Uterine fibroids

Uterine fibroids (leiomyomas or myomas) are benign smooth muscle tumours of the uterus. They affect up to 70% of women by age 50 and, although non-cancerous, can cause significant morbidity depending on their size, number, and location. ✨ Presentation is highly variable, from asymptomatic cases to severe menstrual disturbance and reproductive complications.

🧩 Types of Fibroids

• Intramural: Within the uterine wall – most common, often causes menorrhagia and bulk symptoms.
• Submucosal: Beneath the endometrium → heavy menstrual bleeding + infertility risk.
• Subserosal: Beneath the serosa → may grow large, pressing on bladder/bowel.
• Pedunculated: Attached by a stalk → risk of torsion and acute pain.
• Cervical: Arise from cervix → may cause obstruction or pressure symptoms.

⚠️ Risk Factors

• 👵 Age: Peak 30–50 years.
• 🧬 Family History: Increased risk if first-degree relatives affected.
• 🌍 Ethnicity: More common and earlier onset in African-Caribbean women.
• 💊 Hormonal: Oestrogen + progesterone promote growth → shrink after menopause.
• ⚖️ Obesity: Adipose tissue ↑ oestrogen levels.
• 🚫 Nulliparity: Never pregnant = higher risk.

🩺 Clinical Features

• 💉 Menorrhagia: Heavy/prolonged periods (especially submucosal fibroids).
• 😣 Pelvic Pressure: "Dragging" or fullness sensation.
• 🚽 Urinary Symptoms: Frequency, retention (due to bladder compression).
• 💩 Bowel Symptoms: Constipation from rectal pressure.
• ❤️‍🔥 Dyspareunia: Painful intercourse, esp. cervical fibroids.
• 👶 Reproductive Issues: Infertility, miscarriage, malpresentation, obstructed labour.
• ⚡ Acute Pain: Due to red degeneration (esp. in pregnancy) or torsion of pedunculated fibroid.
• Exam: Enlarged, irregular "lumpy" uterus on bimanual exam; abdominal mass if large.

🔎 Investigations

• 🖤 Ultrasound (TV/TA): First-line to assess size, site, and number.
• 🧲 MRI: For surgical planning or complex cases.
• 🔦 Hysteroscopy: Direct visualisation + removal of submucosal fibroids.
• 💧 Sonohysterography: Saline-infusion scan highlights cavity distortion.

💊 Medical Management

• 🩹 NSAIDs: Symptom relief, ↓ pain (no effect on fibroid size).
• 💊 Hormonal Therapy:
  • COCP → regulates bleeding.
  • Mirena (LNG-IUS) → ↓ menorrhagia, preserves fertility.
  • GnRH Agonists (e.g., leuprolide) → temporary shrinkage, useful pre-op or peri-menopause.
• 🔄 Selective Progesterone Receptor Modulators (e.g., Ulipristal): Shrinks fibroids + controls bleeding.

🔪 Surgical & Interventional Options

• ✂️ Myomectomy: Removes fibroids, uterus preserved → fertility maintained.
• 🏥 Hysterectomy: Definitive option for severe cases, no fertility preservation.
• 🩸 Uterine Artery Embolization (UAE): Cuts off fibroid blood supply → shrinkage. Not recommended if fertility desired.
• 🔥 Endometrial Ablation: For menorrhagia + small submucosal fibroids; not fertility-preserving.
• 🎯 MR-guided Focused Ultrasound: Non-invasive thermal destruction under MRI guidance.

🚑 Complications

• 💉 Iron-Deficiency Anaemia: From chronic menorrhagia.
• 👶 Infertility & Miscarriage: Submucosal fibroids distort uterine cavity.
• 🤰 Pregnancy Complications: Malpresentation, obstructed labour, preterm labour.
• ⚡ Red Degeneration: Painful necrosis, esp. in pregnancy.
• 🚽 Urinary Retention / Recurrent UTIs: From bladder compression.

✅ Key Exam Pearls

• Fibroids are oestrogen-dependent → shrink after menopause.
• Most common type: intramural.
• Most symptomatic for bleeding: submucosal.
• Definitive treatment: hysterectomy.