CAREaboutFibroids.org

INTRODUCTION

terinefibroidsarethemostcommongynecologicalconditionamongwomen,withlifetimeprevalence exceeding 80% among black women and approaching 70% among whitewomen.1Uterinefibroidsareusuallynoncancerousgrowthsthatdevelopwithinthemuscle

tissueoftheuterus.Somefibroidsnevercauseanysymptomsorproblems,andmanywomenwillnever know they have this condition.2 But in rare circumstances, uterine fibroids may lead todevastatingpersonalhealthconsequencesforwomenandtheirlovedones.Since most women have fibroids, the line between normal and abnormal can be blurry. Forexample, is having uterine fibroids actually the norm? And are fibroid symptoms therefore“normal,”orshouldtheybecauseforconcern?Whenisittimetoseeahealthcareprovider?Whenis treatment appropriate and what treatment best meets each woman’s needs and preferences?This understandable and common confusion unfortunately results in an underappreciation offibroids as a clinical problem, delay in identification of symptoms and treatment, and avoidableeconomicandemotionalcosts.

WHATAREUTERINEFIBROIDS?

terine fibroids, also called leiomyomas ormyomas, are common, usually noncancerousgrowthsoftheuterus.Theyareofvaryingsize

andaredistinctfromthesurroundingtissue.3Someareso small, they are undetectable to the human eye;others are large enough to reshape the uterus itself,particularlywhenmultiplefibroidsarepresent.Uterine fibroids grow in various locations within theuterus.4 Intramural fibroids are found within themuscular uterinewall; submucosal fibroids grow intothe uterine cavity; subserosal fibroids extend beyondthe uterus into the pelvic cavity.Uterine fibroids alsogrow at different rates and in different ways: somevery slowly, others very quickly. Some fibroids growandthenstop;somegetsmallerontheirown.Fibroidstendtoshrinkaftermenopauseashormoneproductiondecreases.5Exactlywhyorhowuterinefibroidsgrowisunknown,butongoingresearchindicatesgeneticchanges,hormones,andothergrowthfactorsinthebodyseemtoplayarole.

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Whileitisextremelyrare,thereisaverysmallchance(lessthanonein1,000)thatawomanwillhave a cancerous fibroid, called a leiomyosarcoma.6 Importantly, existing, noncancerous fibroidscannotbecomecancerousand there isnoknownassociationbetween leiomyosarcomaandotherformsofcancer.Uterine fibroidsare themost commongynecological conditionamongwomen.7Whileprevalenceestimates vary, lifetime prevalence of uterine fibroids among black women exceeds 80%, andapproaches70%forwhitewomen.8Prevalenceestimatesforotherracialandethnicgroupsarenotavailable in the literature.Manyof thesewomenwillhaveasymptomaticorundiagnoseduterinefibroids.However,onestudyestimatesthatabout25%ofallwhiteand50%ofallblackwomenwillexperiencesymptomaticfibroidsduringtheirlifetime.9RISKFACTORSWhile the exact cause of uterine fibroids is unknown, the greatest risk factor is simply being awomanofreproductiveagewithauterus.10Othermajorrisk factors include increasingageup tomenopause and black race.11 (This paper offers a detailed discussion of the specific impact forAfrican Americanwomen below.) But other factorsmay contribute aswell, including hereditaryrisk, specific genetic mutations, environmental factors, onset of early menstruation, oralcontraceptiveusebeforeage16,obesity,alcoholuse,vitaminDdeficiency,andanutritionalintakehigherinredmeatandloweringreenvegetables,fruit,anddairy.Useofprogestin-onlyinjectablecontraceptives, a diet higher in fruit, vegetables, and low-fat dairy products, and having morepregnanciesthatreachaviablegestationalageareassociatedwithareducedriskoffibroids.12SYMPTOMSCommonsymptomsofuterinefibroidsincludeheavymenstrualbleeding,menstrualperiodslastingmore than a week, pelvic or lower abdominal pain or pressure, frequent urination, difficultyemptying the bladder, constipation, pain during intercourse, and backache or leg pain.13 Largefibroids that lead to an enlarged uterus can also cause symptoms including bowel and bladderdysfunction and abdominal protrusion.14 Severe fibroid symptoms can be disabling, leading toanemia,urinarytractinfections,andkidneydamage.15Womenwithuterine fibroidsmayalsobemore likely toexperiencedifficultiesduringpregnancyand childbirth. Though it is uncommon, fibroids are associated with infertility.16 Most women,however,experiencehealthypregnanciesandbirths.17

DETECTIONANDDIAGNOSIS

terine fibroids are often found during a routine pelvic exam. If uterine fibroids aresuspected, a patient’s health care providermay order imaging tests.18 Ultrasound, whichusessoundwavestoallowmappingandmeasurementoffibroidswithintheuterus,isoftenU

the first imaging test used in fibroid diagnosis. An ultrasound may be done on the abdomen(transabdominal)orinsidethevagina(transvaginal).Ifadditionalinformationisneededafteranultrasound,aprovidermightorder:

• MagneticResonanceImaging(MRI);• Hysterosonography,whichuses sterile saline (saltwater) todistend theuterine cavity to

obtainbetterimages;• Hysterosalpingography,whichusesdye tohighlight theuterinecavityand fallopian tubes

onx-rayimages;or• Hysteroscopy,whichuses a small endoscopeand fluid to examine thewallsof theuterus

andopeningstothefallopiantubes.19

Healthcareprovidersmayalsoorder labtestssuchasacompletebloodcount(CBC) forpatientsreporting abnormal menstrual bleeding.20 A CBC can determine if abnormal bleeding has led toanemia,adeficiencyofredbloodcellsorhemoglobinintheblood.

DIAGNOSISCHALLENGES

adly, evenwith all the diagnostic tools described above,womenwith symptomatic uterinefibroidswaitanaverageof3.6yearsbeforeseekingdiagnosisortreatment,andnearlyone-thirdwaitmorethanfiveyears.21Whenwomendoseekcare,theyseetwoormoreproviders

inordertoobtainaproperdiagnosis.Surveysofwomenwithsymptomaticorrecently-treateduterine fibroidsrevealsomereasons forthis behavior. First, women report limited knowledge of fibroids: 48 percent of women withfibroids indicated no knowledge of the condition before diagnosis.22 Second, about two-thirds ofwomendidnotbelieve theywereat risk fordeveloping fibroids.Third,women try to ignore theissue altogether, using “avoidance-based coping strategies” and dissociating, or distancingthemselves,fromtheirfibroidsymptoms.A final, key reason cited for delayed diagnosis is the perception that the symptoms - heavymenstrual bleeding, lengthy menstrual periods, or pain during intercourse - are “normal” andthereforenotdeservingofpersonalormedicalattention.23WHATISNORMAL?Sowhat is normal? The average length of amenstrual cycle,measured from the first day of oneperiodtothefirstdayofthenextperiod,is28dayslong.24However,cyclesrangingfrom21to35days are considered normal. Menstrual cycles tend to become shorter and more consistent aswomenage,butmaybecomelessconsistentasmenopauseapproaches.Thelengthofaperiodcanalso vary by month and among different women, but is typically three to five days.25 A periodlastingtwotosevendaysisconsiderednormal.

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Onaverage,awoman losesapproximately twoto three tablespoonsofbloodduringherperiod.26(Menstrual blood comprises approximately 30-50% of menstrual flow, which also includesendometrial lining, cervicalmucus, andother components.27)However,measuringblood loss canbe challenging for awoman in the absence of clinical tools tomeasure hemoglobin contained inusedmenstrualsanitarysupplies.28Given these challenges inmeasuringblood loss, the following guidelineshavebeendeveloped tohelp identify heavymenstrual bleeding.A call to a health careprovidermaybewarranted if thefollowingheavymenstrualbleedingsymptomsarepresent:

• Aperiodthatlastslongerthan8days;• Using(bleedingthrough)oneormorepadsortamponseverytwotothreehours;• Passingmenstrualclotslargerthanthesizeofaquarter;• Feelinglightheaded,weak,dizzy,outofbreath,ortired,whichmaybesymptomsofanemia,

aconditionthatoccursduetoalackofironthatimpedestheabilityofbloodcellstocarryoxygenaroundthebody.29

Menstrual pain and cramping are alsohard tomeasure.Menstrual pain, or dysmenorrhea, is themostcommonproblemwomenhavewithperiods,affectingmorethanhalfofwomen.30Somepain,called primary dysmenorrhea, is common and is caused by the uterus contracting to shed theendometrial lining. This type of menstrual pain typically lessens as women age. However,secondary dysmenorrhea may indicate another health problem. This type of pain worsens as awoman ages and also lasts longer than typically period cramps. Menstrual pain that cannot bemanagedwithover-the-counterpainmedicationorthatinterfereswithworkorschoolisreasontospeakwithahealthcareprovider.31

MENTALHEALTHCHALLENGES

ncediagnosed,somewomenandtheirfamiliessuffermajoremotionalhealthconsequences.In a 2015 study of patients with symptomatic, diagnosed uterine fibroids, most womenreported fear, anxiety, anger, and/or depression. 32 Half of the women reported feeling

helplessandwithoutcontrolovertheirfibroids.Manyofthesewomenworriedthattheirfibroidswould grow, that they would have additional health complications, that they would need ahysterectomy, or that their fibroids could become cancerous (though, as described above,noncancerousfibroidsdonotbecomecancerous).33Many women with symptomatic, diagnosed uterine fibroids also report a negative self-image,includingfeelinglessattractive,whichcanleadtointimacychallengeswiththeirpartners.34Infact,lossofsexual intimacy isamongthegreatest fears forwomenwithsymptomaticuterine fibroids,with52%ofwomenconcernedabout their sexual function.35Adiagnosisofuterine fibroidsmayalsonegativelyinfluencewomen’snon-sexualrelationships,withmorethanoneinfivewomenwith

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symptomatic fibroids reporting that fibroids impede their ability to care for their home andchildrenandinterferewithrelationshipswithfamilyandfriends.36

ECONOMICCOSTS

n addition to the emotional and mental health costs of uterine fibroids, fibroids are alsofinanciallycostlybothforpatientsandthehealthcaresystem.Directannualhealthcaresystemcostsattributabletouterinefibroidsexceed$9.4billion.37Patientsthemselvesalsobearcosts

associatedwithlostwages, lostproductivity,andshort-termdisability.Infact,nearlyone-thirdofwomenwith symptomatic uterine fibroids reportmissingwork due to their condition, and 24%believe their symptoms prevented them from reaching their career potential.38 Altogether, thesecoststopatientsamounttoroughly$4,624perwomaninthefirstyearofdiagnosis,andbetween$5billionand$17billionforallwomen.39

UTERINEFIBROIDSANDAFRICANAMERICANWOMEN

fricanAmericanwomenaremorelikelytohavefibroidsthanwomenofotherracialgroups– a threefold greater incidence and relative risk of fibroids – and they aremore likely tohavefibroidsatyoungerages,tohavebiggerfibroids,andtohavemultiplefibroids.40Sadly,

withsuchhighincidence,uterinefibroidsymptomsmightseemevenmore“normal”inthiscohort.AfricanAmericanwomenarealso2.4timesmorelikelytoundergoahysterectomytotreatfibroidsand 6.8 times more likely to undergo myomectomy (which removes the fibroids but leaves theuterus intact).41 (Seebelow formore informationon these andother treatmentoptions.)AfricanAmericanwomenwithfibroidsarealsomorelikelytohavepreoperativeanemiaandseverepelvicpain.42A2012 surveyofwomenwith symptomatic uterine fibroids also revealed thatAfricanAmericanwomenweresignificantlymorelikelytohavesevereorveryseveresymptomsincluding43:

• Heavyorprolongedmenses;• Menstrualcramps;• Passageofclotsduringtheirperiod;• Interferencewithphysicalactivities;• Interferencewithrelationships;and• Misseddaysofwork.

In fact, this same survey revealed that African Americanwomenwith fibroids report abdominalbloating,pressure,andprotrusionattwotimestherateofCaucasianwomen.TheyreportanemiaatthreetimestherateofCaucasianwomen.African American women also report greater disruption to everyday life. Twenty-two percentreportthatfibroidsaffectedtheirrelationshipwithasignificantotherand14%reportthatfibroids

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affected their ability to care for their home or children. Fibroids also cause a disproportionateeconomic impact onAfricanAmericanwomen, as they are77%more likely tomissworkdue tofibroidsthanCaucasianwomen.A diagnosis of uterine fibroids also seems to cause greater emotional distress and anxiety forAfricanAmericanwomenthanforCaucasianwomen.44Whileblackandwhitewomenreportequallevels of concernaboutneeding a futurehysterectomyor that fibroidsmight cause cancer, blackwomenreportcertainanxietieswithmuchgreaterfrequency,includingthat:

• Fibroidswillaffectmysexlife;• Fibroidswillaffectmyrelationshipwithmysignificantother;• Fibroidswillaffectmyabilitytohaveasuccessfulandhealthypregnancy;and• Fibroidswillmakemedepressed.

Notably, anxiety about treatment for fibroids revealed an even greater racial gap.45 AfricanAmerican women reported much higher rates of concern that fibroid treatments wouldcompromisetheirfertility,theirabilitytohaveahealthypregnancy,theirownsenseoffemininity,andthepotentialforscarring.

TREATMENTOPTIONS

ollowingdiagnosis,uterinefibroidtreatmentandcareoptionsdependupontheseverityofawoman’s symptoms, the location of the fibroids, the type of fibroids, and personalpreferences, particularly with regard to pregnancy. In surveys, women, especially African

American women, express clear preferences for treatment options that avoid invasive surgery,preservetheuterus,andpreservefertilityforthoseofchildbearingage.46Forwomenwithasymptomatic fibroids, treatment isgenerallyunnecessaryand isnotsupportedby evidence.47 For these women, as well as for those who report mild symptoms that are notmeasurablyaffectingtheirlives,“watchfulwaiting”isoftenthechosentreatmentcourse.“Watchfulwaiting” involvesmonitoring the fibroid(s) for growth andmonitoring symptompresentation orprogression.Thisapproachisoftenselectedbywomenwithmildsymptomswhoareapproachingmenopause,whenfibroidstypicallyshrinkandsymptomsdecrease.Forsymptomaticuterinefibroids,patientsandtheirhealthcareprovidershaveavarietyofoptionsincluding medication, noninvasive procedures, minimally invasive procedures, and traditionalsurgical procedures. Ongoing research seeks to compare all of the treatment options outlinedbelow,andtobetterunderstandtherisksandbenefitsofeach,withthegoalofhelpingwomenandtheirlovedonesmakeinformedtreatmentdecisions.48Thetreatmentoptionspresentedheremaynotbeappropriateforallwomenandshouldbeconsideredonlywhenunderthecareofatrainedhealthcareprovider.

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MEDICATIONMedicationmaybeusedtotreatfibroidsymptoms,includingcramping,heavybleeding,andpainfulperiods, or to temporarily shrink fibroids, sometimes in preparation for surgical treatmentoptions.49Medicationsapprovedtotreatsymptomsassociatedwithuterinefibroids(butthatdonottreatthefibroidsdirectly):

• Over-the-counter pain medications, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can help relieve pain,cramping,anddecreasemenstrualbleeding,butdonottreatthefibroidsthemselves.

• Ironsupplementationmayhelptreatsymptomsofanemia,whichmaybecausedbyheavymenstrualperiods.50

• Hormonalbirthcontrol, includingoralcontraceptives,combinedhormonalvaginalrings,and levonorgestrel-releasing intrauterine devices (IUDs) and other long-acting reversiblecontraceptive(LARC)methods,canhelptreatheavyandprolongedmenstrualbleedingthatoftenaccompaniesuterinefibroids,thoughtheyarenotapprovedbytheU.S.FoodandDrugAdministration (FDA) for this purpose. The Mirena (L-IUD) is FDA approved for thetreatmentofheavymenstrualbleeding.

• Tranexamic acid, an oral antifibrinolytic agent approved for the treatment of heavymenstrualbleeding, is takenonlyduringheavymenstrualbleedingandcanhelpdecreasebleeding,usuallywithminimalsideeffects.51

Medicationstotemporarilyshrinkfibroids(uponcessationofmedication,fibroidsreturninsize):

• Gonadotropin-releasing Hormone (GnRH) agonists and antagonists may shrinkfibroids,butonlyduringtreatment.52Thesemedicationstemporarilyplaceawoman’sbodyintomenopause andareprimarily indicated for short-termuse, such as to reduce fibroidsizeinpreparationforalessinvasivesurgicalprocedureorwhenawomanisapproachingmenopause.53 One GnRH agonist, leuprolide, is approved for short-term use in a specificpopulation of women with symptomatic uterine fibroids while another, elagolix, isapprovedtomanagemoderatetoseverepainassociatedwithendometriosis.54

• Progesterone receptor modulators, such as mifepristone and ulipristal acetate, use adifferentmechanismtoshrinkfibroids,alsohelpingtodecreasesymptoms.Althoughbothare approvedby theFDA for otherpurposes, they arenot FDAapproved to treat uterinefibroidsorsymptoms.55Atthetimeofpublication,theFDAhasnotyetapprovedulipristalacetateforthetreatmentofabnormaluterinebleedinginwomenwithfibroids.

• Aromatase inhibitors and androgenic steroids have shown some promising results intreatingfibroidsbuttheyarenotFDAapprovedforthisuseandmoreevidenceisrequiredtosupporttheiruse.

NONINVASIVEPROCEDURESFocusedultrasoundsurgery,guidedbymagneticresonanceimaging(MRI),isanoninvasivesurgicalprocedurethatusessoundwavestoheatanddestroyfibroidtissue.56Sideeffectsforthisprocedurearerareandthereissomeevidenceforhighratesofsuccessfulpregnancyfollowingtheprocedure,butmoreresearchisnecessary.57MINIMALLYINVASIVEPROCEDURESVariousminimallyinvasiveprocedures,whichminimizesurgicalincisionsandareoftenperformedusingthinneedlesand/orsmallscopes,areavailableforthetreatmentofuterinefibroids:

• Myomectomy, whichmay be performed usingminimally invasive or traditional surgicaltechniques, is anoption forwomenwith symptomatic uterine fibroids. In this procedure,fibroidsareremovedbuttheuterusisleftintact.58Dependingonthetype,size,andlocationof fibroids, a physicianmayperform a hysteroscopicmyomectomy, inwhich instrumentsare inserted through the vagina, or a laparoscopic or robotic myomectomy, using smallincisionsmadeintheabdomen.59Myomectomyisthefirst-linetherapyformostwomeninwhomsubmucosal fibroids are the causeof bleeding, and results in rapid recovery andabeneficialeffectonfuturepregnancy.60

• Radiofrequency ablation, which gained FDA approval in 2012, directs radiofrequencyenergy directly into each uterine fibroid, causing cell death.61 Known as the Acessaprocedure, this treatment innovationcan targetalmostall fibroidsizesand locationsand,because it requires just two,one-centimeterabdominal incisions, recovery ismeasured indays,ratherthanweeks.62Duetoitsmorerecentapproval,limiteddataonsideeffectsandthe impact on subsequent pregnancy are available.63 A similar device, the Sonata system,gainedFDAapprovalinAugust2018.64LiketheAcessasystem,theSonatasystemprovidesradiofrequencyablationofuterinefibroids,butusesatranscervicalapproachthatdoesnotrequireincisions.65

• Uterinearteryembolization,whicheliminatestheflowofbloodtothefibroids,canshrinkfibroids and relieve symptoms.66 In this minimally invasive procedure, an interventionalradiologistuseseitherthefemoralorradialarterytogainaccesstothevesselsthatsupplyblood to the uterus. The impact of embolization on future pregnancies requires futurestudy.While successful deliveries have been reported, a randomized trial found a higherrate of delivery and lower rate of miscarriage following myomectomy compared toembolization.67

• Endometrial ablation is anotherminimally invasive procedure that uses various agents,such as heat, electric current, or microwave energy, to destroy the endometrium.68 Thisoptioneithereliminatesmenstruationorsignificantlyreducesmenstrualbleeding.Becauseit increasestheriskofpregnancycomplications,pregnancyisnotrecommendedafterthisprocedure.

TRADITIONALSURGICALPROCEDURESHysterectomy,whichiscompleteremovaloftheuterus,isacommonoptionforwomenwhohavecompletedchildbearing,accountingfornearlythreequartersofallfibroidsurgicalprocedures.69Italso provides themost effective treatment for fibroids since it eliminates the risk of new fibroidformation.70 It is, however, a major surgery and comes with a higher risk of complications andlongerrecoverytimethanothernonsurgicalorminimallyinvasivetreatmentoptions.71Laparoscopic hysterectomy is an alternative to traditional hysterectomy and does not require alarge incision. Until 2014, when the FDA began issuing safety warnings about its use, somelaparoscopichysterectomieswereaccompaniedbypowermorcellation.Powermorcellationdividestheuterussoitcanberemovedthroughsmallincisions.However,itmayalsointroduceariskthatundiagnoseduterinecancermaybespreadthroughouttheabdomenandpelvis,andtheFDAnowdiscourages the use of power morcellation during hysterectomy or myomectomy for uterinefibroids. 72 The use of power morcellation dropped significantly following the FDA’s safetycommunications.73

HEALTHSYSTEMCHALLENGES

heU.S.healthcaresystempresentsseveralchallengestodetecting,diagnosing,andtreatinguterine fibroids and furthering understanding and awareness of the condition amongpatientsandhealthcareproviders.

First, insurancecoveragemaybeabarriertoaccessingcare.Whilemostinsuranceplansarenowrequiredtoprovidecoverageofanannualwellwomenvisitwithoutcost-sharing,anynon-routinescreeningortesting,suchasthatconductedtodiagnosefibroids,orfibroidtreatmentisgenerallysubjecttothehealthplan’stypicalcost-sharingrequirements.Second,thehealthsystemisalsochallengedbytheinsufficiencyofresearchonuterinefibroidsandsignificant gaps in the existing research. In 2011, the U.S. Agency for Healthcare Research andQuality(AHRQ)offeredanassessmentofcurrentevidenceonfibroids.Theyconcludedthatcurrentliteratureis limitedbysignificantgaps.74Someoftheserelatetokeycomponentsofstudydesign,includingvalidity, studypopulationsize,useofvalidatedmeasures,and thedirect comparisonoftreatmentoptions.AHRQalsocalled for thedevelopmentof “patient centeredoutcomemeasuresforfibroidcare.”AHRQ also noted lack of content in certain key areas, such as disease burden, predictors ofsymptom development and resolution, variation in care-seeking, health and quality of lifeoutcomes, risks to fertility and future pregnancy complications, and specific disparities betweenwhite and blackwomen, among other areas.75While research indicates that uterine fibroids aremostcommonamongblackwomenandleastcommonamongAsianwomen,dataregardingotherracialdifferencesaremorelimited,thoughonestudyofwomeninthefirsttrimesterofpregnancydidfinddifferencesinincidenceforblack,Hispanic,andCaucasianwomen.76

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Thereasonsforthesedifferencesarelargelyunknown,thoughresearchershaveexploredpotentialexplanations, including racial differences in the biosynthesis and metabolism of the hormoneestrogen,differencesinhowthebodyreceivesandexpressessteroidhormones,anddifferencesinRNA.77 Other studies have analyzed genetic, lifestyle, dietary, and stress factors in these racialdifferences,butthesefactorsdonotcompletelyexplainobservedincidence.78

PATIENTANDFAMILYAWARENESS

omenmustbeadvocatesfortheirownhealth,andforthehealthoftheirlovedonestosupporttheminseekingcarewhenanysymptomsofuterinefibroidsarepresent.Healthcareprovidersalsomustunderstandwhatisconsidereda“normal”menstrualcycleand

askpatientsabouttheseandotheruterinefibroidsymptoms.CAREAboutFibroidsdeveloped theFibroidMAP tohelpwomenand theirhealth careprovidersdetectsymptomaticuterinefibroids.UsingtheMAPacronymcanhelpwomenandtheirprovidersflag any Menstrual changes, Abdominal, urinary, or bowel problems, or Pain, pressure, andreproductiveproblemsfordiscussionandfollowup.

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Inaddition, theAmericanCollegeofObstetriciansandGynecologistshasdevelopeda listof signsandsymptomsthatmaysignaltheneedforfibroidtreatment,including:

• Heavy or painfulmenstrual periods that cause anemia or that disrupt awoman’s normalactivities

• Bleedingbetweenperiods• Uncertaintywhether thegrowth isa fibroidoranother typeof tumor, suchasanovarian

tumor• Rapidincreaseingrowthofthefibroid• Infertility• Pelvicpain.”79

LOOKINGAHEAD

mproved awareness and understanding of the signs and symptoms of uterine fibroids isimperative. Patients, their loved ones, and their health care providers must work towardsearlierdiagnosisandaccesstoappropriatecare. Inaddition,moreresearchisneededtoshed

greater light on differences in uterine fibroid incidence amongmany different racial and ethnicgroups,aswellastobetterunderstandcausesforandpotentialmitigationofthedisproportionateimpact of uterine fibroids on black women. When treatment is indicated, insurance coveragepolicies must ensure that women can access that treatment with reasonable cost-sharingrequirements.Allofthesethingsmustbesupportedbythoughtfulpublicpolicythatplacesfocusonwomenandtheirlovedoneswhoarenavigatingacomplicatedhealthcaresystem,oftenwithlittleknowledgeoftheircondition,orevenawarenessthattheirsymptomsarenot“normal.”In spite of these challenges, there is reason for hope. Women and their families today have anumberofeffectivediagnosisandtreatmentoptionsforuterinefibroidsandsymptoms,includingmedicationaswellasnoninvasive,minimallyinvasive,andtraditionalsurgicalproceduraloptions.Inaddition, researchcontinueson innovativenewdiagnosisand treatmentoptions thatpreservewomen’sfertility,aswellasoncomparativeeffectivenessresearchtohelpwomen,theirlovedones,and their health care providersmake informed treatment decisions.80 For example, research isunderwayon screeningmethods todetermine if a uterine tumoror fibroid is cancerousprior totreatment.81 With a reliable method to determine that tumors are not cancerous, powermorcellation,whichhelpstoreducecomplicationsinlaparoscopicuterinefibroidprocedures,maybecomemoreprevalent,helpingwomenavoidamoreinvasive,traditionalhysterectomy.In addition, as briefly mentioned above, as of this writing, the FDA has not yet approved thepharmaceuticalulipristalacetatefortreatmentofuterinefibroids.UlipristalacetateisapprovedintheU.S. foranother indication, asemergencycontraception, andapproved inEuropeandCanadafor pre-surgical treatment of fibroids.82 Studies have found the drug can induce cell death in thefibroids, decrease proliferation of fibroids, and reduce fibroid size. In addition, ulipristal acetateshowsgreatpromise in fertilitypreservation,withonestudyfinding71%ofwomentreatedwith

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ulipristal acetate for uterine fibroids achieved pregnancy following conclusion of ulipristal, and66%ofthesepregnanciesresultedinlivebirths.83Morepharmaceuticaltreatmentoptionsmaysoonbeavailable,withclinicaltrialsofthreedrugstotreatheavymenstrualbleedingduetouterinefibroidscurrentlyunderway.Onetrialisevaluatingelagolix, a gonadotropin-releasing hormone agonist, alone and in combination withestradiol/norethindroneacetate,anestrogenprogestincombinationtherapy.84ThisPhase3trialisestimatedtobecompletedbyDecember21,2018.Phase3trialsareunderwayforagonadotropin-releasinghormonereceptorantagonist,relugolix,whichalsotreatsheavymenstrualbleedingduetouterinefibroids.85TwodifferenttrialsofrelugolixareanticipatedtobecompletedinJune2019and January 2020. Finally, a Phase 3 trial investigating the safety and efficacy of vilaprisan, aselective progesterone receptor modulator, to treat heavy menstrual bleeding in women withuterine fibroids is anticipated to be complete inMay 2020.86 Experts note that vilaprisanworksveryquickly,injustthreedays,tocontrolfibroid-relatedheavymenstrualbleeding.87Withregardtoproceduraltreatmentoptions,inAugust2018,theFDAapprovedtheSonatasystem,mentioned above. By offering radiofrequency ablation of uterine fibroids using a transcervicalapproach, awoman can preserve her uteruswhile avoiding all incisions, speeding her return todailyactivities.Themakersof theSonatasystemcontinue to followpatientswhovolunteerviaaregistry that collects questionnaire data on a number of treatment recovery, patient satisfaction,pregnancy,andotherissues.88Research also continues on procedural treatment options for uterine fibroids. For example, themakersoftheAcessaprocedure,describedabove,continuetoevaluatetheefficacyoftheirproduct,which uses radiofrequency to destroy fibroid tissues in a minimally invasive procedure. Onecurrent study isevaluating fibroid-relatedsymptomsatvariouspointsup to36monthsafter theAcessaprocedure.Itisalsoassessingoperativeoutcomes,suchastimetoreturntoactivities,post-operativepain,bloodloss,complications,andmore.89Manyacademicmedicalcentersarealsoinvolvedinuterinefibroidresearch.Forexample,expertsatJohnsHopkinsMedicinehavespentmorethanadecadestudyingthecellularstructureofuterinefibroids, seeking tounderstandwhy fibroids form.90Using thisknowledge, researchers ledbyDr.JamesSegarsaimtodevelopanenzymethatcouldbeinjectedintouterinefibroidsandcausethemtoshrinkordisappearcompletely.Meanwhile, researchersatMountSinaiHospital inCanadaarecomparing patient satisfaction and quality outcomes amongwomenwho undergo uterine arteryembolization using either femoral artery access (in the groin) or radial artery access (in thewrist).91 Observational studies comparing the two access methods for heart procedures havegenerallyconfirmedreducedriskofcomplicationsandimprovedpatientoutcomes,includingfasterrecovery,withtransradialaccess.92

CONCLUSION

terine fibroids are the most common gynecological condition among women, yet manywomensufferdevastatinganddebilitatingsymptomsandcomplicationsofuterinefibroidsforyearsbeforeseekingcare.93This isdue inpart tothebelief that fibroidsymptomsare

normal.Byincreasingawarenessofuterinefibroidsandtheirsymptomsamongwomen,lovedones,and health care providers, women may achieve earlier diagnosis and access an appropriatetreatment thatmeets their needs and preferences. Once patients have been properly diagnosed,their health care providers must present the range of treatment options so women and theirfamiliescandeterminethebestcourseforthem.Inaddition,itisessentialthattheyhaveadequatecoveragetoensurethat theycanaccess therightcare.Earlierdiagnosis, treatment,andadequatecoveragecanhelpmitigatethephysical,emotional,andeconomictoll theuterinefibroidstakeonwomen,theirfamilies,andourhealthcaresystem.

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