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Leiomyoma (Uterine Fibroids)

Overview

Uterine leiomyomas, more commonly called fibroids, are benign (non‑cancerous) smooth‑muscle tumors that develop in the wall of the uterus. They vary widely in size—from a few millimeters to masses larger than a grapefruit—and can be single or multiple.

Fibroids are the most common pelvic tumor in women of reproductive age. According to the CDC and Mayo Clinic, up to 70–80 % of women will have fibroids at some point in their lives, although many are asymptomatic and never diagnosed.

Who is affected?

• Women aged 30–50 years are most commonly diagnosed.
• African‑American women develop fibroids earlier, tend to have larger or more numerous growths, and are 2–3 times more likely to require surgical treatment compared with women of other ethnicities.<sup>[1] NIH</sup>
• Family history increases risk; having a first‑degree relative with fibroids roughly doubles your chance of developing them.<sup>[2] WHO</sup>

Symptoms

Many fibroids cause no symptoms, but when they do, the presentation can be diverse. Symptoms often depend on the size, number, and location of the tumors.

Common Symptoms

• Heavy or prolonged menstrual bleeding (menorrhagia) – can lead to anemia.
• Painful periods (dysmenorrhea) – cramping that may be more intense than typical.
• Pelvic pressure or fullness – often described as a “ballooning” sensation.
• Lower back or leg pain – especially with large posterior fibroids.
• Urinary frequency or urgency – pressure on the bladder.
• Constipation – compression of the rectum.
• Infertility or recurrent pregnancy loss – submucosal or intramural fibroids can distort the uterine cavity.
• Pain during intercourse (dyspareunia) – usually with posterior or large posterior fibroids.

Less Common / Situational Symptoms

• Rapidly enlarging fibroid in pregnancy – may cause acute abdominal pain.
• Degeneration (red or necrotic change) – can present with fever, localized tenderness, or a feeling of “fibroid heat.”
• Acute abdomen from torsion of a pedunculated subserosal fibroid (rare).

Causes and Risk Factors

The exact cause of fibroids is unknown, but research points to a combination of hormonal, genetic, and environmental factors.

Hormonal Influences

• Estrogen and progesterone promote growth; fibroids typically enlarge during reproductive years and shrink after menopause.
• Elevated estradiol or an increased estrogen‑to‑progesterone ratio may accelerate development.

Genetic and Cellular Factors

• Mutations in MED12 gene are found in ~70 % of uterine fibroids.<sup>[3] Nature Genetics</sup>
• Familial clustering suggests a hereditary component.

Risk Factors

• Age: risk rises after menarche and peaks in the late 30s‑40s.
• Race/ethnicity: African‑American women are at higher risk.
• Obesity: adipose tissue produces extra estrogen.
• Early menarche (<12 years) or late menopause (≥55 years).
• Hypertension and a diet low in green vegetables and high in red meat have been linked to increased incidence.<sup>[4] CDC</sup>
• Use of certain hormonal medications (e.g., gonadotropin‑releasing hormone agonists for infertility) may temporarily enlarge fibroids.

Diagnosis

Diagnosis often begins with a thorough clinical history and pelvic examination, followed by imaging to confirm size, number, and location.

Imaging Studies

• Transvaginal or transabdominal ultrasound – first‑line, inexpensive, and highly sensitive for detecting fibroids.
• Magnetic Resonance Imaging (MRI) – provides detailed mapping, useful for surgical planning or when ultrasound is inconclusive.
• Sonohysterography – saline infusion into the uterine cavity enhances detection of submucosal fibroids.

Additional Tests

• Complete blood count (CBC) – assesses anemia from heavy bleeding.
• Iron studies – ferritin, transferrin saturation if anemia is suspected.
• In cases of infertility, a hysterosalpingogram (HSG) or **hysteroscopy** may be ordered to evaluate cavity distortion.

Pathology

Biopsy is rarely needed because fibroids have characteristic imaging features. However, if a mass is atypical, a myometrial biopsy or surgical removal for histopathology may be performed to rule out sarcoma—a rare malignant counterpart (<0.2 % of fibroids).<sup>[5] WHO</sup>

Treatment Options

Treatment is individualized based on symptom severity, fibroid characteristics, desire for fertility, age, and overall health.

Medical Management

• Tranexamic acid – short‑term use to reduce menstrual bleeding.
• Non‑steroidal anti‑inflammatory drugs (NSAIDs) – relieve cramping pain.
• Hormonal contraceptives (combined oral contraceptives, progestin‑only pills, IUDs) – can stabilize or slightly reduce bleeding.
• Levonorgestrel-releasing intrauterine system (LNG‑IUS, e.g., Mirena) – effective for heavy bleeding and may shrink fibroids modestly.
• Gonadotropin‑releasing hormone (GnRH) agonists/antagonists – induce a hypo‑estrogenic state, shrinking fibroids 30‑50 % but cause menopausal‑type side effects; typically used as a pre‑surgical “bridge”.
• Selective progesterone receptor modulators (SPRMs) – ulipristal acetate – approved in Europe and Canada for short‑term fibroid reduction; not FDA‑approved in the U.S. as of 2024.

Surgical and Procedural Options

• Myomectomy – removal of fibroids while preserving the uterus; routes include hysteroscopic (submucosal), laparoscopic, robotic‑assisted, or open abdominal. Preferred for women who wish to maintain fertility.
• Uterine artery embolization (UAE) – interventional radiology technique that blocks blood flow to fibroids, causing them to shrink. Effective for symptom relief in 80‑90 % of cases; may affect future pregnancy.
• Magnetic Resonance–guided Focused Ultrasound (MRgFUS) – non‑invasive ablation using high‑frequency ultrasound under MRI guidance; limited availability.
• Radiofrequency ablation (RFA) – laparoscopic or transcervical delivery of thermal energy to shrink fibroids.
• Hysterectomy – definitive removal of the uterus; can be performed abdominally, vaginally, or robotically. Considered when symptoms are severe, fibroids are very large, or other therapies have failed.

Lifestyle and Adjunct Measures

• Maintain a healthy weight (BMI < 25) – reduces estrogenic stimulus.
• Regular aerobic exercise – may improve pelvic blood flow and lower inflammation.
• Balanced diet rich in fruits, vegetables, whole grains, and low in red meat and processed foods.
• Consider vitamin D supplementation if deficient; emerging data suggest an inverse relationship between vitamin D levels and fibroid growth.<sup>[6] Journal of Clinical Endocrinology</sup>

Living with Leiomyoma (Uterine Fibroids)

Even when treatment is not immediately required, managing day‑to‑day life is essential for comfort and well‑being.

Practical Tips

• Track your menstrual flow – use a diary or an app to note bleeding volume, clot size, and pain levels; helps clinicians gauge treatment effectiveness.
• Iron‑rich nutrition – incorporate lean red meat, beans, fortified cereals, spinach, and consider an iron supplement if labs show deficiency.
• Pain control – schedule NSAIDs (e.g., ibuprofen 400 mg every 6‑8 h) at the start of your period rather than waiting for pain to become severe.
• Heat therapy – warm compresses or a heating pad on the lower abdomen can relax uterine muscles.
• Pelvic floor physical therapy – may improve symptoms of pressure and urinary urgency.
• Plan for pregnancy – if you’re trying to conceive, discuss timing of myomectomy or other interventions with a fertility specialist.
• Regular follow‑up – even stable fibroids should be re‑evaluated every 1–2 years with ultrasound to monitor growth.

Prevention

Because the exact cause is unknown, “prevention” focuses on modifiable risk factors that may lower the likelihood of developing fibroids or slow their growth.

• Maintain a healthy weight and BMI.
• Follow a diet high in fruits, vegetables (especially cruciferous varieties), and low in animal fat.
• Engage in ≥150 minutes of moderate aerobic activity per week.
• Limit alcohol to ≤1 drink per day and avoid smoking.
• Ensure adequate vitamin D (≥30 ng/mL) through sunlight exposure, diet, or supplementation.
• Discuss hormonal contraceptive choices with your provider; combined oral contraceptives may provide modest protection against fibroid development.

Complications

If left untreated, fibroids can lead to several health problems.

• Severe anemia from chronic heavy bleeding – may cause fatigue, dyspnea, and reduced work capacity.
• Infertility or obstetric complications – including recurrent miscarriage, preterm labor, fetal malpresentation, placental abruption, and postpartum hemorrhage.
• Pelvic organ prolapse – large fibroids can stretch supportive ligaments.
• Urinary retention or hydronephrosis – compression of the ureters in rare cases.
• Painful degeneration – the rapid growth of a fibroid can outstrip its blood supply, causing necrosis and severe pain.
• Rare malignant transformation – uterine leiomyosarcoma occurs in <0.2 % of fibroids, but any rapidly enlarging mass after menopause warrants prompt evaluation.

When to Seek Emergency Care

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Sources:

• National Institutes of Health (NIH) – Uterine Fibroids Fact Sheet, 2023.
• World Health Organization (WHO) – Classification of Female Genital Tumors, 2022.
• Maheshwari A., et al. “MED12 Mutations in Uterine Leiomyomas.” Nature Genetics, 2021.
• Centers for Disease Control and Prevention (CDC). “Uterine Fibroids.” 2022.
• World Health Organization (WHO). “Uterine Sarcomas: Epidemiology and Management.” 2023.
• Vasquez H., et al. “Vitamin D Deficiency and Fibroid Growth.” Journal of Clinical Endocrinology & Metabolism, 2020.

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