While most women think of fibroids as an ‘old lady’ condition, that's not actually true at all. In fact, they typically start growing in our 20s and 30s, with the peak incidence of them becoming problematic in our 40s. That’s because during these years we have more estrogen and growth factor hormones, that in excess, feed fibroids like ‘Miracle Grow.’ In fact, as estrogen levels naturally decline in menopause, fibroids usually spontaneously shrink.
Uterine fibroids (‘fibroids’) are solid, well-defined, non-cancerous growths of muscle tissue in the uterus. They’re highly prevalent in the US, where a woman’s lifetime risk of developing them is estimated to be as high as 75% (the often cited 20% to 50% is likely a significantly underestimated range) by age 50, and as high as an 80% lifetime risk for Black women.
Uterine fibroids are important to understand, prevent, and know your treatment options for, because not only can they cause discomfort, they can sometimes affect conception and pregnancy, and they are the most common cause of hysterectomies, other than uterine cancer, with approximately 17% of all hysterectomies in the US performed for uterine fibroids. The peak incidence of surgery occurs for women around age 45, making fibroids the primary cause of premenopausal hysterectomy. Most of these hysterectomies, including those done on women in their 20s and 30s, are considered unnecessary, with women remaining uninformed about medical alternatives to surgery by their physicians.
Given the remarkably high incidence of uterine fibroids, their significant impact on women's health, and the high rate of hysterectomies as a result of fibroids, it’s incredibly important for all women to know how to prevent them, and the strategies that are available to reduce them to avoid unnecessary surgery – and possibly unnecessary medications. It’s important also to recognize that like so many chronic women’s health conditions, fibroids may be a symptom of reversible environmental and dietary factors that can be associated with other medical conditions. An integrative approach can therefore not only prevent and reduce fibroids, but can be part of a plan for lifetime hormonal and total health.
Uterine Fibroids 101
Uterine fibroids, properly called uterine leiomyomata, vary in size, from practically microscopic to that of a jumbo grapefruit – or bigger. A fibroid uterus is described in comparison to a pregnant uterus size, as in a 16-week uterus or a 24-week uterus. They may grow singly or in clusters, and can grow in a variety of locations in the uterus.
They are classified according to their site of growth in the uterine or surrounding tissue as follows:
- Subserosal are in the outer wall of the uterus (55%)
- Intramural are found in the muscular layers of the uterine wall (40%)
- Submucosal protrude into the uterine cavity (5%)
They may also occur in the cervix (cervical fibroids), between the uterine broad ligaments (interligamentous fibroids), or they may be attached to a stalk (pedunculated fibroids) and protrude into the uterine cavity (pedunculated submucosal fibroids) or through the cervix.
Uterine Fibroid Symptoms
While not all women will experience symptoms, it’s estimated that 1 in 3 will, and in fact, nearly 70,000 women go to the emergency department each year for symptoms due to fibroids, a rate that has tripled over recent years.
Symptoms may be mild, or can be terribly uncomfortable, negatively impacting quality of life. Symptoms may include:
- Heavy periods
- Menstrual periods lasting more than a week
- Severe menstrual cramps
- Bleeding between periods
- A feeling of fullness in the lower abdomen
- Pain during sex
- Low back ache, leg ache
- Abdominal distention
- Abdominal pain
- Urinary frequency, urgency, or difficulty peeing
- Abnormal uterine bleeding – present in about 30% of all women with fibroids
Some symptoms are similar to endometriosis, so the diagnosis of one or the other may be missed. While malignancy is rarely associated with uterine fibroids, they occur with increased frequency in endometrial hyperplasia and are associated with a fourfold increased risk of developing endometrial cancer. On top of that, large fibroids may sometimes mask the diagnosis of serious gynecologic cancer.
Causes of Uterine Fibroids
It’s not clear exactly what causes uterine fibroids, but we do know quite a lot about what contributes to them. Foremost, we know that they are hormone dependent – with excess estrogen considered the primary culprit, and they are also ‘fed’ by insulin-like growth factors. And like so many hormonally driven conditions, there are many additional factors that conspire – from genetics to environmental exposures, nutritional imbalances, and lifestyle factors – to trigger fibroids to develop and grow.
Environmental factors: Environmental exposures play a tremendous role as a root cause of fibroids. Endocrine disrupting chemicals (EDCs), defined by the U.S. National Institute of Environmental Health Sciences (NIEHS) as “chemicals that interfere with the body's endocrine system and produce adverse developmental, reproductive, neurological and immune effects” may be a major contributing factor to estrogen overload and fibroid development and growth. A number of persistent organic pollutants (POPs) and their breakdown products have been detected in the endometrium of premenopausal women undergoing hysterectomies for fibroids. Additionally, EDCs alter the way your DNA works; in the case of uterine fibroids, this allows for unregulated overgrowth of uterine cells.
Genetics: If you have fibroids, it’s quite likely your mom or sisters also have this health issue as genetics definitely play a role in predisposing women to the development of fibroids. This also means if you have daughters, they’re more likely to be at risk of developing fibroids. We also know epigenetics play an important role and that we can stop this domino effect by addressing the estrogen excess, environmental exposures, and nutritional factors that contribute to fibroids.
Ethnicity: Fibroids are also three times more common in Black women than white, Asian, and Latina women, occur at an earlier age (in women’s 20s), and are associated with more severe symptoms. While reasons for this increased prevalence are not yet fully understood, a possible relationship to vitamin D deficiency is being studied, and we have to take into consideration the fact that Black women are at higher risk of exposure to environmental toxins. Another theory is that dairy consumption, already a possible contributor to fibroids, may be more problematic due to dairy intolerance in people of African descent.
Diet: Diet plays a role in the risk of developing fibroids. Vitamin D deficiency (or insufficiency), which is very common in the general population, is considered a risk factor for fibroid development, and preliminary data suggests that Vitamin D supplementation prevents fibroid growth. Greater consumption of red meat and pork, particularly ham, and less consumption of green vegetables, fruit (particularly citrus fruit), and fish, are all associated with greater likelihood of having uterine fibroids, and some studies suggest that dairy consumption, ostensibly due to hormones, especially growth factors, especially in but not exclusive to conventional dairy products, may play a role.
Other risk factors: Evidence suggests that hypertension is involved in the pathogenesis of fibroids and precedes their development]. Hypertension is significantly more likely in women with fibroids than without, and the risk of fibroid growth increases with blood pressure. This is thought to be due to the inflammatory cells and chemicals associated with both conditions. Being significantly overweight is also a risk factor. While you can be overweight and absolutely healthy, being significantly overweight leads to more circulating estrogen and growth factors, both of which are a risk for fibroids. Thus, in women who are significantly overweight, the risk is two to three times greater than average. Metabolic syndrome is also a risk factor, due to a combination of weight, hypertension, and increased growth factors that can contribute to fibroid formation and growth. Finally, the medical literature does suggest a possible association between a history of trauma (emotional, sexual) and uterine fibroid incidence in women. The reasons are unclear and may just represent the high incidence of both – or there could possibly be some relationship between immune and hormonal dysregulaton as a result of stress and trauma.
Can Fibroids Affect Fertility and Pregnancy?
A common question I get is: “Will my fibroid impact my likelihood of getting and staying pregnant?” The short answer is possibly, though it's unlikely, as in most cases they are not at all problematic for either conception or during pregnancy and birth. However, they can sometimes cause a variety of problems, and because fibroids are so common, prevention, especially through lifestyle and diet, which are low hanging fruit any of us can shift, remains important to avoid any potential impact on conception or pregnancy complications.
Fibroids are present in 5-10% of women facing fertility challenges, suggesting the overall prevalence of fibroids in women in their childbearing years, rather than their impact on fertility. According to some data, fibroids may be the sole cause of infertility in 1-2.4%; however, this is a controversial figure, and according to most studies fibroids usually don't interfere with getting pregnant. It is possible, however, that in some cases they may cause obstruction in the fallopian tubes, interfering with conception or implantation (because the fertilized egg cannot make its way to the uterus), or may affect implantation if uterine fibroids are significantly impacting the uterine lining. If you have been struggling to get pregnant, an evaluation for fibroids is an appropriate part of a workup.
Fibroids occur in 0.1-10.7% of all pregnancies. Despite the fact that fibroids usually do grow in pregnancy due to the influence of pregnancy hormones, most women with fibroids do not have any complications during pregnancy related to the fibroids. Rarely, larger fibroids may contribute to miscarriage, premature labor, malpresentation of the fetus (especially breech presentation), placental abruption, and postpartum hemorrhage, however the preponderance of data do not show an increased risk of adverse events. Approximately 11% of women with uterine fibroids experience some pain in pregnancy, due to something called fibroid degeneration – where limited blood supply to the fibroid causes it to “die” or degenerate – which occurs during late pregnancy. More rare complications can occur, but any complications due to fibroids in pregnancy are infrequent.
Fibroids are associated with a higher rate of cesarean section, though statistically women with fibroids larger than 10 cm can still have a vaginal delivery approximately 70% of the time, so it’s unclear whether that increased rate is due to medically necessary cesareans, or inadequate knowledge on the part of obstetricians regarding vaginal birth and fibroids.
If you have large fibroids, it is important to work with a skilled OB or Family doctor in addition to your midwife. If you know that you have fibroids prior to becoming pregnant, an ultrasound in pregnancy is appropriate to assess their size and location. Postpartum, fibroids may actually regress to less than their pre-pregnancy size, or even resolve.
Conventional Treatment for Uterine Fibroids
Generally, the treatment approach depends on a few important factors including: the type and severity of symptoms, size and location of fibroids, a woman’s age, her plans to have children, and her personal preferences for the type of treatment she wants to engage in.
In most cases, if fibroids are small and aren’t causing symptoms, or occur in a woman who is nearing menopause, no treatment is necessary and you simply monitor for symptoms over time. Thus the very high rate of hysterectomies for fibroids has been very controversial, with leading medical agencies pushing for a reduction in unnecessary hysterectomies, and a greater reliance on non-surgical, less aggressive approaches.
How do you decide between alternative and conventional therapy? Actually, even if you require medical treatment, a diet and lifestyle approach should always be followed to prevent recurrence and address the root causes that led to fibroid growth. But conventional therapies can play an important role if symptoms are impacting your quality of life, you’re experiencing abnormal bleeding, there’s rapid growth of the fibroid, or the size is causing issues like fertility challenges, and if you're experiencing heavy bleeding, for example, medical treatment may be necessary.
In every case, the least interventional approach that is possible to achieve your goals and keep you safe is optimal. Options include:
- For aching and discomfort, pain medications such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used.
- Hormonal IUDs (i.e., the Mirena) are an option for women with fibroids that do not distort the inside of the uterus. It reduces heavy and painful bleeding but does not treat the fibroids themselves. Possible side effects include acne, spotting (vaginal bleeding between periods), weight gain, abdominal pain and breast tenderness.
- Birth control pills have minimal research for fibroid treatment but may reduce heavy menstrual bleeding and prevent anemia.
- GnRH agonists (e.g., Leuprolide) can reduce symptoms and fibroid size by as much as 30% to 64% after 3 to 6 months of treatment, through suppression of estrogen and progesterone production. Side effects include hot flashes, headache, vaginal dryness and vaginitis, decreased libido, joint and muscle stiffness, and depression, and 30% of patients continue to have light, irregular vaginal bleeding. Bone loss occurs but is reversible, and a small number of women (2%) experience major vaginal hemorrhage 5 to 10 weeks after treatment commences. After discontinuation, fibroids usually return to their previous size.
- Ulipristal acetate, a medication used for short-term treatment (up to 3 months), can relieve symptoms such as heavy periods and shrink the fibroids somewhat. It’s slightly less effective than GnRH agonists but tends to cause fewer side-effects; fibroids grow again after treatment and symptoms usually return. Because of the risk of life-threatening liver damage, ulipristal acetate was taken off the market throughout the European Union in March 2020 for the treatment of uterine fibroids and will remain off the market until further studies are done.
- Surgical options include myomectomy, endometrial ablation, and hysterectomy. For large fibroids, pre-surgical treatment with leuprolide acetate (Lupron) may facilitate more conservative surgery. Between 15% and 30% experience fibroid regrowth after 5 years. While a rare complication, it's important to know that uterine scarring may occur from endometrial ablation if not done by a skilled provider, and can later affect fertility and conception (as the result of a condition called Asherman's Syndrome). Surgery should be reserved for women who are past childbearing, who are heavily symptomatic and not responsive to drug therapy, or who have suspected malignancies.
When it comes to uterine fibroids, there is, in my opinion, a time and place for hysterectomy: you’ve tried natural and pharmaceutical options, minimally invasive surgery, and/or you’re past childbearing and uncomfortable, bleeding, fatigued, and fibroids are affecting your quality of life, sex, happiness. While it’s not a decision to rush into, it is a legitimate choice when made from a well-informed, confident place. In most cases of uterine fibroids, it is possible to spare the ovaries and remove the uterus only, which from a long-term health-perspective, is ideal.
You should absolutely consult your medical provider if you experience:
- Persistent pelvic pain
- Spotting or bleeding between periods
- Heavy, prolonged or painful periods
- Difficulty urinating
- Fatigue, Anemia
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A Natural Approach to Uterine Fibroids
Medical and surgical approaches do not address or reverse the underlying causes that contributed to fibroids, and that when persistent, may contribute to a variety of other conditions that can result from its root causes including hypertension, high estrogen, chronic inflammation, insulin resistance, the impacts of chronic Vitamin D deficiency, and more.
Natural approaches can be effective in addressing these root causes and helping women avoid pharmaceutical and surgical intervention. A pilot study comparing a combination of natural approaches vs conventional treatments for uterine fibroids demonstrated no statistically significant difference in change of symptoms between the two groups when measured after 6 months of treatment. Both experienced improvement in symptoms and fibroid size. Those in the treatment group considered the study a success because they were able to achieve results equivalent to pharmaceutical or surgical interventions using nonconventional methods. It is possible to significantly reduce symptoms of small to medium sized fibroids naturally, and if symptoms are reduced, further medical and surgical treatment are then not usually needed.
The plan I use in my medical practice, and share in depth in my book Hormone Intelligence, is based on addressing the known risk factors for fibroids that I've shared with you earlier, using a combination of dietary, lifestyle, nutritional and botanical strategies with evidence of their benefits in preventing and reducing fibroids.
Step 1: Reduce exposure to endocrine disruptors
Minimizing your exposure to environmental endocrine disruptors is a critical step in creating healthy estrogen levels so that you’re not driving fibroid growth, especially considering that they can also drive weight problems, another risk factor. You can find a full protocol for reducing your exposure to endocrine disruptors here and more tips for reducing excess estrogen in this article. Here are some go-to strategies to start:
- Pass on plastic. Change to glass or stainless-steel water bottles and food storage containers and avoid plastic cling-wrap.
- Reduce your exposure to the toxins in our food system by choosing organic produce over conventionally grown whenever possible and always for meats, eggs, and dairy.
- Swap your cosmetics and body care products
- Wash hands well after handling receipts, which may be coated with endocrine disrupting chemicals like BPA or BPS.
Step 2: Eat a plant rich, anti-Inflammatory diet
- Choose fish and legumes over red meat and pork: Eat a full 3 servings each week of healthy fish, which is protective against fibroids, and include legumes in your diet 2 to 3 times weekly to help improve estrogen levels and for their high fiber content.
- Eliminate dairy: Dairy contains a hormone called insulin-like growth factor 1 (IGF-1) that’s similar to insulin and stimulates the growth of cells, while preventing unhealthy cells from doing what they’re supposed to do naturally – die. Adding to this, the dairy industry allows the use of a growth factor called rbGH, which amps up the levels of IGF-1. IGF-1. In addition to being associated with breast and other cancers, it likely plays a role in the growth of uterine fibroids.
- Increase veggies and fruit to 8 to 10 servings daily: Especially emphasize leafy greens which help reduce excess estrogen, and citrus fruit which has been specifically found to be protective against fibroids.
- Maximize dietary fiber intake and healthy estrogen levels with the addition of 2 Tbsp. of ground flaxseed in your diet daily.
- Include food sources of vitamin A like eggs, fish, and yellow, red, green, and orange vegetables. Vitamin A has been shown to be protective for fibroids prevention – though supplementing vitamin A has not been shown to reduce or prevent fibroids.
- Ditch the alcohol (especially beer) since it appears to be associated with an increased risk of developing fibroids. Recent data suggests its current, rather than past alcohol use, that poses a risk.
Step 3: Use Herbs and Supplements
- Vitamin D: Not only is deficiency associated with increased risk of fibroids, but vitamin D appears to be a powerful protectant against the development of uterine fibroids. I recommend supplementing 2000 units daily, but for best results, have your medical provider test your vitamin D level and help you supplement to reach a blood level between 50 and 80 ng/dL.
- Green tea extract has been found helpful for reducing uterine fibroid size and symptoms, including heavy bleeding. In one study women who took green tea extract daily for four months had a 32.6% reduction in fibroid volume and a 32.4% reduction in severity of fibroid symptoms. Dose: 800 mg of green tea extract (look for a product ideally standardized to 45% EGCG, 95% polyphenols). (Not for use in pregnancy!)
- Broccoli Extracts [DIM, sulforaphane, Indole-3-Carbinol (I3C)]: Potently increases phase 2 detox and helps to metabolize estrogen. To help reduce excess estrogen, take either Indole-3-carbinol at 300 to 600 mg/day OR Diindolylmethane (DIM) at 100 to 200 mg/day.
- Black cohosh was historically used for the treatment of symptoms presumably due to fibroids. In a small 2014 study, women who took 40 mg daily of black cohosh daily experienced an average decrease in fibroid size of 30.3% after a 12-week treatment period. (Not for use in pregnancy!)
Dr. Aviva’s Uterine Fibroid Blend ((Not for use in pregnancy)
Combine the following liquid extracts into a 4 oz. tincture bottle:
- Yarrow (Achillea millefolium) 40 mL
- Black cohosh (Actea racemosa) 20 mL
- Red raspberry leaf (Rubus ideas) 15 mL
- White peony (Paeonia lactiflora) 15 mL
- Ginger (Zingiber officinalis) 10 mL
- Dose: 4 mL twice daily
Step 4: Lifestyle Support
- Exercise: can lead to a substantial decrease in fibroids. It not only encourages weight reduction, but also improves pelvic circulation, promotes uterine muscular tone, and promotes regular bowel elimination. Women who exercise seven hours or more per week reduce their risk. Make sure to include a 1-hour daily walk, yoga, dance, or other form of movement you love. Yoga postures, vigorous walking, hip circling, pelvic thrusts, and belly dancing can all be useful to improve pelvic circulation and reduce discomfort.
- Check for anemia: Bleeding from uterine fibroids can all cause you to get low on your iron stores and cause symptoms like fatigue, loss of concentration, depression, and in severe cases, breathing difficulties and a racing heart.
What to Expect with a Natural Approach to Uterine Fibroids
Like so many hormonal problems, 3 to 6 months is a realistic window in which to begin to see symptom improvement, which is the most important goal with treating fibroids. Symptom improvement is a likely sign that fibroid size is shrinking, which you typically see within 2-3 menstrual cycles after treatment, and in that case, I recommend continuing the above plan until you have substantial reduction in symptoms.
If after 3 to 6 months you see no improvement, or at any time symptoms become too troublesome, you can consider a conventional medical approach. One option also is to use a medication to reduce large fibroids, and then try to maintain benefits with the natural therapies.
However, if you have very large fibroids (over a 16-week size) these can be much more difficult to reduce. If symptoms aren’t causing you too much trouble, it’s still worth a go with natural therapies, but if, after several months, or anytime, symptoms do become a problem for you, consider your medical options for greater relief. Many women are content to have symptom control over pharmaceutical or surgical intervention, as long as the fibroids present no problems.
Fibroids, like diabetes, high blood pressure, and high cholesterol are not inevitable – they are 21st century chronic conditions that we can seek to prevent, and whenever possible reverse. Addressing uterine fibroids by preventing them is so important for our long-term health and so that we don’t experience unnecessary discomfort, complications, or suffering, nor become yet another hysterectomy statistic. While there’s no shame in using medications and surgery, a more natural approach is such an important part of taking care of our total health.
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