Uterine Fibroid

Aka: Uterine Fibroid, Uterine Leiomyoma, Uterine Leiomyomata, Uterine Myoma

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II. Epidemiology

  1. Most common solid pelvic tumor in women
  2. More common in non-white women
  3. Lifetime Prevalence: 80%

III. Risk factors: Positive (increased risk of fibroids)

  1. Overweight women (increased Body Mass Index)
  2. Advancing age (until Menopause)
    1. Rare before Puberty
    2. Age 20-30 years: 4% fibroid Incidence
    3. Age 30-40 years: Up to 18% fibroid Incidence
    4. Age 40-60 years: 33% fibroid Incidence
    5. Regress after Menopause
  3. Hyperestrogenic states or EstrogenAgonist use
    1. Enlarge in pregnancy (and regress after Menopause)
  4. Black women with higher Incidence
    1. Larger fibroids
    2. More symptomatic fibroids
  5. Comorbid Hypertension
  6. Family History of Uterine Fibroids
  7. Nulliparity

IV. Risk Factors: Negative (lower risk of fibroids)

  1. Five pregnancies or more
  2. Menopause (fibroids typically regress)
  3. Oral Contraceptive or Depo Provera use
  4. Tobacco Abuse

V. Pathophysiology

  1. Benign tumors arising from uterine, myometrial Smooth Muscle
    1. Malignant Leiomyosarcoma is uncommon (0.23%)
  2. Hormonally mediated
    1. Enlarge with Estrogen and Growth Hormone
    2. Regress with Progesterone
  3. Types of leiomyoma
    1. Subserosal leiomyoma
      1. Project outside Uterus
    2. Intramural leiomyoma
      1. Limited to within the myometrium
    3. Submucous leiomyoma
      1. Project into uterine cavity

VI. Symptoms

  1. Symptomatic in 20-50% of fibroid disease
  2. Menorrhagia (prolonged or heavy menstrual flow, most common)
    1. Fibroids are most common cause of Menorrhagia
  3. Pelvic pressure or Pain Sensation (large fibroids)
    1. Pelvic discomfort or Low Back Pain
    2. Dyspareunia
    3. Urine symptoms (urine frequency, urine urgency, urine retention)
    4. Constipation
    5. Exacerbated by pregnancy (see below)
  4. Pregnancy complications
    1. Mixed study results, but at least one large study demonstrates increased complication risk
    2. Recurrent Miscarriage
    3. Premature labor
    4. Fetal Malpresentation
    5. Labor complications including cesarean delivery
    6. Placental Abruption
    7. Stout (2010) Obstet Gynecol 116(5): 1056-63 [PubMed]
  5. Controversial - relationship to fibroids not supported by evidence
    1. Infertility

VII. Signs

  1. Abdominal exam
    1. Uterus palpable above Symphysis Pubis
  2. Bimanual examination
    1. Enlarged, mobile and irregular uterine contour

VIII. Differential Diagnosis

  1. Adenomyoma or Adenomyosis
  2. Ectopic Pregnancy
  3. Intrauterine Pregnancy
  4. Endometrial Cancer
  5. Endometrial Polyp
  6. Endometriosis
  7. Malignant Leiomyosarcoma (0.23% of fibroids)
    1. Age over 45 years old (OR 20)
    2. Post-Menopause (OR 9.7)
    3. History of pelvic radiation
    4. Tamoxifen use
    5. MRI Findings
      1. Intramural Hemorrhage (OR 21)
      2. Endometrial thickening (OR 11)
      3. T2-Weighted signal heterogeneity (OR 10)
      4. Non-myometrial origin (OR 4.9)
    6. References
      1. Tomassin-Naggara (2013) Eur Radiol 23(8):2306-14 [PubMed]

IX. Diagnostics

  1. Transvaginal Ultrasound
    1. Best initial test due to cost efficacy
    2. Least Test Sensitivity and Specificity (misses small fibroids)
  2. Pelvic MRI
    1. Best for fibroid mapping preoperatively
    2. Expensive
  3. Sonohysterography or hysteroscopy
    1. Good Test Sensitivity and Specificity, but invasive

X. Management: Surgery

  1. Hysterectomy
    1. Fibroids account for up to 33-39% of hysterectomies
    2. Indications
      1. Postmenopausal women with enlarging fibroids
      2. Peristent Abnormal Uterine Bleeding
      3. Symptomatic fibroids refractory to other measures
  2. Myomectomy
    1. Performed with hysteroscopy, laparoscopy, robotic-assisted or laparotomy
    2. Excision of fibroids with preservation of Uterus
    3. High risk of recurrence (15-30% in 5 years)
      1. Up to 10% of women will subsequently undergo Hysterectomy within 5-10 years
    4. Indications (typically in women who want to preserve fertility)
      1. Submucosal Fibroids <3 cm (and >50% tumor is intracavitary)
  3. Uterine Fibroid Embolization
    1. Uterine arteries occluded with polyvinyl Alcohol foam (or other embolic agents)
      1. Incomplete embolization used now to reduce pain
      2. Intervention Radiology procedure under IV sedation
      3. Well tolerated (less painful than surgery)
      4. Post-embolization syndrome (low grade fever, pain and passing of fibroid tissue vaginally) is common
    2. Second procedure required in 20-33% of cases within 5 years
    3. References
      1. McLucas (2001) J Am Coll Surg 192:100 [PubMed]
      2. Edwards (2007) N Engl J Med 356: 360-70 [PubMed]
      3. Van der Kooij (2010) ACOG 203(105): e1-13 [PubMed]
  4. Myolysis
    1. Fibroid destruction by coagulation necrosis (Nd-YAG laser, bipolar needle or MR-guided focused Ultrasound)
    2. Often combined with endometrial ablation
    3. Recurrence rate not yet established
    4. Indications
      1. Fibroids in women who want to preserve fertility

XI. Management: Medical

  1. Observation (preferred for asymptomatic cases)
    1. Most fibroids decrease in size with Menopause
  2. Agents effective in Menorrhagia but are not typically effective at reducing fibroid size
    1. Often used as first-line measures due to lower adverse effects
    2. Levonorgestrel IUD (Mirena IUD)
      1. Sayed (2011) Int J Gynaecol Obstet 112(2): 126-30 [PubMed]
    3. Progestins (e.g. Depo Provera)
    4. Oral Contraceptive cycling
      1. Minimally effective (much less effective than Mirena IUD)
    5. NSAIDs
      1. Reduce blood loss and pain
    6. Tranexamic Acid (Lysteda, Cyklokapron)
      1. Take two 650 mg tabs (1.3 g) orally three times daily for up to the first 5 days of the Menstrual Cycle
      2. Avoid combining with Estrogen containing products (increased thrombosis risk)
      3. Peitsidis (2014) World J Clin Cases 2(12): 893-8 [PubMed]
    7. Other agents
      1. Androgenic agents (e.g. Danazol)
  3. GnRH Antagonists
    1. Indicated in Fibroid related Menorrhagia, refractory to other measures above
    2. Limit to no more than 2 years of use
    3. GnRH Antagonists lower Estradiol and Progesterone levels (menopausal levels)
      1. Reduce Menstrual Bleeding
      2. Increases bone loss, Hot Flashes (hence add back therapy as below)
      3. Does not provide Contraception and should not be used with Hormonal Contraception
    4. Combination Agents with add-back Hormones ($1000/month in 2022)
      1. Relugolix/Estradiol/Norethindrone (Myfembree) once daily
      2. Elagolix/Estradiol/Norethindrone (Oriahnn) twice daily
    5. References
      1. (2022) Presc Lett 29(2): 10-1
  4. GnRH Agonists (induce hypoestrogenism)
    1. Indicated in perimenopausal women, or preoperatively to reduce size
    2. Limit to short term use (e.g. bridging to Hysterectomy)
    3. Decreases Estrogen and Progesterone via negaive feedback
      1. Results in Amenorrhea and fibroid mass reduction
      2. Fibroids recur when medication stopped
      3. Hypoestrogenic side effects (Hot Flushes, BMD risk)
    4. Injectable GnRH Agonists include Leuprolide, Goserelin, Triptorelin
    5. Used in combination with Progesterone
      1. Reduces Hot Flushes (vasomotor symptoms)
    6. Lethaby (2002) BJOG 109(10): 1097-108 [PubMed]
  5. Selective Progesterone receptor modulators (SPRM)
    1. Mifepristone (Mifepex) 5 mg daily
      1. Eisinger (2003) Obstet Gynecol 101:243-50 [PubMed]
      2. Fiscella (2006) Obstet Gynecol 108:1381-7 [PubMed]
    2. Ulipristal (Ella)
      1. Carbonell Esteve (2008) Obstet Gynecol 112(5): 1029-36 +PMID:18978102 [PubMed]
  6. Other measures not found consistently effective
    1. Raloxifene (Evista)

XII. References

  1. Stewart (2012) Mayo POIM Conference, Rochester
  2. De La Cruz (2017) Am Fam Physician 95(2): 100-7 [PubMed]
  3. Evans (2007) Am Fam Physician 75:1503-8 [PubMed]
  4. Myers (2002) Obstet Gynecol 100:8-17 [PubMed]
  5. Rackow (2006) Gynecol Clin North Am 33:97-113 [PubMed]
  6. Vilos (2015) J Obstet Gynaecol Can 37(2): 157-81 [PubMed]

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Related Studies

Ontology: Uterine Fibroids (C0042133)

Definition (MEDLINEPLUS)

Uterine fibroids are the most common benign tumors in women of childbearing age. Fibroids are made of muscle cells and other tissues that grow in and around the wall of the uterus, or womb. The cause of fibroids is unknown. Risk factors include being African American or being overweight.

Many women with fibroids have no symptoms. If you do have symptoms, they may include

  • Heavy or painful periods or bleeding between periods
  • Feeling "full" in the lower abdomen
  • Urinating often
  • Pain during sex
  • Lower back pain
  • Reproductive problems, such as infertility, multiple miscarriages or early labor

Your health care provider may find fibroids during a gynecological exam or by using imaging tests. Treatment includes drugs that can slow or stop their growth, or surgery. If you have no symptoms, you may not even need treatment. Many women with fibroids can get pregnant naturally. For those who cannot, infertility treatments may help.

NIH: National Institute of Child Health and Human Development
Definition (NCI) A benign smooth muscle neoplasm arising from the body of the uterus. It is characterized by the presence of spindle cells with cigar-shaped nuclei, interlacing fascicles, and a whorled pattern.
Concepts Neoplastic Process (T191)
MSH D007889
ICD9 218.9, 218
ICD10 D25 , D25.9
SnomedCT 44598004, 95315005, 189106003, 154616000
English UTERUS FIBROMA, Fibroid, Uterine, Fibroids, Uterine, Uterine Fibroids, UTERINE FIBROID, Fibroma, Uterine, Fibromas, Uterine, Uterine Fibromas, Uterus, Fibroid, UTERINE FIBROMYOMA, Uterine Fibroma, Leiomyoma of uterus, unspecified, LEIOMYOMA, UTERINE, UL, Uterine leiomyomata, benign leiomyoma of uterus, benign leiomyoma of uterus (diagnosis), Leiomyoma, no ICD-O subtype, Uterine Corpus Leiomyomata, Uterine fibromyoma, Uterine myoma, Uterine leiomyoma NOS, uterine fibromyoma, fibroleiomyoma, leiomyofibroma, myofibroma, uterine fibroma, fibromyoma, leiomyoma, uterus leiomyoma, Fibroid;uterus, Fibromyoma;uterus, leiomyomas, uterine leiomyoma nos, uterus myoma, Myoma;uterus, uterine fibroids, leiomyoma of uterus, tumor of uterine muscle, uterus fibroid, fibroids, uterine fibromas, uterus fibroids, uterus fibroma, Uterine leiomyomas, benign, Leiomyoma of uterus, Leiomyoma, Uterine, Uterine Leiomyomata, Uterine fibroid (disorder), Uterine leiomyoma NOS (disorder), Leiomyoma, no International Classification of Diseases for Oncology subtype (morphologic abnormality), Leiomyoma, no International Classification of Diseases for Oncology subtype, Leiomyoma, no ICD-O subtype (morphologic abnormality), Leiomyofibroma, Fibromyoma, Leiomyoma, Uterine leiomyoma, Fibroid uterus, Uterine fibroid, Fibroids, Fibroleiomyoma, Leiomyoma of body of uterus, Uterine leiomyoma - fibroids, Uterine fibroids, Uterine leiomyoma (disorder), uterine leiomyoma, uterine leiomyomata, Fibromyoma uterus, fibromyoma; uterus, leiomyoma; uterus, uterus; fibromyoma, uterus; leiomyoma, Leiomyoma, NOS, Uterine leiomyoma, NOS, Uterine Fibroid, Corpus Uteri Fibroid, Corpus Uteri Leiomyoma, Fibroid of Body of Uterus, Fibroid of Corpus Uteri, Fibroid of Uterine Body, Fibroid of Uterine Corpus, Fibroid of the Body of Uterus, Fibroid of the Corpus Uteri, Fibroid of the Uterine Body, Fibroid of the Uterine Corpus, Leiomyoma of Body of Uterus, Leiomyoma of Corpus Uteri, Leiomyoma of Uterine Body, Leiomyoma of Uterine Corpus, Leiomyoma of the Body of Uterus, Leiomyoma of the Corpus Uteri, Leiomyoma of the Uterine Body, Leiomyoma of the Uterine Corpus, Uterine Body Fibroid, Uterine Body Leiomyoma, Uterine Corpus Fibroid, Uterine Corpus Leiomyoma, Body of Uterus Fibroid, Body of Uterus Leiomyoma, Fibroid Uterus, uterine fibroid, fibromyoma of the uterus, uterine myoma
Portuguese FIBROMA UTERINO, Fibromiomas uterinos, Fibromioma uterino, Liomioma do útero NE, Mioma uterino, FIBROMIOMA UTERINO, Útero Fibroide, Fibroides Uterinos, Leiomioma uterino, Fibroma Uterino
Spanish FIBROMA UTERINO, morfología: leiomioma, no clasificado como subtipo en CIE - O, Leiomioma de útero, no especificado, Fibroide uterino, Fibroides uterinos, Fibromioma uterino, Mioma uterino, fibroma uterino, Útero Fibroide, FIBROMIOMA UTERINO, leiomioma uterino, SAI (trastorno), leiomioma uterino, SAI, fibroleiomioma, fibromioma, leiomiofibroma, leiomioma del útero (trastorno), leiomioma del útero, leiomioma uterino, leiomioma, morfología: leiomioma, no clasificado como subtipo en CIE - O (anomalía morfológica), Leiomioma uterino, Fibroides del Útero, Fibroma Uterino
Dutch baarmoederfibroïden, uterus myoom, uterus fibroom, leiomyoom van de uterus, niet-gespecificeerd, uterus fibromyoom, Fibromyoom uterus, fibromyoom; uterus, leiomyoom; uterus, uterus; fibromyoom, uterus; leiomyoom, Leiomyoom van uterus, niet gespecificeerd, uterus leiomyoom, Leiomyoom van uterus, Uterusfibroom, Fibroïd, uterus-, Uterusfibroïd
French Fibromyome utérin, Myome utérin, Léiomyome de l'utérus, non précisé, Fibromes utérins, Fibrome utérin, FIBROMYOME UTERIN, Léiomyome utérin, Fibrome de l'utérus, Utérus fibromateux
German Uterusfibromyom, Uterusfibromyome, Uterusleiomyom, unspezifisch, Uterusmyom, Uterus fibroid, Fibroid, Uterus, FIBROMYOM UTERUS, Leiomyom des Uterus, nicht naeher bezeichnet, Leiomyom des Uterus, UTERUSMYOM, Uterusleiomyom, Fibroide, uterine, Fibrom, Uterus-
Italian Mioma dell'utero, Fibromi dell'utero, Fibromioma dell'utero, Fibroma dell'utero, Leiomioma dell'utero, non specificato, Fibroma uterino, Leiomioma uterino
Japanese 子宮類線維症, 子宮平滑筋腫、詳細不明, 子宮線維筋腫, ｼｷｭｳｷﾝｼｭ, ｼｷｭｳﾍｲｶﾂｷﾝｼｭ, ｼｷｭｳｾﾝｲｷﾝｼｭ, ｼｷｭｳﾙｲｾﾝｲｼｮｳ, ｼｷｭｳﾍｲｶﾂｷﾝｼｭｼｮｳｻｲﾌﾒｲ, 子宮類線維腫, 子宮平滑筋腫, 子宮筋腫, 平滑筋腫-子宮
Czech Děložní leiomyom, Leiomyom dělohy, blíže neurčený, Děložní fibroid, Děložní fibroidy, Děložní fibromyom, Děložní myom, děložní myomy, fibromyom dělohy, děložní myom
Korean 상세불명의 자궁의 평활근종, 자궁의 평활근종
Hungarian Méh fibromyoma, Fibroid méh, Méh leiomyoma, Méh leiomyoma, nem meghatározott, Méhfibroidok, Méhmyoma
Norwegian Leiomyom i uterus
Derived from the NIH UMLS (Unified Medical Language System)

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