What Is It?
A fibroid is a mass of muscle tissue, typically noncancerous, that develops within the wall of the uterus.
Fibroids are masses of muscular tissue that can develop within the wall of the uterus. They are the most common noncancerous tumor in premenopausal women. You may hear your health care professional call fibroids by other terms, including uterine leiomyomas, fibromyomas, fibromas, myofibromas and myomas. They can be small or quite large.
Symptoms of Fibroids
While fibroids can cause a variety of symptoms, they may not cause any symptoms at all--so you may not even know you have one. Heavy bleeding is the most common symptom associated with fibroids and the one that usually prompts a woman to make an appointment with her health care professional. You may learn you have one or more fibroids after having a pelvic exam.
Fibroids may cause a range of other symptoms, too, including pain, pressure in the pelvic region, abnormal bleeding,
painful intercourse, frequent urination or infertility.
Causes & Characteristics of Fibroids
What actually causes fibroids to form isn't clear, but genetics and hormones are thought to play a big role. Your body may be predisposed to developing fibroids. They seem to grow or shrink depending on estrogen levels in your body, but researchers don't know why some women develop them while others don't.
Fibroids usually grow slowly during your reproductive years, but may increase in size with pregnancy. At menopause fibroids shrink because estrogen levels decline. Using menopausal hormone therapy containing estrogen after menopause may cause fibroids to continue to grow and cause symptoms.
Progesterone, growth hormone and prolactin are other hormones that may stimulate a fibroid's growth once it has already formed.
A variety of treatments exist to remove fibroids and relieve symptoms. If you learn you have fibroids but aren't experiencing symptoms, you usually won't need treatment.
Who Is at Risk for Fibroids?
Your risk for developing fibroids increases with age. African-American women are more likely than Caucasian women to have them, and they are more likely to develop fibroids at a younger age. If women in your family have already been diagnosed with fibroids, you have an increased risk of developing them. You may also be at an increased risk if you are obese or have high blood pressure.
Types of Fibroids
Fibroids form in different parts of the uterus:
* Intramural fibroids are confined within the muscle wall of the uterus and are the most common fibroid type. They expand, which makes the uterus feel larger than normal. Symptoms of intramural fibroids include heavy menstrual bleeding, pelvic pain, back pain, frequent urination and pressure in the pelvic region.
* Submucosal fibroids grow from the uterine wall into the uterine cavity. They can cause pain, abnormal bleeding and infertility.
* Subserosal fibroids grow from the uterine wall to the outside of the uterus. They can push on the bladder, bowel or intestine causing bloating, abdominal pressure, cramping and pain.
* Pedunculated fibroids grow on stalks out from the uterus or into the uterine cavity, like mushrooms. If these stalks twist, they can cause pain, nausea or fever, or can become infected.
More than half of women who have fibroids never experience symptoms. When fibroids are symptom-free, they generally don't require treatment. But even small fibroids can cause heavy or longer-than-normal menstrual bleeding and significant pain. Fibroids may also contribute to infertility.
The three most common symptoms caused by fibroids are:
* Abnormal uterine bleeding. The most common bleeding abnormality is menorrhagia--menstrual bleeding that is excessively heavy or long. Normal menstrual periods last four to seven days. If you have abnormal bleeding from fibroids, your periods are likely to last longer or may be heavier. Instead of changing a pad or tampon every four to six hours, you may have to change one every hour and find that your periods greatly interfere with your daily activities. You may also experience breakthrough bleeding, or bleeding that occurs between periods.
* Pelvic pressure. You may experience pressure in the pelvic region. Many women with fibroids have an enlarged uterus. Pelvic pressure may be caused by either the increased size of your uterus or from the location of one fibroid in particular. Health care professionals usually describe the size of a uterus with fibroids in the same terms used for someone who is pregnant, such as a "12-week-size fibroid uterus."
You may also experience pressure on areas near your pelvis, including your bowel or bladder. Pressure against these structures can lead to difficulty or pain with bowel movements and constipation or increased urinary frequency and incontinence. Conversely, you may experience urinary retention or recurrent urinary tract infections.
* Reproductive problems. Fibroids also are associated with a handful of reproductive problems depending on the number of fibroids present in the uterus and on their size and specific location. These risks include a higher risk of miscarriage, infertility, premature labor and labor complications. These problems may occur when fibroids physically change the size and shape of the uterine cavity. While having fibroids may cause complications with pregnancy, most do not have any impact. Fibroids in a uterus do not create a high-risk pregnancy.
Symptoms caused by fibroids can be similar to a number of other symptoms caused by a variety of other conditions, including reproductive cancers, sexually transmitted infections and bowel and bladder disorders. So, if you are having any unusual symptoms, be sure to make an appointment to discuss them with your health care professional.
The first step in diagnosing fibroids is usually a pelvic exam and a comprehensive medical history performed by your health care professional. He or she may be able to feel the fibroids in your uterus during the exam, because fibroids can make the uterus feel enlarged or irregular. If the uterus is enlarged enough, it may also be felt abdominally above the pubic bone.
To confirm the diagnosis, even if nothing is felt, your health care professional may recommend one or more diagnostic tests.
Ultrasound is probably the most common option used to confirm the diagnosis. It is important to note that imaging may find very small fibroids that don't pose any medical problems, wouldn't be felt on physical examination and may not be causing symptoms.
If you have heavy or prolonged bleeding or have had multiple miscarriages, your health care professional may recommend a more involved examination of your uterine cavity to see if you have a submucous fibroid, which might go undetected on a regular ultrasound. The assessment can be performed in one of three ways:
* Hysterosalpingography (HSG). A dye that shows up on an X-ray is injected into your uterus, enabling your health care professional to evaluate the structure of your uterine cavity and look for any abnormalities in the uterus or fallopian tubes. This test may be recommended in women who are trying to get pregnant.
* Sonohysterography. A saline solution is injected into your uterus, and ultrasound is used to visualize the uterine cavity. Also called hysterosonography, this test is most useful in women who have prolonged or heavy menstrual bleeding but normal ultrasound results.
* Hysteroscopy. The uterus is expanded with a liquid or gas, and a hysteroscope (a small telescope) is inserted directly into the uterus through the vagina and cervix enabling your health care professional to see your entire uterus. Fibroids within the uterine cavity can also be removed during this surgery.
Imaging tests, such as magnetic resonance imagery (MRI) or computed tomography (CT), may also be ordered but are rarely necessary.
If you are experiencing abnormal vaginal bleeding as a result of fibroids, your health care professional may want to conduct other blood tests, including a complete blood count (CBC), to rule out other conditions.
If you aren't experiencing symptoms caused by your fibroids, you may not need any treatment. And, if your symptoms aren't severe, you may decide you can put up with them. This may be especially true if you're close to menopause--a time when fibroids shrink and symptoms resolve. It's important to discuss all your options with your health care professional and consider his or her recommendations when weighing your treatment options.
You may want to try the "watch and wait approach," where your health care professional periodically evaluates the size of your fibroids during routine pelvic exams and discusses how much discomfort you're feeling or how the symptoms may be disrupting your lifestyle.
Fibroids that don't cause symptoms rarely need therapy unless they get big enough to affect other structures in the pelvic area, such as the kidneys or the ureter (the tube that drains the kidney to the bladder).
The need for treatment and the type of treatment you choose depends on the size and position of the fibroids, as well as any symptoms they're causing, your age and whether or not you want to have children in the future. Even with a variety of treatment options available, new fibroids may grow back to some degree in the years following most treatments. No treatment--except hysterectomy--can guarantee that fibroids won't recur. The more fibroids you have, the more likely they are to recur after treatment.
If bleeding is your major symptom, some women opt for managing this symptom with medication before surgery or as a way to delay surgery if they're close to menopause (because fibroids generally shrink and cause few or no problems after menopause).
Medical Treatment Options for Fibroids
* Oral contraceptives (OCs). While OCs do not treat fibroids, they may be recommended to manage heavy bleeding caused by fibroids or for women who experience irregular ovulation in addition to fibroids. OCs are the first treatment option for many women, often combined with a nonsteroidal anti-inflammatory such as ibuprofen.
* Intrauterine device (IUD). The levonorgestrel intrauterine device (Mirena), which is usually prescribed for birth control, can help ease the heavy bleeding that accompanies some fibroids. The device won't shrink the fibroids, however, and depending on whether or not the fibroids have distorted the inside of the uterus, it may or may not provide effective birth control. Although the levonorgestrel IUD is FDA-approved for heavy menstrual bleeding, it isn't approved specifically for the treatment of fibroids, so if you are interested in this option, discuss it with your doctor.
* GnRH agonists Gonadotropin-releasing hormone (GnRH) agonists, including leuprolide (Lupron), nafarelin nasal (Synarel) and goserelin (Zoladex), temporarily shrink fibroids by blocking estrogen and progesterone production; estrogen is thought to stimulate their growth. They are mainly used in women close to menopause or to shrink fibroids before removing them surgically or to correct anemia caused by heavy bleeding associated with fibroids. GnRH agonists are considered a short-term treatment because they block hormone production by the ovaries, thus triggering menopausal symptoms caused by estrogen depletion, such as hot flashes, vaginal dryness and bone loss. The usual course of treatment is three to six months, and it may be combined with estrogen and/or progesterone hormones to minimize menopausal symptoms. Once this medication is stopped, fibroids usually grow back to near pretreatment size or larger within several months.
* Antifibrinolytic medicines. Antifibrinolytic medicines are drugs that help slow menstrual bleeding by helping blood to clot. The drug tranexamic acid (Lysteda) is FDA-approved for heavy menstrual bleeding. Side effects include headaches, muscle cramps, or pain. Antifibrinolytic medicines do not affect your chances of becoming pregnant. They should not be taken with hormonal birth control without prior approval from a health care professional as the combination can cause blood clots. Antifibrinolytic therapies are relatively new and expensive--and often not covered by insurance. Check with your insurer if that is a concern.
Minimally Invasive Treatment Options
* Uterine artery embolization (UAE). UAE is a radiological procedure that involves placing a small catheter (a thin tube) into an artery in the leg and guiding it via X-rays to the arteries in the uterus. Then, tiny particles similar in size to grains of sand are injected through the catheter and into the artery. As they move toward the uterus, they obstruct the blood supply to the fibroids. Without an adequate blood supply, the fibroids shrink. The uterus is spared, however, because an alternate blood supply develops to support it.
UAE takes about one hour to perform and is typically performed by an interventional radiologist. It usually requires a one-night hospital stay. Most women are back to their normal activities in seven to 10 days.
While this treatment option leaves your uterus intact, it's not recommended for women who wish to become pregnant in the future.
Potential complications include fever, passage of small pieces of fibroid tissue through the vagina after the procedure, allergic reaction and hemorrhage. Complications can also occur if blood supply to the ovaries or other organs becomes compromised.
* Endometrial ablation. While this technique is not indicated for treating fibroids, it is used to reduce or eliminate heavy periods that may be caused by fibroids. Endometrial ablation uses electrical energy, heat or cold to destroy the lining of the uterus. It is performed on an outpatient basis and is only offered as a treatment option to women who have finished childbearing. It is not recommended for women who wish to preserve fertility. However, using a reliable form of contraception after having ablation is important.
Surgical Options for Fibroids
* Hysterectomy. A hysterectomy offers the only real cure because it completely removes the uterus.
However, hysterectomy is major surgery, requiring between two and eight weeks of recovery, depending on the type of surgery performed. Hospital stays and recovery times can vary based on the type of procedure used and the extent of the surgery performed. Because your uterus and, sometimes, your ovaries, are removed, it is not an option if you want to become pregnant. If your ovaries do not need to be removed, you may want to keep your ovaries to maintain estrogen production.
If you and your health care professional decide that a hysterectomy is the best choice for you, you may have several options about how the procedure is performed:
** Abdominal hysterectomy, in which the uterus is removed through an incision in the abdomen. It is generally used for large pelvic tumors or suspected cancer because this procedure allows the surgeon to see and manipulate the pelvic organs more easily.
** Vaginal hysterectomy, in which the uterus is removed through the vagina.
** Laparoscopically hysterectomy, in which a surgeon uses a laparoscope (a small telescope) inserted through the abdomen to see inside your pelvis. Laparoscopic hysterectomy is less invasive than an abdominal hysterectomy, but more invasive than a vaginal hysterectomy.
** Robotic-assisted laparoscopic hysterectomy, in which a robotic system assists in removal of the uterus in a laparoscopic hysterectomy. It may be helpful with some patients because of the flexibility it allows, but it also adds to the time and cost of the procedure.
* Myomectomy. This procedure removes only the fibroids, leaving the uterus intact, which can preserve fertility. The procedure is performed through an incision in the abdomen (a laparotomy), which requires general anesthesia, or by laparoscopy, which uses a small incision to insert an operative camera (similar to a laparotomy but using a smaller incision).
Robotic myomectomy is a variation of laparoscopic myomectomy during which the surgical procedure is aided with a surgical robot. A full recovery from laparotomy can take up to six weeks and two weeks from laparoscopy. Your health care professional will decide which procedure to use based on the size of the fibroids as well as whether they are superficial or deep (which is too difficult for laparoscopy).
A hysteroscopic myomectomy is performed through the vagina and requires no incision. It is appropriate only for women whose fibroids are in the endometrial canal. With this procedure, fibroids are removed using an instrument called a hysteroscopic resectoscope, which is passed through the vagina into the uterine cavity. A wire loop carrying electrical current is then used to shave off the fibroid.
Myomectomy can be more complicated than hysterectomy. Risks include:
** Greater blood loss and need for transfusion
** Risk of damage to the uterus and other pelvic structures
** Scarring of the uterus that may affect fertility
* Myolysis. This procedure involves using an electric current or laser to destroy the fibroids and shrink the blood vessels that feed them. A similar procedure called cryomyolisis freezes fibroids. The safety and effectiveness and risk of fibroid recurrence with both myolysis and cryomyolisis have not yet been determined.
Fibroids can't be prevented. If you are experiencing symptoms, such as heavy bleeding and pelvic pressure, contact your health care professional for an evaluation. If you have a family history of fibroids or have been treated for them in the past, you may want to be examined more frequently or investigate the various management strategies available to treat fibroids.
Facts to Know
1. Fibroids are rarely cancerous. They are balls of muscular tissue that grow inside the uterus, on the surface of the uterus or in the muscular wall of the uterus.
2. An estimated 80 percent of women have fibroids, but not all of these women have symptoms. They are most commonly found in women in their 30s and 40s.
3. African-American women are more likely to have fibroids than Caucasian women.
4. If there are women in your family who already have been diagnosed with fibroids, you have an increased risk for developing them.
5. Fibroid growth is believed to be related to estrogen levels. They usually grow slowly during the reproductive years, but may increase in size with pregnancy. At menopause, fibroids usually shrink, because estrogen levels decline. Estrogen replacement therapy may interfere with this shrinkage after menopause.
6. More than half of the women who have fibroids never experience symptoms and require no treatment. In general, the severity of symptoms varies based on the number, size and location of the fibroids.
7. The two most common symptoms of fibroids are heavy menstrual bleeding and pelvic pressure. Normal menstrual periods last four to seven days, but if you have fibroids, your periods are likely to last longer. The bleeding might be so heavy that you may need to change your sanitary pads or tampons as often as every hour.
8. Fibroids may be associated with a handful of reproductive problems, such as miscarriage, infertility, premature labor and labor complications. These problems may occur when fibroids physically alter the uterine cavity. But having fibroids doesn't necessarily mean you'll have problems during a pregnancy.
9. Oral contraceptives (estrogen and progestin and progestin-only) are sometimes recommended to manage heavy bleeding caused by fibroids, but they aren't used to treat fibroids.
10. There are several treatment options available for fibroids, including medication, minimally invasive options and surgical options.
Questions to Ask
Review the following Questions to Ask about fibroids so you're prepared to discuss this important health issue with your health care professional:
1. How do I know if I have abnormal or excessive menstrual bleeding?
2. What tests are needed to determine if I have fibroids?
3. What are my treatment options?
4. I want to get the best treatment possible to get rid of my fibroids, but I want to have children as well. What are the best treatment options for me?
5. When should hysterectomy be considered?
6. What's uterine artery embolization and how is it performed?
7. What type of doctors perform the treatment options for fibroids?
8. How can I get a second opinion?
9. Does my insurance cover all the options we're discussing?
10. Will my fibroids recur after any of these treatments?
1. How do I know I have fibroids?
More than half of all women who have fibroids have no symptoms. If you aren't experiencing any problems, there's usually no reason to treat the fibroids. The two most common symptoms of fibroids are heavy menstrual bleeding and pelvic pressure. Normal menstrual periods usually last four to seven days, but if you have fibroids, your periods are likely to last longer.
If you have fibroids, the bleeding might be so heavy that you may need to change your sanitary pad or tampons as often as every hour. Bleeding between periods isn't usually associated with fibroids, but it may occur in rare situations.
You may also experience pressure in the pelvic region from an increase in the size of your uterus or from the location of one fibroid in particular. If you notice these symptoms, you should definitely seek a diagnosis from your health care professional.
2. Are fibroids hard to diagnose?
Not usually. A health care professional should be able to feel some kind of irregularity in your pelvic region during a regular office pelvic exam. If fibroids are suspected, more detailed tests may be conducted to confirm the initial diagnosis. These may include ultrasound (or ultrasonography), MRI (magnetic resonance imagery), CT (computed tomography), X-ray or hysterosalpingogram (HSG), a test that involves injecting a special dye into the uterus and then taking an X-ray of the area. Ultrasound is the most common option used to confirm the diagnosis.
3. Does the location of my fibroids really make a difference in how they're treated?
The symptoms you experience may vary depending on where the fibroids are located. However, the ultimate course of treatment for your fibroids will likely depend more on other factors, such as whether you plan to have children or how close to menopause you are. If preserving your fertility is a priority, several options won't be recommended.
4. Is a hysterectomy really the only way I can get rid of my fibroids forever, or at least before I reach menopause?
Yes. While other procedures are helpful because the existing fibroids are removed surgically or shrink with drug therapies, there is no guarantee that new fibroids won't develop.
5. Is there anything I can do to protect myself from developing fibroids?
Unfortunately, there isn't. Fibroids appear to affect women mostly in their 30s and 40s. Genetics and hormones appear to play a role in who develops fibroids.
6. I've heard that estrogen and other hormones can make fibroids grow. Should I avoid taking birth control pills that contain estrogen?
No, there is no evidence that oral contraceptives have any effect on fibroid size. In fact, health care professionals prescribe oral contraceptive pills for some women with fibroids to help control the prolonged or excessively heavy blood flow during menstruation.
7. Do I need to see a specialist other than my gynecologist to diagnose and treat fibroids?
Your gynecologist should have adequate experience in diagnosing fibroids because they are so common. However, some gynecologists may have more experience or better success at treating fibroids. If you're considering any of the more innovative treatments, whether surgical or medical, make sure you see a practitioner with a strong track record in treating fibroids, and ask about their success rates.
8. Are hormone therapy treatments for fibroids dangerous?
GnRH agonists are one treatment option for fibroids. This treatment shrinks fibroids by blocking hormone production by the ovaries. Because estrogen production is suppressed temporarily, you will experience menopausal symptoms such as hot flashes and vaginal dryness. Treatment is usually limited to three to six months.
To offset hot flashes and other uncomfortable menopausal symptoms caused by GnRH agonists, your doctor may add estrogen and/or progesterone therapy.
Ask your health care professional to review the risks associated with menopausal hormone therapy and how they may or may not be relevant to your treatment needs for fibroids.
1. Regularly track your menstrual cycle
If you have fibroids, your bleeding may last longer than normal and be heavier than normal. If you already know you have fibroids, you should have regular pelvic examinations and ultrasounds. This monitoring enables you to keep tabs on the size of the fibroid and determine if any additional treatments are necessary.
2. Manage pain with over-the-counter drugs
Nonsteroidal anti-inflammatory drugs such as aspirin, ibuprofen and naproxen can help ease menstrual pain. Along with helping with the pain, these drugs can also reduce inflammation. However, long-term use of such drugs can increase the risk of gastrointestinal bleeding and ulcers.
3. Think about adding iron to your diet
You can develop anemia from iron deficiency if fibroids cause excessively heavy bleeding. Sometimes the smaller fibroids, usually the submucosal ones, are more likely to cause heavy bleeding than the larger ones. Some of the best foods for increasing or maintaining iron levels include clams, oysters, beef, pork, poultry and fish.
Organizations and Support
For information and support on coping with Fibroids, please see the recommended organizations, books and Spanish- language resources listed below.
American Association of Gynecologic Laparoscopists (AAGL)
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
American College of Obstetricians and Gynecologists (ACOG)
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
American Society for Reproductive Medicine (ASRM)
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Association of Reproductive Health Professionals (ARHP)
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Center for Uterine Fibroids at Harvard Medical School
Address: Brigham and Women's Hospital
77 Avenue Louis Pasteur, 160, New Research Building
Boston, MA 02115
Hotline: 1-800-722-5520 (ask operator for 525-4434)
National Family Planning and Reproductive Health Association (NFPRHA)
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
National Uterine Fibroids Foundation
Address: P.O. Box 9688
Colorado Springs, CO 80932
Society of Interventional Radiology
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
A Gynecologist's Second Opinion
by William H. Parker, Rachel L. Parker
Fibroid Tumors & Endometriosis
by Susan M. Lark
Uterine Fibroids: What Every Woman Needs to Know
by Nelson, M.D. Stringer
What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies--Including Breakthrough Alternatives to Hysterectomy
by Scott C. Goodwin, David Drum, Michael Broder
Yale Guide to Women's Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin, Carol V. Wright
Medline Plus: Uterine Fibroids
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Center for Uterine Fibroid
Address: Brigham and Women's Hospital
77 Avenue Louis Pasteur--160, New Research Building
Boston, MA 02115
"Uterine fibroids." The Mayo Clinic. June 2011. http://www.mayoclinic.com/health/uterine-fibroids/DS00078. Accessed June 2011.
"Uterine fibroids and hysterectomy--risk factors." University of Maryland Medical Center. August 2009. http://www.umm.edu/patiented/articles/who_gets_fibroids_000073_4.htm. Accessed June 2011.
"Fibroid tumors; fibroid uterus." The American Pregnancy Association. November 2007. http://www.americanpregnancy.org/womenshealth/fibroidtumors.html. Accessed June 2011.
"FDA Approves Additional Use for IUD Mirena to Treat Heavy Menstrual Bleeding in IUD Users." The Food and Drug Administration. October 2009. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm184747.htm. Accessed June 2011.
"Patient information: Fibroids." Uptodate.com. Last updated October 2008. Subscription necessary to view text. www.uptodate.com. Accessed February 2009.
"Types of Surgical Procedures Performed." UNC Department of Obstetrics & Gynecology, University of North Carolina School of Medicine. http://www.med.unc.edu. Accessed April 21, 2009.
"Uterine fibroid embolization." Uptodate.com. Last updated October 2008. Subscription necessary to view text. www.uptodate.com. Accessed February 2009.
"Uterine fibroids." The American College of Obstetricians and Gynecologists. Publication. February 2005. http://www.acog.org. Accessed February 2009.
Pron G, Bennett J, Common A, et al. Ontario Uterine Fibroid Embolization Collaboration Group. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril. 2003 Jan;79(1):120-7.
Spies JB, Bruno J, Czeyda-Pommersheim F, et al. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol. 2005 Nov;106(5 Pt 1):933-9.
Spies JB, et al; Complications After Uterine Artery Embolization for Leiomyomas, Obstetrics & Gynecology 2002;100:873- 880.
OBGYN.net. The Universe of Women's Health. Fibroids. http://www.obgyn.net. Accessed August 2005.
Reuter's Health. Well-Connected Reports. Uterine Fibroids and Hysterctomy. What are Uterine Fibroids? March 2002. http://www.reutershealth.com. Accessed August 2005. (source for lifestyle tips)
"FDA Approves New Labels for Estrogen and Estrogen with Progestin Therapies for Postmenopausal Women Following Review of Women's Health Initiative Data." FDA News/Press Release. January 8, 2003. http://www.fda.gov. Accessed August 2005.
"Estrogen and Progestogen Use in Peri- and Postmenopausal Women: September 2003 position statement of The North American Menopause Society." http://www.menopause.org. Updated September 2003; Accessed August 2005.
The Menopause Guidebook: Helping Women Make Informed Healthcare Decisions through Perimenopause and Beyond. North American Menopause Society: May 2003; http://www.menopause.org Accessed August 2005.
Center for Endometriosis Care. http://www.centerforendo.com. Copyright 2004. Accessed August 2005.
Endometriosis Research Center. http://www.endocenter.org. Updated August 16, 2004. Accessed August 2005.
"Advances in Uterine Leiomyoma Research." Environmental Health Perspectives Volume 108, Supplement 5, October 2000. http://ehpnet1.niehs.nih.gov. Accessed August 2005.
"FDA Approves New Device to Treat Uterine Fibroids." FDA News Release. October 22, 2004. http://www.fda.gov. Accessed August 2005.
Okolo, SO. "Familial prevalence of uterine fibroids is associated with distinct clinical and molecular features." Hum Reprod 2005 Aug;20(8):2321-4.
"What are the Non-hysterectomy Procedures for Uterine Fibroids?" New York Methodist Hospital. http://www.nym.org
"Women's Health Issues: An Overview." US Department of Health and Human Services. http://www.4woman.gov