Understanding Uterine Fibroids
Uterine fibroids (leiomyomas) are benign tumors arising from the smooth muscle cells of the uterus. They're the most common pelvic tumor in women of reproductive age, affecting up to 80% of women by menopause. While many fibroids cause no symptoms, others can significantly impact quality of life through heavy bleeding, pelvic pressure, pain, or fertility challenges.
prof Mykhailo Medvediev
Department of Obstetrics and Gynecology
Types and Locations of Fibroids
Fibroids are classified by their location in the uterus using the International Federation of Gynecology and Obstetrics (FIGO) system. Understanding fibroid location is crucial for treatment planning, as different locations cause different symptoms and require different approaches.
Submucosal (Types 0-2)
Protrude into the uterine cavity. Most likely to cause heavy menstrual bleeding and are often treated with hysteroscopic removal.
Intramural (Types 3-5)
Located within the uterine wall. May enlarge the uterus and distort the cavity or outer surface depending on size.
Subserosal (Types 6-7)
Originate at the outer uterine surface. May have broad or pedunculated bases and typically cause bulk symptoms rather than bleeding.
Cervical (Type 8)
Located in the cervix rather than the uterine body. Less common but require specialized treatment approaches.
Who Gets Fibroids?
Fibroid prevalence varies significantly by age and ethnicity. The incidence increases throughout the reproductive years, with Black women experiencing 2-3 times higher rates than White women. By age 50, cumulative incidence reaches over 80% for Black women and nearly 70% for White women.
26%
Young Women (18-30)
Prevalence in Black women aged 18-30 years
7%
Young Women (18-30)
Prevalence in White women aged 18-30 years
80%
By Late 40s
Estimated frequency in Black women by their late 40s
Risk Factors for Fibroid Development
Reproductive Factors
  • Early menarche (before age 10)
  • Nulliparity (never having given birth)
  • Prenatal DES exposure
  • Hormonal influences throughout reproductive years
Key Protective Factor
Pregnancy and childbirth significantly decrease fibroid risk. Each additional pregnancy further reduces risk, and term delivery is associated with decreased fibroid formation.
Additional Risk Factors
Obesity
Increased body mass index is associated with higher fibroid risk, though the relationship is complex and modified by other factors like parity.
Genetics
Family history increases risk. Specific genetic mutations and susceptibility genes have been identified in fibroid development.
Hypertension
High blood pressure is linked to increased fibroid risk, possibly through the angiotensin-converting enzyme pathway.
Chronic Stress
Major life events and chronic psychological stress may increase fibroid risk, especially among Black women.
Diet and Lifestyle Factors
Research suggests dietary choices may influence fibroid risk. Understanding these relationships can help inform preventive strategies, though more research is needed to establish definitive recommendations.
Increased Risk
  • High consumption of red meat and ham
  • Alcohol, especially beer
  • High dietary glycemic index
  • Marine omega-3 fatty acids (conflicting evidence)
Decreased Risk
  • Green vegetables and citrus fruits
  • Dairy products (particularly in Black women)
  • Vitamin D sufficiency
  • Vitamin A from animal sources
  • High physical activity levels
Common Symptoms Requiring Treatment
Fibroids can cause four main symptom categories, either alone or in combination. Many patients don't initially associate their symptoms with fibroids due to insidious onset or family normalization of symptoms.
Symptoms typically become noticeable when the uterus reaches 12 weeks gestational size or larger. Early recognition and treatment can significantly improve quality of life.
Heavy Menstrual Bleeding
Heavy and prolonged menstrual bleeding is the most common fibroid symptom, occurring in 26-29% of all patients and 37-42% of Black patients. The bleeding pattern is determined largely by fibroid location rather than size.
Submucosal Fibroids
Types 0 and 1 most frequently cause significant heavy bleeding and anemia
Intramural Fibroids
Also commonly associated with heavy or prolonged menstrual bleeding
Subserosal Fibroids
Not considered a major risk factor for heavy menstrual bleeding
Bulk and Pressure Symptoms
Urinary Symptoms
Up to 60% of patients experience urinary frequency, difficulty emptying the bladder, or rarely, complete obstruction. Hydronephrosis occurs in 14% of patients with fibroids on ultrasound.
Other Bulk Symptoms
  • Pelvic pressure and pain
  • Abdominal bloating and protrusion
  • Lower back pain
  • Constipation from rectal pressure
  • Early satiety
  • Venous compression (rare)
Pain Associated with Fibroids
Pain is an underappreciated fibroid symptom that can significantly impact quality of life. Recent evidence shows fibroids cause both menstrual and non-menstrual pain without requiring other conditions like endometriosis.
Menstrual Pain
Painful menses (dysmenorrhea) is common with fibroids and may worsen over time as fibroids grow.
Non-Menstrual Pain
Chronic pelvic pain, lower back pain, and pelvic pressure can occur throughout the menstrual cycle.
Acute Pain
Fibroid degeneration or torsion of pedunculated fibroids can cause sudden, severe pain requiring medical attention.
Dyspareunia
Deep pain with intercourse may occur, particularly with anterior or fundal fibroids.
Impact on Fertility and Pregnancy
Fibroids can affect fertility and pregnancy outcomes, though the relationship is complex and often confounded by age. Fibroids that distort the uterine cavity (FIGO types 0-3) have the greatest impact on fertility.
1
Conception
Submucosal fibroids may impair implantation and reduce pregnancy rates
2
Early Pregnancy
Increased miscarriage risk, though age appears to be the primary driver
3
Later Pregnancy
Risk of placental abruption, fetal growth restriction, and malpresentation
4
Delivery
Increased risk of preterm labor and cesarean delivery
Diagnostic Evaluation
Comprehensive evaluation before treatment includes clinical assessment, laboratory testing, and imaging to exclude other conditions and plan appropriate therapy.
Endometrial sampling should be performed when endometrial hyperplasia or cancer is suspected based on risk factors or bleeding patterns.
Imaging for Fibroids
01
Pelvic Ultrasound
First-line imaging with transvaginal and transabdominal approaches. High sensitivity (95-100%) for uteri less than 10 weeks size.
02
Saline Sonography
Evaluates uterine cavity for submucosal fibroids when planning hysteroscopic resection or assessing infertility.
03
Hysteroscopy
Direct visualization of endometrial cavity to characterize submucosal fibroids and plan surgical approach.
04
MRI
Most accurate for mapping all fibroids. Used for complex surgical planning or when malignancy is suspected.
Treatment Philosophy
Treatment aims to resolve or reduce symptoms while considering the patient's fertility desires, preferences, and overall health. A stepwise approach is used, starting with less invasive options and progressing as needed.
Patient-Centered Care
Shared decision-making based on symptoms, fertility goals, and personal preferences
Stepwise Approach
Begin with least invasive effective options, escalating only when necessary
Symptom-Directed
Treatment tailored to specific symptoms: bleeding, bulk, pain, or fertility
Treatment for Heavy Bleeding: First-Tier Options
For patients not desiring fertility, first-tier treatments focus on controlling bleeding with minimal invasiveness and rapid symptom relief.
Hysteroscopic Myomectomy
For submucosal fibroids (FIGO types 0, 1, some type 2). Outpatient procedure with rapid recovery, low complication risk, and excellent outcomes. Safe for future pregnancy with virtually no uterine rupture risk.
Medical Management
For non-submucosal fibroids:
  1. Combined estrogen-progestin contraceptives (pills, patch, ring)
  1. Levonorgestrel IUD
  1. Tranexamic acid
  1. High-dose oral progestins
Combined Hormonal Contraceptives
Combined estrogen-progestin contraceptives are the most commonly used medical therapy for fibroid-related heavy bleeding. While high-quality evidence is limited, these products offer multiple benefits beyond bleeding control.
Multiple Benefits
Contraception, reduced anemia, decreased risk of uterine and ovarian cancer
Long History
Extensive clinical experience with well-understood safety profile
Accessible
Widely available and relatively inexpensive
Multiple Formulations
Pills, patch, or ring based on patient preference
Levonorgestrel IUD for Fibroids
Key Advantages
  • Most effective progestin-only contraceptive for heavy bleeding
  • Long-acting (3-8 years depending on formulation)
  • Highly effective contraception
  • No daily medication required
Important Considerations
Risk of expulsion is higher in patients with significant submucosal fibroids that distort the endometrial cavity. Pre-insertion imaging helps identify these patients.
Most guidelines support LNG IUDs as first-line therapy for fibroid-related heavy bleeding, though supporting data are mainly observational.
Tranexamic Acid
Tranexamic acid is a nonhormonal option that can be taken only during menstruation or heavy bleeding days. This makes it ideal for patients who cannot or prefer not to use hormonal therapies.
Dosing
1.3 grams three times daily, started with onset of heavy bleeding
Efficacy
More effective than oral progestins in systematic reviews
Advantages
Used only when needed, no hormonal effects, well-tolerated
Second-Tier: GnRH Analogs
GnRH agonists and antagonists effectively reduce heavy bleeding and fibroid volume but have hypoestrogenic side effects that limit long-term use without add-back therapy.
1
GnRH Antagonists
Oral formulations (elagolix, relugolix, linzagolix) with add-back therapy. Better tolerated, approved for up to 24 months
2
GnRH Agonists
Injectable depot formulations (leuprolide). Primarily for preoperative use or perimenopausal transition (3-6 months)
Elagolix Combination Therapy
Elagolix with estradiol and norethindrone (Oriahnn) was FDA-approved in 2020 for fibroid-related heavy bleeding. The combination provides effective symptom control while mitigating hypoestrogenic side effects.
69-77%
Response Rate
Patients meeting primary endpoint (menstrual blood loss <80 mL and ≥50% reduction) at 6 months
88%
Sustained Response
Patients maintaining response with continued treatment at 12 months
1.5%
Bone Density
Median reduction in lumbar spine BMD at 12 months (partially reversible)
Relugolix Combination Therapy
Efficacy
Relugolix with estradiol and norethindrone (Myfembree) was FDA-approved in 2021. In phase III trials, 71-80% of patients achieved the primary endpoint compared to 15-19% with placebo.
The combination decreased bleeding, anemia, bulk symptoms, and pain while preserving bone mineral density.
Advantages
  • Once-daily dosing (vs twice daily for elagolix)
  • Significant pain reduction (45% achieved minimal/no pain)
  • Approved for up to 24 months
  • Sustained benefits in extension studies
Uterine Artery Embolization
UAE is a minimally invasive interventional radiology procedure that blocks blood flow to fibroids, causing them to shrink. It's effective for both bleeding and bulk symptoms but not recommended for patients desiring pregnancy.
90%
Patients report improved or resolved heavy bleeding symptoms after UAE
80%
Symptom improvement rate for bulk and pressure symptoms
70-80%
Patient satisfaction rates at long-term follow-up
UAE: Benefits and Considerations
Advantages
  • Minimally invasive outpatient procedure
  • Shorter hospital stay than surgery
  • Faster return to work
  • Lower transfusion risk
  • Treats all fibroids simultaneously
Disadvantages
  • More short-term complications than surgery
  • Possible ovarian dysfunction
  • Not for patients desiring pregnancy
  • May have less favorable quality of life vs surgery
  • Reintervention may be needed
Third-Tier: Focused Ultrasound Surgery
MRI-guided focused ultrasound (MRgFUS) or high-intensity focused ultrasound (HIFU) uses ultrasound energy to induce fibroid necrosis without incisions. It's noninvasive but time-consuming and requires specific fibroid characteristics for optimal results.
Symptomatic improvement occurs within three months and is maintained through 24-36 months, with more complete ablation leading to better outcomes.
MRgFUS vs UAE Comparison
The FIRSTT study compared MRgFUS with UAE in 81 patients. Both treatments improved quality of life and reduced symptoms, but outcomes differed.
MRgFUS
  • Less pain medication required
  • Lower complication rates
  • Higher reintervention rate (30% vs 12.5% at 3 years)
  • Better ovarian reserve preservation
UAE
  • Greater symptom improvement
  • Lower reintervention rates
  • More complete symptom resolution
  • Greater reduction in AMH levels
Surgical Options: Hysterectomy
Hysterectomy provides definitive treatment by removing the uterus entirely. While it eliminates fibroid symptoms permanently, it's associated with long-term health risks and should be reserved for specific situations.
When to Consider
Failed conservative therapies, significant concomitant disease (adenomyosis, cervical dysplasia, prolapse), or patient preference for definitive treatment
Long-Term Risks
Earlier menopause (even with ovarian conservation), decreased ovarian reserve, possible cardiovascular morbidity, mood disorders
Ovarian Conservation
Unless high-risk mutations (BRCA1/2) or ovarian pathology present, ovaries should be preserved to reduce long-term health risks
Hysterectomy Outcomes
1
Short-Term
Excellent symptom resolution, improved quality of life, low complication rates
2
Medium-Term
Complete elimination of bleeding, no fibroid recurrence, high satisfaction
3
Long-Term
Possible earlier menopause, cardiovascular changes, metabolic effects, bone health considerations
Myomectomy for Non-Fertility Patients
Myomectomy removes fibroids while preserving the uterus. Given the success of less invasive alternatives (UAE, MRgFUS), myomectomy is now reserved for specific situations in patients not desiring fertility.
1
No Other Uterine-Sparing Option
When UAE and MRgFUS are not available or appropriate
2
Suspected Sarcoma
Patient strongly desires uterine preservation despite knowing it may compromise outcome if malignancy confirmed
3
Limited Fibroid Burden
Few large lesions where discrete removal will significantly reduce symptoms
Treatment for Bulk and Pain Symptoms
Patients with bulk or pain symptoms (with or without bleeding) require treatments that reduce fibroid size. Options balance procedure risk and recovery with medication side effects.
Selection depends on patient preferences around invasiveness, recovery time, need for prolonged treatment, and risk-benefit balance.
GnRH Analogs for Bulk Symptoms
Relugolix Combination
Demonstrated reduction in both fibroid volume (12-15%) and pain. In patients with moderate to severe pain, 45% achieved minimal to no pain with combination therapy vs 14% with placebo.
Menstrual pain reduced more than non-menstrual pain.
GnRH Agonists
Greater fibroid volume reduction than antagonists but more severe hypoestrogenic side effects. Primarily used for:
  • Preoperative therapy (3-6 months)
  • Perimenopausal transition
  • Improving anemia before surgery
Fibroids and Fertility: Understanding the Impact
The relationship between fibroids and fertility is complex and often confounded by age. Fibroids that distort the uterine cavity (FIGO types 0-3) have the greatest impact on fertility outcomes.
Submucosal Fibroids
Strongest evidence for fertility impact. Removal can improve outcomes.
Intramural Fibroids
Impact unclear. Treatment decisions individualized based on size and location.
Subserosal Fibroids
Least likely to affect fertility. Treatment rarely indicated for fertility alone.
Age Factor
Age is the major driver of both fibroid prevalence and fertility decline.
Treatment for Fertility: Submucosal Fibroids
For patients desiring pregnancy with submucosal fibroids (FIGO types 0, 1, some type 2), hysteroscopic myomectomy is recommended. This minimally invasive approach optimizes fertility while treating symptoms.
Symptomatic Patients
Hysteroscopic myomectomy for bleeding relief and fertility optimization
Asymptomatic Types 0-1
Consider removal to maximize fertility, given minimal invasiveness
Type 2 Fibroids
Individualized approach due to greater surgical complexity and possible two-stage procedure
Treatment for Fertility: Non-Submucosal Fibroids
For patients desiring pregnancy with bulk symptoms or non-submucosal fibroids, myomectomy via laparoscopy or open surgery is the primary option. The approach depends on fibroid characteristics and surgical expertise.
Evaluate Candidacy
Assess fibroid number, size, location, and uterine size
Choose Approach
Laparoscopic for favorable anatomy and available expertise; open for larger/multiple fibroids
Time Appropriately
Treat close to pregnancy pursuit due to high recurrence risk
Laparoscopic Myomectomy
Laparoscopic myomectomy offers advantages of decreased morbidity and shorter recovery compared to open surgery, but requires specific patient characteristics and surgical expertise.
Size Criteria
Uterine size less than 17 weeks, typically fewer than 5 fibroids
Location
Subserosal or intramural (FIGO types 2-7). Anterior or fundal location preferred
Expertise Required
Advanced laparoscopic suturing skills essential for uterine closure integrity
Pregnancy Counseling
Discuss possible uterine rupture risk; integrity of closure not fully evaluated
Open Abdominal Myomectomy
Indications
  • Numerous fibroids (typically >5)
  • Large fibroids (>10 cm)
  • Large uterus (>17 weeks size)
  • Posterior or complex locations
  • Limited laparoscopic expertise
Advantages
  • Can handle any fibroid size/number
  • Better hemostasis control
  • More secure uterine closure
  • Lower uterine rupture risk in pregnancy
  • May result in less severe adhesions
Laparoscopic vs Open Myomectomy
A systematic review of six randomized trials including 576 patients found small differences between approaches. Both are effective, and choice depends on patient and fibroid characteristics.
13 min
Operative Time
Longer with laparoscopic approach
34 mL
Blood Loss
Less with laparoscopic approach
18-20%
Recurrence
Similar rates between approaches at 6-52 months
Special Population: Perimenopause
Perimenopausal patients can often be managed expectantly since symptoms typically stabilize or regress after menopause. GnRH agonists may serve as bridge therapy to menopause.
1
Perimenopause
Symptoms may fluctuate. Consider expectant management or GnRH agonist bridge therapy
2
Menopause
Symptoms typically resolve as estrogen levels decline. Most fibroids shrink
3
Postmenopause
Monitor for growth. New symptoms or enlargement requires evaluation for malignancy
Postmenopausal Considerations
Monitoring
Evaluate every 1-2 years to ensure fibroids haven't increased in size
New Symptoms
Bleeding or enlargement requires immediate evaluation to exclude leiomyosarcoma
Hormone Therapy
Menopausal hormone therapy may cause some growth but typically without symptoms. Not contraindicated
Pregnancy and Postpartum
Fibroids during pregnancy require special management. Most remain stable, but some complications can occur that require supportive care or, rarely, intervention.
Fibroid Degeneration
Can cause significant pain during pregnancy or postpartum. Managed with supportive therapy including pain control and rest. Self-limited, lasting days to weeks.
Fibroid Torsion
Pedunculated fibroids may twist, causing acute pain. Management varies with size and location. May require surgical intervention in severe cases.
Postpartum uterine remodeling may clear smaller fibroids - over one-third of single fibroids identified during pregnancy are absent on postpartum ultrasound.
Expectant Management
Not all fibroids require treatment. Expectant management is appropriate for many patients and involves periodic monitoring without active intervention.
Ideal Candidates
  • Asymptomatic patients
  • Those attempting pregnancy
  • Stable fibroid size over one year
  • Peri- or postmenopausal patients
  • Uterus less than 12 weeks size
Monitoring
  • Annual evaluation reasonable
  • History and physical examination
  • Periodic imaging as needed
  • Assessment for anemia if bleeding present
When to Treat
  • Development of new symptoms
  • Worsening anemia
  • Need for transfusion
  • Suspicion of malignancy
  • Significant growth on imaging
Preventive Treatment for Fertility
There are no data supporting empiric removal of asymptomatic or minimally symptomatic fibroids before attempting pregnancy. The high recurrence risk means patients may develop new fibroids requiring intervention during pregnancy pursuit.
01
Standard Approach
Treat symptomatic fibroids close to time of actively pursuing pregnancy
02
Large Uterus Exception
For uterus ≥16 weeks size, shorten interval before full fertility evaluation (6 months if <35 years, 3 months if ≥35 years)
03
Complete Evaluation
Perform full fertility workup for both partners before attributing infertility to fibroids alone
Treatments Not Recommended
Several therapies have been studied for fibroids but are not effective, carry unacceptable risks, or lack sufficient evidence for routine use.
Progesterone Receptor Modulators
Despite evidence supporting efficacy, progesterone receptor modulators are not currently recommended due to serious safety concerns.
Ulipristal Acetate
Not available in US for fibroid treatment due to cases of serious liver toxicity, liver transplantation, and fatalities. Restricted use in EU/Canada for selected patients who failed other treatments.
Mifepristone
Showed some efficacy at 5-50 mg doses but reported abnormal endometrial histology. Requires compounding, rarely used off-label.
Quality of Life Impact
Symptomatic fibroids significantly affect quality of life, with patients reporting impacts comparable to or worse than other chronic diseases like diabetes, breast cancer, or cardiovascular disease.
Emotional Health
Anxiety, depression, and stress related to symptoms and treatment decisions
Social Impact
Limitations on activities, relationships, and social engagement
Work Productivity
Missed work days, reduced productivity, career limitations
Relationships
Impact on intimate relationships, family planning concerns
Racial Disparities in Fibroid Care
Disparities in Disease
Black women experience:
  • 2-3 times higher incidence
  • Earlier symptom onset (4-6 years younger)
  • More severe symptoms
  • Larger fibroids and uteri
  • Higher rates of anemia
Disparities in Care
Black women also report:
  • Greater quality of life impairment
  • Different concerns about treatment
  • Less satisfaction with information received
  • Higher surgical complication rates
  • Nearly 3x more concern about fertility
Economic Impact of Fibroids
Uterine fibroids impose substantial costs on both the healthcare system and individual patients, affecting medical expenses, work productivity, and quality of life.
$34B
Annual US Healthcare Costs
Total direct medical costs for fibroid treatment annually
$4,600
Excess Cost Per Patient
Annual additional healthcare costs per patient with fibroids
$771
Lost Productivity
Average annual cost of missed work days per patient
Key Takeaways: Treatment Selection
Successful fibroid management requires individualized treatment based on symptoms, fertility desires, and patient preferences. A stepwise approach optimizes outcomes while minimizing risks.
Start Conservative
Begin with least invasive effective options: medical management or hysteroscopic procedures
Consider Fertility
Preserve reproductive potential when desired; avoid UAE and MRgFUS in fertility patients
Escalate as Needed
Progress to more invasive options only when conservative measures fail
Shared Decisions
Partner with patients to balance efficacy, risks, recovery, and personal values
Future Directions in Fibroid Care
Prevention Research
Studies investigating vitamin D supplementation, dietary interventions, and lifestyle modifications to prevent fibroid formation
Genetic Understanding
Identifying specific genetic mutations and susceptibility genes to develop targeted therapies
Novel Medications
Development of new medical therapies with improved efficacy and safety profiles
Surgical Innovation
Refinement of minimally invasive techniques and development of new interventional approaches
Resources and Support
Patients with uterine fibroids benefit from comprehensive education, support networks, and access to specialized care. Multiple resources are available to help navigate treatment decisions.
Patient Education
UpToDate patient education materials, society guidelines, and reputable online resources
Support Groups
Online and in-person communities for sharing experiences and information
Specialist Care
Gynecologists, reproductive endocrinologists, interventional radiologists, and multidisciplinary teams
Living Well with Fibroids
While uterine fibroids are common and can significantly impact quality of life, numerous effective treatment options exist. With proper diagnosis, individualized treatment planning, and ongoing support, most women can achieve excellent symptom control and maintain their quality of life.
You Have Options
Multiple effective treatments available, from medical management to minimally invasive procedures to surgery
Your Voice Matters
Shared decision-making ensures treatment aligns with your goals, values, and lifestyle
Hope for the Future
Ongoing research continues to improve our understanding and treatment of fibroids
Remember: You are not alone. Millions of women successfully manage fibroids and go on to live full, healthy lives. Work with your healthcare team to find the approach that's right for you.