Uterine fibroids
Uterine fibroids (leiomyomas or myomas) are benign smooth muscle tumours of the uterus.
They affect up to 70% of women by age 50.
Although non-cancerous, fibroids can cause significant morbidity depending on size, number, and location.
Presentation ranges from asymptomatic cases to severe menstrual disturbance, pelvic pressure, or reproductive complications.
🧩 Types of Fibroids
- Intramural: Within the uterine wall – most common, often causes menorrhagia and bulk symptoms.
- Submucosal: Beneath the endometrium → heavy menstrual bleeding + infertility risk.
- Subserosal: Beneath the serosa → may grow large, pressing on bladder/bowel.
- Pedunculated: Attached by a stalk → risk of torsion and acute pain.
- Cervical: Arise from cervix → may cause obstruction or pressure symptoms.
⚠️ Risk Factors
- 👵 Age: Peak 30–50 years.
- 🧬 Family History: Increased risk if first-degree relatives affected.
- 🌍 Ethnicity: More common and earlier onset in African-Caribbean women.
- 💊 Hormonal: Oestrogen and progesterone promote growth; fibroids often shrink after menopause.
- ⚖️ Obesity: Adipose tissue increases circulating oestrogen.
- 🚫 Nulliparity: Never being pregnant increases risk.
🩺 Clinical Features
- 💉 Menorrhagia: Heavy or prolonged periods (especially submucosal fibroids)
- 😣 Pelvic Pressure: "Dragging" or fullness sensation
- 🚽 Urinary Symptoms: Frequency or retention from bladder compression
- 💩 Bowel Symptoms: Constipation or rectal pressure
- ❤️🔥 Dyspareunia: Painful intercourse, esp. cervical fibroids
- 👶 Reproductive Issues: Infertility, miscarriage, malpresentation, obstructed labour
- ⚡ Acute Pain: Red degeneration (esp. pregnancy) or pedunculated fibroid torsion
- Exam: Enlarged, irregular uterus on bimanual palpation; abdominal mass if large
🔎 Investigations
- 🖤 Ultrasound (TV/TA): First-line; assesses size, site, number
- 🧲 MRI: Surgical planning or complex cases
- 🔦 Hysteroscopy: Direct visualisation; allows removal of submucosal fibroids
- 💧 Sonohysterography: Saline infusion highlights cavity distortion
💊 Medical Management
- 🩹 NSAIDs: Symptom relief (pain), no effect on size
- 💊 Hormonal Therapy:
- COCP → regulates bleeding
- Mirena (LNG-IUS) → reduces menorrhagia, preserves fertility
- GnRH agonists (e.g., leuprolide) → temporary shrinkage; pre-op or peri-menopause use
- 🔄 Selective Progesterone Receptor Modulators (SPRM, e.g., ulipristal): Shrinks fibroids + controls bleeding (NICE notes use restrictions due to liver monitoring)
🔪 Surgical & Interventional Options
- ✂️ Myomectomy: Fibroid removal; uterus preserved → fertility maintained
- 🏥 Hysterectomy: Definitive for severe symptoms, no fertility preservation
- 🩸 Uterine Artery Embolization (UAE): Fibroid shrinkage; not recommended if future fertility desired
- 🔥 Endometrial Ablation: For menorrhagia + small submucosal fibroids; not fertility-preserving
- 🎯 MR-guided Focused Ultrasound: Non-invasive thermal ablation
🚑 Complications
- 💉 Iron-deficiency anaemia from chronic menorrhagia
- 👶 Infertility & miscarriage – submucosal fibroids distort cavity
- 🤰 Pregnancy complications – malpresentation, obstructed labour, preterm labour
- ⚡ Red degeneration – painful necrosis, esp. in pregnancy
- 🚽 Urinary retention / recurrent UTIs – from bladder compression
✅ Key Exam Pearls
- Oestrogen-dependent → shrink after menopause
- Most common type: intramural
- Most symptomatic for bleeding: submucosal
- Definitive treatment: hysterectomy
📚 NICE References
