Uterine Fibroids

Amber M. Shiflett MD
Bryan D. Cowan MD
Basics
Description
Uterine myomas are benign, smooth muscle cell tumors, also called fibroids
and leiomyomas.
Described by location, although most myomas involve >1 layer of the uterus:
o

Subserosal: Projects into the pelvis, causing irregular uterine contour;

may be pedunculated

Intramural: Within uterine wall

Submucosal: Projects into the uterine cavity

May arise from cervix or broad ligament

Range from microscopic to easily palpable; size described in gestational

weeks

May be single or multiple

Most common solid pelvic tumor in women

Most common indication for hysterectomy

Age-Related Factors
Develop during hormonally active reproductive years; ~70% of women at age 45
demonstrate fibroids on sonography.
Staging
Based on the location of the fibroid:
Submucous location: Type 0, I, II
Intramural location (confused with Submucosal Type II)

Subserous location

Epidemiology
True incidence and prevalence are unknown because myomas are usually
asymptomatic
If symptomatic, typically in women between the ages of 30 and 40

Black women are 23 times more likely to develop myomas than white
women

Black women tend to be younger at both time of diagnosis and hysterectomy,

have higher uterine weights, and are more likely to be anemic

Risk Factors
Nulliparity
Obesity

Black race

Genetics
Family and twin studies suggest a genetic predisposition
Associated with hereditary syndromes:
o

Reed syndrome: Uterine and subcutaneous myomas

Bannayan-Zoana syndrome: Uterine myomas, lipomas, hemangioma

Familial hereditary leiomyomas and renal cell carcinoma (linked to a

genetic defect in the Krebs cycle [fumarate hydratase])

Pathophysiology
Abnormal uterine bleeding:
o Increased vascularity and venous congestion
o

Increased surface area of uterine cavity

Compression of pelvic structures

Acute pelvic pain:

Torsion of pedunculated myoma

Protrusion of submucosal myoma through cervix

Infarction as myoma outgrows blood supply

Impaired fertility:
o

Mechanical obstruction or distortion of uterine cavity may interfere

with implantation or with ovum or sperm transport.

Associated Conditions
Iron-deficiency anemia
Endometritis

Adenomyosis

Impaired fertility

Diagnosis
Signs and Symptoms
History
Menstrual, sexual, obstetric histories
Quantify blood loss during menses
Review of Systems
Pelvic/Reproductive:
o Heavy, prolonged, painful menses (submucosal myomas):

May be associated with fatigue, pallor, shortness of breath,

palpitations

Pelvic pressure or fullness

Acute pelvic pain

GI:

Increased abdominal girth

Constipation, tenesmus (posterior myomas)

Urinary:
o

Frequency, urgency (anterior myomas)

Physical Exam
Enlarged, firm, irregular uterus
Peritoneal signs (infarcted myoma)

Conjunctival pallor, tachycardia

Tests
Lab
hCG, CBC, type and cross before surgery
Imaging
TVU to confirm diagnosis, evaluate for ovarian neoplasm
Sonohysterogram to locate intramural lesions

Abdominal plain films may show concentric calcifications

MRI to visualize individual myomas

Hysterosalpingography to define extent of submucous myomas before surgery

or to evaluate uterine cavity and patency of fallopian tubes

Renal US to evaluate for urinary obstruction

Differential Diagnosis
Abnormal uterine bleeding:
o Anovulation
o

Endometrial hyperplasia or malignancy

Pelvic pain:
o

Endometriosis

Adenomyosis

Ectopic pregnancy

Torsion or rupture of ovarian cyst

PID

Pelvic mass:
o

Pregnancy

Adenomyosis

Uterine polyp

Ovarian mass:

Functional cyst

Benign neoplasm

Malignancy

Leiomyosarcoma

Treatment
General Measures
Control severe bleeding and pain
Treat iron-deficiency anemia
Medication (Drugs)
Can reduce myoma size and uterine volume as well as bleeding
Goal is to temporarily reduce symptoms and myoma size

May be sufficient for women nearing menopause

Side effects and expense limit long-term use

None shown to improve fertility

Myomas regain pretreatment size within 34 months after drug is stopped.

OCPs may prevent but will not treat established myomas.

3 classes have demonstrated effective reduction of fibroids: GnRH-agonist,

GnRH-antagonist, and progesterone antagonists.

GnRH agonists:
o

Cause hypoestrogenic state:

Leuprolide: 3.75 mg IM monthly or 11.25 mg IM depot every 3

months

Nafarelin: 400 g intranasally b.i.d. (alternate nostrils)

Goserelin: 3.6 mg implant SC every 28 days

Reduce uterine size by up to 65% and induce amenorrhea in most

women

Maximum response achieved by 3 months

Associated with hot flushes, headaches, vaginal dryness, mood swings,

joint and muscle stiffness, and reversible bone loss, although addition
of HRT may reduce side effects

Not well studied beyond 6 months' use

GnRH-antagonists are not FDA approved for treatment of myomas in the US.

Mifepristone, selective estrogen response modifiers, and interferon-alfa may

have benefit, but their use is largely investigational.

P.193
Surgery
Indications for surgery:
o Contraindication to or intolerance of drug therapy
o

Failure of medical management to control abnormal bleeding or

anemia

Concern for malignancy

Mass effect causing pain, pressure, or urinary or GI tract symptoms

Distortion of uterine cavity causing infertility or repeated pregnancy

loss

Carries risk of infection, bleeding, damage to adjacent organs, adhesion

formation

Hysterectomy:

Definitive treatment

Indicated for extensive disease, suspected malignancy, and myomas in

association with other pelvic abnormalities

Significant improvement in symptoms, quality of life

Appropriate only if future pregnancy not desired

Abdominal myomectomy:
o

Removal of myomas via laparotomy while preserving uterus

Indicated for multiple myomas or uterus larger than 16 weeks in size

Preferred in women desiring future pregnancy

Removal of multiple myomas may involve more time and greater

blood loss than hysterectomy

Considerations after myomectomy:

o

Adhesions may impair fertility

Postpone pregnancy for healing to occur

Cesarean delivery is probably preferable

Laparoscopic myomectomy:
o

Removal of myomas via laparoscope while preserving uterus

Indicated for 1 or 2 easily accessible myomas <8 cm in diameter and

uterine size <16 weeks

Risk of uterine rupture during pregnancy is controversial

Hysteroscopic myomectomy:
o

Removal of submucosal myomas via transcervical operative endoscope

May be performed as same-day surgery with local anesthesia and

sedation

More effective when combined with endometrial ablation, but ablation

precludes future pregnancy

Myolysis:
o

Coagulation/Freezing of myoma

May carry increased risk of adhesions and uterine rupture

Uterine artery embolization:

o

Fluoroscopic guidance: Gel, beads, or coils are introduced through a

catheter in the common femoral artery to the uterine artery

Disrupts blood supply, causing degeneration

Minimally invasive procedure under conscious sedation, with more

rapid recovery

Usually requires overnight hospitalization for pain control

Resolution of bleeding symptoms in up to 90% at 6 months, but

limited studies

Associated with significant pain and fever; sepsis and death have been
reported

Disruption of blood supply to ovaries and endometrium causing

permanent amenorrhea reported in up to 3% of women <40

Unknown effects on later fertility and pregnancy

High-intensity focused ultrasound (HIFU):

o

Technique using HIFU in the MRI

This technique uses array focusing to generate heat in tissue areas of

the fibroid.

No surgery is required.

Currently, patients are in the MRI unit for ~34 hours.

This technique is developmental.

Alert
Rapid growth (increase in uterine size by 6 weeks in 1 year) in a nonpregnant woman,
growth in a menopausal woman, or new pain suggest malignancy and should prompt
surgical removal
Followup
Disposition
Issues for Referral
Refer to fertility specialist if infertility
Urology if ureteral obstruction

Interventional radiologist for uterine artery embolization or HIFU

Pregnancy Considerations
Most myomas do not grow in pregnancy; when they do, most of the growth is
in the 1st trimester.
Large myomas may be associated with pain and premature labor.

Increased risk of abruption, preterm labor, and rupture of membranes if

placenta overlies myoma.

Prognosis
Most symptomatic women require surgery
May recur after myomectomy:
o

Risk increases with number of myomas

Up to 50% recurrence at 5 years

Up to 25% require 2nd surgery

Regress during menopause

HRT may stimulate growth

Patient Monitoring
Serial exam or US every 612 months to determine growth pattern if
asymptomatic:
o Examine at same time in cycle to limit effects of hormonal stimulation
on tumor size

Watchful waiting may be appropriate for large, asymptomatic myomas in

women approaching menopause if malignancy has been excluded.

Annual bone mineral density studies if GnRH agonist are continued >6
months; consider calcium and bisphosphonate therapy

Bibliography
ACOG Committee on Gynecologic Practice. Uterine artery embolization. Obstet
Gynecol 2004;103:403404.
de Kroon CD, et al. Saline infusion sonography in women with abnormal uterine
bleeding: An update of recent findings. Curr Opin Obstet Gynecol 2006;18(6):653
657.
Griffiths A, et al. Surgical treatment of fibroids for subfertility. Cochrane Database
Syst Rev. 2006;3:CD003857.
Practice Committee of the American Society for Reproductive Medicine. Myomas
and reproductive function. Fertil Steril. 2006 Nov;86(5 suppl):S194-49.
Speroff L, et al. Clinical Gynecologic Endocrinology and Infertility, 7th ed.
Lippincott, Williams, & Wilkins 2005: 136140, 10431044.
Stewart EA, Morton CC. The genetics of uterine leiomyomata: What clinicians need
to know. Obstet Gynecol. 2006;107(4):917921.
Sudarshan S, et al. Mechanisms of disease: Hereditary leiomyomatosis and renal cell
cancera distinct form of hereditary kidney cancer. Nat Clin Pract Urol.
2007;4(2):104110.
Wallach EE, et al. Uterine myomas: An overview of development, clinical features,
and management. Obstet Gynecol. 2004;104:393406.
White AM, et al. Uterine fibroid embolization. Tech Vasc Interv Radiol. 2006;9(1):2
6.
Miscellaneous
Synonym(s)
Fibroid
Fibroleiomyoma
Fibroma
Fibromyoma
Leiomyofibroma
Myofibroma
Myoma
Leiomyoma
Clinical Pearls
Most women undergo hysterectomy to treat symptomatic uterine fibroids.
Myomectomy is selected to preserve the uterus for women who wish future
pregnancies, or women who desire retention of the uterus.
Endoscopy is used to treat easily accessible uterine fibroids by laparoscopy, or
pedunculated submucous fibroids (hysteroscopy).
Less invasive treatments are now available, but must be considered
developmental; include uterine artery embolization, HIFU, cryolysis, and radio
frequency ablation.
Abbreviations
GnRHGonadotropin-releasing hormone
HCGHuman chorionic gonadotropin
HIFUHigh-intensity focused ultrasound

 HRTHormone replacement therapy

OCPOral contraceptive pill
PIDPelvic inflammatory disease
TVUTransvaginal ultrasound
Codes
ICD9-CM
218.0 Submucous leiomyoma of uterus
218.1 Intramural leiomyoma of uterus
218.2 Subserous leiomyoma of uterus
218.9 Leiomyoma of uterus, unspecified
Patient Teaching
ACOG Patient Education Pamphlets: Uterine fibroids