Fibroids consist of a combination of smooth muscle cells and fibroblasts, resulting in dense, spherical, and convoluted tumours inside the myometrium. The pathogenesis of fibroids is not fully understood; nevertheless, it is hypothesised that each fibroid originates from a mutation in a solitary smooth muscle cell. The uterus is the most prevalent location for fibroids. The geographical setting may influence symptoms and overall quality of life. Submucous fibroids may cause excessive monthly flow and reproductive issues, whereas big fibroids may be situated in many sites and can extend beyond the uterine cavity to the serosal surface.¹

Uterine fibroids, also known as leiomyomas, are the most prevalent benign gynaecological tumours. They consist of smooth muscle and connective tissue. The majority of fibroids are asymptomatic; nonetheless, their quantity, location, and size may result in the emergence of the symptoms detailed below.  They may be singular or many, with variations in size and positioning inside the uterus.²

Clinical manifestations of uterine fibroids

Heavy menstrual bleeding

Menorrhagia, characterised by excessive menstrual flow, impacts 30-50% of women with uterine fibroids. This symptom is most prevalent in women with submucosal fibroids, which develop under the uterine lining and alter the endometrial cavity. These fibroids augment the surface area of the endometrial lining, resulting in increased haemorrhage. Moreover, fibroids may disrupt the uterus's regular contractions, which are crucial for regulating blood flow. Women exhibiting this symptom may endure extended menstrual cycles, frequent alterations of sanitary goods, or the expulsion of substantial blood clots.

Pelvic pain

Pelvic discomfort affects 20-30% of women diagnosed with uterine fibroids. This pain often results from large fibroids exerting pressure on adjacent pelvic organs, including the bladder or rectum. In some instances, fibroids may exceed their blood supply, resulting in deterioration and severe, localised discomfort. The intensity of pelvic discomfort is contingent upon the size, location, and quantity of fibroids and may exacerbate during menstruation owing to heightened uterine contractions.

Frequent urination

Approximately 25% of women with uterine fibroids have frequent urination, especially when the tumours are situated near the bladder. The strain from fibroids might diminish bladder capacity, leading to an elevated need to pee. This symptom is particularly prevalent in women with substantial fibroids or those located in the anterior uterus. Untreated, frequent urination may interfere with everyday activities and adversely affect sleep quality.

Constipation

Constipation affects 10-20% of women with uterine fibroids, particularly when the tumours are situated in the posterior uterus. These fibroids may exert pressure on the rectum, complicating bowel movements. In some instances, this pressure may also induce a feeling of incomplete evacuation. Dietary modifications or medication intervention may be required to address constipation resulting from fibroids.

Back pain

Back discomfort, affecting 10-15% of women with uterine fibroids, is often linked to sizable fibroids situated on the posterior wall of the uterus. These fibroids may exert pressure on spinal nerves, resulting in discomfort that might radiate to the lower back or legs. The pain is often characterised as a dull, persistent aching that may intensify during menstruation.

Abdominal swelling

Abdominal distension or bloating occurs in 20-30% of women with uterine fibroids. This symptom is particularly prevalent in instances of big or numerous fibroids, since their size may lead to uterine enlargement. The edema may mimic pregnancy or weight increase, resulting in physical pain or self-awareness. In extreme instances, an enlarged uterus may compress adjacent abdominal organs, intensifying symptoms such as pelvic discomfort and constipation.

Pain during intercourse

Dyspareunia, or pain during intercourse, impacts 15-20% of women with uterine fibroids. This discomfort is often associated with fibroids located around the cervix or lower uterus. The pressure or distortion induced by these fibroids may make some sexual postures unpleasant or painful.  Women exhibiting this symptom are advised to seek consultation with their healthcare physician to investigate therapeutic alternatives that may enhance their quality of life.

Menstrual irregularities

Menstrual abnormalities, including intermenstrual spotting or extended cycles, affect 20-25% of women with uterine fibroids. These anomalies often arise from disturbances in the hormonal and structural milieu of the uterus. Submucosal fibroids are more prone to induce erratic bleeding.  Women exhibiting these symptoms should pursue medical assessment to exclude other reasons, including hormone abnormalities or endometrial polyps.

Anemia

Anaemia, a prevalent consequence of excessive menstrual bleeding, impacts 20-30% of women with uterine fibroids. Profuse haemorrhage diminishes erythrocyte levels, resulting in manifestations such as weariness, weakness, and dyspnea. Severe anaemia may need interventions such as iron supplements or blood transfusions. Treating the underlying fibroids is crucial for the long-term resolution of anaemia.

Fatigue

Fatigue, often associated with anaemia, is observed by 20-30% of women diagnosed with uterine fibroids. Anaemia diminishes the blood's oxygen-carrying capacity, resulting in chronic fatigue or low energy levels in people. This condition may profoundly affect everyday living, hindering concentration on the job, exercise, or social engagements. Addressing both anaemia and fibroids is essential for mitigating tiredness.^3,4

Diagnostic evaluation of uterine fibroids

How are uterine fibroids diagnosed?

The diagnosis of uterine fibroids starts with a comprehensive patient history and physical assessment. During the examination, a healthcare professional may identify an enlarged or abnormally shaped uterus, perhaps indicating the existence of fibroids. Imaging examinations are often essential to validate the diagnosis and evaluate the size, location, and quantity of fibroids. These tests also assist in excluding other illnesses with similar symptoms, such as ovarian cysts or endometrial polyps. Based on the patient's symptoms and medical history, more tests may be advised for a more thorough assessment.⁵

Pelvic ultrasound

A pelvic ultrasound is a non-invasive diagnostic procedure that uses sound waves to provide precise pictures of the uterus and adjacent organs. The procedure may be conducted transabdominally (across the belly) or transvaginally (inside the vagina), with the latter yielding more accurate visuals.  During the examination, a gel is administered to the skin, and a portable apparatus known as a transducer is manoeuvred over the region to acquire pictures. Transvaginal ultrasounds entail the insertion of a diminutive transducer into the vaginal canal. This examination is crucial for detecting fibroids, evaluating their dimensions, and ascertaining their position inside the uterus.⁶

Ultrasound pictures showing well-defined, solid lumps inside the uterus often suggest the presence of fibroids. These tumours often present as hypoechoic regions relative to the adjacent uterine tissue. The dimensions and quantity of fibroids are recorded to inform treatment choices. If an ultrasound fails to identify fibroids while symptoms continue, other imaging tests, such as MRI, may be advised for enhanced clarity. An unfavourable ultrasound finding may need further exploration of other underlying causes of symptoms.

What if all tests are negative but symptoms persist?

In the event that diagnostic tests provide negative results while symptoms persist, it is crucial to collaborate closely with your healthcare physician. They may suggest advanced imaging examinations or send you to a specialist, such as a gynaecologist, for further assessment. Ongoing symptoms must not be overlooked, since they may signify an underlying illness for intervention. Transparent communication with your healthcare team is crucial for accurately diagnosing and formulating an effective treatment strategy.

When do fibroids need to be treated, and how do doctors and patients select the best treatment? 

Fibroids need treatment alone when they produce symptoms.  Hysterectomy, myomectomy, or uterine artery embolisation should be considered for fibroids above 3 cm that induce significant monthly bleeding and impair quality of life. The primary clinical consideration in assessing prospective treatment options is the goal for fertility, uterine preservation, or both.  This often guides the choices among observational management, medicinal treatment, radiological intervention, uterine-preserving surgery, and hysterectomy.^7,8

A hysterectomy is the conclusive approach to alleviating symptoms related to uterine fibroids; nevertheless, it results in permanent infertility and is seen by many women as more intrusive than other treatments.⁹

Medical interventions for fibroids should be aimed at alleviating symptoms. Mefenamic acid and tranexamic acid, which may alleviate excessive menstrual bleeding and discomfort, are considered safe and are often well tolerated.  As they are used just during menstruation, significant adverse effects are rare.

Hormonal therapies for menorrhagia specifically include the oral contraceptive pill, oral norethisterone, and the levonorgestrel-releasing intrauterine device; however, effectiveness trials have excluded women with conditions beyond minor uterine fibroids.  Both progesterone and estrogen may, however, stimulate the proliferation of fibroids.  Selective progesterone receptor modulators now provide an option for the medicinal therapy of fibroids. A multitude of randomised controlled studies have shown that these medicines diminish haemorrhage and decrease fibroid size.  Ulipristal acetate has just received approval for short-term usage in surgical preparation (three months) and long-term intermittent use (≥12 months) where surgery can be avoided.

Gonadotrophin-releasing hormone agonists are recognised therapies used in primary care, often beginning in secondary care, to alleviate symptoms associated with fibroids, especially those related to size. These agonists are beneficial just during the course of treatment, and symptoms often reemerge upon cessation of therapy.¹⁰