Debra Holloway discusses ten practical tips for the diagnosis and management of fibroids—providing information on the aetiology and symptoms of fibroids, when treatment is necessary, and the treatment options available.

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Read this article to learn more about:

  • the aetiology and symptoms of fibroids
  • when treatment is necessary and the treatment options available
  • supporting the education of affected women, so they can make an informed treatment decision.

After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. Earn 0.5 CPD credits.

The 2017 All-Party Parliamentary Group on Women’s Health report Informed Choice? Giving women control of their healthcare highlighted the perceived inequalities in care of women with fibroids and endometriosis and the difficultly they have in accessing care.1 Fibroids are generally benign tumours of the myometrium that are further described by the area in which they are located—intramural, subserosal, or submucosal.2 They range in size from a few millimetres to 30 cm in diameter or more,3 and sometimes extend up as far as the xiphisternum.

The aetiology of fibroids is not fully understood but they are dependent on oestrogen and so will appear after menarche, grow during reproductive years, and regress slowly after the menopause.2 Fibroids most often occur in women aged 30–504 but are more common in African-Caribbean women; it is also thought that they develop more frequently in women who are overweight or obese, due to associated increases in oestrogen levels.4 Presentation can vary, with some women having more rapidly growing fibroids and multiple fibroids; in these women, presentation is often earlier with large fibroids.5

It is important that all women with fibroids have access to information so that they can make informed decisions about their treatment:

In this article, 10 practical tips are provided to ensure that women presenting with fibroids are given the best care.

1. Not all fibroids need treatment

Fibroids can be found on routine pelvic examinations and on ultrasound scans for other reasons and may not be causing any symptoms,2,3 in these women it is important to take a detailed history and ask about specific symptoms that fibroids can cause. Women with fibroids are usually asymptomatic;3 if there are no symptoms then women should be reassured that treatment is not needed. This is especially true if they are small intramural or subserosal fibroids.

2. There are many factors that increase and decrease the risk of developing fibroids

Risk-factors for developing fibroids include:

  • ethnicity—some estimates suggest that fibroids will affect nearly 70% of white women and more than 80% of black women by the age of 503
  • early menarche—before 11 years of age2
  • genetics—women with a first-degree relative with fibroids have an increased risk of developing them;6 40% of women with fibroids have been found to have chromosomal abnormalities7
  • age—fibroids become more common as women age, particularly between 30 and 50 years8
  • obesity—some studies have suggested that increased body mass index increases the risk of fibroids9
  • red meat consumption is thought to increase the risk2
  • uterine injury is thought to be a causative factor in the development of fibroids due to disordered wound healing (similar behaviour to keloid scarring).6

Factors considered to decrease the risk of developing fibroids include:

  • full-term pregnancy10
  • physical activity—some data suggest that there is a lower risk associated with physical activity11
  • diet—a higher intake of fruit and vegetables has been shown to reduce the risk of developing fibroids6
  • vitamin D—sufficient vitamin D intake may be associated with a decreased risk but more research is required.

3. The main diagnostic tools are examination and ultrasound

In women who present with symptoms that may be associated with fibroids, after taking a good history the first-line diagnostic tools are pelvic and abdominal examination. These will help to direct which investigation is needed next, which is normally an ultrasound. This will be a combination of transvaginal and transabdominal, dependant on the size and number of fibroids. If the uterus is enlarged by fibroids then the kidneys should also be examined to look for hydronephrosis. In a small number of women, the ultrasound scan will not provide all the information needed (e.g, due to the nature of the endometrium, if the cavity is distorted, or due to the size and position of the fibroids), in which case a hysteroscopy will be required. If the uterus is large an MRI scan may be needed to aid in treatment planning.12

4. Fibroids can mask or be mistaken for a number of different disorders

Differential diagnoses include:2

  • tumour of the gastrointestinal or genitourinary system
  • endometrial cancer
  • endometrial polyps
  • hyperplasia
  • lymphoma
  • ovarian cancer
  • uterine sarcoma.

5. The most common presenting complaints of fibroids are heavy menstrual bleeding (HMB) and pressure symptoms

Symptoms caused by fibroids are detailed in Table 1; if a woman who has already been diagnosed with fibroids presents with new-onset symptoms, they should be examined and further investigations carried out as necessary.

Table 1: symptoms caused by fibroids

SymptomMost common fibroid type
HMB Submucosal or any causing a generally enlarged uterus
PCB/IMB Submucosal
Pressure/bloating feeling Any—can be singular large fibroid or multiple small fibroids
Frequency Any—can be singular large fibroid or multiple small fibroids
Pain Any—can be singular large fibroid or multiple small fibroids; can be the result of degeneration
Miscarriage/complications in pregnancy Submucosal fibroids or fibroids in other locations causing distortion of the cavity
Fertility issues Submucosal fibroids or fibroids in other locations causing distortion of the cavity and compression of the fallopian tubes
Constipation Any causing bulk symptoms
No symptoms Any
Painful sex Any
HMB=heavy menstrual bleeding; PCB=post-coital bleeding; IMB=intermenstrual bleeding.

6. Treatment offered to a woman should depend on the symptoms and the position of the fibroids

There is no one-size-fits-all treatment and healthcare professionals need to discuss options and be open with women—they may have spoken to friends or read articles and come with an idea of which treatment they would like. Some treatments, such as myomectomy, have risks that women may not be aware of—these include morbidity associated with the operation, bleeding requiring transfusion, and the possible need for hysterectomy.3 Uterine artery embolization (UAE) may be considered by some women to be a minimally-invasive procedure but the pain following the procedure can be severe, and it can cause nausea and result in vaginal discharge.3 Furthermore, this procedure is associated with a higher rate of re-intervention compared with surgery and the impact on fertility and pregnancy is unknown.3 It may not be suitable to treat all fibroids with UAE—especially submucosal fibroids or pedunculated submucosal or subserosal fibroids.3

7. Some treatments may interfere with other medication or may be a contraceptive as well

Many of the medical treatments available for fibroids are also contraceptive and will only work on certain symptoms—mainly those related to bleeding. Gonadotrophin-releasing hormone (GnRH) analogues work by reducing oestrogen levels, they are not a method of contraception but temporarily induce a menopause, and relieve bulk or pressure symptoms. This effect is temporary and fibroids often regrow when the treatment is stopped. Women that have been prescribed GnRH analogues should be advised to use non-hormonal contraception, such as barrier methods, so there is no overlap between medications. In addition, they should be made aware that menopausal symptoms may occur, such as hot flushes and night sweats; the decreased oestrogen levels may cause a reduction in bone density leading to osteoporosis if GnRH analogues are used for a long period of time.13,14 The use of hormone-replacement therapy can reduce menopausal symptoms and the associated risk of osteoporosis.

Ulipristal acetate (Esmya 5 mg), is a selective progesterone receptor modulator that can be used to alleviate moderate-to-severe symptoms in adult women of reproductive age15—reducing fibroid size and bleeding. Ulipristal acetate 5 mg can be used as a short term pre-operative treatment once daily (for up to 3 months; first treatment should begin during the first week of menstruation) or as a longer treatment regimen. As a longer treatment regimen, the use is ulipristal acetate 5 mg as intermittent 3-month courses (with a 1-month break between each course; repeated intermittent treatment has been studied for up to four intermittent courses) taking one tablet once a day (retreatment courses should start at the earliest during the first week of the second menstruation following the previous treatment course completion).15

The progestogen present in some contraceptives, including the implant, intrauterine system (IUS), and progestogen-only pill (POP), can be affected by ulipristal acetate 5 mg; women should be advised to use barrier methods if they are prescribed ulipristal acetate 5 mg as it is possible that the efficacy of either medications may be impacted.15

8. The use of an IUS to alleviate HMB in the presence of fibroids

Women with submucosal fibroids often present with abnormal bleeding; this can be HMB, intermenstrual bleeding, or post-coital bleeding.

Pharmaceutical treatment should be considered for women experiencing HMB where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity.16 If hormonal contraception is acceptable to the woman, and history and investigations indicate that pharmaceutical treatment (either hormonal or non hormonal) is appropriate, a levonorgestrel-releasing IUS (LNG-IUS) is recommended first-line by NICE provided that long-term (at least 12 months) use is anticipated.16

It is not possible to use an IUS if the uterine cavity is distorted by fibroids; furthermore, there is a high IUS-expulsion rate in the presence of submucosal fibroids.3

9. Fibroids can impact fertility and pregnancy

Fibroids that compress the fallopian tubes may impact fertility—as it will impact on the ability of the ovum and sperm to meet.17 Submucosal fibroids have been implicated in reduced fertility and linked to an increased rate of miscarriage.2

10. Pharmaceutical and surgical treatment options are available for fibroids

There are many different treatments for fibroids and these depend on the symptoms, type and position of fibroid, and the desired outcome. For example, in women with mild symptoms who are nearing the menopause an expectant management option can be used as fibroids will usually regress with the menopause. All medications used in the treatment of fibroids preserve the uterus; however, most medications available are also contraceptive.

Submucosal fibroids that are in the cavity can be described as:

  • type 0—entirely in the cavity
  • type 1—more than 50% within the cavity
  • type 2—less than 50% within the cavity.

For type 0 and 1 submucosal fibroids, a trans-cervical resection can be performed. This is hysteroscopic surgery and involves removing the fibroids and restoring the cavity shape. HMB caused by submucosal fibroids is also reduced as a result of this surgery.

If multiple fibroids are present or the fibroid is not within the cavity it may be appropriate to perform a myomectomy either by open surgery or laparoscopic surgery, depending on the size of the fibroids. When gaining consent from a woman for a myomectomy it is also necessary to gain consent for a hysterectomy but this is very rarely required—as the uterus is a vascular organ excessive bleeding is a risk factor of myomectomy.3

For women that have either completed their family or who are not considering having children a hysterectomy, performed by laparoscopic surgery or open surgery as appropriate, can be considered if necessary for the removal of fibroids.

Interventional radiology is involved in UAE. The procedure is not suitable for women with pedunculated fibroids, as these can fall off into the pelvic cavity and cause infections. It would not be a suitable approach where fibroids are calcified and already regressing. The UAE procedure, which conserves the uterus, is performed under local anaesthesia; alleviation of symptoms can take up to 6 months.3

Closing thoughts

Fibroids can have a big impact on women’s health and can present in many different ways. The need for treatment and the type of treatment used all depend on the size, location, presenting complaint, and fertility needs of each women.


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References

  1. All-Party Parliamentary Group of Women’s Health (WHAPPG). Informed choice? Giving women control of their healthcare. WHAPPG, 2017. Available at: www.appgwomenshealth.org/inquiry2017/

  2. McCool W, Durain D, Davis M. Overview of latest evidence on uterine fibroids. Nurs Womens Health 2014; 18 (4): 314–331.

  3. Lumsden M, Hamoodi I, Gupta J, Hickey M. Fibroids: diagnosis and management. BMJ 2015; DOI: 10.1136/bmj.h4887.

  4. NHS Choices. Fibroids. www.nhs.uk/conditions/Fibroids/Pages/Introduction.aspx (accessed 17 October 2017) 


  5. Parker W. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 2007; 87 (4): 725–736.

  6. Wise L, Laughlin-Tommaso S. Epidemiology of uterine fibroids—from menarche to menopause. Clin Obstet Gynecol 2016; 59 (1): 2–24.

  7. Hodge J, Kim T, Dreyfuss J et al. Expression profiling of uterine leiomyomta cytogenetic subgoups reveals distinct signatures in matched myometrium: transcriptional profiling of the t(12:14) and evidence in support of predisposing genetic heterogeneity. Hum Mol Genet 2012; 21 (10): 2312–2329.

  8. Office on Women’s Health. Uterine fibroids. www.womenshealth.gov/a-z-topics/uterine-fibroids?from=AtoZ (accessed 3 October 2017)
  9. Templeman C, Marshall S, Clarke C et al. Risk factors for surgically removed fibroids in a large cohort of teachers. Fertil Steril 2009; 92 (4): 1436–1446.

  10. Chen C, Buck G, Curey N et al. Risk factors for uterine fibroids among women undergoing tubal sterilisation. Am J Epidemiol 2001; 153 (1): 20–26.

  11. Bard D, Dunson D, Hill M et al. Association of physical activity with development of uterine leiomyoma. Am J Epidemiol 2007; 165 (2): 157–163.

  12. Griffin K, Ellis M, Wilder l, DeArmond L. Clinical inquiries—what is the appropriate diagnostic evaluation of fibroids? J Fam Pract 2005; 54 (5): 458–473.

  13. Hoffman B, Schorge J, Schaffer J et al. Pelvic mass. In: Fried A, Boyle J, editors. Williams Gynecology—second edition. McGraw-Hill, 2012: 246–280.

  14. Simpson P, McLaren J, Rymer J, Morris E. Minimising menopausal side effects whilst treating endometriosis and fibroids. Post Reprod Health 2015; 21 (1): 16–23.

  15. Gedeon Richter (UK) Ltd. Esmya 5 mg Tablets (ulipristal acetate)—summary of product characteristics. November 2016. www.medicines.org.uk/emc/medicine/26068

  16. NICE. Heavy menstrual bleeding: assessment and management. NICE Clinical Guideline 44. NICE, 2007 (updated 2016). Available at: www.nice.org.uk/cg44

  17. Purohit P, Vigneswaran K. Fibroids and infertility. Curr Obstet Gynecol Rep 2016; 5: 81–88.