Benign smooth-muscle tumors of the myometrium causing heavy bleeding, bulk symptoms, and reproductive complications.
Also known as: fibroids, leiomyoma, myoma, uterine myoma
Overview
Benign monoclonal smooth-muscle tumors arising from the myometrium, classified by location (FIGO 0-8): submucosal (0-2), intramural (3-4), subserosal (5-7), or other (8, e.g., cervical, parasitic).
Epidemiology
Most common pelvic tumor in women; cumulative incidence by age 50 is ~70% in white women and >80% in Black women. Black women develop fibroids earlier, more numerous, larger, and more symptomatic.
Try two board-style Uterine Fibroids questions
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Question 1ReproductiveEasy
A 45-year-old female has irregular heavy menstrual bleeding. Pelvic ultrasound shows a 3.5 cm submucosal fibroid distorting the uterine cavity. Endometrial biopsy is negative for hyperplasia or malignancy. She has completed childbearing and wants to avoid hysterectomy and prefers a minimally invasive option. Which of the following is the most appropriate management?
AOral tranexamic acid
BEndometrial ablation
CHysteroscopic myomectomy
DUterine artery embolization
ELevonorgestrel-releasing intrauterine device
Reveal answer & full explanation
Correct answer: C — Hysteroscopic myomectomy
AOral tranexamic acid
BEndometrial ablation
CHysteroscopic myomectomy✓
DUterine artery embolization
ELevonorgestrel-releasing intrauterine device
Why Hysteroscopic myomectomy is correct
Submucosal fibroids (FIGO Type 0, 1, and selected Type 2) are most strongly associated with heavy menstrual bleeding, and hysteroscopic myomectomy allows direct resection in an outpatient setting with an 85-95% bleeding improvement rate while preserving fertility.
It is the ideal procedure for FIGO Type 0, 1, and selected Type 2 submucosal fibroids.
Why the others are wrong
Levonorgestrel-releasing intrauterine device — has reduced efficacy when a submucosal fibroid distorts the uterine cavity (confused-with a normal cavity).
Uterine artery embolization — is better suited for intramural and subserosal fibroids, not the submucosal type distorting the cavity (right-concept-wrong-procedure).
Oral tranexamic acid — provides only symptomatic hemostatic relief and does not address the fibroid itself (premature closure on symptom control).
Endometrial ablation — completed childbearing, a negative endometrial biopsy and the wish to avoid hysterectomy make ablation tempting, but a submucosal fibroid distorting the uterine cavity lowers its success and leaves the fibroid in place (right-patient-wrong-cavity)
Question 2ReproductiveMedium
A 42-year-old woman presents with menorrhagia and pelvic pressure. Pelvic exam reveals an enlarged, irregularly shaped, nontender uterus. Transvaginal ultrasound shows multiple hypoechoic intramural masses, the largest measuring 4.5 cm. Serum beta-human chorionic gonadotropin (beta-hCG) is negative. Which of the following is the most appropriate next step for this symptomatic patient who desires uterine preservation?
For women with both heavy bleeding and bulk symptoms who desire uterine preservation, the standard procedural options that address both are myomectomy (surgical removal of fibroids — open, laparoscopic, or hysteroscopic depending on location) or uterine artery embolization (UAE/UFE), both of which preserve the uterus
Why the others are wrong
Endometrial ablation — preserves the uterus and can reduce bleeding, but it does not relieve bulk symptoms and performs poorly when multiple intramural fibroids up to 4.5 cm distort the cavity
Gonadotropin-releasing hormone (GnRH) agonist therapy — agents such as leuprolide temporarily shrink fibroids but are not long-term solutions due to bone loss and menopausal symptoms; used preoperatively
Oral contraceptive pills — oral contraceptive pills (OCPs), like other medical therapies such as the levonorgestrel IUD or tranexamic acid, are reasonable first-line treatment for fibroid-related heavy bleeding alone, but they do not shrink fibroids or relieve bulk symptoms such as her pelvic pressure
Expectant management with serial ultrasound — fibroids are benign and usually shrink after menopause, which tempts watchful waiting, but expectant management suits asymptomatic or minimally symptomatic women; at 42 she likely has years of menses ahead, and her menorrhagia and pelvic pressure warrant a uterus-sparing intervention
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Estrogen- and progesterone-responsive tumors arising from a single myometrial smooth-muscle progenitor; MED12 mutations identified in ~70%. Grow during reproductive years and typically regress after menopause. Heavy bleeding results from distorted endometrial vasculature and impaired hemostasis; bulk symptoms from mass effect.
Clinical presentation
Symptoms
Heavy menstrual bleeding (most common); prolonged or intermenstrual bleeding
Pelvic pressure or fullness, bloating, increased abdominal girth
Urinary frequency or hesitancy (anterior fibroids on bladder)
Constipation or tenesmus (posterior fibroids on rectum)
Dysmenorrhea, dyspareunia
Infertility, recurrent pregnancy loss (especially submucosal)
Many fibroids are asymptomatic and found incidentally
Signs / physical exam
Enlarged, irregular, firm, nontender uterus on bimanual exam
Uterine size often described in 'weeks' as in pregnancy
Pallor or signs of anemia in chronic blood loss
Classic findings
Premenopausal woman with heavy menses, iron-deficiency anemia, and an enlarged irregular uterus.
Differential diagnosis
Adenomyosis — Diffusely enlarged, tender, boggy uterus; heavy painful menses; MRI shows widened junctional zone
Endometrial polyp — Intermenstrual bleeding; saline-infusion sonohysterography or hysteroscopy
Endometrial hyperplasia/cancer — Postmenopausal or atypical bleeding; endometrial biopsy mandatory if risk factors
Leiomyosarcoma — Rapid growth (especially postmenopausal), heterogeneous on MRI; rare (<1% of myomectomy specimens)
Ovarian mass — Adnexal location, may be confused with pedunculated subserosal fibroid; MRI clarifies
Pregnancy (intrauterine or ectopic) — Always check hCG with abnormal bleeding or uterine enlargement
Adenocarcinoma of cervix or uterus — Postmenopausal bleeding, abnormal Pap; biopsy
Diagnostic workup
Labs
CBC (iron-deficiency anemia common), ferritin
TSH, prolactin if irregular bleeding
Pregnancy test
Endometrial biopsy if age ≥45, risk factors for hyperplasia, or persistent abnormal bleeding
Hysterectomy — definitive; vaginal, laparoscopic, or abdominal route based on size
Second-line / adjunct
GnRH agonist — leuprolide, goserelin — short-term (3-6 months) preoperative shrinkage; add-back therapy if used longer
GnRH antagonist with add-back — elagolix/estradiol/norethindrone, relugolix/estradiol/norethindrone — approved for heavy menstrual bleeding due to fibroids
Selective progesterone receptor modulators (where available; ulipristal — restricted in many regions due to hepatotoxicity)
Complications
Iron-deficiency anemia from chronic heavy bleeding
Infertility, recurrent pregnancy loss (submucosal especially)
Pregnancy complications: malpresentation, obstructed labor, postpartum hemorrhage, red degeneration (painful infarction in pregnancy)
Hydronephrosis from ureteral compression by large fibroids
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.