Fibroids (Uterine Myomas)

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CLINICAL OVERVIEW
Fibroids (Uterine Myomas)

Elsevier Point of Care (see details)
Updated 14 Juli 2021. Copyright Elsevier BV. All rights reserved.
Synopsis
Key Points Urgent Action

Uterine fibroids (also known as myomas or leiomyomas) In the case of hemorrhage,
are benign monoclonal neoplasms of the myometrium
urgent intervention in the
that represent the most common gynecologic tumor. They
form of transfusion,
may be single or multiple, large (bigger than 10 cm) or
small antifibrinolytics (eg,
tranexamic acid), IV
They occur more often in Black women; incidence and estrogen, or high-dose oral
symptoms increase until menopause, at which point contraceptives is indicated;
existing lesions and symptoms regress uterine artery embolization
or hysterectomy may be
Many women are asymptomatic. When symptoms do
required (Related:
occur, they may be related to excess bleeding or to size and
Abnormal Uterine
location of lesions and may include dysmenorrhea,
menorrhagia, metrorrhagia, dyspareunia, bladder Bleeding in Women of
dysfunction (urinary frequency, incontinence, or Reproductive Age)
retention), constipation, and pelvic pain and/or fullness
Reproductive effects may include infertility, recurrent miscarriage, premature birth,

abnormal presentation, placenta abruptio, and intrauterine growth restriction
Because treatment is indicated only for symptomatic fibroids and because malignant
transformation is not thought to occur, there are no standard recommendations for
monitoring asymptomatic fibroids
When treatment of symptomatic fibroids is desired, tailor the approach to the nature of
symptoms (ie, bleeding, bulk, or both); number, location, and size of fibroids; and patient's
reproductive plans
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10/09/21 10.41 Fibroids (Uterine Myomas) - ClinicalKey
Hysterectomy is the definitive treatment, but it carries inherent surgical risks and is not
suitable for women who wish to preserve childbearing potential
Less invasive measures include myomectomy, uterine artery embolization, ablation with
high-frequency ultrasonography, and other less common techniques. These measures,
generally, are quite effective in relieving symptoms caused by bleeding or size while
retaining fertility
Pharmacologic therapy is indicated for urgent control of severe bleeding, to reduce

fibroid size and correct anemia before surgical intervention, and as a bridge to
anticipated menopause and decline in fibroid size
Heavy menstrual bleeding can be controlled with NSAIDs, tranexamic acid, hormonal
contraceptives, or gonadotropin-releasing hormone antagonists, but these have little or
no effect on fibroid size
Gonadotropin-releasing hormone agonists and selective progesterone receptor

modulators can be used to reduce size and bulk as well as to diminish bleeding
Size and symptoms of fibroids regress after menopause. Whether malignant transformation
of fibroids contributes to development of leiomyosarcoma is not known with certainty;
however, malignant degeneration of fibromas is exceedingly rare
Pitfalls
Most pharmacologic treatments that are effective in reducing fibroid size are limited to
short-term use (eg, 6 months) owing to menopausal symptoms and adverse effects on bone
density
Morcellation of the uterus or uterine myomas carries risk of dissemination of an occult

malignancy 1
Terminology
Clinical Clarification
Uterine fibroids (also known as myomas or leiomyomas) are benign monoclonal neoplasms
of the myometrium that represent the most common gynecologic tumor
May be single or multiple, of variable size
May be asymptomatic or may cause menstrual abnormalities, anemia, and pelvic pain
Occur in women of reproductive age and regress after menopause
Classification
Commonly classified based on the location in the uterus 2
Submucosal: arising just beneath the endometrium
Intramural: arising within the uterine wall
Subserosal: arising from the serosal surface
Transmural: extending from the endometrium to the serosal surface
Most detailed classification is the International Federation of Gynecology and Obstetrics

scheme, based on location and structure 2
0: intracavitary, pedunculated
1: submucosal (less than 50% intramural)
2: submucosal (50% or more intramural)
3: intramural with endometrial contact
4: intramural
5: subserosal (50% or more intramural)
6: subserosal (less than 50% intramural)
7: subserosal, pedunculated
8: other (eg, cervical)
Diagnosis
Clinical Presentation
History
Many women are asymptomatic
In most symptomatic patients, nature of the complaint depends on size and location of
lesions and may include:
Irregular (metrorrhagia) and/or heavy (menorrhagia) menstrual bleeding
Dysmenorrhea
Noncyclic pelvic pain
Dyspareunia
Pelvic and/or abdominal fullness
Urinary frequency, incontinence, or retention
Constipation
Symptoms associated with anemia (eg, fatigue)
Other symptoms may be related to fertility or pregnancy:
Infertility
Recurrent miscarriage
Physical examination
Bimanual examination may show a distended uterus (sometimes equivalent to third
trimester of pregnancy) with palpable, knoblike irregularities
Occasionally, a fibroid may be seen protruding through the cervix on speculum examination
Patients with a long history of menorrhagia may exhibit signs of anemia such as pallor with
pale conjunctiva and nailbeds
Causes and Risk Factors
Causes
Monoclonal proliferation, most likely resulting from heightened responsiveness to estrogen
and progesterone in a genetically susceptible myometrial cell 3
Risk factors and/or associations
Age
Risk increases with age from time of menarche until menopause, at which point it declines
significantly
Genetics
Several mutations that appear to increase sensitivity to estrogen and progesterone have been
identified: 4
MED12 mutations, resulting in alterations in cell signaling and increased cell

proliferation; found in about 70% of fibroids 4
Deletions within Xq22.3 locus of COL4A5 and COL4A6 genes, which results in enhanced
cell proliferation 5
Inactivation of the fumarate hydratase gene; occurs in a small percentage of sporadic

fibroids and in the rare hereditary syndrome of leiomyomatosis and renal cell cancer 5 6
Ethnicity/race
More common in Black women 3 7
Lifetime risk is approximately 70% for White women and over 80% for Black women
Tumors tend to be larger, more numerous, and more symptomatic, and develop at a
younger age in Black women than in White women
Clinically significant fibroids (defined as a uterine size equivalent to 9 weeks or more of

gestation, at least 1 tumor bigger than 4 cm, or 1 submucosal lesion) occur twice as often
in Black women than in White women
Other risk factors/associations

Nulliparity increases risk; multiparity and older age at first full-term pregnancy appear to
reduce risk 3
Increased risk has been associated with BMI defined as overweight, but some studies show
lower risk with BMI defined as obese compared with overweight 3
Risk may be reduced by physical exercise, although the parameters that provide benefit are
not clearly defined 3
Use of depot medroxyprogesterone acetate reduces risk, which declines progressively with
longer duration of use 3
Roles of dietary and other factors are the subject of ongoing study
Vitamin D supplementation has been associated with a decrease in risk of fibroids 8

Diagnostic Procedures
Primary diagnostic tools

History and physical examination findings may suggest the diagnosis in many patients 8
Exclude pregnancy in women of childbearing age
Ultrasonography is the initial diagnostic test of choice 9 10
Saline infusion sonohysterography may define the endometrium and cavity more clearly
if conventional ultrasonography suggests a submucosal or pedunculated intracavitary
lesion 9 11
Conventional hysteroscopy can differentiate pedunculated intracavitary fibroids from

endometrial polyps or provide clarity if there is a suspicion of malignancy requiring an
endometrial biopsy 9
MRI may be indicated to provide more detail regarding the number and depth of
fibroids detected by ultrasonography, if ultrasonography is nondiagnostic, or in the
setting of abnormal vaginal bleeding if an intracavitary mass is suspected and
hysteroscopy is not feasible 9 11
Recommended to measure hemoglobin and hematocrit levels in women who report

heavy bleeding 9
Laboratory
Imaging
Procedures
Differential Diagnosis
Most common
Symptoms predominately Menopausal transition (Related: Perimenopause and
menstrual (ie, heavy and/or Menopause)
irregular bleeding,
dysmenorrhea): Like fibroids, may cause irregular or heavy bleeding in
women in their late 40s through early 50s
Unlike fibroids, menopausal transition may be

accompanied by symptoms associated with
hypoestrogenism (eg, hot flashes)
Menopause is characterized by follicle-stimulating

hormone level higher than 30 to 40 mU/L
Owing to increasing prevalence of fibroids during the

fifth decade, perimenopausal symptoms may converge
with those caused by fibroids; however, symptoms
caused by fibroids tend to subside as menopause
progresses
Endometrial polyps
Common endometrial or endocervical epithelial

proliferations consisting of variable vascular, glandular,
fibromuscular, and connective tissues
Like fibroids, may present with abnormal bleeding, and

ultrasonography may show intracavitary mass
May be differentiated from fibroids by serial

ultrasonography showing typical evolution during the
course of the menstrual cycle or, more commonly, by
sonohysterography or hysteroscopy
Adenomyosis
Disruptive pockets of endometrial glands and stroma

internal to myometrium
Like fibroids, occur most commonly in women aged 35

to 50 years and may be associated with dysmenorrhea,
noncyclic pelvic pain, and menorrhagia
Differentiated from fibroids by ultrasonography or MRI;

definitive diagnosis is made on histologic examination
after hysterectomy
Endometriosis
Inflammatory disease in which ectopic endometrial-like

tissue forms lesions outside the uterus
Like fibroids, may present with dysmenorrhea,

infertility, menorrhagia, long-term pelvic discomfort,
and dyspareunia
Occurs primarily in younger women

Diagnosis usually can be made by clinical presentation

and imaging; laparoscopy and biopsy provide a definitive
diagnosis of endometriosis if imaging is not diagnostic
Endometrial hyperplasia or carcinoma (Related:

Endometrial Hyperplasia)
Thickening of the endometrium attributable to

increased proliferation of endometrial glands relative to
stroma; may undergo malignant transformation to
endometrial carcinoma
Like fibroids, typically manifests with abnormal uterine

bleeding and pelvic pain
Endometrial carcinoma is uncommon, particularly in

younger women; however, clinical presentation may be
indistinguishable from fibroids (Related: Endometrial
Carcinoma)
Differentiation suggested by imaging findings;

endometrial biopsy confirms diagnosis
Symptoms predominately Pregnancy

caused by bulk and
location (ie, urinary Like fibroids, may be associated with pelvic and/or
symptoms, constipation, abdominal fullness, urinary or bowel symptoms, and
pelvic and/or abdominal uterine enlargement
fullness)
Bluish discoloration of cervix and vagina and cervical
softening suggest pregnancy
Differentiation is based on positive pregnancy test result

and ultrasonography findings
Pregnancy and fibroids may occur concomitantly, and

presence of fibroids may complicate pregnancy
Mass lesions caused by pelvic organ malignancy
Bulky lesions of colon, uterus, bladder, ovaries, cervix,

fallopian tubes, or kidneys may result in feeling of
fullness, distention, and pelvic pain, and may cause
dysfunction of bowel and/or bladder
Pain may be progressively severe
Differentiation is made by imaging

Treatment
Goals
Relieve symptoms caused by excessive bleeding or size of fibroids
Prevent further growth
Restore fertility
Disposition
Admission criteria
Severe bleeding requiring transfusion and urgent medical or surgical therapy
Required for some elective treatment modalities (eg, hysterectomy, abdominal

myomectomy, uterine artery embolization)
Recommendations for specialist referral

Refer to an obstetrician/gynecologist for selection and management of appropriate
pharmacotherapy or surgical intervention (myomectomy or hysterectomy)
Refer to an interventional radiologist for uterine artery embolization or magnetic

resonance–guided focused ultrasonography
Treatment Options
Therapy is generally indicated only for symptomatic fibroids, including infertility, when they
are considered to play a significant role 8
Selection of treatment modality depends on the nature of symptoms (ie, bleeding versus pain
or bulk); location, size, and number of fibroids; and the patient's age and reproductive plans 15
16 17
Hysterectomy is the only permanent curative treatment, but it carries operative risks and
eliminates childbearing potential
72% to 90% of women experience at least moderate improvement in symptoms 18

Symptom improvement may not be immediate, but is reported in about 80% of patients
by 6 to 12 months 19
If a woman chooses to preserve childbearing potential or retain her uterus, consider

alternatives to hysterectomy
Surgical myomectomy, uterine artery embolization, and ablation with magnetic

resonance–guided ultrasonography offer potential for more durable relief in women who
choose not to have hysterectomy but whose symptoms are attributed to large fibroids 19
Myomectomy may be done via open abdominal approach, laparoscopically, or

hysteroscopically depending on the size, location, and type of fibroid. Laparoscopic
myomectomy results in fewer complications and shorter recovery than open
myomectomy, but not all patients are suitable candidates; hysteroscopic myomectomy
is an option for submucosal leiomyomas 20 21
A 2020 randomized trial suggested that, among women with symptomatic uterine
fibroids, those undergoing myomectomy experienced better fibroid-related quality
of life at 2 years than those undergoing uterine artery embolization 22
About 20% of patients who are treated by myomectomy require a second procedure
owing to recurrent symptoms
A Cochrane review of myomectomy in treatment of infertility found insufficient

evidence to assess the efficacy of myomectomy for this indication. Comparison
between various myomectomy techniques did not indicate any method was superior
in improving rates of live birth, preterm delivery, clinical pregnancy, ongoing
pregnancy, miscarriage, or cesarean delivery 20 23
Uterine artery embolization is a minimally invasive option with high initial success
rates (82%-90% for menorrhagia and 77%-86% for dysmenorrhea and symptoms due
to size), but about 10% of patients require intervention within several years owing to
recurrent symptoms 19
Ablation with magnetic resonance–guided ultrasonography improves symptoms in

about 80% of patients by 6 to 12 months; however, long-term results are uncertain 19
Less common procedures include laparoscopic or vaginal ligation of the uterine arteries
and laparoscopic cryomyolysis or thermocoagulation 9
Pharmacologic treatment options include medications that treat only abnormal bleeding
symptoms (gonadotropin-releasing hormone antagonists, levonorgestrel-releasing
intrauterine devices, hormonal contraceptives, tranexamic acid) and medications that
reduce both bleeding and leiomyoma size (gonadotropin-releasing hormone agonists and
selective progesterone receptor modulators) 7
Heavy menstrual bleeding can be controlled with NSAIDs, tranexamic acid, or

hormonal contraceptives; these have little or no effect on fibroid size (Related:
Abnormal Uterine Bleeding in Women of Reproductive Age)8
Levonorgestrel-releasing intrauterine devices decrease heavy menstrual bleeding in

patients both with and without leiomyomas; however, there is insufficient evidence
to support their use in treatment of other uterine leiomyoma symptoms 7 24
Progestin-only or combination estrogen-progesterone contraceptive agents are also

reasonable options 7
However, there is evidence that progesterone and progestogens play a role in the
pathogenesis of uterine myomas and treatment may cause an increase in fibroid
size 25
Tranexamic acid is an effective treatment for heavy menstrual bleeding, including

that associated with leiomyomas 7
Gonadotropin-releasing hormone antagonists
Elagolix and relugolix are both FDA-approved for treatment of heavy menstrual
bleeding associated with uterine leiomyomas 7 26 27 28
Can be used for up to 2 years, in conjunction with hormonal add-back therapy 7
Hormonal add-back therapy is indicated to offset the hypoestrogenic effects

including hot flushes, increased serum lipid levels, and bone mineral density loss
29 30
Hormonal agents that are effective at reducing both size and bulk of fibroids and
bleeding are generally limited to short-term use; fibroid growth and symptoms resume
several months after discontinuation 4
Indications include:
For urgent control of severe bleeding
To reduce fibroid size and correct anemia before interventional procedures or

surgical management
As a bridge to anticipated menopause and decline in fibroid size
Options include: 4
Gonadotropin-releasing hormone agonists (eg, leuprolide, goserelin)
Primarily used as a short-term bridging treatment
Treatment is typically limited to 6 months without add-back therapy and 12

months with add-back therapy
Reduces leiomyoma size and overall size of the uterus, heavy bleeding, and
dysmenorrhea 7
When used preoperatively, reduction in uterine volume may then allow the
use of a minimally invasive surgical route or a smaller incision 7
Associated with an initial flare of symptoms followed by reduction or absence

of menstrual blood flow; often attended by symptoms of menopause (eg, hot
flashes, vaginal dryness)
Add-back therapy can be used to reduce hypoestrogenic effects
Add-back regimens include progesterone, estrogen, combined estrogen and

progesterone, tibolone (not available in the United States), ipriflavone, and
raloxifene
A Cochrane review showed low to moderate evidence of a positive effect on

preserving bone density with tibolone, raloxifene, estriol, and ipriflavone
and a reduction in vasomotor symptoms with medroxyprogesterone acetate
and tibolone; larger uterine sizes were associated with use of conjugated
estrogens, medroxyprogesterone, and tibolone 31
Selective progesterone receptor modulators (eg, mifepristone, ulipristal)
Mifepristone and ulipristal acetate are effective in treatment of heavy bleeding

and uterine enlargement associated with uterine leiomyomas, but are not
currently approved in the United States for the treatment of leiomyomas 7
Prolonged intermittent administration of these agents can be used to treat

fibroid-related symptoms and is generally effective, safe, and well tolerated 32 33
Effective in reducing bleeding and fibroid size, with fewer vasoactive adverse
effects and less effect on bone density than gonadotropin-releasing hormone
analogues 34 35
Ulipristal is associated with effects that last longer than those of other
pharmacologic agents (up to 6 months 36 after drug discontinuation), and
courses may be repeated 12 36
Amenorrhea occurs promptly in a majority of patients, and fibroid size

decreases by a median of 45% after the first 3-month course of treatment,
with increased rates of amenorrhea and fibroid shrinkage with further
courses 12
Rarely reported cases of serious liver injury, including some requiring

transplantation, have prompted for a recall of safety review of the drug by the
European Medicines Agency and the UK Medicines and Healthcare Products
Regulatory Agency 37
Canadian Society for Obstetricians and Gynaecologists recommends

screening women for risk of liver impairment before commencing ulipristal
therapy and monitoring liver enzymes monthly during treatment courses

and 2 to 4 weeks after completion of the course of therapy 32
Other agents that may have potential roles in treatment of fibroids include
androgens (eg, danazol), aromatase inhibitors (eg, letrozole), and selective estrogen
receptor modulators (eg, raloxifene)
Use of aromatase inhibitors has been proposed to reduce bulk; individual

studies have shown significant treatment response, but a Cochrane review
concluded that evidence was insufficient to support a recommendation 35 38
Drug therapy
Agents to control menorrhagia
Antifibrinolytic agent
Tranexamic acid
Tranexamic Acid Oral tablet; Adult females of reproductive potential: 1,300 mg PO 3

times daily for 5 days during monthly menstruation.
NSAIDs
Naproxen
Naproxen Oral tablet; Adults: 500 mg PO, then 250 mg PO q6—8h PRN; use lowest
effective dose for shortest possible duration; consider lower doses in geriatric
patients. Max: 1250 mg on day 1 and 1000 mg/day thereafter.
Mefenamic acid
Mefenamic Acid Oral capsule; Adult and Adolescent females >= 14 years: 500 mg PO
at menses onset; then, 250 mg every 6 hours PRN for 2 to 3 days.
Hormonal contraceptives
Medroxyprogesterone
Medroxyprogesterone Acetate Suspension for injection [Contraception]; Adult and

Adolescent females: 150 mg IM every 3 months. Treatment for longer than 2 years is
not recommended.
Levo-norgestrel intrauterine device
Levonorgestrel Vaginal insert; Adult females: Insert 1 IUD into the uterus as per
device instructions. At the end of the 5 year period, remove and replace the IUD if
continued treatment for heavy menstrual bleeding is needed.
Norgestimate/ethinyl estradiol
Inert Oral tablet, Norgestimate, Ethinyl Estradiol Oral tablet; Adult and Adolescent
females: Follow dose as for routine contraception.
Norethindrone/ethinyl estradiol
Ethinyl Estradiol, Norethindrone Oral tablet, Ethinyl Estradiol, Norethindrone Oral

tablet, Inert Oral tablet; Adult and Adolescent females: Follow dose as for routine
contraception (1 tablet, containing norethindrone in combination with ethinyl
estradiol, PO once daily for 21 days, followed by 7 days of inert, inactive tablets, in
the order directed on the pack).
Levonorgestrel, Ethinyl Estradiol Oral tablet
Inert Oral tablet, Levonorgestrel, Ethinyl Estradiol Oral tablet; Adult and Adolescent
females: Follow dose as for routine contraception.
Agents to control menorrhagia and reduce fibroid size
Gonadotropin-releasing hormone agonists
Leuprolide
Leuprolide Acetate Suspension for injection; Adults: 3.75 mg IM once per month or
11.25 mg IM once every 3 months with supplemental iron. The recommended
duration of therapy is 3 months or less. Only use the 3-month depot dosage when 3
months of hormonal suppression is deemed necessary. LIMITATIONS OF USE:
Leuprolide 3-month Depot 11.25 mg is not indicated for combination use with
norethindrone acetate add-back therapy; do not substitute leuprolide 3-month
depot 11.25 mg for leuprolide 1- month depot 3.75 mg.
Goserelin
Goserelin Acetate Implant; Adult females: 3.6 mg injected subcutaneously into the
anterior abdominal wall below the navel line every 28 days. Coadministration of
certain drugs may need to be avoided; review drug interactions.
Gonadotropin-releasing hormone antagonists
Elagolix
Elagolix Oral capsule, Elagolix, Estradiol, Norethindrone Acetate Oral capsule; Adult
Premenopausal Females: 1 capsule (300 mg elagolix; 1 mg estradiol; 0.5 mg
norethindrone) PO in the AM and 1 capsule (300 mg elagolix) PO in the PM at
approximately the same time each day, with or without food. Max treatment
duration: 24 months.
Relugolix
Relugolix, Estradiol, Norethindrone Acetate Oral tablet; Adult Premenopausal

Females: 1 tablet (40 mg relugolix; 1 mg estradiol; 0.5 mg norethindrone) PO once
daily at approximately the same time each day, with or without food. Max treatment
duration: 24 months.
Selective progesterone receptor modulators
Mifepristone
Mifepristone Oral tablet; Adult females: 2.5 to 10 mg PO daily has been studied. 39
Ulipristal
Only the 30 mg strength tablets of ulipristal are available in the United States for
postcoital contraception
As of March 2020, all ulipristal 5 mg tablets were recalled in Europe and patients
were instructed to stop therapy due to a case of hepatic failure requiring liver
transplantation despite appropriate monitoring for hepatic complications. A drug
safety review is currently underway by the European Medicines Agency. 37
Ulipristal Acetate Oral tablet; Adult females: 5 mg PO once daily is approved in

Europe for intermittent treatment or preoperative treatment of moderate to severe
symptoms of uterine fibroids in adult women of reproductive age. Therapy should
be initiated during the first week of a menstrual cycle and should not exceed 3
months; no data are available on treatment beyond 3 months or on repeat courses of
treatment. 40
Aromatase inhibitors
Letrozole
Letrozole Oral tablet; Adult females: 2.5 mg PO daily for 12 weeks has been studied.
41
Add-back therapy for gonadotropin-releasing hormone agonist regimens longer than 6

months
Estradiol
Estradiol Oral tablet; Adult females: 0.5 mg PO daily.
Medroxyprogesterone
Medroxyprogesterone Acetate Oral tablet; Adult and Adolescent females: 5 to 10 mg PO

once daily for 5 to 10 days during the latter half of the cycle (days 16 to 21). If the
endometrium has been primed with estrogens, administer 10 mg PO once daily for 10
days starting on the 16th day of the cycle. Withdrawal bleeding usually occurs 3 to 7
days after discontinuation of therapy.
Raloxifene
Raloxifene Hydrochloride Oral tablet; Postmenopausal Adult Females: 60 mg PO once

daily in 28-day cycles reduced mean uterine and leiomyoma size after 6, 9, and 12
cycles of treatment. LIMITATIONS OF USE: There is no indication for the use of
raloxifene in premenopausal women; safety has not been established and use is not
recommended.
Continuous low-dose Estradiol 0.5 mg/norethindrone acetate 0.1 mg
Ethinyl Estradiol, Norethindrone Oral tablet; Adult and Adolescent females: Follow
dose as for routine contraception (1 tablet, containing norethindrone in combination
with ethinyl estradiol, PO once daily for 21 days, followed by 7 days of inert, inactive
tablets, in the order directed on the pack).
Norethindrone
Norethindrone Acetate Oral tablet; Adults and Adolescents: 2.5—10 mg PO once daily
for 5—10 days. Withdrawal bleeding usually occurs within 3—7 days after
discontinuation of the progestin.
5 mg PO once daily is commonly used
Nondrug and supportive care

Calcium supplementation is recommended for patients treated with gonadotropin-releasing
hormone agonists
Procedures
Hysterectomy
General explanation
Surgical removal of the uterus, which may be performed via an abdominal or vaginal
approach and may be open, laparoscopic, or vaginal with laparoscopic assistance
Indication
Symptomatic fibroids in women who choose not to preserve childbearing potential
Contraindications
Pregnancy
Complications
Postoperative transfusion is required in about 2% of patients 35
Ureteral injury
Urinary incontinence
Vaginal prolapse
Morcellation has been used to enable hysterectomy through a smaller incision than
standard; this has become controversial owing to the risk of disseminating malignant cells
from an unsuspected leiomyosarcoma 35
Although the occurrence of lesions from disseminated malignant cells is very rare,
guidelines recommend that patients be advised of the associated risk when morcellation
is anticipated 17 35
Before considering morcellation of the uterus or myoma, evaluate for increased risk of
uterine malignancy 1
Guidelines recommend that when morcellation is anticipated, patients be advised of the

risks and benefits, and alternatives to morcellation 1
Myomectomy
General explanation
Surgical removal of fibroids by hysteroscopic, laparoscopic, or open abdominal approach 8 35
A 2020 randomized trial suggested that, among women with symptomatic uterine fibroids,
those undergoing myomectomy experienced better fibroid-related quality of life at 2 years
after surgery than those undergoing uterine artery embolization 22
Indication
May consider hysteroscopic myomectomy for symptomatic type 0 or 1 submucosal fibroids
smaller than 3 cm 35
Laparoscopic myomectomy, with or without robotic assistance, may be appropriate when

lesions are few and relatively small (especially when multiple) and easily reached by a
laparoscope 9 35
Open abdominal myomectomy is preferred for deep or large fibroids or when more than 3
or 4 fibroids are to be removed 35
Contraindications
Laparoscopic myomectomy is contraindicated in patients with numerous, deep, or very
large fibroids
Complications
Postoperative transfusion required in 2% to 28% of patients 35
Intrauterine adhesions, which may impair subsequent fertility, may occur after
hysteroscopic surgery; adnexal scarring may occur after open or laparoscopic myomectomy
and may affect fertility 42
Uterine rupture in pregnancy may occur after laparoscopic myomectomy 35
Morcellation, mechanized slicing of fibroids into small pieces for laparoscopic extraction,
has been associated with inadvertent seeding of the abdomen and pelvis with tissue
fragments that generate parasitic leiomyomata; a thorough peritoneal lavage may avert this
complication 9
Although the risk of inadvertent seeding is extremely low, the FDA issued a warning
based on the description of at least 1 case in which morcellation of an unsuspected
leiomyosarcoma resulted in dissemination of malignant cells with an ultimately fatal
outcome
Before considering morcellation of the uterus or myoma, evaluate for increased risk of
uterine malignancy 1
Guidelines recommend that when morcellation is anticipated, patients be advised of the

risks and benefits, and alternatives to morcellation 1 17 35
Uterine artery embolization 18 19
General explanation
Image-guided catheterization of uterine artery with injection of an embolic agent
Indication
Symptomatic uterine fibroids in women who do not desire future pregnancy 35
Especially appropriate in patients with multiple or very large fibroids and in patients who
are poor surgical candidates owing to other medical morbidities or physical conditions (eg,
multiple previous abdominal or pelvic surgeries, extreme obesity) 43
Contraindications
Pregnancy
Active infection of uterus or adnexa
Complications
Severe pain caused by infarction of fibroids is the most common complication and may
require hospitalization 35
A small percentage of patients develop ovarian dysfunction manifested by amenorrhea; this

may result in permanent infertility 35
In women who become pregnant after the procedure, there is an increased risk of pregnancy
complications (ie, miscarriage, preterm labor, abnormal presentation of the fetus, need for
cesarean delivery) 35
Ablation with magnetic resonance–guided focused ultrasonography 35 44
General explanation
Using magnetic resonance to map and guide high-intensity ultrasonography, induce
coagulation necrosis in uterine fibroids
Indication
A single or a few symptomatic fibroids of moderate size (4-6 cm)
Contraindications
Uterine size equivalent to 24 weeks of gestation or larger
Pedunculated, nonenhancing, or heavily calcified fibroid
Significant abdominal scarring
Complications
Skin burns
Paresthesias of sciatic nerve
Special populations
Pregnant women
Although fibroids have been associated with complications of pregnancy and delivery,
myomectomy during pregnancy is not routinely recommended 45
Pharmacologic treatment of fibroids is contraindicated in pregnancy 4
Monitoring
Because treatment is indicated only for symptomatic fibroids and malignant transformation
is not thought to occur, there are no standard recommendations for monitoring
asymptomatic fibroids 8
Complications and Prognosis
Complications
Iron deficiency anemia 35
Infertility 35
Fibroids are associated with infertility in 10% of cases and are the only identified cause in
about 5%
Recurrent miscarriage 46
There is a small increase in risk of some pregnancy-associated complications, primarily

with submucosal fibroids: 42 47
Breech presentation
Placenta previa
Need for cesarean delivery
Placenta abruptio
Premature rupture of membranes
Premature birth
Intrauterine death with fetal growth restriction

15
15
Red degeneration (infarction)
Rarely, may result in life-threatening uterine hemorrhage 35
Urgent intervention is required: transfusion, antifibrinolytics (eg, tranexamic acid), IV

estrogen, or high-dose oral contraceptives. Uterine artery embolization or hysterectomy
may be required
Prognosis
Before menopause, pattern of fibroid growth is variable and unpredictable, but risk of
symptoms increases until menopause
Fibroids (and associated symptoms) regress after menopause
Cause of leiomyosarcoma is unknown (ie, whether they arise de novo or from uterine
fibromas); however, malignant degeneration of fibromas is exceedingly rare
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Fibroids (Uterine Myomas) - ClinicalKey

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Key Points Urgent Action

Reproductive effects may include infertility, recurrent miscarriage, premature birth,

Pharmacologic therapy is indicated for urgent control of severe bleeding, to reduce

Gonadotropin-releasing hormone agonists and selective progesterone receptor

Morcellation of the uterus or uterine myomas carries risk of dissemination of an occult

May be single or multiple, of variable size

Occur in women of reproductive age and regress after menopause

Submucosal: arising just beneath the endometrium

Intramural: arising within the uterine wall

Subserosal: arising from the serosal surface

Transmural: extending from the endometrium to the serosal surface

Most detailed classification is the International Federation of Gynecology and Obstetrics

1: submucosal (less than 50% intramural)

2: submucosal (50% or more intramural)

3: intramural with endometrial contact

5: subserosal (50% or more intramural)

6: subserosal (less than 50% intramural)

8: other (eg, cervical)

Irregular (metrorrhagia) and/or heavy (menorrhagia) menstrual bleeding

Noncyclic pelvic pain

Pelvic and/or abdominal fullness

Urinary frequency, incontinence, or retention

Symptoms associated with anemia (eg, fatigue)

Other symptoms may be related to fertility or pregnancy:

Causes and Risk Factors

Risk factors and/or associations

MED12 mutations, resulting in alterations in cell signaling and increased cell

Inactivation of the fumarate hydratase gene; occurs in a small percentage of sporadic

Clinically significant fibroids (defined as a uterine size equivalent to 9 weeks or more of

Other risk factors/associations

Vitamin D supplementation has been associated with a decrease in risk of fibroids 8

Primary diagnostic tools

Exclude pregnancy in women of childbearing age

Ultrasonography is the initial diagnostic test of choice 9 10

Conventional hysteroscopy can differentiate pedunculated intracavitary fibroids from

Recommended to measure hemoglobin and hematocrit levels in women who report

Unlike fibroids, menopausal transition may be

Menopause is characterized by follicle-stimulating

Owing to increasing prevalence of fibroids during the

Common endometrial or endocervical epithelial

Like fibroids, may present with abnormal bleeding, and

May be differentiated from fibroids by serial

Disruptive pockets of endometrial glands and stroma

Like fibroids, occur most commonly in women aged 35

Differentiated from fibroids by ultrasonography or MRI;

Inflammatory disease in which ectopic endometrial-like

Like fibroids, may present with dysmenorrhea,

Occurs primarily in younger women

Diagnosis usually can be made by clinical presentation

Endometrial hyperplasia or carcinoma (Related:

Thickening of the endometrium attributable to

Like fibroids, typically manifests with abnormal uterine

Endometrial carcinoma is uncommon, particularly in

Differentiation suggested by imaging findings;

Symptoms predominately Pregnancy

Differentiation is based on positive pregnancy test result

Pregnancy and fibroids may occur concomitantly, and

Mass lesions caused by pelvic organ malignancy