Overview

Diagnosis

Uterine fibroids are often discovered incidentally during a routine pelvic exam. During the exam, your doctor may feel irregularities in the shape of the uterus that suggest the presence of fibroids.

If you have symptoms, additional tests may be recommended:

  • Ultrasound: Uses sound waves to create images of the uterus.

    • Transabdominal ultrasound: The transducer is moved over the abdomen to view the uterus.

    • Transvaginal ultrasound: The transducer is placed inside the vagina to get more detailed images.

  • Lab tests: Blood tests may be done to check for anemia caused by heavy menstrual bleeding or to look for other conditions such as thyroid disorders or bleeding disorders.

  • Magnetic resonance imaging (MRI): Provides detailed images of fibroid size, location, and type. Often used for larger uteri or people nearing menopause.

  • Hysterosonography: Saline is introduced into the uterus to expand the cavity, making it easier to image submucosal fibroids and the uterine lining.

  • Hysterosalpingography: A dye highlights the uterine cavity and fallopian tubes on X-ray images, used to check for blockages or submucosal fibroids.

  • Hysteroscopy: A small, lighted telescope (hysteroscope) is inserted through the cervix into the uterus, allowing the doctor to directly view the uterine cavity and fallopian tube openings.

These tests help confirm the presence, size, location, and type of fibroids, which guide treatment decisions.

Treatment

Treatment for uterine fibroids depends on symptoms, size and location of fibroids, age, and fertility goals. Many people with fibroids may not require treatment and can be monitored with watchful waiting.

Watchful Waiting

  • Many fibroids grow slowly or not at all and tend to shrink after menopause.

  • Fibroids are not cancerous and rarely interfere with pregnancy.

  • Mild or non-bothersome symptoms may not require immediate treatment.

Medicines

Medicines can help manage symptoms such as heavy menstrual bleeding and pelvic pressure. They may shrink fibroids but do not remove them.

  • Gonadotropin-releasing hormone (GnRH) agonists: Reduce estrogen and progesterone to shrink fibroids temporarily. Examples include leuprolide, goserelin, and triptorelin. Often used before surgery or to ease menopausal transition.

  • GnRH antagonists: Reduce heavy bleeding but do not shrink fibroids. Examples include elagolix and relugolix. Can be used with add-back therapy to reduce side effects.

  • Progestin-releasing intrauterine device (IUD): Relieves heavy bleeding but does not shrink fibroids.

  • Tranexamic acid: Non-hormonal medication to reduce heavy menstrual bleeding.

  • Other medicines: Low-dose birth control pills to control bleeding, NSAIDs like ibuprofen or naproxen for pain relief, and iron or vitamins if anemia is present.

Noninvasive Procedures

  • MRI-guided focused ultrasound surgery (FUS): Uses high-energy ultrasound waves under MRI guidance to destroy fibroid tissue. Outpatient procedure that preserves the uterus.

Minimally Invasive Procedures

  • Uterine artery embolization: Small particles block blood flow to fibroids, causing them to shrink.

  • Radiofrequency ablation: Uses heat energy to destroy fibroids, done laparoscopically, transcervically, or transvaginally. Known as Lap-RFA or Sonata procedure.

  • Laparoscopic or robotic myomectomy: Fibroids are removed through small abdominal incisions while preserving the uterus. Robotic assistance provides a magnified 3D view for precision.

  • Hysteroscopic myomectomy: Submucosal fibroids removed through the cervix.

  • Endometrial ablation: Destroys the uterine lining to reduce heavy menstrual flow. Not recommended for those wishing to become pregnant.

Traditional Surgical Procedures

  • Abdominal myomectomy: Removal of fibroids through a larger abdominal incision, suitable for multiple, large, or deep fibroids.

  • Hysterectomy: Complete removal of the uterus, providing a permanent solution for fibroids but ending fertility.

Morcellation Considerations

  • Morcellation breaks fibroids into smaller pieces for removal.

  • It can increase the risk of spreading undetected cancer.

  • Risk can be minimized by using a surgical bag or enlarging the incision to remove fibroids intact.

  • FDA advises caution, especially for people nearing or after menopause.

Fertility Considerations

  • Hysterectomy and endometrial ablation prevent future pregnancy.

  • Uterine artery embolization and radiofrequency ablation may affect fertility.

  • Myomectomy is usually preferred for those wishing to preserve fertility.

Risk of New Fibroids

  • Except for hysterectomy, there is a possibility of new fibroids forming or previously undetected fibroids growing, which may require additional treatment in the future.

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