ESSENTIALS OF DIAGNOSIS
Irregular enlargement of the uterus (may be asymptomatic).
Heavy or irregular vaginal bleeding, dysmenorrhea.
Pelvic pain and pressure.
Uterine leiomyomas are the most common benign neoplasm of the female genital tract. They are discrete, round, firm, often multiple, uterine tumors composed of smooth muscle and connective tissue. The most convenient classification is by anatomic location: (1) intramural, (2) submucous, (3) subserous, and (4) cervical. Submucous myomas may become pedunculated and descend through the cervix into the vagina.
In nonpregnant women, myomas are frequently asymptomatic. The two most common symptoms of uterine leiomyomas for which women seek treatment are AUB and pelvic pain or pressure. Occasionally, degeneration occurs, causing intense pain. Myomas that significantly distort the uterine cavity may affect fertility by interfering with implantation, rapidly distending in early pregnancy, or impairing uterine contractility.
Iron deficiency anemia may result from blood loss.
Ultrasonography will confirm the presence of uterine myomas and can be used sequentially to monitor growth. When multiple subserous or pedunculated myomas are being followed, ultrasonography is important to exclude ovarian masses. MRI can delineate intramural and submucous myomas accurately and is typically used prior to uterine artery embolization to determine fibroid size and location in relation to uterine blood supply. Hysterography or hysteroscopy can also confirm cervical or submucous myomas.
Irregular myomatous enlargement of the uterus must be differentiated from the similar, but symmetric enlargement that may occur with pregnancy or adenomyosis. Subserous myomas must be distinguished from ovarian tumors. Leiomyosarcoma is an unusual tumor occurring in 0.5% of women operated on for symptomatic myomas. It is very rare under the age of 40 but increases in incidence thereafter.
Women who have small asymptomatic myomas can be managed expectantly and evaluated annually. In patients wishing to defer surgical management, nonhormonal therapies (such as NSAIDs and tranexamic acid) have been shown to decrease menstrual blood loss. Women with heavy bleeding related to fibroids often respond to estrogen-progestin oral contraceptives or the levonorgestrel IUD, although an IUD cannot be used with a distorted cavity. Hormonal therapies, such as GnRH agonists and selective progesterone receptor modulators (eg, low-dose mifepristone and ulipristal acetate), have been shown to reduce myoma volume, uterine size, and menstrual blood loss. Selective progesterone receptor modulators are not approved for fibroid treatment in the United States, however. Surgical intervention is based on the patient’s symptoms and desire for future fertility. Uterine size alone is not an indication for surgery. Cervical myomas larger than 3–4 cm in diameter or pedunculated myomas that protrude through the cervix ...