Fibroids

Definition/diagnostic criteria Fibroids, also known as uterine myomas or leiomyomas, are benign, smooth muscle tumours of the uterus. Most are asymptomatic and discovered incidentally during a pelvic examination or ultrasound. However, when symptoms are present, they may include heavy menstrual bleeding, pelvic pain or pressure, and infertility. The diagnosis is usually clinical, supported by imaging techniques. The gold standard for diagnosis is pelvic ultrasound, with MRI used for further characterisation if needed.

Epidemiology Fibroids are the most common benign tumours in women of reproductive age, with a reported incidence of up to 70-80% by the age of 50. They are more prevalent among African-Caribbean women. The exact aetiology remains unclear, but a combination of genetic, hormonal and environmental factors is involved. Risk factors include age (more common in women in their 30s and 40s), obesity, a family history of fibroids and early onset of menstruation.

Diagnosis
Clinical features: Symptoms vary depending on the size, number and location of the fibroids. Common symptoms include menorrhagia, pelvic pain or pressure, urinary symptoms, constipation and infertility. However, up to 70% of women with fibroids are asymptomatic.

Investigations: The primary modality for diagnosis is transvaginal or abdominal ultrasound, which can determine the size, number and location of fibroids. MRI may be used for further characterisation or when the ultrasound is inconclusive. Additional tests may include FBC to check for anaemia due to heavy menstrual bleeding and other imaging techniques if needed for differential diagnosis.

Treatment Treatment options depend on the severity of symptoms, size and location of the fibroids, age and the patient’s desire for future fertility. Management may range from watchful waiting in asymptomatic cases to medications, non-invasive procedures or surgery.

• Medications: Gonadotropin-releasing hormone (GnRH) analogues, levonorgestrel intrauterine system (LNG-IUS), NSAIDs and tranexamic acid are used to manage symptoms such as heavy menstrual bleeding. However, they do not reduce fibroid size.
• Non-invasive procedures: Uterine artery embolisation (UAE) and MRI-guided focused ultrasound surgery are options for reducing fibroid size and treating symptoms.
• Surgical options: Myomectomy is the surgical removal of fibroids, preserving the uterus and often chosen by women who wish to conceive. Hysterectomy is the removal of the uterus and is a definitive treatment for fibroids.

Prognosis The prognosis for women with fibroids is generally good. Symptomatic fibroids can significantly affect quality of life, but effective treatments are available. Infertility issues can be a significant concern for some women; however, with appropriate treatment, many women with fibroids will conceive and have a normal pregnancy. Recurrence is possible, particularly after myomectomy, with reported rates varying widely Fibroids usually shrink post-menopausally.