Fibroids
Exam Tips
- Submucosal fibroids are classically most associated with heavy bleeding and reduced fertility, even when small.
- A firm, irregularly enlarged non-tender uterus on bimanual exam strongly suggests fibroids over adenomyosis (typically diffusely tender/boggy).
- First-line imaging is transvaginal ultrasound; always document size, number, and precise location because this drives management.
- In heavy menstrual bleeding, check FBC early and treat iron deficiency alongside fibroid-directed therapy.
- Red flags in exams: rapid uterine enlargement after menopause, acute severe pain with peritonism, urinary retention, or hydronephrosis.
- For surgery-focused viva questions: link treatment choice to fertility plans (myomectomy if future pregnancy desired; hysterectomy definitive).
- Image reference: See schematic uterine fibroid location diagrams in standard gynae texts (submucosal vs intramural vs subserosal) and correlate with symptom patterns.
Definition
Uterine fibroids (leiomyomas) are benign, monoclonal smooth-muscle tumours of the myometrium with varying fibrous connective tissue content. They are usually hormone-responsive (oestrogen/progesterone dependent), occur mainly in reproductive years, and are classified by location as submucosal, intramural, or subserosal, which strongly influences symptoms and fertility impact.
Pathophysiology
Fibroids arise from proliferation of myometrial smooth muscle cells and fibroblasts, with excess extracellular matrix deposition creating firm, whorled nodules. Growth is promoted by ovarian steroids and local growth factors; lesions often enlarge during reproductive years/pregnancy and tend to regress after menopause. Symptom pattern is largely anatomical: submucosal fibroids distort the endometrial cavity and increase bleeding/implantation problems, intramural fibroids impair uterine contractility and vascular haemostasis during menses, and large subserosal/intramural fibroids cause pressure effects on bladder, bowel, and ureters.
Risk Factors
- Increasing age during reproductive years (peak in perimenopause, then decline after menopause)
- Early menarche (especially <11 years)
- Nulliparity
- Older age at first pregnancy
- Family history in a first-degree relative
- Black and Asian ethnicity (earlier onset, often larger/multiple and more symptomatic)
- Obesity (especially central adiposity)
- Hypertension
- Diabetes mellitus
Clinical Features
Symptoms
- Heavy menstrual bleeding (with or without intermenstrual bleeding) and dysmenorrhoea
- Pelvic pressure, pelvic pain, or dyspareunia
- Abdominal distension/bloating, back pain
- Urinary frequency, urgency, stress symptoms, or retention
- Constipation, painful defecation, bowel pressure symptoms
- Subfertility/infertility (particularly with submucosal cavity distortion)
- Acute severe pain if red degeneration or torsion of a pedunculated fibroid
Signs
- Firm, enlarged, irregular, usually non-tender uterus on bimanual examination
- Palpable central irregular abdominal/pelvic mass if large fibroid burden
- Pallor or tachycardia if significant iron-deficiency anaemia
- Possible bladder distension or flank tenderness if obstructive uropathy is present
Investigations
Management
Lifestyle Modifications
- Shared decision-making based on symptom burden, fibroid size/location, age, and fertility wishes
- Symptom and bleeding diary to guide treatment response
- Iron replacement and dietary iron optimisation if iron deficiency is present
- Safety-net urgently for severe acute pain, heavy ongoing bleeding with haemodynamic symptoms, urinary retention, or postmenopausal rapid uterine enlargement
Pharmacological Treatment
Antifibrinolytic
- Tranexamic acid 1 g orally three times daily during menstruation; can increase to 1 g four times daily (max 4 g/day)
Reduces menstrual blood loss; avoid in active/history of thromboembolic disease unless specialist advice.
NSAID for bleeding pain and dysmenorrhoea
- Mefenamic acid 500 mg orally three times daily from onset of menses while symptomatic
Useful when dysmenorrhoea coexists; avoid in active peptic ulcer disease, severe renal impairment, or NSAID-sensitive asthma.
Levonorgestrel intrauterine system
- Levonorgestrel-releasing IUS 52 mg device (licensed for up to 5 years)
Effective for heavy menstrual bleeding when cavity distortion does not preclude insertion; counsel about irregular bleeding initially.
Combined hormonal contraception
- Combined oral contraceptive pill (e. g, ethinylestradiol/levonorgestrel, 1 tablet daily in 21/7 or tailored regimen)
Can reduce bleeding and pain; contraindicated in women with VTE risk factors, migraine with aura, uncontrolled hypertension, smokers aged >=35 years.
Progestogen options
- Norethisterone 5 mg orally three times daily on cycle days 5-26 for heavy menstrual bleeding control
May be used when oestrogen-containing methods are unsuitable; monitor for mood, weight, and thrombotic risk profile.
GnRH analogue (short-term pre-operative or specialist bridging therapy)
- Leuprorelin 3.75 mg IM monthly
- Goserelin 3.6 mg SC every 28 days
- Triptorelin 3 mg IM monthly
Temporarily shrinks fibroids and improves pre-op haemoglobin; hypo-oestrogenic adverse effects (bone loss, vasomotor symptoms) limit duration without add-back therapy.
Oral GnRH antagonist combination (specialist use)
- Relugolix/estradiol/norethisterone acetate 40 mg/1 mg/0.5 mg orally once daily
For moderate-severe symptoms when appropriate; review contraindications to oestrogen/progestogen and thromboembolic risk before prescribing.
Surgical / Interventional
- Hysteroscopic myomectomy/resection for submucosal fibroids causing bleeding or infertility
- Laparoscopic/open myomectomy for symptomatic fibroids when uterine preservation is desired
- Uterine artery embolisation for selected women not seeking future pregnancy (fertility outcomes less predictable)
- Hysterectomy (definitive treatment) when symptoms are severe/refractory and fertility is not desired
- Emergency surgery may be required for rare torsion, haemoperitoneum, or uncontrolled bleeding
Complications
- Iron-deficiency anaemia from chronic heavy menstrual bleeding
- Urinary frequency/retention and recurrent UTIs due to bladder compression
- Hydronephrosis and potential renal dysfunction from ureteric compression (rare)
- Subfertility/infertility, especially with submucosal or deep intramural cavity distortion
- Pregnancy complications: miscarriage, pain from red degeneration, malpresentation, preterm birth, increased operative delivery risk
- Torsion of pedunculated fibroid causing acute abdomen (rare)
- Haemoperitoneum from rupture/avulsion or vessel rupture overlying fibroid (rare)
Prognosis
Course is variable and unpredictable before menopause: some fibroids remain stable, some enlarge, and a minority regress spontaneously over months to years. Most persist until ovarian hormone levels fall, then usually shrink after menopause, although calcified lesions may regress less and exogenous hormones (for example HRT) can limit shrinkage.
Sources & References
🏥BMJ Best Practice(2)
💊BNF Drug References(7)
- Clomifene citrate[cautions]
- Goserelin[management.pharmacological]
- Leuprorelin acetate[management.pharmacological]
- Linzagolix[management.pharmacological]
- Triptorelin[management.pharmacological]
- Ulipristal acetate[contraindications]
- Ulipristal acetate[management.pharmacological]
✅NICE Guidelines(1)
- Fibroids[overview]
📖Textbook References(16)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1831)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1831)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1845)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1715, 1716)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1714)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 164, 165)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 256)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 49)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 48, 49)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 258)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 319)[context]
- Netter F. Netter Atlas of Human Anatomy. Classic Regional Approach 8ed 2022.pdf(pp. 579)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 434, 435)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1420)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1415, 1416)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1415, 1416)[context]