Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 18-03: Leiomyoma of the Uterus (Fibroid Tumor) + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + Diagnosis Download Section PDF Listen +++ +++ Laboratory Findings ++ Iron deficiency anemia may result from blood loss +++ Imaging ++ 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 + Treatment Download Section PDF Listen +++ +++ 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 is not an indication for surgery A variety of surgical measures are available for the treatment of myomas Myomectomy (hysteroscopic, laparoscopic, or abdominal) Hysterectomy (vaginal, laparoscopy-assisted vaginal, laparoscopic, abdominal, or robotic) Myomectomy is the treatment of choice for women who wish to preserve fertility Submucous myomas can be removed by hysteroscopic resection Uterine artery embolization (UAE) Minimally invasive The goal is to block the blood vessels supplying the fibroids, causing them to shrink Magnetic resonance–guided high-intensity focused ultrasound, myolysis/radiofrequency ablation, and laparoscopic or vaginal occlusion of uterine vessels are newer interventions, with a smaller body of evidence + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Women who have small asymptomatic myomas can be managed expectantly and evaluated annually +++ Prognosis ++ Surgical therapy is curative In women desiring future fertility, myomectomy can be offered, but patients should be counseled that Recurrence is common Postoperative pelvic adhesions may impact fertility Cesarean delivery may be necessary secondary to interruption of the myometrium Approximately 80% of women have long-term improvement in symptoms following UAE +++ When to Refer ++ Refer to a gynecologist for treatment of symptomatic leiomyomata +++ When to Admit ++ For acute abdomen associated with an infarcted leiomyoma or hemorrhage not controlled by outpatient measures + References Download Section PDF Listen +++ + +Chudnoff S et al. Ultrasound-guided transcervical ablation of uterine leiomyomas. Obstet Gynecol 2019 Jan;133(1):13–22. [PubMed: 30531573] + +Donnez J et al. The current place of medical therapy in uterine fibroid management. Best Pract Res Clin Obstet Gynaecol. 2018 Jan;46:57–65. [PubMed: 29169896] + +Havryliuk Y et al. Symptomatic fibroid management: systematic review of the literature. JSLS. 2017 Jul–Sep;21(3). [PubMed: 28951653] + +Murji A et al. Selective progesterone receptor modulators (SPRMs) for uterine fibroids. Cochrane Database Syst Rev. 2017 Apr 26;4:CD010770. [PubMed: 28444736] + +Osuga Y et al. Oral gonadotropin-releasing hormone antagonist relugolix compared with leuprorelin injections for uterine leiomyomas: a randomized clinical trial. Obstet Gynecol. 2019 Mar;133(3):423–33. [PubMed: 30741797]