Uterine leiomyoma

Last updated: September 20, 2022

Summarytoggle arrow icon

Uterine leiomyomas (also known as fibroids) are benign, hormone-sensitive uterine neoplasms. They are classified as either submucosal (beneath the endometrium), intramural (within the muscular uterine wall of the uterus), or subserosal (beneath the peritoneum) and can occur within the uterine corpus or the cervix. Symptoms depend on the location, size, and number of leiomyomas, and include menstrual abnormalities (e.g., menorrhagia), mass effect (e.g., back, abdominal, and/or pelvic pain; bladder and/or bowel dysfunction), and infertility. Ultrasound is typically used to establish the diagnosis. Treatment is selected using shared decision-making, taking into consideration the patient's desire for fertility and/or uterine preservation, menopausal status, and symptom severity. Asymptomatic patients can often be managed expectantly. Treatment for symptomatic patients may include surgery (myomectomy or hysterectomy), nonsurgical interventional treatments (e.g., uterine artery embolization), and/or pharmacotherapy, including gonadotropin-releasing hormone (GnRH) agonists, GnRH antagonists, intrauterine devices (IUDs), and/or oral contraceptives.

Predisposing factors [1][2]

Leiomyomas are classified according to their location. [3]

  • Subserosal leiomyoma: located in the outer uterine wall beneath the peritoneal surface
  • Intramural leiomyoma (most common): growing from within the myometrium wall
  • Submucosal leiomyoma: located directly below the endometrial layer (uterine mucosa)
  • Cervical leiomyoma: located in the cervix
  • Diffuse uterine leiomyomatosis: The uterus is grossly enlarged due to the presence of numerous fibroids.

-

Symptoms depend on the number, size, and location of leiomyomas. Most women have small, asymptomatic fibroids.

General principles [4][5]

Uterine leiomyomas are extremely common (affecting 70% of women) and are often found incidentally on ultrasound; do not attribute abnormal uterine bleeding to leiomyomas until other etiologies have been ruled out! [4][6]

Imaging [5][7]

Ultrasound pelvis (transvaginal, transabdominal)

  • Most appropriate initial test for all patients with a suspected uterine leiomyoma [7]
  • Supportive findings [8]
    • Well-circumscribed hypoechoic solid mass
    • Calcifications and/or cystic areas due to degeneration
    • Mass effect (e.g., hydronephrosis) may be seen in patients with large leiomyomas.

Neither plain radiography nor CT is recommended in the workup of leiomyomas because of poor visualization (unless calcified). [7][9]

Further imaging [7][10]

Although imaging cannot definitively distinguish between a leiomyoma and a leiomyosarcoma, hypervascularity within a solitary heterogeneous uterine mass should raise suspicion for a leiomyosarcoma. [8]

Laboratory studies [4][5][11]

Advanced studies

Not routinely performed; consider in case of diagnostic uncertainty

Consult a gynecologic oncologist early to help guide further diagnostic studies if leiomyosarcoma is suspected (e.g., in patients with continued leiomyoma growth after menopause).

  • Macroscopic
    • Grayish-white surface
    • Homogeneous; tissue bundles on cross-section partly in a whorled pattern
    • Some leiomyomas may involve regressive changes: scar formation, calcification, and cysts
  • Microscopic: Smooth muscle tissue in a whorled pattern with well-demarcated borders, consisting of monoclonal cells interspersed with connective tissue

References:[13]

Overview [4][14]

Management should be based on shared decision-making and tailored to the patient's symptoms and desire for fertility and/or uterine preservation.

Leiomyomas tend to regress after menopause; expectant management or pharmacotherapy as a bridge to menopause is recommended for most perimenopausal patients. [4]

Racial disparity exists in the treatment of leiomyomas: Typically, Black patients are less likely to be offered nonsurgical or minimally invasive therapies than White patients, even after adjusting for clinical features such as leiomyoma size. [4]

Expectant management [4]

Indications

  • Asymptomatic or minimally symptomatic patients
  • Perimenopausal patients

Management

  • Monitor reported symptoms for any worsening at annual well-woman exams.
  • Typically, no active treatment is required.
  • Surveillance imaging is not routinely required. [14]
  • Recommend follow-up if symptoms change or pregnancy is planned.

Pharmacotherapy [4]

  • Medications can either be used long-term for symptom control or temporarily as a bridge until a more definitive modality can be performed.
  • Pharmacotherapy should be selected based on the patient's symptoms.
  • There is currently insufficient evidence to recommend one agent over other for first-line therapy.
Pharmacotherapy for uterine leiomyoma [4]
Predominant symptoms Agents Important considerations
Heavy menstrual bleeding without features of mass effect
  • Difficult insertion if uterine cavity is distorted
  • High rate of IUD expulsion in patients with leiomyomas
  • May be more effective than oral contraceptives at reducing menstrual blood loss [4]
Mass effect with or without heavy menstrual bleeding

Selective progesterone receptor modulators (e.g., ulipristal acetate) and androgenic agonists (e.g., danazol) are used in some countries for the management of leiomyomas; these medication classes are not FDA-approved for managing leiomyomas in the US, as the potential adverse effects are thought to outweigh the benefits.

GnRH antagonists have a faster clinical effect than GnRH agonists, as there is no initial increase in FSH/LH and estrogen with GnRH antagonists.

Nonsurgical interventional treatments [4][17]

Recommended in patients with symptomatic leiomyoma who desire uterine preservation and/or want to avoid surgery.

Uterine artery embolization (UAE)

Radiofrequency ablation (RFA) [4][17]

Additional modalities (not currently recommended)

Nonsurgical interventional therapies preserve the uterus; however, there is insufficient data regarding their effect on fertility to support their use in women who may wish to conceive in the future.

Surgery [4]

Myomectomy

A uterus-preserving surgical option for the removal of leiomyomas

Hysterectomy

  • Indications
    • Patients seeking definitive treatment who do not desire fertility and/or have had an insufficient response to alternative treatments
    • Suspected leiomyosarcoma [20]
  • Approach : vaginal, abdominal, or laparoscopic

Patients often receive GnRH agonists or antagonists prior to surgery to reduce leiomyoma size, which may allow less invasive procedures to be performed. [4]

Differential diagnosis of uterine leiomyoma
Factors Uterine leiomyoma (fibroids) Adenomyosis Endometriosis Uterine polyps Uterine leiomyosarcoma [21][22]
Definition
  • Overgrowth of localized endometrial tissue attached to the inner wall of the uterus, usually benign [23]
Risk factors
Clinical features
  • Symptoms similar to uterine fibroids
  • Menstrual irregularities
  • Postmenopausal bleeding
  • Pelvic pain
Uterine findings
  • Irregularly enlarged, firm
  • Uniformly enlarged
  • Typically not enlarged
  • Typically not enlarged
  • Rapidly enlarging
Pathology

The differential diagnoses listed here are not exhaustive.

We list the most important complications. The selection is not exhaustive.

Uterine leiomyomas during pregnancy [26]

  • Estimates of leiomyoma occurrence during pregnancy range from 2.7% to > 25%. [27]
  • The majority of patients with leiomyomas have good outcomes, but increased surveillance by a maternal-fetal medicine specialist is recommended because of the elevated risk of pregnancy complications.
  • Select appropriate agents to manage pain caused by uterine leiomyomas; see “Analgesics in pregnancy.”
Effects of leiomyomas in pregnancy [26][27]
Common complications
Antenatal period
Peripartum period
Postpartum period

After pregnancy, leiomyomas typically return to their prepartum size; however, some leiomyomas may spontaneously resolve. [28]

  1. Malik M, Norian J, McCarthy-Keith D, Britten J, Catherino WH. Why leiomyomas are called fibroids: the central role of extracellular matrix in symptomatic women.. Semin Reprod Med. 2010; 28 (3): p.169-179. doi: 10.1055/s-0030-1251475 . | Open in Read by QxMD
  2. Ciavattini A, Di Giuseppe J, Stortoni P, et al. Uterine fibroids: Pathogenesis and interactions with endometrium and endomyometrial junction. Obstet Gynecol Int. 2013; 2013 : p.1-11. doi: 10.1155/2013/173184 . | Open in Read by QxMD
  3. Munro MG, Critchley HOD, Fraser IS. The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertil Steril. 2011; 95 (7): p.2204-2208.e3. doi: 10.1016/j.fertnstert.2011.03.079 . | Open in Read by QxMD
  4. Stewart AE, Adelman MR, Jacoby VL. ACOG Practice Bulletin No. 228: Management of Symptomatic Uterine Leiomyomas. Obstet Gynecol. 2021; 137 (6): p.e100-e115. doi: 10.1097/aog.0000000000004401 . | Open in Read by QxMD
  5. Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women. Updated: July 1, 2012. Accessed: September 15, 2022.
  6. Stewart E, Cookson C, Gandolfo R, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017; 124 (10): p.1501-1512. doi: 10.1111/1471-0528.14640 . | Open in Read by QxMD
  7. Fibroids. https://acsearch.acr.org/docs/3188532/Narrative/. Updated: April 1, 2022. Accessed: September 13, 2022.
  8. Arleo EK, Schwartz PE, Hui P, McCarthy S. Review of Leiomyoma Variants. AJR Am J Roentgenol. 2015; 205 (4): p.912-921. doi: 10.2214/ajr.14.13946 . | Open in Read by QxMD
  9. Forstner R, Cunha TM, Hamm B. MRI and CT of the Female Pelvis. Springer ; 2018
  10. Lumsden MA, Hamoodi I, Gupta J, Hickey M. Fibroids: diagnosis and management. BMJ. 2015 : p.h4887. doi: 10.1136/bmj.h4887 . | Open in Read by QxMD
  11. ACOG. Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. Obstetrics & Gynecology. 2013; 121 (4): p.891-896. doi: 10.1097/01.aog.0000428646.67925.9a . | Open in Read by QxMD
  12. ACOG. Uterine Morcellation for Presumed Leiomyomas. Obstetrics & Gynecology. 2021; 137 (3): p.e63-e74. doi: 10.1097/aog.0000000000004291 . | Open in Read by QxMD
  13. Uterus Stromal tumors Leiomyoma. http://www.pathologyoutlines.com/topic/uterusleiomyoma.html. Updated: February 9, 2017. Accessed: March 14, 2017.
  14. Memarzadeh S, Berek JS. Uterine sarcoma: Classification, epidemiology, clinical manifestations, and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/uterine-sarcoma-classification-epidemiology-clinical-manifestations-and-diagnosis.Last updated: November 1, 2019. Accessed: June 22, 2020.
  15. Roberts ME, Aynardi JT, Chu CS. Uterine leiomyosarcoma: A review of the literature and update on management options. Gynecol Oncol. 2018; 151 (3): p.562-572. doi: 10.1016/j.ygyno.2018.09.010 . | Open in Read by QxMD
  16. Wethington SL, Herzog TJ, Burke WM, et al. Risk and Predictors of Malignancy in Women with Endometrial Polyps. Ann Surg Oncol. 2011; 18 (13): p.3819-3823. doi: 10.1245/s10434-011-1815-z . | Open in Read by QxMD
  17. Stewart E. Uterine adenomyosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/uterine-adenomyosis?source=search_result&search=adenomyosis&selectedTitle=1~51#H6.Last updated: February 9, 2017. Accessed: February 17, 2017.
  18. Oliva E. Practical issues in uterine pathology from banal to bewildering: the remarkable spectrum of smooth muscle neoplasia. Modern Pathology. 2015; 29 (S1): p.S104-S120. doi: 10.1038/modpathol.2015.139 . | Open in Read by QxMD
  19. De La Cruz MS, Buchanan EM. Uterine Fibroids: Diagnosis and Treatment. Am Fam Physician. 2017; 95 (2): p.100-107.
  20. Al-Hendy A, Lukes AS, Poindexter AN, et al. Treatment of Uterine Fibroid Symptoms with Relugolix Combination Therapy. N Engl J Med. 2021; 384 (7): p.630-642. doi: 10.1056/nejmoa2008283 . | Open in Read by QxMD
  21. Wright D, Kim JW, Lindsay H, Catherino WH. A Review of GnRH Antagonists as Treatment for Abnormal Uterine Bleeding-Leiomyoma (AUB-L) and Their Influence on the Readiness of Service Members. Mil Med. 2022 . doi: 10.1093/milmed/usac078 . | Open in Read by QxMD
  22. Expert Panel on Interventional Radiology:., Knuttinen MG, Stark G, et al. ACR Appropriateness Criteria: Radiologic Management of Uterine Leiomyomas. J Am Coll Radiol. 2018; 15 (5S): p.S160-S170. doi: 10.1016/j.jacr.2018.03.010 . | Open in Read by QxMD
  23. Schirf BE, Vogelzang RL, Chrisman HB. Complications of uterine fibroid embolization.. Seminars in interventional radiology. 2006; 23 (2): p.143-9. doi: 10.1055/s-2006-941444 . | Open in Read by QxMD
  24. Vitale SG, Padula F, Gulino FA. Management of uterine fibroids in pregnancy. Curr Opin Obstet Gynecol. 2015; 27 (6): p.432-437. doi: 10.1097/gco.0000000000000220 . | Open in Read by QxMD
  25. Ghirardi V, Bizzarri N, Guida F, et al. Role of surgery in gynaecological sarcomas. Oncotarget. 2019; 10 (26): p.2561-2575. doi: 10.18632/oncotarget.26803 . | Open in Read by QxMD
  26. Lee HJ, Norwitz ER, Shaw J. Contemporary management of fibroids in pregnancy.. Reviews in obstetrics & gynecology. 2010; 3 (1): p.20-7.
  27. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008; 198 (4): p.357-366. doi: 10.1016/j.ajog.2007.12.039 . | Open in Read by QxMD
  28. Delli Carpini G, Morini S, Papiccio M, et al. The association between childbirth, breastfeeding, and uterine fibroids: an observational study. Sci Rep. 2019; 9 (1). doi: 10.1038/s41598-019-46513-0 . | Open in Read by QxMD

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer