- 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)
- 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
|Risk factors|| || |
|Uterine features|| || || |
- Uterine fibroids, adenomyosis, and endometriosis may be present simultaneously in the same patient.
- See also benign tumors of the endometrium and
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.
- Hormone therapy
- NSAIDs: to control pain
- Antifibrinolytics (e.g., tranexamic acid): reduce bleeding
- Androgenic agonists (e.g., danazol): suppress growth of fibroids but has many side effects (e.g., acne, edema, hair loss, etc.)
- In cases of uncontrollable bleeding: ergot derivatives (methylergometrine), packed red blood cells
- Indications: rapidly growing fibroid, recurrent refractory bleeding: secondary to medical therapy, severe symptoms
- Myomectomy: excision of subserosal or intramural fibroids
- Hysterectomy: definitive treatment
- Malignant transformation to leiomyosarcoma is rare
- Fibroid torsion
- Fibroids typically shrink after menopause.
We list the most important complications. The selection is not exhaustive.
- 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