Medically Fit For Exams
Medically Fit For Exams

Fibroids - Dr Deac Pimp


  • A benign tumour of the myometrium (muscular layer of uterus)


Risk factors

  • Increased oestrogen levels:
    • Obesity
    • Early menarche
    • Nulliparity
    • Limited evidence for COC and HRT (tends to be related to increased growth, rather than new onset)
  • Family history (increases risk by 2-2.5 times)
  • Black African/African-American ethnicity
  • Protective factors:
    • Multiple parity
    • Smoking (possibly)


Differential diagnoses

  • Bleeding:
    • Endometrial polys
    • Endometrial cancer
  • Mass:
    • Ovarian cyst
    • Ovarian cancer
    • Pregnancy
  • Pain:
    • Endometriosis
    • Dysmenorrhoea
    • PID
    • Tubo-ovarian abscess



  • Occur to some degree in up to 77% of women
    • Clinically recognised in 25% of women
  • Most common benign tumour in women
  • Usually present age 30-50, with increasing incidence approaching age of menopause



  • Cause isn’t well understood
  • Possibly starts as a response to local endometrial damage during menses
    • Effects of hormonal changes and growth factors
  • Likely some genetic component, as runs in families


Clinical features

  • Around half of women with fibroids have no symptoms and will only be diagnoses incidentally
  • Menorrhagia and dysmenorrhoea, often with long menses
    • May result in iron-deficiency anaemia
  • IMB (intermenstrual bleeding), especially if pedunculated
  • Pelvic pain
  • Pressure effects of mass:
    • Urinary frequency/urgency
    • Bowel frequency/urgency
    • Constipation
  • Palpable mass
  • Recurrent miscarriage/infertility (submucous)
  • On examination:
    • Enlarged, irregular, firm, non-tender uterus



  • Monoclonal tumours of myometrium
  • Start as single cells distributed through myometrium
  • Stimulation by oestrogens and progestogens causes them to increase in size slowly over years
  • Likely to be more than one fibroid
  • Contain large amount of extra-cellular matrix and collagen
  • If they grow large, there may be insufficient blood supply to the centre, which can necroes and calcify
  • Classification is by location in uterine wall:
    • Most are intramural
    • Submucosal grow into the uterine cavity. May be pedunculated
    • Subserosal grow out of the uterus into the pelvic/abdominal cavity, cervix or ligaments
  • Only very rarely undo malignant change to sarcomas



  • Pregnancy test
  • FBC + iron studies
  • Pelvic ultrasound (transvaginal)
  • MRI for further mapping of fibroids if considering surgical removal (myomectomy)
  • Pipelle biopsy (to rule out endometrial cancer)
  • Hysteroscopy and biopsy if suspicion of cancer



  • Many cases don’t require treatment
  • Medical:
    • NSAID eg ibuprofen to reduce bleeding and pain
    • Tranexamic acid to reduce bleeding
    • Mirena coil to reduce bleeding/stop periods
    • Mifepristone (progesterone receptor antagonist), but should be used carefully, as results in unopposed oestrogens which can increase risk of endometrial cancer
    • Ulipristal acetate is also a progestogen receptor modulator, and similarly should be used sparingly bearing in mind endometrial cancer risk
  • Surgical:
    • Appropriate if very large size, pressure symptoms, bleeding/pain uncontrolled by medical management, affecting fertility
    • Myomectomy – removal of the fibroid(s), ideally laparscopically or hysteroscopically, allows woman to keep fertility
    • Endometrial ablation – allows woman to keep fertility
    • Uterine artery ablation – results in shrinking of fibroid, and allows option of pregnancy
    • Hysterectomy – appropriate in women who have completed their family



  • Fibroids typically shrink once menopause starts, and symptoms improve
  • Recurrence is a risk for every management option aside from hysterectomy
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