reduces the amount of bone density lost, and may allow the woman to have better, long-lasting relief of pain compared to other treatments. Monitoring of bone density is usually recommended while GnRH agonists are used. Danazol — Danazol is a medication that increases the level of androgens (male type hormone) and decreases the level of estrogen. This temporarily stops the menstrual period by inhibiting ovulation and ovarian production of estrogen and by shrinking the endometrium.

The medication is taken by mouth at a dose of 200 to 400 mg two to four times per day for 6 months or more. Eighty percent of patients will have good pain relief and shrinkage of implants. However, there is a high (75 percent) incidence of one or more side effects, but only a small percentage of patients discontinue the drug because of them.

Side effects may include weight gain, edema, decreased breast size, acne, oily skin, hirsutism (male pattern hair growth), deepening of the voice, headache, hot flashes, changes in libido, and mood changes. All of these changes are reversible, except for voice changes; however, return to normal may take many months.

Danazol should not be taken by women with certain types of liver, kidney, and heart disease because these disorders may worsen. Women who could become pregnant must use a nonhormonal form of birth control (eg, condoms) while taking danazol because of a serious risk of birth defects if danazol is taken during pregnancy. (See "Patient information: Barrier methods of birth control"). Progestins — Progestins (eg, medroxyprogesterone acetate (Depo Provera®) norethindrone acetate (Micronor®, NorQD®, Aygestin®) norgestrel acetate) may be recommended for women who do not get pain relief from or who cannot take a birth control pill (eg, smokers). These medications cause the endometrial lining and endometriosis implants to shrink, and usually cause the menstrual periods to temporarily stop. (See "Patient information: Long-term methods of birth control").

Side effects are common and include: bloating, weight gain, irregular uterine bleeding, and rarely, aggravation of depression. Women who use long-acting medroxyprogesterone acetate may not have a menstrual period for six to twelve months after stopping the treatment. Therefore, this drug may not be the best choice for women planning pregnancy in the near future. Surgery — Surgery is an option when medication has failed to improve pain or if there is severe disease (scarring, endometriomas, involvement of the bowel or bladder) that is unlikely to respond to medications alone. The goal of conservative surgery is to eliminate as many implants and adhesions as possible.

Pain relief is achieved in 80 to 90 percent of women, but the risk of recurrent pain within 10 years is 40 percent. Surgical therapy avoids the side effects of medication and can improve fertility, although there are some risks, including damage to pelvic organs, development of new adhesions, bleeding, and infection.

Definitive surgery consists of removal of the uterus (hysterectomy), ovaries, and endometrial implants to eliminate as much of the disease as possible and create a low estrogen state. It may be recommended for women who are not planning pregnancy if severe symptoms remain after trying other less invasive treatments. Low dose hormone replacement therapy (eg, estrogen pills or a patch) is usually given after surgery to prevent menopausal symptoms and other complications of a low estrogen level; this treatment usually does not cause the pain to return. (See "Patient information: Abdominal hysterectomy" and see "Patient information: Vaginal hysterectomy").

Pelvic mass — A pelvic mass in a woman with endometriosis may be an endometrioma, chocolate cyst, a combination of scarring and normal pelvic organs, or a mass unrelated to the disease. Surgery is the best way to make a definite diagnosis and remove the mass. Medical therapy is not effective.

Infertility — Endometriosis sometimes interferes with the ability to become pregnant. Reduced fertility may develop because of adhesions that develop between the ovaries and fallopian tubes or as a result of substances produced by endometriosis implants that impair normal ovulation, fertilization, and implantation. However, as many as 70 percent of women with minimal or mild endometriosis and infertility will conceive within three years without any therapy. If pregnancy occurs, endometriosis often regresses or resolves. Women with endometriosis who become pregnant have no increased risk of pregnancy complications.

The treatment of infertility caused by endometriosis includes a combination of observation, surgery, use of medications that enhance ovulation combined with intrauterine insemination, or in vitro fertilization (IVF). Medical treatments for endometriosis (eg, GnRH agonists) are of no benefit in improving fertility. (See "Patient information: Infertility treatment with clomiphene (Clomid® or Serophene®)").

The ideal infertility treatment for women with mild to moderate endometriosis is surgical removal (burning or cutting) of endometriosis implants. Women found to have severe endometriosis are best treated with IVF.

PREVENTION — There is no proven way to prevent endometriosis. Reducing the number of periods and amount of bleeding during the menstrual period may reduce the risk. Having one or more pregnancies or using hormonal contraception (eg, birth control pills) may be of benefit.

SUMMARY Endometriosis is a common condition in women. Its name is based on the endometrium, which is the tissue inside the uterus. During a woman's monthly period, the endometrium sheds and bleeds (show figure 1). With endometriosis, tissues that are similar to the endometrium grow outside the uterus. These growths also bleed during a woman's monthly period. The condition is not related to cancer. The cause of endometriosis is not known. Women whose mother, sister, or aunt had endometriosis have a higher chance of developing it. The most common symptom of endometriosis is pain. Pain may occur in the abdomen, lower back, or pelvis, and is usually worst before and during a woman's monthly period. Some women also have pain during sex. Surgery is needed to be certain of the diagnosis of endometriosis. Surgery is not always performed if endometriosis is likely and pain improves with medical treatment. There are many treatments for endometriosis. For most women, the first option is to use a medication to reduce pain and shrink the abnormal growths. Surgery may be the best choice for women with severe disease or pain that does not improve with medications. Endometriosis can cause difficulty becoming pregnant (infertility). If endometriosis is mild, surgery to remove the abnormal growths can treat infertility. Some women also need to use infertility medications or procedures to become pregnant (eg, in vitro fertilization or IVF).

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
The Hormone Foundation

(www.hormone.org)
The Endometriosis Association

(www.endo-online.org)


[1-4]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Kennedy, S, Bergqvist, A, Chapron, C, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005; 20:2698.
2. Dlugi, AM, Miller, JD, Knittle, J, Lupron Study Group. Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: A randomized, placebo-controlled, double-blind study. Fertil Steril 1990; 54:419.
3. Schlaff, WD, Carson, SA, Luciano, A, et al. Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Fertil Steril 2006; 85:314.
4. Porpora, MG, Koninckx, PR, Piazze, J, et al. Correlation between endometriosis and pelvic pain. J Am Assoc Gynecol Laparosc 1999; 6:429.

Endometriosis

INTRODUCTION — The normal tissue that lines the uterus and bleeds during the menstrual period is called the endometrium (show figure 1). Endometriosis is a noncancerous disorder in which tissue that is similar to the endometrium develops outside of the uterus. Typically this occurs in the pelvis, but it may occur in virtually any part of the body.

The most common locations for endometriosis are: the outer surface of the ovaries, peritoneum (the tissue that lines the abdomen) and peritoneal structures (the area behind the uterus and the various ligaments that hold the uterus in place), uterus, fallopian tubes, bowel, and bladder. Most women have endometriosis in more than one location.

RISK FACTORS — It is not known how many women are affected by endometriosis; the disease can only be diagnosed with a biopsy of lesions seen during surgery. Therefore, women who have no symptoms and never have surgery may not know that they are affected. Studies in small groups of women have shown that endometriosis is present in at least 5 percent of all women of reproductive age.

Endometriosis is rarely diagnosed before menarche (the first menstrual period of a woman's life) and new cases are seldom diagnosed after menopause (the last menstrual period of a woman's life). The growth and function of endometriosis depends upon stimulation from estrogen and progesterone, which are produced by the ovaries in women who menstruate. The condition is most common among women 25 to 29 years old and least common in women over age 44.

Risk factors for developing endometriosis include: No pregnancies resulting in the birth of an infant Endometriosis in a woman's mother (7 percent chance) Short menstrual cycles (<27>8 days) (2 percent chance) Partial or complete obstruction of normal menstrual flow (eg, from uterine abnormalities such as a tight cervical opening or vaginal septa [band of tissue] blocking the flow of menses) White or Asian race

Conditions that decrease the amount or frequency of menstrual bleeding lower the risk of endometriosis. Some examples are amenorrhea (absent menstrual periods), pregnancy, and prolonged use of birth control pills.

CAUSES — The cause of endometriosis is not known, but several theories have been suggested. Retrograde menstruation is a theory that menstrual blood and tissue flows backwards from the uterus, through the fallopian tubes and into the pelvis (show figure 1). This theory was proposed because women with a partial or complete obstruction of the uterus or cervix that prevents normal menstrual flow are more likely to have endometriosis. This is presumably because menstrual blood and tissue are more likely to flow backwards. Retrograde menstruation has been observed during surgery. The endometrial tissue shed during a menstrual period is able to grow when "planted" in the pelvis. Endometrial tissue from the uterus may be transported through blood and lymphatic vessels to sites elsewhere in the body, including the pelvis. Changes in the immune system allow endometrial tissue outside of the uterus to grow and develop. Coelomic metaplasia is the concept that the cells from lining of the abdomen and surface of the ovaries can change into endometrial tissue with certain stimuli, such as irritation from retrograde menstruation or infection.

SYMPTOMS AND SIGNS — For many women, severe pelvic pain is the main symptom of endometriosis. Pelvic pain usually occurs just before or during menses or during or after sex. Other symptoms may include pain during bowel movements, spotting before the menstrual period, frequent or heavy uterine bleeding, and pain during urination. Painful periods cause mild to severe discomfort (often cramps) in the lower abdomen; this may worsen over a period of years. Some women have constant pelvic soreness or pain in the lower back and legs that is aggravated during menses or intercourse. (See "Patient information: Chronic pelvic pain in women").

Pelvic pain is probably the result of bleeding from areas of endometriosis and release of substances that cause pain (eg, prostaglandins). Endometriosis implants respond to the hormonal changes that occur during the menstrual cycle, similar to the normal endometrium. Thus, at the end of the menstrual cycle, small amounts of endometrial tissue are shed and bleeding occurs (show figure 2).

Endometriomas are areas of endometriosis that are large enough to be considered a mass or tumor. They are usually filled with old blood that resembles chocolate syrup; thus, they are sometimes called chocolate cysts. Endometriomas may be seen as a mass on the ovary during a pelvic ultrasound, although only surgery can confirm that the mass is an endometrioma.

DIAGNOSIS — The diagnosis of endometriosis is one possibility for women who develop pelvic pain, problems with fertility, or have an abnormal pelvic examination or ultrasound. The disease may have no signs or symptoms and the intensity of the symptoms (eg, amount of pain and bleeding) does not always correlate with the severity or amount of endometriosis. For example, it is possible to have mild endometriosis with severe pelvic pain.

Pelvic examination — During a pelvic examination, a healthcare provider may feel thickening of, or nodules on, pelvic structures, an adnexal mass (a mass in the area of the ovary), or fixed or distorted pelvic organs, which suggests the presence of endometriosis. However, since these signs and symptoms are present in a variety of disorders, the diagnosis and stage (severity) of endometriosis can only be made with certainty by viewing the implants (small areas of endometriosis) during surgery, with either laparoscopy or laparotomy.

There are no blood tests or x-ray examinations that can make a definitive diagnosis, but a mildly elevated CA-125 blood level or growth near the ovaries on ultrasonography may suggest the disease.

Surgical evaluation — Laparoscopy and laparotomy are surgical procedures that are commonly used to diagnose and treat endometriosis. Both procedures are usually done in an operating room after the woman has received general anesthesia to induce sleep and prevent pain. After laparoscopy most women go home the same day. After laparotomy most women go home after spending one to three nights in the hospital.

At surgery, endometriosis appears as small (< 1/4 inch) blue, purple, or red implants. Scar tissue (adhesions) and/or an ovarian cyst may also be noted. A biopsy (removal of a small piece of tissue) can be done to confirm the diagnosis.

Staging — Surgery is also helpful for staging (determining the volume and location of disease) and treating the disorder. To stage the disease, the surgeon assigns points based upon size, depth, and location of implants (show figure 3). Endometriosis is classified as minimal (stage I, 1 to 5 points) if there are isolated superficial implants; mild (stage ll, 6 to 15 points) if there are several small, superficial implants and no more than a few small adhesions. Endometriosis is moderate (stage lll, 16 to 40 points) if the implants are superficial and deep with prominent adhesions. Endometriosis is severe (stage lV, over 40 points) when there are multiple superficial and deep implants with large endometriomas and prominent adhesions.

TREATMENT — There are several treatment options for women with endometriosis: No therapy Pain medication Birth control pills Other forms of hormonal therapy Surgery A combination of therapies

The treatment strategy depends upon whether the woman's major concern is pain, infertility, or a pelvic mass.

Women with minimal disease or who are near menopause and have no troubling symptoms may choose to have no treatment of endometriosis. Young women with minimal disease may consider taking birth control pills to protect against unplanned pregnancy and to prevent progression of disease. Near menopause, endometriosis may regress without treatment because the ovaries produce lower levels of estrogen, which decreases stimulation of the implants.

Endometriosis progresses slowly, over years, and resolves after menopause. Most women with endometriosis will get relief of pain from taking medication, after a pregnancy, or after menopause; some women will be helped only by surgery. Removal of the ovaries almost always provides excellent pain relief, making this an option for women who do not wish to have children.

Some women with endometriosis will have difficulty becoming pregnant, especially those who have severe disease and extensive adhesions. However, most women can achieve pregnancy after medical or surgical therapy or with fertility enhancing drugs or procedures (eg, in vitro fertilization). Rarely, endometriosis causes other problems such as blockage of the intestines or urinary tract or disease in the chest. ( See "Patient information: Evaluation of the infertile couple" and see "Patient information: Infertility treatment with clomiphene (Clomid® or Serophene®)").

Pelvic pain — When a laparoscopy is performed to diagnose endometriosis, endometrial implants and scar tissue are usually removed, which may relieve pain temporarily. However, the disease and pain tend to recur unless the uterus and ovaries are removed.

Recurrent or persistent pain after surgery is usually treated with medication. Studies have not determined the best medical therapy for treating pelvic pain, and no medical therapy has been proven to improve the chance of becoming pregnant in the future.

One advantages of medical therapy is that surgery can be avoided. Pelvic surgery has potential risks, some of which include damage to pelvic organs and formation of scar tissue. Another advantage is that medical therapy treats all implants, not just those seen during surgery. Disadvantages of medical therapy include the inability to treat existing adhesions or endometriomas. Medications may have side effects, including prevention of pregnancy (if drugs suppressing ovulation are used), and pain often recurs when medical therapy is stopped. Nonsteroidal antiinflammatory drugs — Nonsteroidal antiinflammatory drugs (NSAIDs, eg, ibuprofen, naproxen sodium) may be useful in relieving mild pain. NSAIDs inhibit prostaglandins, one of the main chemicals responsible for pain during menses. NSAIDs do not shrink or prevent the growth of implants, and pain often returns when medication is stopped.

The recommended dose of ibuprofen 400 to 600 mg by mouth every six hours, taken when pain starts or is expected. Other NSAIDs may also be used (show table 1).

Serious side effects from NSAIDs, although uncommon, include gastrointestinal pain and bleeding, kidney problems, and worsening high blood pressure. Oral contraceptive pills — Oral contraceptive pills (OCPs or birth control pills) contain both estrogen and progestin and cause the endometrial lining and endometriosis implants to shrink. There is no effect on scar tissue or endometriomas. OCPs are usually less effective than GnRH agonists and danazol (see below) for women with moderate or severe disease, but are a good choice for women with minimal or mild symptoms. OCPs prevent pregnancy and generally have tolerable side effects.

Birth control pills work by reducing the number of menstrual cycles and volume of bleeding. For most patients with only mild pain, this results in less painful periods and may also slow progression of endometriosis. The side effects of OCPs include nausea, breast tenderness, and decreased libido, although most side effects improve after being on the pill for several months. Serious side effects (eg, blood clots, stroke, heart attack) are rare in women who do not smoke and have no underlying blood vessel disease.

Continuous use of OCPs can be effective in relieving painful periods. Traditional birth control pill packs can be used in continuous dosing. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This regimen can be continued for as long as desired.

Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not indicate an increased risk of pill failure (unless pills are forgotten). Gonadotropin releasing hormone agonists — Gonadotropin releasing hormone (GnRH) agonists (eg, nafarelin, leuprolide, goserelin) work by turning off ovarian production of estrogen, thereby causing a temporary type of menopause. The lack of estrogen causes the endometriosis implants to shrink and reduces pain in over 80 percent of patients. The drugs may be given as a nasal spray, implant, or injection.

The full dose of a GnRH agonist is usually taken for up to six months; they are not usually taken for longer due to the risk of bone thinning. Side effects of GnRH agonists include headaches in 20 percent of women, especially in patients with a history of migraine, and the signs and symptoms of menopause: lack of menstrual bleeding, hot flashes, vaginal dryness, decreased libido, insomnia, and loss of bone density (on average a 2 to 7 percent loss). Bone strength recovers substantially after the drug is stopped.

Many of these side effects can be minimized by giving estrogen or a bone strengthening drug along with the GnRH agonist. Five years after completing GnRH agonist treatment, many women will again have pain (37 of women with mild disease and 74 percent of women with severe disease).

Alternate dosing regimens that use lower doses of the GnRH agonist for longer than five years may be considered for some women; this reduces the amount of bone density lost, and may allow the woman to have better, long-lasting relief of pain compared to other treatments. Monitoring of bone density is usually recommended while GnRH agonists are used. Danazol — Danazol is a medication that increases the level of androgens (male type hormone) and decreases the level of estrogen. This temporarily stops the menstrual period by inhibiting ovulation and ovarian production of estrogen and by shrinking the endometrium.

The medication is taken by mouth at a dose of 200 to 400 mg two to four times per day for 6 months or more. Eighty percent of patients will have good pain relief and shrinkage of implants. However, there is a high (75 percent) incidence of one or more side effects, but only a small percentage of patients discontinue the drug because of them.

Side effects may include weight gain, edema, decreased breast size, acne, oily skin, hirsutism (male pattern hair growth), deepening of the voice, headache, hot flashes, changes in libido, and mood changes. All of these changes are reversible, except for voice changes; however, return to normal may take many months.

Danazol should not be taken by women with certain types of liver, kidney, and heart disease because these disorders may worsen. Women who could become pregnant must use a nonhormonal form of birth control (eg, condoms) while taking danazol because of a serious risk of birth defects if danazol is taken during pregnancy. (See "Patient information: Barrier methods of birth control"). Progestins — Progestins (eg, medroxyprogesterone acetate (Depo Provera®) norethindrone acetate (Micronor®, NorQD®, Aygestin®) norgestrel acetate) may be recommended for women who do not get pain relief from or who cannot take a birth control pill (eg, smokers). These medications cause the endometrial lining and endometriosis implants to shrink, and usually cause the menstrual periods to temporarily stop. (See "Patient information: Long-term methods of birth control").

Side effects are common and include: bloating, weight gain, irregular uterine bleeding, and rarely, aggravation of depression. Women who use long-acting medroxyprogesterone acetate may not have a menstrual period for six to twelve months after stopping the treatment. Therefore, this drug may not be the best choice for women planning pregnancy in the near future. Surgery — Surgery is an option when medication has failed to improve pain or if there is severe disease (scarring, endometriomas, involvement of the bowel or bladder) that is unlikely to respond to medications alone. The goal of conservative surgery is to eliminate as many implants and adhesions as possible.

Pain relief is achieved in 80 to 90 percent of women, but the risk of recurrent pain within 10 years is 40 percent. Surgical therapy avoids the side effects of medication and can improve fertility, although there are some risks, including damage to pelvic organs, development of new adhesions, bleeding, and infection.

Definitive surgery consists of removal of the uterus (hysterectomy), ovaries, and endometrial implants to eliminate as much of the disease as possible and create a low estrogen state. It may be recommended for women who are not planning pregnancy if severe symptoms remain after trying other less invasive treatments. Low dose hormone replacement therapy (eg, estrogen pills or a patch) is usually given after surgery to prevent menopausal symptoms and other complications of a low estrogen level; this treatment usually does not cause the pain to return. (See "Patient information: Abdominal hysterectomy" and see "Patient information: Vaginal hysterectomy").

Pelvic mass — A pelvic mass in a woman with endometriosis may be an endometrioma, chocolate cyst, a combination of scarring and normal pelvic organs, or a mass unrelated to the disease. Surgery is the best way to make a definite diagnosis and remove the mass. Medical therapy is not effective.

Infertility — Endometriosis sometimes interferes with the ability to become pregnant. Reduced fertility may develop because of adhesions that develop between the ovaries and fallopian tubes or as a result of substances produced by endometriosis implants that impair normal ovulation, fertilization, and implantation. However, as many as 70 percent of women with minimal or mild endometriosis and infertility will conceive within three years without any therapy. If pregnancy occurs, endometriosis often regresses or resolves. Women with endometriosis who become pregnant have no increased risk of pregnancy complications.

The treatment of infertility caused by endometriosis includes a combination of observation, surgery, use of medications that enhance ovulation combined with intrauterine insemination, or in vitro fertilization (IVF). Medical treatments for endometriosis (eg, GnRH agonists) are of no benefit in improving fertility. (See "Patient information: Infertility treatment with clomiphene (Clomid® or Serophene®)").

The ideal infertility treatment for women with mild to moderate endometriosis is surgical removal (burning or cutting) of endometriosis implants. Women found to have severe endometriosis are best treated with IVF.

PREVENTION — There is no proven way to prevent endometriosis. Reducing the number of periods and amount of bleeding during the menstrual period may reduce the risk. Having one or more pregnancies or using hormonal contraception (eg, birth control pills) may be of benefit.

SUMMARY Endometriosis is a common condition in women. Its name is based on the endometrium, which is the tissue inside the uterus. During a woman's monthly period, the endometrium sheds and bleeds (show figure 1). With endometriosis, tissues that are similar to the endometrium grow outside the uterus. These growths also bleed during a woman's monthly period. The condition is not related to cancer. The cause of endometriosis is not known. Women whose mother, sister, or aunt had endometriosis have a higher chance of developing it. The most common symptom of endometriosis is pain. Pain may occur in the abdomen, lower back, or pelvis, and is usually worst before and during a woman's monthly period. Some women also have pain during sex. Surgery is needed to be certain of the diagnosis of endometriosis. Surgery is not always performed if endometriosis is likely and pain improves with medical treatment. There are many treatments for endometriosis. For most women, the first option is to use a medication to reduce pain and shrink the abnormal growths. Surgery may be the best choice for women with severe disease or pain that does not improve with medications. Endometriosis can cause difficulty becoming pregnant (infertility). If endometriosis is mild, surgery to remove the abnormal growths can treat infertility. Some women also need to use infertility medications or procedures to become pregnant (eg, in vitro fertilization or IVF).

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
The Hormone Foundation

(www.hormone.org)
The Endometriosis Association

(www.endo-online.org)


[1-4]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Kennedy, S, Bergqvist, A, Chapron, C, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005; 20:2698.
2. Dlugi, AM, Miller, JD, Knittle, J, Lupron Study Group. Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: A randomized, placebo-controlled, double-blind study. Fertil Steril 1990; 54:419.
3. Schlaff, WD, Carson, SA, Luciano, A, et al. Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Fertil Steril 2006; 85:314.
4. Porpora, MG, Koninckx, PR, Piazze, J, et al. Correlation between endometriosis and pelvic pain. J Am Assoc Gynecol Laparosc 1999; 6:429.

Dilation and curettage (D&C)

INTRODUCTION — Dilation and curettage (D&C) is a procedure in which material from the inside of the uterus is removed. The "dilation" refers to dilation of the cervix, the lower part of the uterus that opens into the vagina (show figure 1). "Curettage" refers to the scraping or removal of tissue lining the uterine cavity (endometrium) with a surgical instrument called a curette. Some curettes are sharp while others use suction.

REASONS FOR DC — There are a number of reasons a D&C might be performed. In some cases, the procedure is used to gain information about the uterus to diagnose a medical condition (called diagnostic D&C). In other cases, the procedure is used to treat a medical problem or condition (called therapeutic D&C).

Diagnostic DC — The primary reason for a diagnostic D&C is to obtain samples of the endometrium to evaluate abnormal uterine bleeding or abnormal cells found during routine screening for cervical cancer. (See "Patient information: Screening for cervical cancer").

In most cases, a healthcare provider will try to obtain a tissue sample with an office procedure called endometrial biopsy. In some cases, endometrial biopsy is not possible or insufficient tissue is obtained. When this occurs, D&C must be done to obtain an adequate tissue sample.

Diagnostic D&C is usually done with hysteroscopy; this involves dilating the cervix and inserting a small instrument that allows the physician to examine and photograph the inside of the uterus. The images are displayed on a monitor, allowing the physician to visualize the endometrium. This helps the physician to avoid missing small polyps and ensures that the most visibly abnormal areas are sampled. (See "Patient information: Abnormal uterine bleeding").

Examination of the endometrial tissue by a pathologist can help establish certain diagnoses, including endometrial (uterine) cancer, endometrial polyps, or precancerous conditions of the lining of the uterus (endometrial hyperplasia).

Therapeutic DC — Therapeutic D&C is done to remove the contents of the uterus in the following circumstances:

Miscarriage — In some miscarriages, the tissues from a pregnancy are passed completely. In other cases, a D&C is needed to remove this tissue or to ensure that all of it has been passed. (See "Patient information: Miscarriage").

Abortion — A D&C can be done to remove the contents of the uterus when a woman chooses to end a pregnancy.

Treatment of molar pregnancies — A molar pregnancy occurs when a tumor forms in place of normal pregnancy placenta. It is often treated with a D&C.

Prolonged or excessive vaginal bleeding — D&C may be done as a treatment in some cases of prolonged or excessive bleeding that do not respond to medical treatment. (See "Patient information: Abnormal uterine bleeding").

Postpartum hemorrhage — Curettage may be done to manage excessive bleeding after delivery of an infant (postpartum hemorrhage).

PREPARING FOR DC — Some patients will need to have blood testing before D&C (such as a blood count), although this is not always necessary. Patients should not eat or drink anything before the procedure. All patients will need someone to accompany them home because it will not be safe to drive after receiving anesthesia, which causes sedation.

Some patients will need to have a device or medication placed in the cervix the day before their procedure. The purpose is to safely and gradually enlarge the cervical opening, reducing the risk of cervical injury. Devices are used when the cervix must be dilated to a larger size than is typically needed for D&C, such as with pregnancy terminations and some types of hysteroscopy. Some patients will be instructed to insert a medicine in the vagina to soften the cervix prior to the procedure.

After arriving for the procedure, a nurse may place an intravenous (IV) line, which can be used to give fluids and medicine before, during, and after the procedure. The nurse or doctor will review the patient's medical history, list of medications used, and any drug allergies.

PROCEDURE — D&C can be performed in an operating room in a hospital or clinic. Many patients have a D&C performed in an outpatient setting. A woman's blood pressure, pulse, and blood oxygen levels are monitored during the procedure. The procedure takes 15 to 30 minutes to complete.

Anesthesia — The procedure can be done using general, regional, or local (paracervical) block anesthesia. The type of anesthesia chosen depends upon the reason for the procedure as well as the medical history.

General anesthesia — General anesthesia induces sleep and completely relaxes the muscles, which makes it easier for the doctor to perform a pelvic examination.

Regional anesthesia — Reginonal anesthesia uses an injection of an anesthetic into the area around the spinal cord to block pain sensation during surgery. The patient may be sedated with medicine given through an intravenous (IV) line.

Paracervical block — Anesthetic agents are injected directly into and around the cervix, numbing the area. The woman is given a sedative through an intravenous (IV) line.

POST-PROCEDURE CARE — After the procedure, the patient will be cared for in a recovery or post-anesthesia care unit for a few hours. This is necessary to monitor for excessive vaginal bleeding or other complications, and allows time for recovery from the anesthesia. Patients who received general anesthesia occasionally have nausea and vomiting, which can be treated with medications.

Most patients should be able to resume their regular activities within a day or two. Mild cramping and spotting may occur for a few hours or days; cramping can be treated with nonsteroidal antiinflammatory medications such as ibuprofen (Advil®, Motrin®). Patients should not put anything into the vagina (tampons, douches) during this time and should ask when they can safely have sexual intercourse. The next menstrual period usually occurs within 4 to 6 weeks of the procedure.

A woman should call her physician if she develops fever (temperature greater than 100.4º F), cramps lasting longer than 48 hours, increasing rather than decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.

COMPLICATIONS — D&C is a commonly performed procedure that is usually very safe. Yet as with any operation, complications occur. Complications of D&C can include:

Uterine perforation — Uterine perforation occurs when one of the surgical instruments makes a hole in the uterus. It is more common when the procedure is done during pregnancy due to softening of the uterine wall.

Fortunately, most uterine perforations heal on their own and do not require any treatment. Two potential problems caused by perforation are bleeding from injury to a blood vessel and injury to other internal organs. A second procedure may be needed to repair these types of injury.

Cervical injury — Injuries to the cervix can occur during dilation or from trauma related to the curettage. Lacerations (cuts) to the cervix are managed with pressure to the area, application of medications that help stop bleeding, or in some cases, stitches in the cervix.

Infection — Infection from D&C is rare.

Intrauterine adhesions — Adhesions (areas of scar tissue) can sometimes form in the uterus following D&C. Adhesion is most common when D&C is performed postpartum or postabortion. In some cases, this can lead to abnormalities in the menstrual cycle, painful menstrual cycles, infertility, or miscarriage. If adhesions are extensive, a woman can be treated with hormones to encourage growth of healthy uterine tissue and the scar tissue can be removed with a surgical procedure.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
The Mayo Clinic

(www.mayoclinic.com)


[1-3]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, May 2002.
2. Chen, SS, Lee, L. Reappraisal of endocervical curettage in predicting cervical involvement by endometrial carcinoma. J Reprod Med 1986; 31:50.
3. Gebauer, G, Hafner, A, Siebzehnrubl, E, Lang, N. Role of hysteroscopy in detection and extraction of endometrial polyps: results of a prospective study. Am J Obstet Gynecol 2001; 184:59.

Dilation and curettage (D&C)

INTRODUCTION — Dilation and curettage (D&C) is a procedure in which material from the inside of the uterus is removed. The "dilation" refers to dilation of the cervix, the lower part of the uterus that opens into the vagina (show figure 1). "Curettage" refers to the scraping or removal of tissue lining the uterine cavity (endometrium) with a surgical instrument called a curette. Some curettes are sharp while others use suction.

REASONS FOR DC — There are a number of reasons a D&C might be performed. In some cases, the procedure is used to gain information about the uterus to diagnose a medical condition (called diagnostic D&C). In other cases, the procedure is used to treat a medical problem or condition (called therapeutic D&C).

Diagnostic DC — The primary reason for a diagnostic D&C is to obtain samples of the endometrium to evaluate abnormal uterine bleeding or abnormal cells found during routine screening for cervical cancer. (See "Patient information: Screening for cervical cancer").

In most cases, a healthcare provider will try to obtain a tissue sample with an office procedure called endometrial biopsy. In some cases, endometrial biopsy is not possible or insufficient tissue is obtained. When this occurs, D&C must be done to obtain an adequate tissue sample.

Diagnostic D&C is usually done with hysteroscopy; this involves dilating the cervix and inserting a small instrument that allows the physician to examine and photograph the inside of the uterus. The images are displayed on a monitor, allowing the physician to visualize the endometrium. This helps the physician to avoid missing small polyps and ensures that the most visibly abnormal areas are sampled. (See "Patient information: Abnormal uterine bleeding").

Examination of the endometrial tissue by a pathologist can help establish certain diagnoses, including endometrial (uterine) cancer, endometrial polyps, or precancerous conditions of the lining of the uterus (endometrial hyperplasia).

Therapeutic DC — Therapeutic D&C is done to remove the contents of the uterus in the following circumstances:

Miscarriage — In some miscarriages, the tissues from a pregnancy are passed completely. In other cases, a D&C is needed to remove this tissue or to ensure that all of it has been passed. (See "Patient information: Miscarriage").

Abortion — A D&C can be done to remove the contents of the uterus when a woman chooses to end a pregnancy.

Treatment of molar pregnancies — A molar pregnancy occurs when a tumor forms in place of normal pregnancy placenta. It is often treated with a D&C.

Prolonged or excessive vaginal bleeding — D&C may be done as a treatment in some cases of prolonged or excessive bleeding that do not respond to medical treatment. (See "Patient information: Abnormal uterine bleeding").

Postpartum hemorrhage — Curettage may be done to manage excessive bleeding after delivery of an infant (postpartum hemorrhage).

PREPARING FOR DC — Some patients will need to have blood testing before D&C (such as a blood count), although this is not always necessary. Patients should not eat or drink anything before the procedure. All patients will need someone to accompany them home because it will not be safe to drive after receiving anesthesia, which causes sedation.

Some patients will need to have a device or medication placed in the cervix the day before their procedure. The purpose is to safely and gradually enlarge the cervical opening, reducing the risk of cervical injury. Devices are used when the cervix must be dilated to a larger size than is typically needed for D&C, such as with pregnancy terminations and some types of hysteroscopy. Some patients will be instructed to insert a medicine in the vagina to soften the cervix prior to the procedure.

After arriving for the procedure, a nurse may place an intravenous (IV) line, which can be used to give fluids and medicine before, during, and after the procedure. The nurse or doctor will review the patient's medical history, list of medications used, and any drug allergies.

PROCEDURE — D&C can be performed in an operating room in a hospital or clinic. Many patients have a D&C performed in an outpatient setting. A woman's blood pressure, pulse, and blood oxygen levels are monitored during the procedure. The procedure takes 15 to 30 minutes to complete.

Anesthesia — The procedure can be done using general, regional, or local (paracervical) block anesthesia. The type of anesthesia chosen depends upon the reason for the procedure as well as the medical history.

General anesthesia — General anesthesia induces sleep and completely relaxes the muscles, which makes it easier for the doctor to perform a pelvic examination.

Regional anesthesia — Reginonal anesthesia uses an injection of an anesthetic into the area around the spinal cord to block pain sensation during surgery. The patient may be sedated with medicine given through an intravenous (IV) line.

Paracervical block — Anesthetic agents are injected directly into and around the cervix, numbing the area. The woman is given a sedative through an intravenous (IV) line.

POST-PROCEDURE CARE — After the procedure, the patient will be cared for in a recovery or post-anesthesia care unit for a few hours. This is necessary to monitor for excessive vaginal bleeding or other complications, and allows time for recovery from the anesthesia. Patients who received general anesthesia occasionally have nausea and vomiting, which can be treated with medications.

Most patients should be able to resume their regular activities within a day or two. Mild cramping and spotting may occur for a few hours or days; cramping can be treated with nonsteroidal antiinflammatory medications such as ibuprofen (Advil®, Motrin®). Patients should not put anything into the vagina (tampons, douches) during this time and should ask when they can safely have sexual intercourse. The next menstrual period usually occurs within 4 to 6 weeks of the procedure.

A woman should call her physician if she develops fever (temperature greater than 100.4º F), cramps lasting longer than 48 hours, increasing rather than decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.

COMPLICATIONS — D&C is a commonly performed procedure that is usually very safe. Yet as with any operation, complications occur. Complications of D&C can include:

Uterine perforation — Uterine perforation occurs when one of the surgical instruments makes a hole in the uterus. It is more common when the procedure is done during pregnancy due to softening of the uterine wall.

Fortunately, most uterine perforations heal on their own and do not require any treatment. Two potential problems caused by perforation are bleeding from injury to a blood vessel and injury to other internal organs. A second procedure may be needed to repair these types of injury.

Cervical injury — Injuries to the cervix can occur during dilation or from trauma related to the curettage. Lacerations (cuts) to the cervix are managed with pressure to the area, application of medications that help stop bleeding, or in some cases, stitches in the cervix.

Infection — Infection from D&C is rare.

Intrauterine adhesions — Adhesions (areas of scar tissue) can sometimes form in the uterus following D&C. Adhesion is most common when D&C is performed postpartum or postabortion. In some cases, this can lead to abnormalities in the menstrual cycle, painful menstrual cycles, infertility, or miscarriage. If adhesions are extensive, a woman can be treated with hormones to encourage growth of healthy uterine tissue and the scar tissue can be removed with a surgical procedure.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
The Mayo Clinic

(www.mayoclinic.com)


[1-3]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, May 2002.
2. Chen, SS, Lee, L. Reappraisal of endocervical curettage in predicting cervical involvement by endometrial carcinoma. J Reprod Med 1986; 31:50.
3. Gebauer, G, Hafner, A, Siebzehnrubl, E, Lang, N. Role of hysteroscopy in detection and extraction of endometrial polyps: results of a prospective study. Am J Obstet Gynecol 2001; 184:59.

Surgical sterilization of women

INTRODUCTION — Surgical sterilization is a safe, highly effective, permanent, and convenient form of contraception. The most common surgical sterilization procedure for women is called a tubal ligation or having the "tubes tied". The fallopian tubes are attached to the uterus and adjacent to the ovaries (show figure 1). The fallopian tubes are the site where the egg becomes fertilized by the male's sperm prior to traveling to the uterus. In tubal sterilization, the fallopian tubes are separated or sealed shut, thus preventing the egg and sperm from meeting.

A tubal sterilization is usually performed by laparoscopic surgery, in which a flexible tube (laparoscope) is inserted through a small incision and used to view and operate inside a woman's abdomen. It can also be performed by a laparotomy, where an incision is made in the abdomen. This is most often performed in women who have recently given birth, during the postpartum period.

DECIDING TO HAVE A TUBAL LIGATION — Sterilization is a major decision; it means that a woman and her partner do not want children at any time in the future. A woman's decision to undergo sterilization must be voluntary and not forced by her family, partner, or health care provider. In the United States, a woman's husband or partner is not required to give consent for the procedure, though both partners should have an understanding of the procedure as well as tubal sterilization's benefits, alternatives, and potential risks. The woman and her partner should review the risks and benefits of all methods of contraception, including male sterilization (vasectomy). (See "Patient information: Vasectomy").

The physician should provide an explanation of the details of the procedure, including anesthesia (general, spinal, local), and the possibility of pregnancy following the procedure (see "Outcomes" below), including the chance of ectopic pregnancy (when a pregnancy begins to grow outside the uterus, usually in the fallopian tubes). A woman may change her mind at anytime before the procedure.

Tubal sterilization should be considered permanent; reversing the procedure involves major surgery, is not always successful, and is rarely covered by most insurance plans.

ALTERNATIVES — Alternatives to permanent female sterilization include male sterilization (vasectomy) and reversible types of contraception (birth control pills/patch/vaginal ring, condoms, diaphragm, cervical cap, intrauterine device, or hormone injections).

REGRET AFTER STERILIZATION — Regret after tubal sterilization occurs in 3 to 25 percent of women. However, only about 1 to 2 percent of all women who have undergone sterilization seek a reversal of the procedure [1-3]. The most common factor associated with regret is a change in marital status. Other factors include marital problems at the time of procedure, stress due to recent pregnancy complications, and young age (less than age 30) at the time of sterilization.

For these reasons, women who are younger than 30, have recently given birth and had significant complications (eg, premature birth, death of an infant), or who are having difficulty with their marriage or relationship should initially consider other birth control options. A healthcare provider may recommend that sterilization be delayed until a woman is sure of her decision, aware of the risks and benefits, and aware of the alternatives to permanent sterilization.

TIMING OF STERILIZATION — Sterilization can be performed at any time during a woman's menstrual cycle, though another form of birth control is recommended for one month before the procedure to reduce the risk of pregnancy (see below).

Sterilization can also be performed postpartum, after an abortion, or in conjunction with another surgical procedure (eg, gallbladder removal). Ideally, postpartum procedures are performed immediately after delivery or within 24 hours, but may be done up to seven days later. Further delay increases the difficulty of the procedure and the risk of infection.

Contraception before and after sterilization — Some form of contraception (condom, diaphragm, birth control pill) should be used before sterilization to decrease the risk of pregnancy. A woman can become pregnant if fertilization occurs just prior to the tubal ligation. Performing the tubal ligation procedure immediately postpartum or during a woman's menstrual period reduces the chance of becoming pregnant at the time of the procedure.

Although contraception is not necessary after the procedure, condoms should be used for protection against sexually transmitted diseases (eg, chlamydia, HIV) if the woman has multiple sex partners or a partner with other partners.

STERILIZATION PROCEDURES

Minilaparotomy — A minilaparotomy is commonly used postpartum; a small cut (one to three inches) is made in the abdomen, through which the procedure is performed on the fallopian tubes. General, regional, or local anesthesia can all be used for this procedure. In postpartum women, having the procedure does not lengthen the hospital stay.

There are three common surgical methods for the minilaparotomy that correspond to three different techniques of sealing the fallopian tubes: the Pomeroy technique (show figure 2-5), the Irving technique (show figure 6-9), or the Uchida method (show figure 10). Each has advantages and disadvantages.

One advantage of minilaparotomy is that a tissue specimen can be removed to prove the fallopian tubes have been completely cut. Disadvantages of minilaparotomy include a greater need for pain medication, slightly longer recovery time, and a larger surgical incision than with a laparoscopic procedure [4].

Laparoscopic sterilization — Laparoscopic sterilization is the most common surgical method for interval (at a time unrelated to pregnancy) sterilization. In laparoscopic surgery, a small incision is cut near the belly button and in the lower abdomen and a flexible tube (laparoscope) is used to view the fallopian tubes and pelvis. The physician uses rings or clips to close the fallopian tubes or seals them shut using electrocoagulation (a procedure in which the fallopian tubes are cauterized) (show figure 11).

Severe heart or lung disease, a bleeding tendency, intraabdominal scarring, and obesity make laparoscopic procedures more dangerous and may prevent a woman from undergoing a laparoscopic sterilization.

Vaginal sterilization — The vaginal route for tubal sterilization is uncommon because it is more difficult to see the fallopian tubes than with the laparoscopic approach. In the vaginal sterilization technique, an incision is made through the vagina to reach the fallopian tubes, which are then cauterized, banded, or clipped.

Hysteroscopic sterilization — A minimally invasive hysteroscopic technique for tubal sterilization is also available. The Essure® permanent birth control procedure is a minimally invasive hysteroscopic technique for permanent tubal blockage whereby a tiny coil mechanism is inserted into the fallopian tube hysteroscopically under local anesthesia. Patients must use contraception until a procedure (called hysterosalpingogram) is performed three months after coil placement confirms tubal blockage. Some patients will require a second procedure if the tubes are not completely blocked.

OUTCOMES

Complications — The risk of surgical complications is approximately 1 in every 1000 procedures, but depend on the type of procedure. These complications include infection, bowel or bladder injury, internal bleeding, and problems related to anesthesia. Burns may occur if electrocautery is used. Blood clots and death are very rare.

Menstrual periods — There is no evidence that bleeding or uterine cramping is increased after tubal sterilization [5-7]. In fact, women who undergo sterilization are more likely to have fewer days of bleeding during menstruation, a lower amount of blood loss, and less menstrual pain. However, sterilized women have described more cycle irregularity than women who were not sterilized.

Sex — Tubal sterilization does not affect sexual desire or performance.

Pregnancy — Sterilization failure resulting in pregnancy is uncommon. In a study of 10,685 women who underwent tubal sterilization and were followed for 8 to 14 years, 143 women became pregnant (approximately 1 percent) [8,9] (show table 1A-1B) . The risk of pregnancy was highest among women sterilized at a young age (under age 30). When pregnancy occurs, it is more likely to be an ectopic pregnancy. (See "Patient information: Ectopic (tubal) pregnancy").

Other — Women who have undergone tubal sterilization have a slightly lower risk of developing ovarian cancer.

AFTER SURGERY — Patients may go home a few hours after an outpatient procedure, but someone should be available to drive and help as needed. There will be some discomfort at the incision site and menstrual-type cramping; this can be treated with pain medication such ibuprofen. Depending upon the type of procedure and anesthesia, patients may have a sore throat (from a tube placed to help with breathing during general anesthesia), neck or shoulder pain, or vaginal discharge/slight bleeding. Most patients should be able to return to a normal routine within a couple of days.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
Planned Parenthood

(www.plannedparenthood.org)
Society of Obstetricians and Gynaecologists of Canada (SOGC)

(www.sogc.org/health)
Managing Contraception

(www.managingcontraception.com/cmanager/publish/choices.shtml)


[1-11]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Grubb, GS, Peterson, HB, Layde, PM, Rubin, GL. Regret after decision to have a tubal sterilization. Fertil Steril 1985; 44:248.
2. Allyn, DP, Leton, DA, Westcott, NA, Hale, RW. Presterilization counseling and women's regret about having been sterilized. J Reprod Med 1986; 31:1027.
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