Uterine Fibroid Symptoms and Diagnosis

Uterine fibroids are benign smooth muscle tumours of the uterine wall, and they affect 70 to 80% of women by the age of 50. Uterine fibroid symptoms depend on where the fibroids grow: heavy or irregular bleeding, pelvic pressure, pain during intercourse, infertility or miscarriage, while many cause no symptoms at all. Diagnosis rests on a pelvic examination confirmed by ultrasound, with MRI reserved for doubtful cases.

Dr. Supriya Malhotra, Senior Consultant Obstetrics & Gynaecology, Fortis La Femme, Greater Kailash II, New Delhi, India, described fibroids to an audience of doctors from across Africa as common and usually benign, with symptoms that differ according to where they grow. That variability is the central clinical point: the same diagnosis can mean a lifelong silent finding in one woman and severe anaemia or repeated miscarriage in another. This guide covers what fibroids are, who develops them, how the symptoms map to location, how the diagnosis is made and which beliefs about fibroids are wrong. Treatment is covered in depth in two companion articles: medical management of uterine fibroids and myomectomy, hysterectomy and embolisation compared.

What are uterine fibroids?

Uterine fibroids, also called myomas or leiomyomas, are benign smooth muscle tumours that start in the myometrium, the muscular layer of the uterus. They are hormone dependent: oestrogen and progesterone drive their growth, which is why they appear in the reproductive years and why most shrink once those hormones fall after menopause.

Their size spans an extraordinary range. Dr. Malhotra described fibroids running from a small seedling, barely visible, to the size of a cricket ball and, at the extreme, a watermelon. A single uterus may hold one fibroid or many of different sizes.

How common are fibroids, and what are the risk factors?

Fibroids affect 70 to 80% of women by the age of 50, the figure Dr. Malhotra gave, which makes them among the most common conditions a gynaecologist sees. They are most common between 30 and 50, because it takes years after the first period (menarche) for oestrogen and progesterone acting on the uterus to grow a fibroid large enough to matter.

She identified the following risk factors:

• Hormones. Oestrogen and progesterone acting through the reproductive years are the most important driver.
• Genetic predisposition and family history. Where a mother has had fibroids, a daughter is often affected too.
• Early menarche. The earlier periods begin, the longer the uterus is exposed to hormonal stimulation. Dr. Malhotra noted that she now sees girls starting their periods at 8 to 10 years of age, and that these girls are more prone to fibroids later.
• Obesity and metabolic factors. Obesity, diabetes, hypertension and lifestyle factors are all implicated. Fat tissue produces oestrogen, which adds to the stimulus on the uterus.
• Ethnic background. Fibroids are more prevalent among women of African descent, and in Dr. Malhotra's description they are also larger and more severe in this group.

That last point carries direct weight for clinicians in Africa: a higher baseline prevalence, larger fibroids and more severe symptoms mean a lower threshold for examination and imaging when a woman presents with heavy bleeding, pelvic pressure or difficulty conceiving.

Types of uterine fibroids by location

Fibroids are classified by where they sit relative to the layers of the uterus. Every fibroid starts in the muscle wall; the type depends on the direction in which it then grows.

Location matters more than size for many symptoms. A small submucosal fibroid can prevent a pregnancy, while a large subserosal fibroid may cause nothing more than a visible swelling.

Uterine fibroid symptoms

The most common symptom pattern, Dr. Malhotra stressed, is no symptoms at all. Many women have fibroids that are found by chance during a pelvic examination for another reason, during an unrelated scan or when they become pregnant. When fibroids do cause symptoms, they fall into five groups.

Heavy menstrual bleeding

Heavy bleeding can show up as periods that come more often than monthly, last longer than usual or are heavier than usual. Dr. Malhotra linked heavy menstrual bleeding to intramural fibroids, which can cause it, although submucosal fibroids, which distort the cavity, are the type most strongly associated with it. The consequence that brings many women to a clinic is anaemia: breathlessness on walking, malaise and constant tiredness.

Bleeding between periods

Intermenstrual bleeding is especially associated with submucosal fibroids. The endometrium, the lining of the uterus, builds up each month and is shed as a period if no pregnancy occurs. A fibroid lying beneath that lining disrupts the normal pattern of growth and shedding.

Pelvic pain and pressure

Large fibroids, and subserosal fibroids in particular, grow out of the uterus and can rise from the pelvis into the abdomen. A fibroid pressing on the bladder causes frequent urination. One on the back wall of the uterus can press on the rectum and cause constipation. Some simply enlarge the abdomen.

Pain during intercourse

Large fibroids can cause dyspareunia, pain during intercourse. In the discussion that followed the lecture, Dr. Malhotra explained how to separate this from the dyspareunia of pelvic inflammatory disease. Infection usually brings cervical motion and adnexal tenderness on examination, an abnormal or foul-smelling vaginal discharge and sometimes fever or urinary symptoms; fibroid-related pain does not. Endocervical swabs taken at speculum examination support pelvic inflammatory disease when they detect chlamydia or gonorrhoea, although a negative result does not exclude it.

Infertility and miscarriage

Fibroids growing towards the cavity occupy the small space in which an embryo needs to implant. They can therefore prevent conception or, if conception occurs, cause early and recurrent miscarriage because the newly fertilised embryo cannot find room to settle. This is why a submucosal fibroid is one of the clearest indications for removal before a woman tries to conceive, as the surgical treatment article explains.

When to see a doctor about fibroid symptoms

Dr. Malhotra listed the signals that should prompt a woman to seek medical attention:

1. Severe or heavy menstrual bleeding.
2. Bleeding between periods.
3. Periods heavy enough to disrupt daily life.
4. Signs of anaemia, such as breathlessness, fatigue and malaise.
5. Difficulty conceiving or repeated miscarriage.
6. Persistent pelvic pain.

How uterine fibroids are diagnosed

Uterine fibroids are diagnosed by pelvic examination and confirmed by ultrasound, with MRI added when ultrasound leaves doubt. Diagnosis moves from the least to the most invasive step, and in most women it ends at the second.

Clinical examination. On bimanual pelvic examination, a doctor can often feel an enlarged uterus with an irregular outline, and can tell whether the bulk lies at the front, the back or the sides. Very small fibroids cannot be felt.

Ultrasound, the first-line test. Ultrasound confirms the diagnosis and gives the exact location. Fibroids are encapsulated and have a characteristic whorled appearance, which Dr. Malhotra described as impossible to miss on a scan.

MRI, for mapping and doubt. Magnetic resonance imaging uses no ionising radiation and produces very thin slices of the soft tissues, giving a detailed map of every fibroid. Dr. Malhotra advises MRI when ultrasound leaves doubt, in particular the small possibility of a cancerous growth. MRI can also show associated findings that ultrasound sometimes misses, such as enlarged lymph nodes or a small amount of free fluid.

Hysteroscopy and laparoscopy, not first-line. Both are invasive and are not used as first-line tests. A fibroid may be seen when either is done for another reason: through a hysteroscope, a camera passed through the cervix, a submucosal fibroid appears as a tongue-like projection into the cavity; through a laparoscope, subserosal fibroids are seen on the outer surface. Dr. Malhotra regards hysteroscopy as a treatment tool, where the lesion is seen and removed in the same sitting.

Distinguishing a fibroid from a molar pregnancy

A molar pregnancy, an abnormal growth of placental tissue, can also enlarge the uterus. Dr. Malhotra separates the two on imaging and hormones. A fibroid is round, encapsulated and whorled on ultrasound or MRI; a molar pregnancy is a disorganised collection of tissue with no capsule. The pregnancy hormone hCG is raised in any pregnancy, but in a molar pregnancy it climbs far above normal pregnancy levels.

Are fibroids cancerous? Three myths

Fibroids are almost never cancerous: Dr. Malhotra put the chance of malignant change at less than 1 in 1,000 fibroids. Among women who have surgery for presumed fibroids, the US FDA estimates that about 1 in 225 to 1 in 580 turn out to have an unexpected uterine sarcoma, which is why the surgical technique is chosen with that possibility in mind. She addressed this and two other common myths.

Myth 1: fibroids turn into cancer. Fibroids are almost always benign. The cancer that arises in the uterine muscle, leiomyosarcoma, is rare. Most leiomyosarcomas develop as cancers from the start rather than through a benign fibroid becoming malignant.

Myth 2: every fibroid needs treatment. Many do not. Fibroids that cause no symptoms can simply be followed. Because they depend on oestrogen and progesterone, fibroids smaller than about 5 cm very often shrink after menopause and never cause a problem.

Myth 3: hysterectomy is the only cure. Hysterectomy is the definitive cure, but it is not the only treatment. Medicines, minimally invasive procedures and fertility-preserving surgery all have a place.

How uterine fibroids are treated: an overview

Dr. Malhotra described four tiers of treatment, chosen according to symptoms, size, location and the woman's plans for pregnancy.

1. Watchful waiting for fibroids that cause no symptoms, with follow-up to check that they are not growing.
2. Medical management with pain relief, tranexamic acid, hormonal treatments and gonadotrophin-releasing hormone (GnRH) analogues, alongside lifestyle measures. These control bleeding and pain, and some shrink fibroids temporarily. The medical management article sets out each option, its regimen and its limits.
3. Minimally invasive procedures, principally uterine artery embolisation, which cuts off a fibroid's blood supply without surgery.
4. Surgery: myomectomy, which removes the fibroids and preserves the uterus, or hysterectomy, which removes the uterus and is the definitive cure. Both, along with embolisation, pregnancy after surgery and the handling of the ovaries, are compared in the myomectomy vs hysterectomy article.

For a different emphasis on the same decision, Dr. Suman Lal's guide to uterine fibroid treatment options works through how size, number and age shape the choice. Questions from doctors in Uganda, Nigeria, Kenya, Ghana, Tanzania and the Democratic Republic of Congo, with Dr. Malhotra's answers, are collected in the Live Discussion from this masterclass.

Key takeaways

• Fibroids affect 70 to 80% of women by 50, and they are more common, larger and more severe in women of African descent.
• Location drives symptoms: submucosal fibroids cause heavy bleeding, bleeding between periods and fertility problems, intramural fibroids can also cause heavy bleeding, and large subserosal fibroids cause pressure.
• Many fibroids cause no symptoms and need only follow-up.
• A pelvic examination and an ultrasound diagnose almost all fibroids; MRI is for doubt and detailed mapping.
• Malignant change is rare, at less than 1 in 1,000.
• Treatment depends on symptoms, size, location and fertility goals, and ranges from observation to hysterectomy.

More on Dr. Malhotra's clinical practice is on her doctor profile, and the wider range of women's health masterclasses sits on the obstetrics and gynaecology hub.