Uterine leiomyomas, more commonly referred to as fibroids, are the most common benign pelvic tumors experienced by women.1 An estimated 70% to 80% of women will develop fibroids during their reproductive years.1 Although fibroids are often asymptomatic, they may cause a variety of symptoms that can negatively affect a woman’s quality of life.
Heavy menstrual bleeding is a common symptom of fibroids and can result in anemia and fatigue. Other symptoms of fibroids include cyclic and noncyclic pelvic pain, dyspareunia, and bulk symptoms of abdominal distention, pelvic pressure, urinary frequency, and constipation. Additionally, uterine fibroids have been linked to infertility, pregnancy loss, and preterm birth.2
Fibroids are commonly described by their location: subserosal fibroids project outside of the uterus, intramural are located within the uterine smooth muscle tissue (myometrium), and submucosal extend into the uterine cavity.3 Extent of symptoms and impact on fertility often depend on fibroid location.
The pathophysiology of fibroid development is not completely understood. These benign tumors originate from the myometrium and contain extracellular matrix. The cells involved proliferate under the influence of both estrogen and progesterone, explaining the increase in fibroid prevalence during a woman’s reproductive years and decrease in size after menopause.3 Risk factors for fibroids have been identified through retrospective research studies, but the extent to which each individual factor contributes to fibroid development is unknown. Women at greatest risk of developing fibroids include those of Black race, in the last decade of their reproductive years, and who have a family history of fibroids.2,3
Clinicians should be suspicious of fibroids if a woman reports increasingly heavy menstrual periods, including bleeding through clothing or soaking through sanitary protection at night. Heavier bleeding may be accompanied by the passage of blood clots, increased menstrual cramping, and pelvic pain that is unrelated to the menstrual period. These symptoms often develop gradually over time, which can delay diagnosis and treatment. Although changes in the menstrual cycle are common during the perimenopausal period, fibroids should always be considered for women in the fourth and fifth decades of life who present with these symptoms.
Transvaginal ultrasound is the recommended imaging method for diagnosing fibroids.3,4 Ultrasound images will provide information on the number, location, and size of fibroids, as well as any abnormalities of the uterine cavity that may result from the fibroids. This information will help clinicians tailor the conversation regarding treatment options.
Patient Counseling on Treatment Options for Fibroids
Patient counseling on treatment options for uterine fibroids should be individualized based on the patient’s symptoms, age, desire to maintain fertility, access to therapy, and treatment preferences.4 Treatment also should be tailored to the size and location of fibroids.4
Patient preference on preserving fertility or her uterus is a fundamental aspect that guides the discussion of options and needs to be determined prior to counseling about available treatments.2,3 In addition, women should be asked about their most bothersome symptoms and their goals for treatment. Understanding patients’ expectations is pivotal to suggesting a treatment that meets their needs. Some medical treatments also provide a contraceptive benefit, while others should be avoided during pregnancy.
Women with fibroids that are asymptomatic may require no treatment and can be managed expectantly.4 No established evidence-based guidelines exist for ultrasound surveillance for asymptomatic women. Follow-up is often determined based on examination findings and symptomatology.
For women with fibroids that are symptomatic, the goal of treatment is to reduce or eliminate symptoms, including correction of anemia and improving quality of life. Patients should be educated on both medical and surgical treatment options to aid in the shared decision-making process.
Medical Treatments for Fibroids
Medical management is a first-line treatment option for fibroids because it is noninvasive, uterus sparing, and avoids the risks and recovery associated with surgery. Medical options include nonsteroidal anti-inflammatory drugs (NSAIDs), oral and injectable progestin therapy; levonorgestrel-releasing intrauterine device (IUD); gonadotropin-releasing hormone (GnRH) agonists; combination elagolix/estradiol/norethindrone acetate; and the antifibrinolytic agent tranexamic acid.3-5 Combination oral contraceptive pills also have been used to address heavy bleeding associated with fibroids.3
Many of these medical options for fibroids, such as progesterones and GnRH agonists, alter the menstrual cycle and can result in lighter periods but more unpredictable bleeding or spotting.3 Unscheduled bleeding may be an unacceptable side effect for some women while others can tolerate irregular spotting if it means that they will no longer have prolonged and heavy bleeding. Treatment with GnRH agonists and combination elagolix/estradiol/norethindrone acetate can result in menopausal symptoms and decreased bone mass and, therefore, should be used for only a limited amount of time.
Women should be counseled that if an initial treatment trial is not effective or has bothersome side effects, they can switch to other treatments to find the best option. Communication during this process is important so that treatment can be tailored appropriately.
Surgical Treatments for Uterine Fibroids
Women who are considering surgery for the treatment of fibroids should be counseled on risks and all available treatment options, including medical management as an alternative to surgery. Comorbidities that could further increase surgical risks must be explored. Consultation with a surgical colleague is necessary to determine the most appropriate surgical approach. For all women who choose surgery, anemia should be corrected prior to the procedure. Short-term preoperative use of GnRH agonists may be considered to improve anemia and reduce fibroid bulk before surgery.2-3
Surgical approaches include the following:
- Myomectomy. This involves removal of the fibroid(s) while preserving the uterus. Women may choose this option if they desire a future pregnancy or do not want complete removal of their uterus. Whether or not a myomectomy is appropriate will depend on multiple factors, including the size and location of the fibroid(s).3
- Hysterectomy. Surgical removal of the uterus, with or without removal of the ovaries and fallopian tubes, provides definitive treatment for heavy menstrual bleeding, which is one of the most common symptoms experienced by women with fibroids. Hysterectomy may also be appropriate for women who do not desire future pregnancies, have multiple fibroids, and report symptoms related to the bulk of the fibroids.
Additional available surgical treatments for fibroids include uterine artery embolization and endometrial ablation; magnetic resonance-guided focused ultrasound is less often performed because of difficulty getting insurance approval. The 3 procedures are less invasive than myomectomy and hysterectomy but can affect fertility.3
Conclusion
Uterine fibroids are a common, benign gynecologic condition that may be asymptomatic or result in a range of symptoms. Heavy menstrual bleeding associated with fibroids can result in anemia, fatigue, and decreased quality of life. Clinicians who care for women should ask about menstrual cycle concerns and consider a pelvic ultrasound if fibroids are suspected. Treatment options can be individualized based on a woman’s most concerning symptom, desire to preserve fertility, and discussion of the risks and benefits of both medical and surgical options.
Author’s Note: Throughout this article, I use the terms woman and women, although I understand there are diverse gender identities and not every person with fibroids identifies as a woman. Clinicians should always ask about preferred names, pronouns, and identities to ensure the delivery of sensitive, respectful, and inclusive care.
Heidi Collins Fantasia, PhD, RN, WHNP-BC, FNAP, is an associate professor and department chair in the Solomont School of Nursing, Zuckerberg College of Health Sciences at the University of Massachusetts Lowell. She is a certified women’s health nurse practitioner with extensive experience working in public health settings.
References
- Pavone D, Clemenza S, Sorbi F, Fambrini M, Petraglia F. Epidemiology and risk factors of uterine fibroids. Best Prac Res Clin Obstet Gynaecol. 2018;46:3-11. doi:10.1016/j.bpobgyn.2017.09.00
- Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017;124(10):1501-1512. doi:10.1111/1471-0528.14640
- Vilos GA, Allaire C, Laberge P-Y, Leyland N. The management of uterine leiomyomas J Obstet Gynaecol Canada. 2015;37(2):157-178. doi:10.1016/S1701-2163(15)30338-8
- De La Cruz MS, Buchanan EM. Uterine fibroids: diagnosis and treatment. Am Fam Physician. 2017;95(2):100-107.
- Antoun J. Elagolix, estradiol, and norethindrone kit (Oriahnn) for the management of heavy menstrual bleeding associated with fibroids. Am Fam Physician. 2021;103(8):505-506.
