Introduction

Uterine fibroids are non-cancerous tumours found in the smooth muscle of the uterus. Although most are benign, they could also be cancerous sometimes. They are most commonly found in individuals assigned female at birth (AFAB) of reproductive age. However, they can affect individuals AFAB of all ages. It is estimated that nearly 80% of individuals AFAB in their 50s have uterine fibroids worldwide.¹ Uterine fibroids are also known as uterine myomas, and they can vary in size and amount depending on hormonal and genetic features. 

The clinical presentation of fibroids includes abnormal menstrual bleeding, pressure and pain in the pelvic area. It is common not to experience any symptoms. However, some may experience all symptoms severely and frequently. These symptoms are specific to the individual and are very important in guiding diagnosis and treatment for healthcare professionals. 

Bleeding symptoms 

The most common clinical presentation of uterine fibroids is abnormal uterine bleeding. This includes bleeding heavily during your periods, having a prolonged period and irregular bleeding between periods.² Menorrhagia is known as heavy menstrual bleeding and is essentially diagnosed if you are passing large clots and having to change pads or tampons frequently during your period. Heavy menstrual bleeding tends to affect individuals (AFAB) who are on anticoagulation and those who have an associated bleeding disorder.³ 

The duration of menstrual bleeding is also important in indicating a healthy uterine lining. Periods typically last from 3 to 7 days, and anything lasting more than 7 days is considered prolonged menstruation.⁴ Nevertheless, irregular periods occur when there are changes to the normal pattern of the menstrual cycle. This indicates that your cycle may have a longer or shorter duration. 

Similarly, bleeding can be heavier or lighter than normal. Irregular bleeding also refers to bleeding between periods and not having periods each calendar month. The underlying causes associated with irregular periods are due to oestrogen and progesterone hormone levels changing frequently.⁵ Treatment for abnormal bleeding is very important, as heavy periods can lead to iron-deficiency anaemia. If you are experiencing heavy periods with symptoms such as fatigue, dizziness and shortness of breath, this can indicate anaemia. 

Pressure symptoms

Pressure on surrounding organs like the bladder and bowel depends on the size and number of uterine fibroids.⁶ Bloating or pressure can be felt near the lower stomach, which can cause discomfort. Pressure in the lower stomach can cause heaviness in the area. If fibroids are close enough to the bladder to press on it, this will result in various bladder problems, such as having to go to the toilet urgently to empty the bladder or having difficulties doing so. On the other hand, if the fibroids press against the bowel, you may experience constipation and bloating.⁷

Many fibroids are also asymptomatic and do not cause pressure-like symptoms. However, if the fibroids are found inside the uterus, this may create fertility problems and make it difficult to get pregnant. Studies have shown an increased risk of miscarriage in pregnancies with fibroids in comparison to those who do not have any.⁸ In addition, there are possibilities of pain and bleeding in early pregnancies if the uterine fibroids are large in size and close to the placenta. Surgery may be required for removal.⁹

Pain symptoms

Pelvic pain symptoms associated with fibroids can vary from mild to severe and may affect your day-to-day lifestyle. Menstrual cramping, also known as dysmenorrhoea, is known to increase and intensify with the presence of uterine fibroids compared to those that do not have any.¹⁰ Although pelvic pain is commonly experienced, larger fibroids outside of the uterus can cause lower back or leg pain, depending on their location. 

The severity of pain experienced by those with fibroids is dependent on the person's body mass index, age, reproductivity, and menopausal status.¹⁰  Pain symptoms may only be present during your period or can happen at any time during the menstrual cycle. Nevertheless, the second most common pain seen with the presence of uterine fibroids is during intercourse, which is also called dyspareunia.¹¹ Approximately 10% of the United States AFAB population is affected by dyspareunia, which affects quality of life and increases chances of sexual dysfunction.¹² There is also an increased risk of psychological stress and relationship problems developing with dyspareunia. 

Symptoms of pain can be cured by taking over-the-counter painkillers like paracetamol and aspirin. These are a quick and effective way of relieving symptoms of pain without the need for a prescription. Alternatively, a study has shown oral contraceptives to be effective in reducing symptoms of pain for secondary dysmenorrhoea.¹³ Non-medical options to relieve the symptoms of pain include having a warm bath and applying a hot water bottle to the abdomen. 

Additional clinical presentations

Severe symptoms of bleeding, pain and pressure can indicate fertility issues, iron-deficiency anaemia and other health complications. Infertility and miscarriages can be associated with fibroids if they are present near the fallopian tubes.¹⁴ In this case, there may be a blockage of the tubes, making it difficult for the eggs to travel to the uterus. Approximately 10% of infertile individuals AFAB present with fibroid symptoms.¹⁴ Submucosal fibroids, which grow outside of the uterine cavity, tend to be more dangerous as they can cause blockages of the tubes, cut blood supply to the uterus and put pressure on the lining and wall of the uterus. 

Nevertheless, bloating is very common with uterine fibroids, specifically if the fibroids are larger in size. This can even result in abdominal bloating that mimics pregnancy. Also, anaemia is common with abnormally heavy bleeding and passing large clots. If you are experiencing fatigue and tiredness symptoms, then this may be anaemia. Addressing anaemia-related fibroids, taking iron supplements and eating an iron-rich diet can help relieve these symptoms. Alternatively, if these are not improving symptoms of bleeding, pain and pressure, a surgical procedure called a myomectomy could be done, which is essentially removing the fibroids from the uterus surgically.

Risk factors 

There are many risk factors of uterine fibroids, including a family history of uterine fibroids, older age and being premenopausal.¹⁵ In particular, uterine fibroids are more commonly seen in populations of African descent compared with other ethnicities.¹⁶ Nevertheless, environmental and lifestyle factors also affect the risk of uterine fibroids developing. Smoking tobacco and drinking alcohol excessively increase the risk of fibroid development as well as other health complications. Also, other risk factors, such as obesity and vitamin D deficiency, should be addressed by taking vitamin D supplements and maintaining a healthy weight.      

FAQs 

When to see a doctor?

If you are experiencing abnormal bleeding and pain during your period and are having difficulties conceiving, then you should contact your doctor. 

What causes a fibroid pain flare-up?

Flare-ups can be caused by sexual intercourse, extensive sports activities, during your period and bowel movements. 

What causes fibroid pain?

Fibroid pain is caused by pressure on organs, nerves, and muscles surrounding the pelvic region. 

How is the clinical examination of uterine fibroids? 

A physical examination of the pelvis and abdomen helps to check for signs of fibroids. 

What are the signs of cancerous fibroids?

An abnormal growth of uterine fibroids and unusual blood tests can be signs of cancerous fibroids. 

Summary 

Although uterine fibroids can be asymptomatic, some may present with symptoms of pain such as cramping and pain in the pelvis, heavy and abnormal menstrual bleeding and lastly, pressure on the lower stomach, bowel or bladder. These symptoms depend on the location, number and size of the fibroids. 

Whilst some individuals AFAB present with all symptoms severely disrupting their daily lifestyle, some only experience one to two symptoms without major effect. If you are experiencing these symptoms, then you must visit a doctor for an appropriate diagnosis and treatment. Treating uterine fibroids in a timely manner will not only improve quality of life but will also help you reduce the risks of infertility and further health problems.