Reproductive · PANCE / PANRE

Uterine Fibroids (Leiomyoma)

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 (3-5), subserosal (6-7), 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.

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Risk factors

  • Black race (2-3x relative risk)
  • Early menarche, nulliparity
  • Obesity, hypertension
  • Family history
  • Vitamin D deficiency

Pathophysiology

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

Imaging

  • Transvaginal ultrasound — first-line; characterizes size, number, location
  • Saline-infusion sonohysterography or hysteroscopy — best for submucosal fibroids and cavity distortion
  • MRI — pre-operative mapping, suspected adenomyosis, or assessment before uterine artery embolization

Diagnostic algorithm

FIGO TypeLocationBest Approach
0Pedunculated submucosal, entirely in cavityHysteroscopic resection
1Submucosal, <50% intramuralHysteroscopic resection
2Submucosal, ≥50% intramuralHysteroscopic (skilled) or laparoscopic
3100% intramural, contacts endometriumMyomectomy (laparoscopic/abdominal)
4Intramural, no cavity or serosa contactMyomectomy if symptomatic
5-7SubserosalLaparoscopic myomectomy
8Other (cervical, parasitic)Individualized
FIGO leiomyoma subclassification — location drives surgical approach.

Treatment

First-line

  • Expectant management for asymptomatic fibroids
  • NSAIDs for dysmenorrhea
  • Tranexamic acid 1.3 g TID × up to 5 days per cycle for heavy bleeding
  • Combined hormonal contraception or progestin-only options for bleeding control
  • Levonorgestrel IUD — effective for heavy menstrual bleeding when cavity not significantly distorted
  • Iron supplementation for anemia

Procedural / surgical

  • Hysteroscopic myomectomy — submucosal fibroids (FIGO 0-2)
  • Laparoscopic, robotic, or abdominal myomectomy — preserves fertility
  • Uterine artery embolization — alternative for women not pursuing pregnancy (data on subsequent fertility limited)
  • MR-guided focused ultrasound (MRgFUS) — selected cases
  • 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
  • Rare leiomyosarcoma (<1% — historically overestimated)

PANCE pearls

  • Submucosal fibroids (FIGO 0-2) most disrupt fertility and bleeding; hysteroscopic myomectomy can dramatically improve both.
  • Avoid morcellation in women at risk for occult malignancy (postmenopausal, rapid growth) due to risk of disseminating leiomyosarcoma.
  • Tranexamic acid is highly effective for heavy menstrual bleeding and is contraindicated in patients with active thromboembolic disease.
  • Red degeneration in pregnancy presents with localized pain, low-grade fever, and leukocytosis — manage conservatively with analgesics.
  • Fibroids regress after menopause; postmenopausal growth raises concern for sarcoma.

References

  • ACOG PB 228 — ACOG Practice Bulletin No. 228: Management of Symptomatic Uterine Leiomyomas (Obstet Gynecol 2021)
  • FIGO Classification — FIGO Classification System (PALM-COEIN) for Causes of Abnormal Uterine Bleeding (Munro et al., Int J Gynaecol Obstet 2011)
  • AAGL 2012 — AAGL Practice Report: Diagnosis and Management of Submucous Leiomyomas (J Minim Invasive Gynecol 2012)

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