Understanding Uterine Fibroids: Symptoms, Diagnosis, and Treatment Options

Table of Contents

• The Clinical Problem: How Fibroids Affect Patients
• Diagnosis and Evaluation Methods
• Medical Treatment Options
• Surgical and Interventional Alternatives
• Clinical Recommendations for Patients
• Study Limitations
• Source Information

The Clinical Problem: How Fibroids Affect Patients

Uterine fibroids (also known as leiomyomas) are noncancerous growths in the uterine wall that represent the leading reason for hysterectomy surgeries. These common growths affect a remarkable 70-80% of people with uteruses during their lifetime, though only about half of those with fibroids actually experience symptoms.

The symptoms can significantly impact quality of life, including:

• Heavy and prolonged menstrual bleeding that may require 8-9 tampons per day on heaviest days
• Iron-deficiency anemia and associated fatigue
• Pelvic pressure and abdominal bloating
• Menstrual and nonmenstrual pain
• Compression symptoms affecting bowel function (constipation), bladder function (urinary frequency, urgency, or retention), and sexual function (painful intercourse)

Diagnostic delays present a major problem, with one-third of patients waiting approximately 5 years for diagnosis, and some waiting more than 8 years. These delays adversely affect fertility, quality of life, and financial stability. In one qualitative study, 95% of symptomatic patients reported psychological effects including depression, worry, anger, and body-image distress.

The research highlights significant racial disparities. Black patients experience earlier onset of fibroids, higher cumulative risk of symptoms, greater overall disease burden, and more severe disease presentation compared to White patients. Black patients are also more likely to undergo surgical hysterectomy and myomectomy while simultaneously expressing stronger preference for noninvasive therapies to avoid hysterectomy.

Diagnosis and Evaluation Methods

Pelvic ultrasonography serves as the most cost-effective initial imaging method for diagnosing fibroids, providing information about size, location, and number of fibroids while ruling out other pelvic masses. Ultrasound is particularly recommended for evaluating abnormal uterine bleeding, palpable pelvic masses, and bulk-related symptoms including pelvic pressure and bloating.

However, ultrasound has limitations when the uterine volume exceeds 375 ml or when more than four fibroids are present. In these situations, magnetic resonance imaging (MRI) provides better visualization and is particularly useful when uterine sarcoma is suspected (though this cancer is relatively rare, occurring in approximately 1 per 770 to 10,000 patients with abnormal bleeding) or when planning alternatives to hysterectomy.

The International Federation of Gynecology and Obstetrics developed a classification system (types 0-8) that helps clinicians better describe fibroid location relative to the uterine cavity and outer surface. This system enables clearer communication and more tailored treatment planning, with lower numbers indicating fibroids closer to the endometrial lining.

Medical Treatment Options

For patients seeking alternatives to surgery, several medical options are available. Contraceptive hormones typically serve as the first-line treatment for fibroid-related heavy bleeding, though the evidence supporting their effectiveness is considered low-quality.

Other options include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) taken during menstruation
• Tranexamic acid taken during menstrual periods
• Gonadotropin-releasing hormone (GnRH) agonists in depot form for short-term use

The most significant advancement in medical therapy comes from oral GnRH antagonist combinations, which combine:

1. An oral GnRH antagonist (elagolix or relugolix) that rapidly inhibits ovarian steroid production
2. Estradiol and progestin at doses producing systemic levels equivalent to the early follicular phase

Clinical trial data demonstrates these combinations effectively reduce heavy menstrual bleeding by 50-75%, decrease pain by 40-50%, and improve bulk-related symptoms with modest uterine volume reduction (approximately 10%). Side effects remain relatively low, with hot flushes, headaches, and nausea occurring in less than 20% of patients.

These medications are currently approved for 24 months of use in the United States and for unlimited duration in the European Union. However, they do not provide contraception, which represents a limitation for long-term use in many patients.

Surgical and Interventional Alternatives

Several procedures can reduce bleeding, decrease fibroid size, and improve quality of life without resorting to hysterectomy. The appropriate approach depends largely on fibroid size and location.

Transcervical approaches (through the cervix) work well for smaller fibroids classified as types 1-4 (submucosal to intramural locations). These include:

• Hysteroscopic myomectomy: Using a small endoscope to excise fibroids under direct visualization
• Transcervical radiofrequency ablation: Using targeted energy guided by intrauterine ultrasonography to cause coagulative necrosis

Abdominal approaches are needed for larger fibroids or those classified as types 5-7 (subserosal locations). These include:

• Uterine-artery embolization: A minimally invasive procedure using catheterization to release embolic particles into uterine arteries, causing ischemic infarction of fibroids
• MRI-guided focused ultrasound ablation: Non-invasive procedure using ultrasonic energy targeted to fibroids with MRI guidance
• Laparoscopic radiofrequency ablation: Performed through small abdominal incisions using ultrasound guidance
• Myomectomy: Surgical removal of fibroids through incisions in the uterine wall

Research shows uterine-artery embolization provides substantial symptom relief, though one randomized trial found myomectomy was superior regarding quality of life improvement. Both approaches significantly improve symptoms compared to no treatment.

Clinical Recommendations for Patients

Based on the comprehensive evidence review, patients with uterine fibroids should consider the following approach:

1. Seek timely evaluation if experiencing heavy menstrual bleeding (using more than 5-6 tampons/pads per day on heaviest days), pelvic pressure, or menstrual accidents
2. Request pelvic ultrasonography as a first diagnostic step, particularly if experiencing abnormal uterine bleeding or palpable pelvic masses
3. Discuss racial disparities with your provider - Black patients should be aware of their increased risk and potentially more severe disease course
4. Consider medical options first - Oral GnRH antagonist combinations offer significant symptom reduction with acceptable side effect profiles
5. Explore uterus-preserving procedures before opting for hysterectomy, including uterine-artery embolization and various ablation techniques
6. Address iron-deficiency anemia proactively, as this common complication significantly affects quality of life

For the patient described in the case vignette - a 33-year-old Black woman with heavy menstrual bleeding, iron-deficiency anemia, and multiple fibroids who anticipates pregnancy in 2 years - the recommended approach would prioritize medical management with oral GnRH antagonist combinations initially, followed by reassessment of symptoms and fertility goals.

Study Limitations

While this comprehensive review provides valuable insights, several limitations should be noted:

• Contraceptive hormones remain first-line treatment despite low-quality evidence supporting their effectiveness for fibroid-related bleeding
• Many clinical trials excluded patients with large or submucosal fibroids, limiting generalizability of findings for these common presentations
• Oral GnRH antagonist combinations do not provide contraception, creating limitations for long-term use
• Selective progesterone-receptor modulators aren't available in the United States due to concerns about rare but severe hepatic toxicity
• More research is needed on long-term outcomes beyond 24 months for newer medical therapies

Source Information

Original Article Title: Uterine Fibroids
Authors: Elizabeth A. Stewart, M.D. and Shannon K. Laughlin-Tommaso, M.D., M.P.H.
Publication: The New England Journal of Medicine, November 7, 2024
DOI: 10.1056/NEJMcp2309623

This patient-friendly article is based on peer-reviewed research originally published in The New England Journal of Medicine. It preserves all significant findings, data points, and clinical recommendations from the original work while making the information accessible to educated patients.