Uterine Fibroids: Diagnosis and Treatment

 

Am Fam Physician. 2017 Jan 15;95(2):100-107.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/uterine-fibroids.html.

Author disclosure: No relevant financial affiliations.

Uterine fibroids are common benign neoplasms, with a higher prevalence in older women and in those of African descent. Many are discovered incidentally on clinical examination or imaging in asymptomatic women. Fibroids can cause abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia. Ultrasonography is the preferred initial imaging modality. Expectant management is recommended for asymptomatic patients because most fibroids decrease in size during menopause. Management should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to maintain fertility, and access to treatment; and the experience of the physician. Medical therapy to reduce heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs. Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause. Surgical treatment includes hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance–guided focused ultrasound surgery.

Uterine fibroids, or leiomyomas, are the most common benign tumors in women of reproductive age.1 Their prevalence is age dependent; they can be detected in up to 80% of women by 50 years of age.2 Fibroids are the leading indication for hysterectomy, accounting for 39% of all hysterectomies performed annually in the United States.3 Although many are detected incidentally on imaging in asymptomatic women, 20% to 50% of women are symptomatic and may wish to pursue treatment.4

WHAT IS NEW ON THIS TOPIC: UTERINE FIBROIDS

Compared with total laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy, vaginal hysterectomy is associated with shorter operative time, less blood loss, shorter paralytic ileus time, and shorter hospitalization.

In 2014, the U.S. Food and Drug Administration recommended limiting the use of laparoscopic power morcellation to reproductive-aged women who are not candidates for en bloc uterine resection. Morcellation should not be used in women with suspected or known uterine cancer.

An estimated 15% to 33% of fibroids recur after myomectomy, and approximately 10% of women undergoing myomectomy will undergo a hysterectomy within five to 10 years.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography is the recommended initial imaging modality for diagnosis of uterine fibroids.

C

4, 25

Management of uterine fibroids should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to preserve fertility, and access to therapy; and the physician's experience.

C

4, 11

Expectant management is appropriate for women with asymptomatic uterine fibroids.

C

4

In women undergoing hysterectomy for treatment of uterine fibroids, the least invasive approach possible should be chosen.

B

39, 43


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography is the recommended initial imaging modality for diagnosis of uterine fibroids.

C

4, 25

Management of uterine fibroids should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to preserve fertility, and access to therapy; and the physician's experience.

C

4, 11

Expectant management is appropriate for women with asymptomatic uterine fibroids.

C

4

In women undergoing hysterectomy for treatment of uterine fibroids, the least invasive approach possible should be chosen.

B

39, 43


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Epidemiology and Etiology

Fibroids are benign tumors that originate from the uterine smooth muscle tissue (myometrium) whose growth is dependent on estrogen and progesterone.5,6 Fibroids are rare before puberty, increase in prevalence during the reproductive years, and decrease in size after menopause.6 Aromatase in fibroid tissue allows for endogenous production of estradiol, and fibroid stem cells express estrogen and progesterone receptors that facilitate tumor growth in the presence of these hormones.

The Authors

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MARIA SYL D. DE LA CRUZ, MD, is an assistant professor and the assistant clerkship director in the Department of Family and Community Medicine at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa....

EDWARD M. BUCHANAN, MD, is an assistant professor specializing in maternal-child care in the Department of Family and Community Medicine at the Sidney Kimmel Medical College at Thomas Jefferson University.

Address correspondence to Maria Syl D. de la Cruz, MD, Sidney Kimmel Medical College at Thomas Jefferson University, 833 Chestnut St., Ste. 301, Philadelphia, PA 19107 (e-mail: mariasyl.delacruz@jefferson.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol. 2004;104(2):393–406....

2. Zimmermann A, Bernuit D, Gerlinger C, et al. Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Womens Health. 2012;12(1):6.

3. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol. 2008;198(1):34.e1–34.e7.

4. Vilos GA, Allaire C, Laberge PY, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015;37(2):157–181.

5. Bulun SE. Uterine fibroids. N Engl J Med. 2013;369(14):1344–1355.

6. Ishikawa H, Ishi K, Serna VA, et al. Progesterone is essential for maintenance and growth of uterine leiomyoma. Endocrinology. 2010;151(6):2433–2442.

7. Ross RK, Pike MC, Vessey MP, et al. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives [published correction appears in Br Med J (Clin Res Ed). 1986;293(6553):1027]. Br Med J (Clin Res Ed). 1986;293(6543):359–362.

8. Ryan GL, Syrop CH, Van Voorhis BJ. Role, epidemiology, and natural history of benign uterine mass lesions. Clin Obstet Gynecol. 2005;48(2):312–324.

9. Chiaffarino F, Parazzini F, La Vecchia C, et al. Use of oral contraceptives and uterine fibroids: results from a case-control study. Br J Obstet Gynaecol. 1999;106(8):857–860.

10. Stewart EA, Nicholson WK, Bradley L, et al. The burden of uterine fibroids for African-American women: results of a national survey. J Womens Health (Larchmt). 2013;22(10):807–816.

11. Munro MG, Storz K, Abbott JA, et al. Practice guidelines for the management of hysteroscopic distending media. J Minim Invasive Gynecol. 2013;20(2):137–148.

12. Drayer SM, Catherino WH. Prevalence, morbidity, and current medical management of uterine leiomyomas. Int J Gynaecol Obstet. 2015;131(2):117–122.

13. Bukulmez O, Doody KJ. Clinical features of myomas. Obstet Gynecol Clin North Am. 2006;33(1):69–84.

14. Carranza-Mamane B, Havelock J, Hemmings R, et al. The management of uterine fibroids in women with otherwise unexplained infertility. J Obstet Gynaecol Can. 2015;37(3):277–288.

15. Metwally M, Cheong YC, Horne AW. Surgical treatment of fibroids for subfertility. Cochrane Database Syst Rev. 2012;(11):CD003857.

16. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2009;91(4):1215–1223.

17. De Vivo A, Mancuso A, Giacobbe A, et al. Uterine myomas during pregnancy: a longitudinal sonographic study. Ultrasound Obstet Gynecol. 2011;37(3):361–365.

18. Hammoud AO, Asaad R, Berman J, et al. Volume change of uterine myomas during pregnancy: do myomas really grow? J Minim Invasive Gynecol. 2006;13(5):386–390.

19. Stout MJ, Odibo AO, Graseck AS, et al. Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol. 2010;116(5):1056–1063.

20. Klatsky PC, Tran ND, Caughey AB, et al. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008;198(4):357–366.

21. Knight J, Falcone T. Tissue extraction by morcellation: a clinical dilemma. J Minim Invasive Gynecol. 2014;21(3):319–320.

22. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387–400.

23. Practice Committee of American Society for Reproductive Medicine; Society of Reproductive Surgeons. Myomas and reproductive function. Fertil Steril. 2008;90(5 suppl):S125–S130.

24. Singh SS, Belland L. Contemporary management of uterine fibroids: focus on emerging medical treatments [published correction appears in Curr Med Res Opin. 2016;32(4):797]. Curr Med Res Opin. 2015;31(1):1–12.

25. Dueholm M, Lundorf E, Hansen ES, et al. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol. 2002;186(3):409–415.

26. Cicinelli E, Romano F, Anastasio PS, et al. Transabdominal sonohysterography, transvaginal sonography, and hysteroscopy in the evaluation of submucous myomas. Obstet Gynecol. 1995;85(1):42–47.

27. Thomassin-Naggara I, Dechoux S, Bonneau C, et al. How to differentiate benign from malignant myometrial tumours using MR imaging. Eur Radiol. 2013;23(8):2306–2314.

28. Bonneau C, Thomassin-Naggara I, Dechoux S, et al. Value of ultra-sonography and magnetic resonance imaging for the characterization of uterine mesenchymal tumors. Acta Obstet Gynecol Scand. 2014;93(3):261–268.

29. Varelas FK, Papanicolaou AN, Vavatsi-Christaki N, et al. The effect of anastrazole on symptomatic uterine leiomyomata. Obstet Gynecol. 2007;110(3):643–649.

30. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA. 2014;312(12):1253–1255.

31. Fleischer AC, James AE Jr, Millis JB, et al. Differential diagnosis of pelvic masses by gray scale sonography. AJR Am J Roentgenol. 1978;131(3):469–476.

32. Lethaby A, Vollenhoven B, Sowter M. Efficacy of pre-operative gonadotrophin hormone releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy. BJOG. 2002;109(10):1097–1108.

33. Sayed GH, Zakherah MS, El-Nashar SA, et al. A randomized clinical trial of a levonorgestrel-releasing intrauterine system and a low-dose combined oral contraceptive for fibroid-related menorrhagia. Int J Gynaecol Obstet. 2011;112(2):126–130.

34. Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013;(1):CD000400.

35. Tristan M, Orozco LJ, Steed A, et al. Mifepristone for uterine fibroids. Cochrane Database Syst Rev. 2012;(8):CD007687.

36. Donnez J, Tatarchuk TF, Bouchard P, et al. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med. 2012;366(5):409–420.

37. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4):CD000249.

38. Lukes AS, Moore KA, Muse KN, et al. Tranexamic acid treatment for heavy menstrual bleeding. Obstet Gynecol. 2010;116(4):865–875.

39. Aarts JW, Nieboer TE, Johnson N, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;(8):CD003677.

40. Stewart EA, Gostout B, Rabinovici J, et al. Sustained relief of leiomyoma symptoms by using focused ultrasound surgery. Obstet Gynecol. 2007;110(2 pt 1):279–287.

41. Bhave Chittawar P, Franik S, et al. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2014;(10):CD004638.

42. Gupta JK, Sinha A, Lumsden MA, et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2014;(12):CD005073.

43. Sesti F, Cosi V, Calonzi F, et al. Randomized comparison of total laparoscopic, laparoscopically assisted vaginal and vaginal hysterectomies for myomatous uteri. Arch Gynecol Obstet. 2014;290(3):485–491.

44. Hwang JL, Seow KM, Tsai YL, et al. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g. Acta Obstet Gynecol Scand. 2002;81(12):1132–1138.

45. Zapata LB, Whiteman MK, Tepper NK, et al. Intrauterine device use among women with uterine fibroids. Contraception. 2010;82(1):41–55.

46. Venkatachalam S, Bagratee JS, Moodley J. Medical management of uterine fibroids with medroxyprogesterone acetate (Depo Provera). J Obstet Gynaecol. 2004;24(7):798–800.

47. Verspyck E, Marpeau L, Lucas C. Leuprorelin depot 3.75 mg versus lynestrenol in the preoperative treatment of symptomatic uterine myomas. Eur J Obstet Gynecol Reprod Biol. 2000;89(1):7–13.

48. Ichigo S, Takagi H, Matsunami K, et al. Beneficial effects of dienogest on uterine myoma volume. Arch Gynecol Obstet. 2011;284(3):667–670.

49. Ip PP, Lam KW, Cheung CL, et al. Tranexamic acid-associated necrosis and intralesional thrombosis of uterine leiomyomas. Am J Surg Pathol. 2007;31(8):1215–1224.

50. Peitsidis P, Koukoulomati A. Tranexamic acid for the management of uterine fibroid tumors. World J Clin Cases. 2014;2(12):893–898.

51. Milsom I, Andersson K, Andersch B, et al. A comparison of flurbiprofen, tranexamic acid, and a levonorgestrel-releasing intrauterine contraceptive device in the treatment of idiopathic menorrhagia. Am J Obstet Gynecol. 1991;164(3):879–883.

52. Carbonell Esteve JL, Acosta R, Heredia B, et al. Mifepristone for the treatment of uterine leiomyomas. Obstet Gynecol. 2008;112(5):1029–1036.

53. Hilário SG, Bozzini N, Borsari R, et al. Action of aromatase inhibitor for treatment of uterine leiomyoma in perimenopausal patients. Fertil Steril. 2009;91(1):240–243.

54. Gurates B, Parmaksiz C, Kilic G, et al. Treatment of symptomatic uterine leiomyoma with letrozole. Reprod Biomed Online. 2008;17(4):569–574.

55. Song H, Lu D, Navaratnam K, et al. Aromatase inhibitors for uterine fibroids. Cochrane Database Syst Rev. 2013;(10):CD009505.

56. Sadan O, Ginath S, Sofer D, et al. The role of tamoxifen in the treatment of symptomatic uterine leiomyomata—a pilot study. Eur J Obstet Gynecol Reprod Biol. 2001;96(2):183–186.

57. Deng L, Wu T, Chen XY, et al. Selective estrogen receptor modulators (SERMs) for uterine leiomyomas. Cochrane Database Syst Rev. 2012;(10):CD005287.

58. U.S. Food and Drug Administration. Updated: laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDAsafety communication. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm. Accessed January 20, 2016.

59. American College of Obstetricians and Gynecologists. Power morcellation and occult malignancy in gynecologic surgery. http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group-Reports/Power-Morcellation-and-Occult-Malignancy-in-Gynecologic-Surgery. Accessed January 20, 2016.

60. Bogani G, Cliby WA, Aletti GD. Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma. Gynecol Oncol. 2015;137(1):167–172.

61. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine women's health study: I. outcomes of hysterectomy. Obstet Gynecol. 1994;83(4):556–565.

62. Camanni M, Bonino L, Delpiano EM, et al. Hysteroscopic management of large symptomatic submucous uterine myomas. J Minim Invasive Gynecol. 2010;17(1):59–65.

63. Goodwin SC, Spies JB. Uterine fibroid embolization. N Engl J Med. 2009;361(7):690–697.

64. Hirst A, Dutton S, Wu O, et al. A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. Health Technol Assess. 2008;12(5):1–248.

65. Taran FA, Tempany CM, Regan L, et al.; MRgFUS Group. Magnetic resonance-guided focused ultrasound (MRgFUS) compared with abdominal hysterectomy for treatment of uterine leiomyomas. Ultrasound Obstet Gynecol. 2009;34(5):572–578.

66. Quinn SD, Vedelago J, Gedroyc W, et al. Safety and five-year re-intervention following magnetic resonance-guided focused ultrasound (MRgFUS) for uterine fibroids. Eur J Obstet Gynecol Reprod Biol. 2014;182:247–251.

67. Rabinovici J, David M, Fukunishi H, et al.; MRgFUS Study Group. Pregnancy outcome after magnetic resonance-guided focused ultrasound surgery (MRgFUS) for conservative treatment of uterine fibroids. Fertil Steril. 2010;93(1):199–209.

68. Evans P, Brunsell S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician. 2007;75(10):1503–1508.

 

 

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