Symptoms - of the Disease

Fact Explanation
Menorrhagia This is the most common presenting symptom, and can be due to either submucosal or intramural fibroids. Submucosal fibroids facilitate bleeding by increasing the endometrial surface area, and thus enlarging the region of menstrual blood loss. Intramural fibroids impair the normal physiological contractions of the uterus which minimize menstrual blood loss; they also increase the vascularity of the myometrium. Note that subserosal fibroids do not give rise to menorrhagia. [1,2,3,4,5,6]
Dysmenorrhea This a form of secondary dysmenorrhoea (as it is associated with an underlying pelvic pathology), and is typically spasmodic in nature. The underlying pathophysiology is the uterus going into spasms as it attempts to expel the clots and excess blood. Note that the pain classically starts with the onset of bleeding, and ends abruptly once the bleeding ceases. [1,2,3,11]
Abdominal Distension Gradual abdominal distension may occur, as the fibroid(s) enlarge over time. Note that many patients ignore this symptom, assuming it to be a normal consequence of aging. [3,5,6,8]
Intermenstrual Bleeding This is much less common than menorrhagia; where present, this due to necrotic ulceration of a submucosal fibroid. Note that an offensive discharge may occur if the raw area on the fibroid becomes infected.[2,3,5,6,7]
Back Pain A dull lower back pain may occur in some patients; this is due to compression of the sacral plexus of nerves. [2,3,5,6]
Urinary Frequency This is another pressure symptom, and is due to a fibroid in the anterior aspect of the uterus compressing the bladder, and thus stimulating the trigone. [1,3,8,9,10]
Ankle Swelling Yet another pressure symptom, this may occur if a very large fibroid compresses the inferior vena cava. [5,8,9,10]
Postcoital Bleeding This is a rarest form of bleeding caused by fibroids, and may occur if a pedunculated fibroid ends up extruded through the cervix. [3,5,6,8,9]
References
  1. WALSH CA. Uterine fibroid embolization. N Engl J Med [online] 2009 Dec 3, 361(23):2292-3; author reply 2294 [viewed 23 August 2014] Available from: doi:10.1056/NEJMc091839
  2. SMITH SJ. Uterine fibroid embolization. Am Fam Physician [online] 2000 Jun 15, 61(12):3601-7, 3611-2 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10892632
  3. ROSS JW. The uterine fibroid. J Natl Med Assoc [online] 1955 Jan, 47(1):45-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13222142
  4. EVANS P, BRUNSELL S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician [online] 2007 May 15, 75(10):1503-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555142
  5. BOULTON P. Intra-Uterine Fibroid Polypus. Br Med J [online] 1882 Sep 30, 2(1135):616 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20750331
  6. BUEK J. Management options for uterine fibroid tumors. Am Fam Physician [online] 2007 May 15, 75(10):1452-3 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555138
  7. SABRY M, AL-HENDY A. Medical treatment of uterine leiomyoma. Reprod Sci [online] 2012 Apr, 19(4):339-53 [viewed 23 August 2014] Available from: doi:10.1177/1933719111432867
  8. EZEAMA C, IKECHEBELU J, OBIECHINA NJ, EZEAMA N. Clinical Presentation of Uterine Fibroids in Nnewi, Nigeria: A 5-year Review. Ann Med Health Sci Res [online] 2012 Jul, 2(2):114-8 [viewed 23 August 2014] Available from: doi:10.4103/2141-9248.105656
  9. FENNESSY FM, KONG CY, TEMPANY CM, SWAN JS. Quality-of-life assessment of fibroid treatment options and outcomes. Radiology [online] 2011 Jun, 259(3):785-92 [viewed 23 August 2014] Available from: doi:10.1148/radiol.11100704
  10. KHAN AT, SHEHMAR M, GUPTA JK. Uterine fibroids: current perspectives. Int J Womens Health [online] 2014:95-114 [viewed 23 August 2014] Available from: doi:10.2147/IJWH.S51083
  11. DAWOOD MY. Dysmenorrhea. J Reprod Med [online] 1985 Mar, 30(3):154-67 [viewed 23 December 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3158737

Symptoms - of Complications

Fact Explanation
Abdominal Pain Severe abdominal pain mimicking an acute abdomen may indicate torsion of a pedunculated fibroid, or red degeneration; the latter is more likely if the patient is pregnant. Necrosis of a fibroid, or infection can also cause pain, although typically of a lesser degree. Note that abdominal pain in these patients is usually due to co-existing pathology (such as endometriosis of pelvic inflammatory disease), rather than to the fibroid itself. [1,2,3,5,9,10]
Subfertility There is a well recognized association between subfertility and fibroids, although the underlying mechanism has not been definitively established. A popular hypothesis is that fibroids distort the architecture of the uterine cavity, hindering implantation, and may also obstruct the fallopian tubes, preventing migration of the ova into the uterus. [5,6,8,10]
Miscarriages This is a rare complication; a submucosal fibroid can interfere with implantation and lead to abortion. [1,2,3,4,6,9]
Postpartum Hemorrhage Pooled cumulative data suggest that postpartum hemorrhage is significantly more likely in women with fibroids compared with control subjects. Possible reasons include distortion of the uterine architecture, and interference with myometrial contractions, leading to uterine atony. [1,2,3,4,6,9] [1 new]
References
  1. LEE HJ, NORWITZ ER, SHAW J. Contemporary Management of Fibroids in Pregnancy Rev Obstet Gynecol [online] 2010, 3(1):20-27 [viewed 23 December 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319

Risk Factors

Fact Explanation
Age Fibroids found in women of reproductive age; they are almost unheard of in prior to puberty, and tend to undergo spontaneous regression following menopause. The highest incidence is between 35 to 45 years of age. [1,3,5,6]
Nulliparity Studies have shown fibroids to be more common in nulliparous women. [1,3,5,6]
Secondary Subfertility Studies have shown fibroids to be more common in women with a history of secondary sub fertility. [1,3,5,6]
Pregnancy As fibroids are an estrogen dependent tumor, they tend to ??? <-- need to look into this more - will pregnancy cause fibroids? or just cause their enlargement? It is an. So the unopposed estrogen action oral contraceptives and pregnancy are thought to be in favor of its development. [1,3,5,6]
Oral Contraceptive Use Fibroids are more common in women who use the combined oral contraceptive pill (COCP). This is possibly because fibroids are stimulated by the estrogen present in the COCP. [1,3,5,6]
Obesity Obesity is a known risk factor for fibroids. [1,3,5,6]
Family History In some individuals, a family history may be present; it has been postulated that there may be a genetic predisposition. [1,3,5,6]
References

Signs - of the Disease

Fact Explanation
Uterine Enlargement This is the most common sign in these patients, and can be easily elicited via bimanual examination. As is obvious, it is due to the fibroid growing within the uterine wall, and enlarging the uterus. [1,2,3,4]
Cervical Displacement Speculum examination may reveal the cervix to be distorted in shape and/or pushed down or deviated to a side; this is secondary to distortion of the uterine architecture by the fibroid. [1,2,3,4]
A Visible Fibroid This is an uncommon finding; where a polypoidal fibroid is present, this may be seen upon speculum examination; asking the patient to strain may facilitate this. [1,2,3,4]
References
  1. EVANS P, BRUNSELL S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician [online] 2007 May 15, 75(10):1503-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555142
  2. SABRY M, AL-HENDY A. Medical treatment of uterine leiomyoma. Reprod Sci [online] 2012 Apr, 19(4):339-53 [viewed 23 August 2014] Available from: doi:10.1177/1933719111432867
  3. EZEAMA C, IKECHEBELU J, OBIECHINA NJ, EZEAMA N. Clinical Presentation of Uterine Fibroids in Nnewi, Nigeria: A 5-year Review. Ann Med Health Sci Res [online] 2012 Jul, 2(2):114-8 [viewed 23 August 2014] Available from: doi:10.4103/2141-9248.105656
  4. BUEK J. Management options for uterine fibroid tumors. Am Fam Physician [online] 2007 May 15, 75(10):1452-3 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555138

Signs - of Complications

Fact Explanation
Pallor In women with longstanding menorrhagia (secondary to the fibroid), anemia may result, giving rise to this finding. [1,2,3]
Polycythemia This is a rare complication, and is due to <----- where does this go? Very rarely a fibroid may also lead to polycythemia due to the secretion of erythropoietin by the fibroid itself or irritation of the retroperitoneal area of the kidney. [2,3,4]
Malpresentations Malpresentations, and non engagement of the head may occur during pregnancy. This is because fibroids rapidly enlarge during this period, secondary to high estrogenic and progesterogenic activity; they may thus distort the architecture of the uterine cavity.[1,2,3,4,6,9] <--- from Hx references
References

Differential Diagnoses

Fact Explanation
Adenomyosis Adenomyosis can give rise to menorrhagia and uterine enlargement (which is usually symmetrical, but which can be nodular); clinically, it is almost impossible to differentiate this from fibroids. Pelvic ultrasound can help in the differentiation by demonstrating ?; MRI of the pelvis is also of use. Uterine biopsy is more invasive resort and will demonstrate ? [1,3]
Uterine Leiomyosarcoma ? DD of uterine enlargement / uterine mass +/- DD of bleeding?
Endometrial Polyp DD of uterine enlargement / uterine mass
Pregnancy DD of uterine enlargement Usually presents with a period of amenorrhea as opposed to the menstrual irregularities seen with fibroid. Other signs of pregnancy are present. On palpation of the abdominal lump, it is soft and elastic as opposed to the firm fibroid. Ultrasound scan can definitively differentiate the pregnancy from the fibroid. [1,2]
Ovarian tumors DD of abdominal enlargement / uterine enlargement Ovarian tumors and fibroids are often difficult to differentiate clinically specially when it is a solid ovarian tumor like fibroma. On examination it may be possible to feel the lump separately from the uterus. [2,4]
Endometrial Cancer DD of bleeding
Endometrial Hyperplasia DD of bleeding
Cervical carcinoma if postcoital bleeding
References
  1. EVANS P, BRUNSELL S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician [online] 2007 May 15, 75(10):1503-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555142
  2. KHAN AT, SHEHMAR M, GUPTA JK. Uterine fibroids: current perspectives. Int J Womens Health [online] 2014:95-114 [viewed 23 August 2014] Available from: doi:10.2147/IJWH.S51083
  3. LEVY G, DEHAENE A, LAURENT N, LERNOUT M, COLLINET P, LUCOT JP, LIONS C, PONCELET E. An update on adenomyosis. Diagn Interv Imaging [online] 2013 Jan, 94(1):3-25 [viewed 23 August 2014] Available from: doi:10.1016/j.diii.2012.10.012
  4. FISCHEROVA D, ZIKAN M, DUNDR P, CIBULA D. Diagnosis, treatment, and follow-up of borderline ovarian tumors. Oncologist [online] 2012, 17(12):1515-33 [viewed 23 August 2014] Available from: doi:10.1634/theoncologist.2012-0139

Investigations - for Diagnosis

Fact Explanation
Ultra sound scan This is the investigation of choice. It can differentiate fibroids from other differential diagnoses. But a subserous pedunculated fibroids may also be difficult to be differentiated from an ovarian tumor. [1,3,4]
Hysterosalpingogram (HSG) This is specially helpful in presence of subfertility. A HSG is done to detect any tubal blockage in subfertiity. Submucosal fibroid can be seen as a filling defect. [1,3,5,6]
Laparoscopy This is also useful in the presence of subfertility. Laparoscopy is performed to detect any pelvic pathology may reveal a subserosal fibroid. It is also of use in differentiation of such a fibroid from an ovarian tumor when the clinical examination and ultrasound scan have failed. [1,3,4,6]
TIssue biopsy A partial or excisional biopsy is indicated as diagnosis is based on tissue examination. Uterine fibroid is a well differentiated smooth muscle tumors. Elongated smooth muscle nuclei are characteristic. They are often described as cigar or eel shaped. Also perinuclear vacuolization may be appreciated when cut in the cross-section. [2,3,4,5]
Full blood count Since erythrocytosis has been reported in patients with multiple leiomyomas, hemoglobin and/or hematocrit levels might be considered [1,2,3]
References
  1. SMITH SJ. Uterine fibroid embolization. Am Fam Physician [online] 2000 Jun 15, 61(12):3601-7, 3611-2 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10892632
  2. SABRY M, AL-HENDY A. Medical treatment of uterine leiomyoma. Reprod Sci [online] 2012 Apr, 19(4):339-53 [viewed 23 August 2014] Available from: doi:10.1177/1933719111432867
  3. ROSS JW. The uterine fibroid. J Natl Med Assoc [online] 1955 Jan, 47(1):45-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13222142
  4. BUEK J. Management options for uterine fibroid tumors. Am Fam Physician [online] 2007 May 15, 75(10):1452-3 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555138
  5. EZEAMA C, IKECHEBELU J, OBIECHINA NJ, EZEAMA N. Clinical Presentation of Uterine Fibroids in Nnewi, Nigeria: A 5-year Review. Ann Med Health Sci Res [online] 2012 Jul, 2(2):114-8 [viewed 23 August 2014] Available from: doi:10.4103/2141-9248.105656
  6. EVANS P, BRUNSELL S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician [online] 2007 May 15, 75(10):1503-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555142

Investigations - for Management

Fact Explanation
Full blood count Since erythrocytosis has been reported in patients with multiple leiomyomas, hemoglobin and/or hematocrit levels might be considered[1,2,3]
Ultrasound scan Serial Ultrasound scans are done to assess the response to medical treatment. [1,2,3]
References
  1. SABRY M, AL-HENDY A. Medical treatment of uterine leiomyoma. Reprod Sci [online] 2012 Apr, 19(4):339-53 [viewed 23 August 2014] Available from: doi:10.1177/1933719111432867
  2. BUEK J. Management options for uterine fibroid tumors. Am Fam Physician [online] 2007 May 15, 75(10):1452-3 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555138
  3. ROSS JW. The uterine fibroid. J Natl Med Assoc [online] 1955 Jan, 47(1):45-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13222142

Management - General Measures

Fact Explanation
Tranexamic acid Tranexamic acid is a synthetic analog of the amino acid lysine. It can be used to alleviate menstrual problems such as menorrhagia. [3,5,6]
Norethisterone Progesterone preparations such as norethisterone can be used to alleviate menstrual problems such as menorrhagia. [3,6,7]
Calcium channel blockers The pain associated with many cases is relieved by the drugs (Particularly nifedipine). [1,3,4,6,7]
References

Management - Specific Treatments

Fact Explanation
Selection of Technique The treatment of fibroid can be categorized into three main areas namely conservative management, medical and surgical management. Symptoms, age, fertility wishes, and the size of the uterus are crucial factors in determining the treatment option.
Conservative management Asymptomatic small fibroids are managed with conservative methods. The patient is closely followed up with repeating utrasound scans and clinical assessment in 6-12 months. This is specially indicated in young females with future fertility wishes and also in perimenapausal females where where one can expect the fibroid to undergo spontaneous regression after menopause. This patients should be reassured that in the absence of symptoms it is unnecessarily to perform surgery. [1,2,3,4,5]
GnRH analogues A gonadotropin-releasing hormone analogue (GnRH analogue or analog), also known as a luteinizing hormone releasing hormone agonist brings about a medical menopause that results in regression of the tumor. It is sometimes used prior to surgery in order to reduce the tumor size and its vascularity before the actual surgery. However this can cause some increase in menopause symptoms and bone pain due to osteopenia. Therefore these patients need to be started on concomitant hormone replacement therapy as add back therapy. [2,3,4,5,6]
Myomectomy Polyp , intermenstrual bleeding, subfertility and severe symptom presentation are indications to perform a surgery. The surgical option will depend on the age and fertility wishes of the patient. Myomectomy is performed in those who have future fertility wishes. Myomectomy is performed in two approaches. Vaginal Myomectomy is performed for submucosal and smooth fibroids. It is done by hysteroscopy. Abdominal myomectomy can be done as open surgery or laparoscopically. Myomectomy has the risks of increased bleeding, blood transfusion and another surgery in the future. [1,2,3,8]
Hysterectomy This is the surgery of choice in symptomatic individuals, specially in the absence of any indication for myomectomy. Therefore it is ideally considered in patients who are symptomatic and over the age of 40 years and who have completed their families. The advantage of this surgery is there is no chance of recurrence. The symptomatic relief mainly in menstrual irregularities is almost 10% and the post operative morbidity is lower than that of myomectomy. It is the treatment of choice in the presence of large or multiple fibroids. Abdominal hysterectomy is undertaken when the size of the tumor is greater than the size of a 12-week gravid uterus and also in multiple fibroids. Vaginal hysterectomy is done when the size is smaller. The post operative morbidity is less in vaginal approach. [6,7,8,9,10]
Selective arterial embolization This is a novel method of treatment. Selective embolization of the arteries feeding the tumor results in the atrophy of the tumor enabling easier removal. [2,3,5,9]
References
  1. WALSH CA. Uterine fibroid embolization. N Engl J Med [online] 2009 Dec 3, 361(23):2292-3; author reply 2294 [viewed 23 August 2014] Available from: doi:10.1056/NEJMc091839
  2. KHAN AT, SHEHMAR M, GUPTA JK. Uterine fibroids: current perspectives. Int J Womens Health [online] 2014:95-114 [viewed 23 August 2014] Available from: doi:10.2147/IJWH.S51083
  3. BUEK J. Management options for uterine fibroid tumors. Am Fam Physician [online] 2007 May 15, 75(10):1452-3 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555138
  4. EZEAMA C, IKECHEBELU J, OBIECHINA NJ, EZEAMA N. Clinical Presentation of Uterine Fibroids in Nnewi, Nigeria: A 5-year Review. Ann Med Health Sci Res [online] 2012 Jul, 2(2):114-8 [viewed 23 August 2014] Available from: doi:10.4103/2141-9248.105656
  5. BOULTON P. Intra-Uterine Fibroid Polypus. Br Med J [online] 1882 Sep 30, 2(1135):616 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20750331
  6. ROSS JW. The uterine fibroid. J Natl Med Assoc [online] 1955 Jan, 47(1):45-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13222142
  7. SABRY M, AL-HENDY A. Medical treatment of uterine leiomyoma. Reprod Sci [online] 2012 Apr, 19(4):339-53 [viewed 23 August 2014] Available from: doi:10.1177/1933719111432867
  8. EVANS P, BRUNSELL S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician [online] 2007 May 15, 75(10):1503-8 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17555142
  9. FENNESSY FM, KONG CY, TEMPANY CM, SWAN JS. Quality-of-life assessment of fibroid treatment options and outcomes. Radiology [online] 2011 Jun, 259(3):785-92 [viewed 23 August 2014] Available from: doi:10.1148/radiol.11100704
  10. SMITH SJ. Uterine fibroid embolization. Am Fam Physician [online] 2000 Jun 15, 61(12):3601-7, 3611-2 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10892632