Uterine Fibroids

Uterine Fibroids - Womb's Unwanted Roommates

• Benign monoclonal tumors of myometrial smooth muscle cells (leiomyoma/myoma).
• Epidemiology: Most common benign gynecological tumor. Affects 20-50% of reproductive-age women; ↑ prevalence & severity in Black women. Peak incidence: 40-50 years.
• Risk Factors:
  • Nulliparity, early menarche (<10 yrs)
  • Obesity (peripheral estrogen conversion)
  • Family history, Black ethnicity
  • Diet (↑red meat, ↓green vegetables)
• Etiology: Estrogen & progesterone sensitive (growth ↑ during pregnancy, ↓ post-menopause). Genetic predisposition (e.g., MED12 mutations).

⭐ Submucosal fibroids are most likely to cause heavy menstrual bleeding (HMB) and infertility.

Uterine Fibroids - Types & Troubles

• Nature: Benign monoclonal tumors of myometrial smooth muscle (leiomyomas). Estrogen & progesterone dependent.
• FIGO Classification (Location):
  • Submucosal (SM): Project into uterine cavity.
    • Type 0: Pedunculated, intracavitary.
    • Type 1: <50% intramural.
    • Type 2: ≥50% intramural.
  • Intramural (IM): Within myometrium.
    • Type 3: Contacts endometrium, 100% intramural.
    • Type 4: Entirely within myometrium.
  • Subserosal (SS): Project outwards from serosa.
    • Type 5: ≥50% intramural component.
    • Type 6: <50% intramural component.
    • Type 7: Pedunculated, subserosal.
  • Other: Type 8 (cervical, parasitic, etc.). Hybrid (e.g., 2-5: SM & SS features).
• Troubles (Clinical Presentation):
  • Often Asymptomatic.
  • Abnormal Uterine Bleeding (AUB - Menorrhagia/HMB): Most common; esp. SM (Types 0-2) & some IM.
  • Pressure/Bulk Symptoms: Urinary frequency, constipation, pelvic pain/heaviness.
  • Infertility / Recurrent Pregnancy Loss (RPL): Cavity distortion, impaired implantation.
  • Dysmenorrhea.
  • Acute Pain: Red degeneration (esp. during pregnancy), torsion of pedunculated fibroid.

⭐ Submucosal fibroids (FIGO Types 0, 1, 2) are the most common cause of fibroid-related heavy menstrual bleeding and infertility.

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Uterine Fibroids - Spotting the Squatters

• Key Diagnostic Tools:

  • USG:
    • TVS: Initial choice. Hypoechoic, well-defined.
    • SIS: Better view of submucosal fibroids.
  • MRI: Most accurate (size, number, location); differentiates adenomyosis. For complex cases/surgery planning.
  • Hysteroscopy: Dx & Rx for submucosal/intracavitary.

• Differential Diagnosis:

  • Adenomyosis
  • Ovarian mass
  • Leiomyosarcoma (esp. rapid postmenopausal growth ⚠️)
  • Endometrial polyp

⭐ MRI is the gold standard for differentiating fibroids from adenomyosis and for pre-operative mapping.

• Diagnostic Approach:

Uterine Fibroids - Eviction Notices

Tailor management: symptoms, age, fertility desire, fibroid size/location.

• Medical Management:
  • Hormonal:
    • GnRH Agonists (Leuprolide, Goserelin): Pre-op to ↓ size/vascularity. Max 6 months (risk of osteoporosis); consider add-back therapy.
    • SPRMs (Ulipristal Acetate): Intermittent use for HMB/bulk.
    • OCPs/Progestins/LNG-IUS: Manage AUB; no size ↓.
  • Non-hormonal:
    • Tranexamic Acid: ↓ HMB.
    • NSAIDs: Dysmenorrhea relief.
• Surgical Management:
  • Myomectomy: Fertility-sparing. Routes: hysteroscopic, laparoscopic, abdominal.
  • Hysterectomy: Definitive. For women completing family.
• Interventional Radiology:
  • Uterine Artery Embolization (UAE): Symptomatic, poor surgical candidates, fertility not primary concern.

⭐ Ulipristal acetate, an SPRM, can be used for long-term intermittent treatment of symptomatic fibroids, offering a medical alternative to surgery for some.

High‑Yield Points - ⚡ Biggest Takeaways

• Uterine fibroids (leiomyomas) are the most common benign tumors in females, primarily affecting reproductive-aged women.
• They are estrogen-dependent; growth often ↑ during pregnancy and ↓ after menopause.
• Submucosal fibroids are most associated with abnormal uterine bleeding (AUB) and infertility.
• Intramural fibroids are the most common type overall.
• Transvaginal ultrasound (TVS) is the gold standard for diagnosis.
• Asymptomatic fibroids often require no treatment, just observation.
• Red degeneration is a common type of acute painful degeneration, especially during pregnancy.