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Common Uterine Conditions

Options for Treatment

If you have a problem that affects your uterus or another part of your reproductive system, this information is for you. It explains most of the problems that can affect a woman's reproductive system and ways the problems can be treated, including medication, surgery, and other kinds of treatments.

About the Uterus

The uterus is located in the lower abdomen between the bladder and the rectum. The uterus is also called the womb. It is pear-shaped, and the lower, narrow end of the uterus is the cervix. When a woman is pregnant, the baby grows in the uterus until he or she is born.

On each side of the uterus at the top are the fallopian tubes and ovaries. Together, the uterus, vagina, ovaries, and fallopian tubes make up the reproductive system. Select for illustration of The Uterus (26 KB).

In women who have not gone through menopause ("the change" or "change of life"), the ovaries produce the hormone estrogen at the beginning of the menstrual cycle. Estrogen helps to prepare the lining of the uterus (called the endometrium) for possible pregnancy. When the uterus is ready, one of the ovaries releases an egg. The egg travels down the fallopian tube where it waits for possible fertilization.

If the woman becomes pregnant, the fertilized egg travels to the uterus where it attaches to the endometrium. If she does not, the endometrium and the unfertilized egg are discharged through the vagina during the woman's next period (menstruation).

Some of the problems that can affect your uterus are:

Noncancerous growths in the uterus, called fibroids, which can cause pain and bleeding.
Endometriosis, a condition in which the tissue that forms the lining of the uterus grows outside the uterus.
Heavy bleeding each time you have your period or between periods.
Hormonal imbalances.
Unexplained pelvic pain.

You will find words throughout this document that are in italics. These words are explained in the glossary at the end or you may select the word to get its definition.

Treatment Options

Your doctor may have recommended that you have a hysterectomy or another kind of treatment. Before you decide what to do, it is important that you understand the problem and the different options you have for dealing with it.

The following information can help you think about your condition, learn about your treatment choices, and decide on some questions to ask your doctor.

Keep in mind that every woman is different and every situation is different. A good treatment choice for one woman may not be the best choice for another. That is why you should:

Talk over your options carefully with your doctor.
Ask questions until you understand what the doctor is telling you.
Consider getting a second opinion.
Work with your doctor to choose the treatment that is best for you.

You Are Not Alone

The first thing you need to know is that you are not alone. About 1 of every 10 women between the ages of 18 and 50 has this type of problem. Usually, the problem can be treated, and the symptoms can be relieved. Most women who have had treatment are satisfied with the results and are glad to be free of pain or other unpleasant symptoms.

The first step in getting relief is to find out what the problem is.

Finding out about the problem
Noncancerous uterine conditions
   Fibroids
   Endometriosis
   Endometrial hyperplasia
   Uterine prolapse
   Ovarian cysts
   Pelvic inflammatory disease
   Severe menstrual pain
   Very heavy menstrual bleeding
   Chronic pelvic pain
What you should know about hysterectomy
Questions to ask you doctor
Glossary
Resources for more information

Finding Out About the Problem

There are several ways your doctor can find out (diagnose) what is causing your symptoms. The most common include:

A Medical History

The first step in diagnosing your problem is a medical history. The doctor—or sometimes the nurse—will ask you questions about your medical history. This will include questions about your symptoms and any serious illnesses you have had, as well as whether you have ever had surgery, been pregnant, or had children. You also may be asked about the medical history of close family members.

If you have been using herbs, acupuncture, or other "natural remedies," be sure to tell your doctor about them.

The doctor may ask about your sex life. You may be uncomfortable talking about such personal matters, but it is important for your doctor to know if something that is happening in your sex life might be related to your condition.

A Vaginal Exam

The doctor will use instruments to look inside your cervix and uterus. The doctor will use a speculum to keep the walls of the vagina apart during the exam. Sometimes this exam is uncomfortable. You may feel a slight cramp, but it usually is not painful. If you are able to relax, you will be more comfortable. The doctor may look inside the vagina and cervix with a lighted tube.

A Pap Test (or Pap Smear)

During the vaginal exam, the doctor usually takes a sample of cells from the cervix with a wooden scraper, cotton swab, or small brush. The test is quick and painless. The cells are placed on a glass slide, which is sent to a lab. A Pap test is one way that doctors can find cancer of the cervix or dysplasia, which is a condition that sometimes can turn into cancer.

All women over 18 years of age—and younger women who are sexually active—should have a Pap test done every 1 to 3 years.

Laboratory Tests

The doctor will take a sample of your blood and a urine specimen and send them to a lab to be examined. The results of these tests will tell the doctor a lot about your general health.

Imaging Tests

There are many ways to look inside the body without surgery. X-rays are the most well known. Your doctor may also suggest a sonogram, CAT scan, or MRI. These tests help the doctor to learn more about your body and what is causing your problem.

Depending on your symptoms, the doctor may suggest an endometrial biopsy, dilation and curettage (D&C), or other tests to help diagnose your problem.

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Noncancerous Uterine Conditions

After your medical history, examination, and tests are done, your doctor will explain your condition to you and talk about your options for treatment. Later in this booklet you will find a list of questions you may want to ask your doctor.

Surgery, medicine (including hormones), a combination of the two, or "watchful waiting" are the most common choices for dealing with most noncancerous uterine conditions. Watchful waiting means having no treatment but seeing the doctor regularly to keep track of your condition and discuss symptoms. After a period of watchful waiting, if you are still having problems, you may decide with your doctor to consider one or more treatment options.

There are always new treatments in development. Be sure to ask your doctor if there are any new treatments for your condition that are not described in this booklet.

Your doctor may recommend that you have a hysterectomy. If so, you will want to see the section on hysterectomy.

Remember, all treatments—including medicine, surgery, other types of treatments, and even a decision to wait or not be treated—have risks and benefits. Be sure to ask your doctor about the risks and benefits of each treatment option you are offered. Then you can work with your doctor to weigh your options and make an informed choice.

Fibroids

What are fibroids?

Fibroids are growths in the walls of the uterus. Sometimes, a fibroid is attached to the outside of the uterus by a stalk. Fibroids can be as small as a seed or a pea or as large as an orange or small melon. Although fibroids are called "tumors," they are not cancer. They are smooth muscle growths.

About 2 of every 10 women who have not gone through menopause have fibroids. The technical term for a fibroid tumor is leiomyoma.

Fibroids may cause no symptoms at all, or they may cause pain or bleeding. Fibroids may make it hard to pass urine if they grow large enough to press on the bladder.

Fibroids also can make it hard for you to get pregnant. Sometimes fibroids can cause problems with pregnancy, labor, or delivery, including miscarriage and premature birth.

Select for illustration of Uterine Fibroids (29 KB).

How are fibroids treated?

You may have several treatments to choose from if you have fibroids. It depends on how big the fibroids are, where they are, and whether you are pregnant or want to become pregnant.

Watchful waiting may be all the treatment you need if your fibroid is small and you do not have any symptoms. You will need regular visits to your doctor for a pelvic exam to monitor the growth of the fibroid.

Nonsurgical treatments for fibroids include hormones and pain relief medicines.

Taking gonadotropin releasing hormone (GnRH) can cause fibroids to shrink. This may make surgery easier, or it may be used instead of an operation.
Your doctor may prescribe ibuprofen (for example, Advil), acetaminophen (for example, Tylenol), or another medicine to relieve pain.

Surgical treatments for fibroids include hysterectomy and myomectomy.

Hysterectomy is usually recommended when the fibroids are causing symptoms, when they have grown rapidly, or when the fibroids are large (as large as a grapefruit).
Myomectomy is an operation to remove a fibroid tumor without taking out the uterus. This means that pregnancy is still possible, although a Cesarean section may be necessary.

Recovery time after a myomectomy is about 3 to 4 weeks. About 20 percent of women who undergo myomectomy need a blood transfusion, about 30 percent have a fever after surgery, and many patients develop adhesions (scar tissue) in their pelvis in the months following surgery. These complications are more likely to occur when there is more than one fibroid and when the fibroids are large.

The growths may come back after a myomectomy, and repeat surgery may be necessary. If you are considering a myomectomy, be sure to ask the doctor how likely it is that new fibroids might grow after the surgery.

You also should ask your doctor how much experience he or she has in doing this procedure. Not all gynecologists have been trained to perform myomectomies.

Another option is laser surgery, which usually is an outpatient procedure. With laser surgery, the doctor uses a high-intensity light to remove small fibroids.
Depending on the location of the fibroid, it may be possible to remove it during a laparoscopy. Or, the doctor may put a thin tube (called a hysteroscope) with a laser through the vagina and into the uterus. The tube may have a small scraper to scrape away the fibroid from the wall of the uterus.

Endometriosis

What is endometriosis?

Endometrial tissue lines the uterus. Each month, in tune with the menstrual cycle, the endometrial tissue thickens and is shed during menstruation.

If you have endometriosis, it means that the same kind of tissue that lines your uterus is also growing in other parts of your body, usually in the abdomen. This can cause scar tissue to build up around your organs.

Endometriosis may cause severe pain and abnormal bleeding, usually around the time of your period. Pain during intercourse is another common symptom. However, it is possible to have endometriosis and not have any symptoms. Endometriosis is a leading cause of infertility (inability to get pregnant). Often it is not diagnosed until a woman has trouble getting pregnant.

Endometriosis will lessen after menopause and during pregnancy, since the growth of endometrial tissue depends on estrogen. If you have endometriosis and take estrogen-replacement therapy after menopause, the tissue may grow back.

The only way to be sure that you have endometriosis is through a surgical procedure, laparoscopy. Endometriosis can be a chronic condition and may return even after treatment with medicine or surgery.

How can endometriosis be treated?

There are several options for treating endometriosis. The best treatment for you may depend on whether you want to relieve pain, increase your chances of getting pregnant, or both. It is important to work with your doctor to weigh the benefits and risks of each treatment.

Nonsurgical treatments include:

Medicine, including hormones. There are two types of hormone therapy: those that will make your body think it is pregnant and those that will make your body think it is in menopause. Both are meant to stop the body from producing the messages that cause the endometrial tissue to grow. Birth control pills may be used for a few months to try to shrink the adhesions in women who want to become pregnant. Other hormones—GnRH and danazol—also may help relieve the pain of endometriosis.
Doctors sometimes prescribe pain relievers, such as ibuprofen (for example, Advil and Motrin) or, for severe pain, codeine.
Other nonsurgical options include watchful waiting and changes in diet and exercise.

Several types of surgery are used to treat endometriosis, including:

Laser laparoscopy, in which a cut is made in the abdomen and adhesions are removed, either by laser beams or electric cauterization.
Hysterectomy, which may not cure endometriosis. Unless the ovaries are removed also, they will continue to produce estrogen. This may encourage endometrial tissue to grow in other areas of the body.
Bowel resection, which means taking out a section of the bowel, if endometriosis is affecting the bowel.
Cutting certain nerves, called the sacral nerves, in the lower back to relieve pain.

Endometrial Hyperplasia

What is hyperplasia?

Hyperplasia is a condition in which the lining of the uterus becomes too thick, which results in abnormal bleeding. Hyperplasia is thought to be caused by too much estrogen.

Depending on your age and how long you have had hyperplasia, your doctor may want to do a biopsy before beginning treatment to rule out cancer.

How is hyperplasia treated?

Hormone treatment with birth control pills or progesterone helps some women who have hyperplasia.
Hysterectomy is often recommended to treat hyperplasia. Because some types of hyperplasia can lead to cancer, your doctor will watch your condition carefully if you choose not to have a hysterectomy.

Uterine Prolapse

What is uterine prolapse?

If you have uterine prolapse, it means that your uterus has tilted or slipped. Sometimes it slips so far down that it reaches into the vagina. This happens when the ligaments that hold the uterus to the wall of the pelvis become too weak to hold the uterus in its place.

Uterine prolapse can cause feelings of pressure and discomfort. Urine may leak.

Select for illustration of Uterine Prolapse (33 KB).

How is uterine prolapse treated?

Treatment choices depend on how weak the ligaments have become, your age, health, and whether you want to become pregnant.

Options that do not involve an operation include:

Exercises (called Kegel exercises) can help to strengthen the muscles of the pelvis. How to do Kegel exercises: Tighten your pelvic muscles as if you are trying to hold back urine. Hold the muscles tight for a few seconds and then release them. Repeat this exercise up to 10 times. Repeat the Kegel exercises up to four time each day.
Taking estrogen to limit further weakening of the muscles and tissues that support the uterus.
Inserting a pessary—which is a rubber, diaphragm-like device—around the cervix to help prop up the uterus. The pessary does have drawbacks. It may dislodge or cause irritation, it may interfere with intercourse, and it must be removed regularly for cleaning.
Watchful waiting.

Surgical treatments include:

Tightening the weakened muscles without taking out the uterus. This is usually done through the vagina, but it also can be done through the abdomen. Although this is a type of surgery, it is not as extensive as a hysterectomy.
Hysterectomy. Doctors usually recommend this operation if symptoms are bothersome or if the uterus has dropped so far that it is coming through the vagina.

Ovarian Cysts

What are ovarian cysts?

Ovarian cysts are small, fluid-filled sacs that usually are not malignant. They may not cause any symptoms, or they may be quite painful. Sometimes, ovarian cysts appear in connection with the menstrual cycle, and they may go away on their own in a few months. When these cysts grow large, they may cause feelings of pressure or fullness.

Although most ovarian cysts are benign (not cancer), they must be taken very seriously. A sonogram will show whether a cyst is fluid-filled or has solid matter in it. If it is solid, it may be related to endometriosis, or it may be cancerous.

What are the treatments for ovarian cysts?

If you have not yet gone through menopause, you may not need any treatment, unless the cyst is very big or causing pain. Sometimes, taking birth control pills will make the cyst smaller. Surgery may be needed if the cyst is causing symptoms or is more than 2 inches across.

If surgery is needed, often the cyst can be removed without removing the ovary. Even if one ovary has to be removed, it is still possible to become pregnant as long as one ovary remains.

After menopause, the risk of ovarian cancer increases. Surgery to remove an ovarian cyst is usually recommended in this case. Your doctor will probably want to do a biopsy to see if cancer is present.

If you have gone through menopause and you have an ovarian cyst, talk with your doctor about what will be done during surgery. Make sure you understand whether he or she plans to remove just the cyst, the cyst and the ovary, or to do a hysterectomy. Talk over the options with your doctor and make your own wishes known.

Treatment options include:

Watchful waiting.
Hormone therapy to reduce the size of the cyst.
Cystectomy to remove the cyst.
Oophorectomy to remove the affected ovary.
Hysterectomy. This usually is not necessary unless the cyst is cancerous.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is caused by an infection that starts in the vagina. Most often, it is caused by a sexually transmitted disease (STD). The infection spreads upward into the uterus, fallopian tubes, and pelvis.

Women who use intrauterine devices (IUDs) are at increased risk for PID. Rarely, the bacteria that cause PID enter the body during childbirth or abortion.

PID can cause pelvic pain and fevers. It also may cause infertility (inability to get pregnant) because of damage to the fallopian tubes. Sacs of pus, called abscesses, may form in the pelvis. Sometimes the vagina will discharge a pus-like substance.

If PID is not treated, pain may be so intense that it is hard to walk. The infection may spread into the bloodstream and throughout the body, causing fever, chills, joint infections, and sometimes death.

How is PID treated?

If you have PID and it is the result of an STD, you and your sexual partner will be given drugs called antibiotics to treat the infection.
If an abscess has formed, it may need to be drained.
Treatment may include hospitalization.
An operation may be done to help heal scar tissue.
If the disease cannot be stopped in any other way, you may need surgery to remove the infected organs.

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Severe Menstrual Pain

What is severe menstrual pain?

Some women have extreme cramping just before and during their period. The technical term for this is dysmenorrhea. If you have this kind of pain, you should seek treatment. Severe menstrual pain may be a symptom of endometriosis.

What can be done about severe menstrual pain?

Several types of medicine are used to treat painful cramps. These include:

Over-the-counter pain relievers, such as aspirin, ibuprofen, naproxen (for example, Aleve), or acetaminophen may be helpful.
If over-the-counter medicines don't work, your doctor can give you a prescription for a stronger pain reliever, such as codeine.
Birth control pills or other medicines may be used to reduce cramping.
Surgery usually is not necessary if severe menstrual pain is the only problem.

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Very Heavy Menstrual Bleeding

What is very heavy menstrual bleeding?

As you get closer to menopause, it may be hard to tell when your period is going to start. The time between your periods may be longer or shorter than usual. When it does start, bleeding may be very heavy and last for several weeks.

You may have dysfunctional uterine bleeding or DUB. DUB most often affects women over 45. Usually it is caused by an imbalance in the chemicals in the body (hormones) that control the menstrual cycle.

Younger women also may have heavy bleeding. Usually it is because of an irregular menstrual cycle. A woman may go for several months without a period, but the lining of her uterus continues to build up. When finally her body sheds the uterine lining, she may have very heavy bleeding.

The symptoms can be very upsetting and may make you feel limited in the things you can do. Sometimes, the symptoms are a sign of a more serious problem.

Your doctor will probably do a blood test. Depending on the results, your medical history, and your age, the doctor may recommend that you have a biopsy to rule out endometrial hyperplasia.

What treatments are used for very heavy menstrual bleeding?

Birth control pills or other medicines may be helpful.
Another choice is watchful waiting.
A surgical procedure called endometrial ablation may help to relieve very heavy menstrual bleeding. Endometrial ablation causes sterility (inability to become pregnant), but it does not trigger menopause. The long-term effects of endometrial ablation are unknown.

Do you have a bleeding disorder?

If you have very heavy periods (lasting more than 7 days or soaking more than one pad or tampon every 2 to 3 hours), frequent or long-lasting nosebleeds, easy bruising, or prolonged oozing of blood after dental work, you may have a bleeding disorder such as von Willebrand Disease. This is not the same as very heavy menstrual bleeding, but it can be an underlying cause. It can be diagnosed at the Hemophilia Treatment Center, and it can be treated. Call the National Hemophilia Foundation at 800-424-2634, extension 3051, to find the Hemophilia Treatment Center nearest you.

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Chronic Pelvic Pain

What is chronic pelvic pain?

If you feel intense pain in your pelvis, but the doctor can find no cause, you may have chronic pelvic pain.

How is chronic pelvic pain treated?

Options that do not involve surgery include:

Combination therapy—including anti-inflammatory medicines that contain ibuprofen, birth control pills, physical therapy, and nutritional and psychological counseling—may be helpful.
Depending on the severity of the pain, watchful waiting may be another option.

Surgical options include:

Surgery to take out scar tissue that may be causing pain. This is called adhesiolysis.
Hysterectomy may be an option for women whose pelvic veins are persistently swollen or when all other measures have been tried without success. However, it does not always relieve the pain.
Cutting certain nerves in the lower back to help relieve pain.

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