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Uterine leiomyomata, or fibroids, are very common, affecting up to 70% or even 80% of women at some point in their lives.1,2 Despite this lifetime prevalence, many cases go undiagnosed, increasing the probable incidence,1 while clinical guidelines appear to lack consensus on optimal evidence-based treatment strategies.3
In general, uterine fibroids are known to be estrogen responsive,4 and both genetics and ovarian hormone exposure are likely antecedents for the development of fibroids.2 Studies have shown a notable difference in the prevalence and presentation of fibroids based on race, with Black women experiencing larger fibroids more often and at a younger age than some other racial populations.1,2,5 The heavy bleeding associated with fibroids can cause anemia, fatigue, and pain.1 Women with uterine fibroids report a decreased quality of life, difficulty getting diagnosed, and concerns about available treatment options.6,7
Often, women with fibroids want to avoid hysterectomy.6,7 However, in the United States, uterine fibroids are one of the most common reasons for a hysterectomy,8 yet it is well known that even when the ovaries are conserved, hysterectomies can greatly increase risks for other health issues like cardiovascular and metabolic conditions, including congestive heart failure.9 What risk factors may play a role in the development of uterine fibroids, and what options other than hysterectomy are available for patients?
The underlying cause of uterine fibroids and the mechanisms of their growth are not fully known, and the factors that predispose women to fibroid development continue to be studied. Age, race, genetic predisposition, and family history are a few of the noted risk factors that are not modifiable; however, certain modifiable lifestyle factors may also play a role in fibroid development.5,10-12 Increased blood pressure correlates with the increased risk of fibroids.2,5 Obesity, high serum lipids, and metabolic syndrome also increase the risk of fibroids, suggesting a cardiometabolic connection.13-15 Low vitamin D levels may also increase risk for fibroids.16,17 In addition, chronic inflammation may also play a role in fibroid formation.18
As mentioned, Black women are much more likely to develop fibroids, and they are also more likely to report more severe symptoms.5,19 Adding to this connection, central centrifugal cicatricial alopecia (which primarily affects Black women) is highly correlated with uterine fibroids, suggesting a similar underlying pathophysiological mechanism.20
Either as part of an inflammatory milieu or otherwise, environmental toxicants also likely play a role in the development of fibroids, including exposures to cosmetic or beauty-product-related chemicals,21,22 polluted drinking water,23 and air pollution. One large-scale, longitudinal study demonstrated that exposure to high amounts of air pollution [particulate matter (PM) 2.5] correlated with an increased risk of fibroids.24 Heavy metals25 and endocrine-disrupting chemicals26 such as persistent organic pollutants (POPs)25,27 and polychlorinated biphenyls (PCBs)27 have also been correlated with uterine fibroid development. Critical windows of exposure may affect long-term hormonal patterns, especially pre-menarche exposures.28
Healthy lifestyle factors may not only play a preventative role in fibroid risk but may also be part of an effective treatment plan. As part of a personalized therapeutic strategy to decrease uterine fibroids, the following are all components of a foundational functional medicine approach:
- Addressing hormonal imbalances that may include estrogen dominance.
- Supporting gut health and decreasing overall inflammation.
- Improving detoxification and waste elimination to help remove excess estrogen.
- Stabilizing blood sugar and insulin.
- Reducing exposure to endocrine-disrupting chemicals.
- Implementing the most effective exercise and nutritional plan for an individual patient.
In addition, one of the emerging non-surgical treatments for fibroids is modulating progesterone.11 In one study, perioperative treatment with the progesterone receptor modulator ulipristal acetate (or UPA) resulted in 61% of women electing not to continue with surgery, as their symptoms were adequately managed.29 Fibroids themselves alter the expression patterns of estrogen and androgen receptors.30 For that reason, it’s important to help patients restore hormonal balance even after their fibroids and the resulting symptoms are adequately treated.
Best practices for treating fibroids have not yet been established;31 however, from a functional medicine perspective, interventions that prioritize hormonal balance and reduced systemic inflammation, improve modifiable lifestyle factors, and reduce exposure to environmental toxicants are treatment approaches that should be considered. For the many women who suffer from fibroids but wish to avoid hysterectomy, these low-harm therapies may provide the relief they seek.
- Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review.2017;124(10):1501-1512. doi:10.1111/1471-0528.14640
- Giuliani E, As-Sanie S, Marsh EE. Epidemiology and management of uterine fibroids. Int J Gynaecol Obstet. 2020;149(1):3-9. doi:1002/ijgo.13102
- Amoah A, Joseph N, Reap S, Quinn SD. Appraisal of national and international uterine fibroid management guidelines: a systematic review. BJOG. 2022;129(3):356-364. doi:1111/1471-0528.16928
- Ulin M, Ali M, Chaudhry ZT, Al-Hendy A, Yang Q. Uterine fibroids in menopause and perimenopause. Menopause. 2020;27(2):238-242. doi:1097/GME.0000000000001438
- Eunice Kennedy Shriver National Institute of Child Health and Human Development. What are the risk factors for uterine fibroids? National Institutes of Health. Reviewed November 2, 2018. Accessed April 5, 2023. https://www.nichd.nih.gov/health/topics/uterine/conditioninfo/people-affected
- Borah BJ, Nicholson WK, Bradley L, Stewart EA. The impact of uterine leiomyomas: a national survey of affected women. Am J Obstet Gynecol. 2013;209(4):319.e1-319.e20. doi:1016/j.ajog.2013.07.017
- Marsh EE, Al-Hendy A, Kappus D, Galitsky A, Stewart EA, Kerolous M. Burden, prevalence, and treatment of uterine fibroids: a survey of U.S. women. J Womens Health (Larchmt). 2018;27(11):1359-1367. doi:1089/jwh.2018.7076
- Morgan DM, Kamdar NS, Swenson CW, Kobernik EK, Sammarco AG, Nallamothu B. Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women. Am J Obstet Gynecol. 2018;218(4):425.e1-425.e18. doi:1016/j.ajog.2017.12.218
- Laughlin-Tommaso SK, Khan Z, Weaver AL, Smith CY, Rocca WA, Stewart EA. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study. Menopause. 2018;25(5):483-492. doi:1097/GME.0000000000001043
- Pavone D, Clemenza S, Sorbi F, Fambrini M, Petraglia F. Epidemiology and risk factors of uterine fibroids. Best Pract Res Clin Obstet Gynaecol. 2018;46:3-11. doi:1016/j.bpobgyn.2017.09.004
- MacLean JA 2nd, Hayashi K. Progesterone actions and resistance in gynecological disorders. Cells. 2022;11(4):647. doi:3390/cells11040647
- Szydlowska I, Nawrocka-Rutkowska J, Brodowska A, Marciniak A, Starczewski A, Szczuko M. Dietary natural compounds and vitamins as potential cofactors in uterine fibroids growth and development. Nutrients. 2022;14(4):734. doi:3390/nu14040734
- Uimari O, Auvinen J, Jokelainen J, et al. Uterine fibroids and cardiovascular risk. Hum Reprod. 2016;31(12):2689-2703. doi:1093/humrep/dew249
- Qin H, Lin Z, Vásquez E, Luan X, Guo F, Xu L. Association between obesity and the risk of uterine fibroids: a systematic review and meta-analysis. J Epidemiol Community Health. 2021;75(2):197-204. doi:1136/jech-2019-213364
- Brewster LM, Haan Y, van Montfrans GA. Cardiometabolic risk and cardiovascular disease in young women with uterine fibroids. Cureus. 2022;14(10):e30740. doi:7759/cureus.30740
- Vahdat M, Allahqoli L, Mirzaei H, et al. The effect of vitamin D on recurrence of uterine fibroids: a randomized, double-blind, placebo-controlled pilot study. Complement Ther Clin Pract. 2022;46:101536. doi:1016/j.ctcp.2022.101536
- Mohammadi R, Tabrizi R, Hessami K, et al. Correlation of low serum vitamin-D with uterine leiomyoma: a systematic review and meta-analysis. Reprod Biol Endocrinol. 2020;18(1):85. doi:1186/s12958-020-00644-6
- AlAshqar A, Reschke L, Kirschen GW, Borahay MA. Role of inflammation in benign gynecologic disorders: from pathogenesis to novel therapies†. Biol Reprod. 2021;105(1):7-31. doi:1093/biolre/ioab054
- Katon JG, Plowden TC, Marsh EE. Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context. Fertil Steril. 2023;119(3):355-363. doi:1016/j.fertnstert.2023.01.022
- Dina Y, Okoye GA, Aguh C. Association of uterine leiomyomas with central centrifugal cicatricial alopecia. JAMA Dermatol.2018;154(2):213-214. doi:1001/jamadermatol.2017.5163
- Wise LA, Palmer JR, Reich D, Cozier YC, Rosenberg L. Hair relaxer use and risk of uterine leiomyomata in African-American women. Am J Epidemiol. 2012;175(5):432-440. doi:1093/aje/kwr351
- Gaston SA, James-Todd T, Harmon Q, Taylor KW, Baird D, Jackson CL. Chemical/straightening and other hair product usage during childhood, adolescence, and adulthood among African-American women: potential implications for health. J Expo Sci Environ Epidemiol. 2020;30(1):86-96. doi:1038/s41370-019-0186-6
- Hammarstrand S, Jakobsson K, Andersson E, et al. Perfluoroalkyl substances (PFAS) in drinking water and risk for polycystic ovarian syndrome, uterine leiomyoma, and endometriosis: a Swedish cohort study. Environ Int. 2021;157:106819. doi:1016/j.envint.2021.106819
- Mahalingaiah S, Hart JE, Laden F, et al. Air pollution and risk of uterine leiomyomata. Epidemiology. 2014;25(5):682-688. doi:1097/EDE.0000000000000126
- Qin YY, Leung CK, Leung AO, Wu SC, Zheng JS, Wong MH. Persistent organic pollutants and heavy metals in adipose tissues of patients with uterine leiomyomas and the association of these pollutants with seafood diet, BMI, and age. Environ Sci Pollut Res Int. 2010;17(1):229-240.
- Bariani MV, Rangaswamy R, Siblini H, Yang Q, Al-Hendy A, Zota AR. The role of endocrine-disrupting chemicals in uterine fibroid pathogenesis. Curr Opin Endocrinol Diabetes Obes. 2020;27(6):380-387. doi:1097/MED.0000000000000578
- Trabert B, Chen Z, Kannan K, et al. Persistent organic pollutants (POPs) and fibroids: results from the ENDO study. J Expo Sci Environ Epidemiol. 2015;25(3):278-285. doi:1038/jes.2014.31
- Mahalingaiah S, Missmer SE, Cheng JJ, Chavarro J, Laden F, Hart JE. Perimenarchal air pollution exposure and menstrual disorders. Hum Reprod. 2018;33(3):512-519. doi:1093/humrep/dey005
- Fernandez H, Schmidt T, Powell M, Costa AP, Arriagada P, Thaler C. Real world data of 1473 patients treated with ulipristal acetate for uterine fibroids: Premya study results. Eur J Obstet Gynecol Reprod Biol. 2017;208:91-96. doi:1016/j.ejogrb.2016.11.003
- Wong JY, Gold EB, Johnson WO, Lee JS. Circulating sex hormones and risk of uterine fibroids: Study of Women’s Health Across the Nation (SWAN). J Clin Endocrinol Metab. 2016;101(1):123-130. doi:1210/jc.2015-2935
- Al-Hendy A, Myers ER, Stewart E. Uterine fibroids: burden and unmet medical need. Semin Reprod Med. 2017;35(6):473-480. doi:1055/s-0037-1607264