Uterine fibroid

A uterine fibroid is a benign tumor that grows in the muscle layer of the uterus (womb).

Fibroids are common, affecting about one in three women, with or without symptoms, and are present in up to 70% of women by menopause.

A fibroid (also called a myoma or fibroma) develops within or is attached to the uterine wall. It consists of an abnormal proliferation of smooth muscle cells (myoma) and may also involve an overgrowth of connective tissue fibers (fibroma).

The uterus, a hollow, inverted pear-shaped organ, is where a fetus develops during pregnancy.

Uterine fibroids vary widely in size, from as small as 1–2 centimeters in diameter to several kilograms in weight. These rounded, firm, and elastic masses can grow as a single tumor or as multiple tumors. Growth is partially driven by estrogen, a female sex hormone, and fibroids can sometimes reach very large sizes.

The development of fibroids is influenced by several factors, including:

• Age
• Premenopausal status
• Family history
• Time since the last birth
• Underlying health conditions such as high blood pressure or obesity

Uterine fibroids are asymptomatic in up to 70% of women and are often discovered incidentally during a routine ultrasound. When symptoms do occur, they may include:

• A feeling of fullness or bloating in the abdomen.
• Very heavy or irregular menstruation, sometimes with bleeding between cycles.
• Frequent urge to urinate.
• More painful menstruation (dysmenorrhea).
• Occasional abdominal pain.
• Difficulty conceiving (infertility).
• Premature labor or preterm birth during pregnancy.
• Early pregnancy loss (miscarriage).

During a physical examination, the gynecologist may detect a uterus that is larger than normal or irregular in shape through palpation. However, in cases where the woman is obese or for other reasons, this finding might be mistaken for pregnancy or other conditions, such as ovarian tumors or inflammation of the fallopian tubes.

Ultrasound is the first-line imaging technique for detecting fibroids and is sufficient for diagnosis in most cases. A sonohysterography (saline infusion sonogram) is even more sensitive for identifying fibroids.

When fibroids are located within the inner walls of the uterus (submucosal fibroids), hysteroscopy is the preferred diagnostic method. Hysteroscopy involves examining the inside of the uterus using a video camera, and it also allows for biopsies to be taken if necessary.

Magnetic resonance imaging (MRI) is another diagnostic tool that provides a more detailed evaluation of fibroid location and can help identify other uterine conditions, such as adenomyosis. MRI is typically used for women planning uterine-preserving surgery or when a more precise assessment is needed.

In many cases, only periodic monitoring is necessary, especially for women without symptoms or those with small fibroids.

Treatment options depend on several factors, including the woman's age, severity of symptoms, desire for future pregnancy, persistence of symptoms despite treatment, and the recurrence of fibroids after conservative surgery.

Hormonal therapy is often the first-line treatment, typically combined with oral iron supplements to counteract anemia caused by heavy menstrual bleeding. Symptomatic treatment for menstrual pain involves using anti-inflammatory medications. Hormonal treatments may have side effects, mimicking menopausal symptoms such as hot flashes, vaginal dryness, and bone density loss.

Short-term hormonal therapy is recommended primarily as a bridge to definitive radiological or surgical treatment, helping reduce symptoms and slow fibroid growth.

Surgical and radiological treatment approaches vary based on the patient's age, pregnancy desires, and menopausal status:

For women who wish to preserve the uterus:

• Acessa^® or Laparoscopic radiofrequency ablation (Lap-RFA): A minimally invasive procedure that treats fibroids while preserving uterine structure.
• Uterine artery embolization (UAE): Cuts off the blood supply to fibroids, causing them to shrink. However, its effects on future pregnancies are not fully understood.
• Myomectomy: Surgical removal of fibroids while leaving the uterus intact. This can be performed via laparoscopy, hysteroscopy, or open surgery (laparotomy), depending on the size and location of the fibroids. It is particularly suitable for women who want to become pregnant.
• Endometrial ablation: A treatment for fibroids causing heavy vaginal bleeding, suited for women who wish to preserve their uterus but do not plan future pregnancies.
• Hysteroscopic myomectomy: Removal of submucosal fibroids located inside the uterine cavity via a minimally invasive hysteroscopic procedure.

For women who do not wish to preserve the uterus:

• Total hysterectomy: Complete removal of the uterus, recommended for women with multiple or inaccessible fibroids, or when uterine conservation is not necessary (e.g., post-menopause). Whenever possible, a minimally invasive approach (e.g., laparoscopic hysterectomy) is preferred.