The Essentials of Diagnosing and Treating Uterine Fibroids
Uterine fibroids, also known as leiomyomas, are common benign cysts that are typically asymptomatic. It is estimated that 20% to 50% of patients are symptomatic.1 Uterine fibroids are most common among women of reproductive age, but their prevalence increases with age and among those of African descent.1 Recent research suggests that size of the fibroma may impact pregnancy outcomes among this population, and the size of fibroids typically decreases after menopause.2
Risk factors for uterine fibroids include increased parity or nulliparity, menarche after age 16 years or before age 10 years, smoking, use of oral contraceptives, African descent, age older than 40 years, family history of uterine fibroids, and obesity.1 Leiomyomatosis can also be hereditary, which can be identified via a detailed clinical history.3
This review gives a general overview of current US guidelines and recently published research. However, it has been noted that more-robust guidelines are needed.4
Screening and Diagnosis
Diagnosing uterine fibroids should be based on an extensive physical examination and detailed clinical history.5 Current guidelines recommend confirming the diagnosis via ultrasonography scanning.1,5 Results will show an enlarged, irregular-shaped uterus.5 Magnetic resonance imaging is highly sensitive and specific, and can help determine the vascularization and degeneration of the fibromas.5,6
The most common presenting symptoms include abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia.1 However, because most patients with uterine fibroids are asymptomatic, fibroids are typically identified incidentally. For these patients, clinical surveillance is recommended.1
The differential diagnosis for uterine fibroids includes adenomyosis, ectopic pregnancy, endometrial carcinoma, endometrial polyps, endometriosis, metastatic disease, pregnancy, uterine carcinosarcoma, and uterine sarcoma.1
Treatment
Treatment options depend on age, symptoms, and fertility desirability of the patient; location and size of the fibroids; and access to treatment.1 Moreover, treatment will depend on the level of comfortability of providing treatment and experience of the physician. If a surgical procedure is required, referral to a gynecologic surgeon is recommended.
Guideline-recommended medical treatments include hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs.1,7 Other medications are also being investigated, including OBE2109,8 relugolix,9 and CDB-2914.10
Surgical treatment options include hysterectomy, myomectomy, uterine artery embolization, and magnetic-resonance–guided focused ultrasonography surgery.1 Although fibroids often recur after myomectomy, it is often the treatment of choice for premenopausal women. Results of the SONATA trial indicate that sonography-guided transcervical fibroid ablation can reduce fibroid-related symptoms.11
For patients who are approaching menopause or require symptom relief before surgery, gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are recommended.1
Conclusions
Although uterine fibromas are common, multiple treatment options are available, and new therapies are in development. The most important take-away is for physicians to be able to tailor the treatment to their individual patient and work with their colleagues in obstetrics and gynecology, surgery, and endocrinology to deliver the best care.
References
1. De La Cruz MS, Buchanan EM. Uterine fibroids: diagnosis and treatment. Am Fam Physician. 2017;95(2):100-107. https://www.aafp.org/afp/2017/0115/p100.html
2. Al Sulaimani R, Machado L, Al Salmi M. Do large uterine fibroids impact pregnancy outcomes? Oman Med J. 2021;36(4):e292. https://doi.org/10.5001/omj.2021.93
3. Foo T, Nama V, Attygalle AD, et al. Uterine leiomyomatosis in adolescents and young adults (AYAs) may represent a narrow phenotypic variant of FH tumour predisposition syndrome. Fam Cancer. Published online September 14, 2021. https://doi.org/10.1007/s10689-021-00272-y
4. Florence AM, Fatehi M. Leiomyoma. In: StatPearls. StatPearls Publishing; July 20, 2021. https://www.ncbi.nlm.nih.gov/books/NBK538273/
5. Amoah A, Joseph N, Reap S, Quinn S. Appraisal of national and international uterine fibroid management guidelines: a systematic review. BJOG. Published online September 17, 2021. https://doi.org/10.1111/1471-0528.16928
6. American Association of Gynecologic Laparoscopists (AAGL): Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol. 2012;19(2):152-171. https://doi.org/10.1016/j.jmig.2011.09.005
7. Myovant Sciences and Pfizer receive FDA approval for Myfembree®, the first once-daily treatment for heavy menstrual bleeding associated with uterine fibroids. News release. Pfizer. May 26, 2021. Accessed September 22, 2021. https://www.pfizer.com/news/press-release/press-release-detail/myovant-sciences-and-pfizer-receive-fda-approval-myfembreer
8. Efficacy and Safety of OBE2109 in Subjects With Heavy Menstrual Bleeding Associated With Uterine Fibroids (PRIMROSE 2). ClinicalTrials.gov. Accessed September 22, 2021. ClinicalTrials.gov identifier NCT03070951. https://clinicaltrials.gov/ct2/show/NCT03070951
9. Al-Hendy A, Lukes AS, Poindexter AN 3rd, et al. Treatment of uterine fibroid symptoms with relugolix combination therapy. N Engl J Med. 2021;384(7):630-642. https://doi.org/10.1056/nejmoa2008283
10. Treatment of Uterine Fibroids With CDB-2914, an Experimental Selective Progesterone Receptor Antagonist. ClinicalTrials.gov. Accessed September 22, 2021. ClinicalTrials.gov identifier NCT00044876. https://clinicaltrials.gov/ct2/show/NCT00044876
11. Lukes A, Green MA. Three-year results of the SONATA pivotal trial of transcervical fibroid ablation for symptomatic uterine myomata. J Gynecol Surg. Published online October 1, 2020. https://doi.org/10.1089/gyn.2020.0021