Leiomyoma of the Uterus (Fibroid Tumor)

KEY FEATURES

Essentials of Diagnosis

• Irregular enlargement of the uterus (may be asymptomatic)

• Heavy or irregular uterine bleeding

• Pelvic pain, dysmenorrhea, and pressure

General Considerations

• Uterine leiomyomas are discrete, round, firm, often multiple uterine tumors, composed of smooth muscle and connective tissue

• They are the most common benign neoplasm of the female genital tract

• The most commonly used 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

• The most common symptoms are abnormal uterine bleeding and pelvic pain or pressure

• Occasionally, degeneration occurs, causing intense pain

• The risk of miscarriage is increased if the myoma significantly distorts the uterine cavity and interferes with implantation

• Fibroids rarely cause infertility by leading to bilateral tubal blockage; more commonly, they cause miscarriage and pregnancy complications, such as preterm labor, preterm delivery, and malpresentation

• Torsion of subserosal pedunculated fibroids may lead to necrosis and pain

Differential Diagnosis

• Pregnancy

• Adenomyosis

• Ovarian tumors

• Leiomyosarcoma

  • Unusual malignant tumor occurring in 0.5% of women who undergo surgery for symptomatic myomas

  • Rare under the age of 40 but increases in incidence thereafter

DIAGNOSIS

Laboratory Findings

• Iron deficiency anemia may result from blood loss

• Polycythemia is rare but may result from production of erythropoietin

Imaging

• Ultrasonography

  • Confirms presence of uterine myomas

  • Can be used sequentially to monitor growth

• MRI

  • Can delineate intramural and submucous myomas accurately

  • Necessary prior to uterine artery embolization to determine fibroid size and location and to assess blood flow to the fibroids

Diagnostic Procedures

• Hysterography or hysteroscopy can also confirm cervical or submucous myomas

TREATMENT

Medications

• In patients wishing to defer surgical management, nonhormonal therapies (such as NSAIDs and tranexamic acid) have been shown to decrease menstrual blood loss

• Estrogen-progestin oral contraceptives or a hormonal IUD may decrease heavy bleeding related to fibroids

  • However, an IUD cannot be used by patients with a distorted cavity or cavity length > 10 cm

• Hormonal therapies such as gonadotropin-releasing hormone (GnRH) agonists, GnRH antagonists, and selective progesterone receptor modulators, such as low-dose mifepristone, have been shown to reduce myoma volume, uterine size, and menstrual blood loss

• Two combination treatments using GnRH antagonists can be used to manage heavy menstrual bleeding associated with uterine fibroids in premenopausal women for up to 24 months

  • Relugolix, 40 mg, estradiol, 1 mg, and norethindrone acetate, 0.5 mg once daily (combination commercial ...