- Clinical science
Uterine leiomyomas (fibroids) are benign, hormone-sensitive uterine neoplasms. These tumors are classified as either submucosal (beneath the endometrium), intramural (within the muscular uterine wall of the uterus), or subserosal (beneath the peritoneum). Symptoms depend on the location, size, and number of myomas, and include menstrual abnormalities (menorrhagia), features of mass effects (e.g., back/abdominal/pelvic pain or bladder and bowel dysfunction), and infertility. Physical examination and sonohysterography are used to establish the diagnosis. Treatment for symptomatic patients includes surgery (myomectomy or hysterectomy) as well as interventional (uterine artery embolization) and/or medical therapy (GnRH agonists).
- A benign, hormone-sensitive smooth muscle tumor of the uterus
- Can be submucosal, intramural, or subserosal
- Arises from a single myometrial cell (monoclonal growth) and causes:
- Results in an overgrowth of smooth muscle cells and connective tissue (often multiple tumors)
- The myometrium also develops vascular changes (e.g., increased arterioles and venules, dilated veins).
- The most common tumor of the female genital tract.
- Early menarche (< 10 years old)
- Age: 25–45 years
- Increase incidence in African Americans
- Family history
Most women have small, asymptomatic fibroids. Symptoms depend on the number, size, and location of leiomyomas.
- Abnormal menstruation
- Features of mass effect
- Reproductive abnormalities
Ultrasound (best initial test)
- Concentric, hypoechoic, heterogeneous tumors
- Calcifications or cystic areas suggest necrosis.
- MRI: to evaluate the uterus and ovaries for potentially complicated surgical cases and visually differentiate between leiomyomas, adenomyomas, and adenomyosis
- Grayish-white surface
- Homogenous; tissue bundles on cross-section partly in a whorled pattern
- Some leiomyomas may involve regressive changes: scar formation, calcification, and cysts
- Microscopic: Smooth muscle tissue in a whorled pattern with well-demarcated borders, consisting of monoclonal cells interspersed with connective tissue
|Uterine leiomyoma (fibroids)||Uterine polyps|
|Risk factors|| || |
|Uterine features|| || || || |
- Uterine fibroids, adenomyosis, and endometriosis may be present simultaneously in the same patient.
- See also
The differential diagnoses listed here are not exhaustive.
Treatment should only be considered in symptomatic patients because of the side effects of medical therapy and surgery. The goal is to relieve symptoms. Perimenopausal women warrant expectant management in most cases.
- Do not require treatment
- Frequent follow-ups (approx. every 6–12 months) are necessary to monitor any potential growth.
Gonadotropin-releasing hormone (GnRH) agonists: e.g., leuprolide, goserelin, nafarelin
- Optimal treatment prior to surgery; but not suited for long-term monotherapy (> 6 months) because they cause osteoporosis, hot flushes, depression
- Decrease size of leiomyomas
- Suppress growth of new leiomyomas
- Decrease tumor vascularization
- Induce amenorrhea and thereby improve anemia
- Leiomyomas grow back once therapy is discontinued (rebound growth)
- Usually used as add-ons to GnRH agonist therapy
- Control bleeding and pain but may promote growth of leiomyomas
- Progestin-releasing intrauterine device (IUD): controls heavy and painful bleeding but does not treat fibroids themselves (only for fibroids that do not distort the inside of the uterus)
- Gonadotropin-releasing hormone (GnRH) agonists: e.g., leuprolide, goserelin, nafarelin
- Antifibrinolytics (e.g., tranexamic acid): reduce heavy bleeding
- Androgenic agonists (e.g., : danazol): suppress growth of fibroids but have many side effects (e.g., acne, edema, hair loss, etc.)
- NSAIDs: : for dysmenorrhea
Uterine fibroid embolization (a type of uterine artery embolization)
- Procedure: injection of polyvinyl alcohol (PVA) into the arteries that supply blood to the fibroid, causing it to shrink; ¼ of patients may require further invasive treatment
- Continued heavy bleeding and/or severe pain with insufficient response to medical treatment
- Contraindications to surgery or personal preference to avoid surgery
- No wish to conceive in the future
- Indications: rapidly growing fibroid, recurrent refractory bleeding: secondary to medical therapy, severe symptoms
- Myomectomy: excision of subserosal or intramural fibroids (preferred for women planning future pregnancies)
- Hysterectomy: definitive treatment
- Elevated concentrations of progestin and estrogen foster the growth of leiomyomas. Pain may be caused by:
- Premature contractions
- Depending on location and size:
- Cervical leiomyoma: obstruction of the birth canal → indication for cesarean section
- Postpartum: atonic hemorrhages
- Puerperium: fibroid regression accompanied by calcification