Uterine fibroids (leiomyomas) are benign growths of the smooth muscle of the uterus and are the most common pelvic tumor in women, especially in Black women. Many cause no symptoms, but some lead to heavy bleeding, anemia, pelvic pressure or trouble getting pregnant.
Key symptoms
- Heavy or prolonged menstrual bleeding, sometimes with clots
- Pelvic pressure, bloating or a lower belly that looks bigger
- Frequent urination or constipation from pressure on the bladder or bowel
- Painful periods or pain during sex
- Fatigue and shortness of breath from iron deficiency anemia
What you find on exam
- Enlarged, firm, irregular uterus on bimanual exam
- Mass felt above the pubic bone when the uterus is large
- Pale skin and conjunctiva, fast heart rate if anemic
- Speculum exam to rule out a cervical or vaginal source of bleeding
Tests
- Pregnancy test in every patient of reproductive age
- Transvaginal and pelvic ultrasound as the first imaging test
- Blood count and ferritin to look for anemia
- Saline sonogram, hysteroscopy or MRI to map fibroids; endometrial biopsy if at risk for cancer
Treatment basics
- No symptoms: watchful waiting; fibroids often shrink after menopause
- Bleeding control: NSAIDs, tranexamic acid, hormonal contraceptives or a levonorgestrel IUD
- GnRH agonist or antagonist (leuprolide, relugolix combination) to shrink fibroids or stop bleeding short term
- Iron replacement for anemia
- Procedures: myomectomy to keep fertility, uterine artery embolization or hysterectomy
Red flags
- Heavy bleeding with dizziness, fainting or a falling hemoglobin
- A mass that grows quickly after menopause (concern for sarcoma)
- Sudden severe pelvic pain with fever (degenerating or twisted fibroid)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.