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For further information, see CMDT Part 18-03: Leiomyoma of the Uterus (Fibroid Tumor)

Key Features

Essentials of Diagnosis

  • Irregular enlargement of the uterus (may be asymptomatic)

  • Heavy or irregular vaginal bleeding, dysmenorrhea

  • Pelvic pain and pressure

General Considerations

  • Uterine leiomyomas are the most common benign neoplasm of the female genital tract

  • They are discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue

  • More common in African American women

  • The most convenient classification is by anatomic location

    • Intramural

    • Submucous

    • Subserous

    • Cervical

  • Submucous myomas may become pedunculated and descend through the cervix into the vagina

Clinical Findings

Symptoms and Signs

  • Frequently asymptomatic in nonpregnant women

  • Abnormal uterine bleeding and pelvic pain or pressure most common symptoms

  • Occasionally, degeneration occurs, causing intense pain

  • Cervical myomas larger than 3–4 cm in diameter or pedunculated myomas that protrude through the cervix can cause

    • Bleeding

    • Infection

    • Degeneration

    • Pain

    • Urinary retention

  • Myomas that significantly distort the uterine cavity may affect fertility by

    • Interfering with implantation

    • Rapidly distending in early pregnancy

    • Impairing uterine contractility

Differential Diagnosis

  • Pregnancy

  • Adenomyosis

  • Ovarian tumors

  • Leiomyosarcoma


Laboratory Findings

  • Iron deficiency anemia may result from blood loss


  • Ultrasonography

    • Confirms presence of uterine myomas

    • Can be used sequentially to monitor growth

    • Can be used to exclude ovarian masses when multiple subserous or pedunculated myomas are being monitored

  • MRI

    • Can delineate intramural and submucous myomas accurately

    • Typically used prior to uterine artery embolization to determine fibroid size and location in relation to uterine blood supply

Diagnostic Procedures

  • Hysterography or hysteroscopy can also confirm cervical or submucous myomas


Nonsurgical Measures

  • 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 (SPRMs), such as low-dose mifepristone and ulipristal acetate, have been shown to reduce

    • Myoma volume

    • Uterine size

    • Menstrual blood loss

  • SPRMs are not approved for fibroid treatment in the United States, however

  • GnRH analogs such as depot leuprolide, 3.75 mg intramuscularly monthly, or nafarelin, 0.2–0.4 mg intranasally twice a day, can be used preoperatively for 3- to 4-month periods to

    • Induce reversible hypogonadism

    • Temporarily reduce the size of myomas

    • Reduce surrounding vascularity

Surgical Measures

  • Surgical intervention is based on the patient's symptoms and desire for future fertility

  • Uterine size alone ...

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