Uterine Fibroids

Symptoms

• Heavy menstrual bleeding (menorrhagia)
• Prolonged menstrual periods (lasting more than 7 days)
• Bleeding between periods (intermenstrual bleeding)
• Pelvic pain or pressure (a feeling of fullness in the lower abdomen)
• Increased urinary frequency or urgency due to pressure on the bladder
• Difficulty emptying the bladder completely
• Constipation or painful bowel movements due to pressure on the rectum
• Low back pain or leg pains
• Abdominal enlargement
• Pain during sexual intercourse (dyspareunia)
• Infertility or subfertility
• Acute, severe pelvic pain (may indicate fibroid degeneration or torsion, requiring urgent medical evaluation)
• Symptoms of severe anemia (extreme fatigue, shortness of breath, dizziness, palpitations) resulting from chronic heavy bleeding

Causes & Risk Factors

• The exact cause of uterine fibroids is unknown, but their growth is influenced by multiple factors.
• Hormonal factors: Fibroids are sensitive to estrogen and progesterone, containing more receptors for these hormones than normal uterine muscle. They tend to grow during pregnancy and shrink after menopause when hormone levels decrease.
• Genetic factors: Somatic mutations in specific genes, most commonly the MED12 gene, are found in a high percentage of fibroids. Other genetic alterations, such as those involving HMGA2, are also implicated.
• Growth factors: Substances like insulin-like growth factor (IGF) may play a role in fibroid growth.
• Extracellular matrix (ECM): Fibroids contain a large amount of ECM, which stores growth factors and contributes to their fibrous nature.
• The initial event that triggers the transformation of a normal uterine muscle cell into a fibroid is not fully understood.
• The precise interaction between genetic predispositions and environmental or hormonal triggers is an ongoing area of research.
• Age: The frequency of fibroids increases with age during the reproductive years, peaking in the 40s and early 50s.
• Ethnicity: Women of African descent have a significantly higher prevalence of fibroids, an earlier onset, and tend to develop larger, more numerous, and more symptomatic fibroids.
• Heredity/Genetics: Having a first-degree relative (mother or sister) with fibroids increases your risk.
• Early Menarche: Starting menstruation at a young age increases lifetime exposure to estrogen, which is linked to a higher risk.
• Obesity: An increased body mass index (BMI) is associated with a higher risk of fibroids.
• Diet: High consumption of red meat and ham is linked to an increased risk, while high consumption of green vegetables and fruit (especially citrus) is associated with a decreased risk.
• Vitamin D Deficiency: A growing body of evidence suggests a correlation between low vitamin D levels and the presence of uterine fibroids.
• Alcohol Consumption: Particularly beer, has been associated with an increased risk.
• Hypertension: An association has been observed, but the exact causal relationship is not yet clear.
• Parity: An increasing number of term pregnancies is associated with a decreased risk of fibroids.
• Hormonal Contraception: Long-term use of combined oral contraceptives or depot medroxyprogesterone acetate (DMPA) is associated with a decreased risk.

Diagnosis

• A detailed medical history, including menstrual history (frequency, duration, volume of bleeding), presence of bulk-related symptoms, reproductive history, future fertility desires, and impact of symptoms on quality of life.
• Physical examination, including an abdominal examination to check for a mass and a bimanual pelvic examination to assess the size, contour, and mobility of the uterus. A large, firm, irregularly shaped uterus is a classic finding.
• Complete Blood Count (CBC) to check for anemia, which can result from heavy bleeding.
• Other laboratory tests, such as thyroid function tests or coagulation studies, may be performed to rule out other causes of abnormal uterine bleeding if indicated.
• Transvaginal Ultrasound (TVS) is the primary imaging test for diagnosing and characterizing uterine fibroids. It is widely available, cost-effective, and can accurately identify the presence, number, and size of fibroids.
• Saline Infusion Sonohysterography (SIS) involves instilling saline into the uterine cavity during a transvaginal ultrasound to better visualize submucosal fibroids and distinguish them from endometrial polyps.
• Magnetic Resonance Imaging (MRI) provides the most detailed images of the uterus and is used for precise mapping of fibroid size, number, and location, especially before surgery. It can also help differentiate fibroids from adenomyosis.
• Hysteroscopy involves inserting a camera into the uterine cavity and can be used for both diagnosing and treating submucosal fibroids.
• Differential diagnosis considers other conditions such as adenomyosis, endometrial polyps, ovarian cysts or tumors, uterine sarcoma (rare), pregnancy, and endometrial hyperplasia or carcinoma.

Treatment Options

• Treatment is recommended only for symptomatic fibroids. The choice of treatment is individualized based on symptom severity, fibroid size and location, patient age, desire for future fertility, and personal preference.
• Watchful waiting (expectant management) is recommended for women who are asymptomatic or have mild symptoms that do not significantly impact their quality of life. This involves periodic monitoring of symptoms and fibroid growth.
• Non-hormonal medications for heavy menstrual bleeding (HMB) include tranexamic acid (an antifibrinolytic) and nonsteroidal anti-inflammatory drugs (NSAIDs).
• Hormonal medications for HMB include the levonorgestrel-releasing intrauterine system (LNG-IUS), combined oral contraceptives (COCs), progestin-only pills, and depot medroxyprogesterone acetate (DMPA) injection.
• Gonadotropin-releasing hormone (GnRH) agonists (e.g., leuprolide acetate) induce a temporary 'medical menopause,' which can shrink fibroids and stop bleeding. Their use is typically limited to 3-6 months due to potential bone density loss and menopausal side effects, often used pre-operatively.
• Gonadotropin-releasing hormone (GnRH) antagonists (e.g., elagolix, relugolix) are newer drugs that also reduce estrogen levels. They are often formulated with low-dose 'add-back' hormone therapy to reduce side effects, allowing for longer-term use.
• Selective Progesterone Receptor Modulators (SPRMs) (e.g., ulipristal acetate) are effective at controlling bleeding and shrinking fibroids, though their use has been restricted in some regions due to rare liver injury concerns.
• Myomectomy is a surgical procedure to remove fibroids while preserving the uterus. It can be performed hysteroscopically (for submucosal fibroids), laparoscopically/robotically, or via an open abdominal incision (laparotomy).
• Uterine Artery Embolization (UAE), also known as Uterine Fibroid Embolization (UFE), is an interventional radiology procedure that blocks the blood vessels supplying the fibroids, causing them to shrink.
• Radiofrequency Ablation (RFA) uses heat to destroy fibroid tissue and can be performed laparoscopically or transvaginally.
• MRI-guided Focused Ultrasound Surgery (MRgFUS) is a non-invasive procedure that uses high-intensity ultrasound waves to heat and destroy fibroid tissue.
• Hysterectomy, the surgical removal of the uterus, is the only definitive cure for uterine fibroids.
• Referral to a specialist is indicated for suspicion of malignancy, uncertain diagnosis, failure of initial medical management, desire for surgical or interventional treatment, associated infertility, or significant anemia.

Frequently Asked Questions