Fibroids are benign and usually asymptomatic tumors of the uterus. They occur in women of reproductive age. The best method for diagnosing fibroids is transvaginal ultrasound. The treatment, whether conservative or surgical, depends mainly on the age, symptoms, and desire of the patient for future fertility.

 

It is estimated that one in five women over the age of 35 has one or more fibroids. Most tumors are benign and do not cause symptoms. The exact cause of fibroid formation remains unknown. One of the most significant factors implicated in the formation of these tumors is estrogen. The size of fibroids increases in conditions associated with increased estrogen levels in the body, such as pregnancy, reproductive age, ovarian stimulation, or administration of exogenous estrogens.

The size of fibroids decreases when the level of estrogen in the body is low, such as after pregnancy or during menopause when the ovaries stop producing estrogen.

What is the appearance of fibroids?

Fibroids typically appear as hard, round, multiple but well-defined masses in the uterine wall. The size of the masses ranges from a few grams to some kilograms (usually multiple fibroids). Microscopically, they consist of smooth muscle fibers from the uterine wall, connective tissue elements, and blood vessels.

How are fibroids classified?

Anatomically, fibroids are classified according to their location in the uterus.

 

Subserosal: They are located beneath the outer serosa of the uterus (peritoneum), protruding outside the uterine cavity and usually have a stalk connecting the main mass to the uterine wall.

Intramural: They are located within the uterine wall.

Submucosal: They appear beneath the uterine mucosa (endometrium) and project into the interior of the uterine cavity.

 

What progression can fibroids have?

Most fibroids remain unchanged. However, they rarely undergo the following changes:

Atrophic degeneration: Occurs when the blood supply to the tumor is partially interrupted, leading to shrinking of the fibroid.

Cystic degeneration: The cavity of the fibroid fills with fluid.

Calcification: Deposition of calcium in the tumor. Torsion: Usually occurs in fibroids with a stalk.

Necrotic infection: This change causes acute abdominal pain and fever.

Red degeneration: Occurs in cases of bleeding within the main mass of the fibroid. Fatty degeneration: The fibroid fills with fatty tissue.

Malignant transformation: The fibroid transforms into a leiomyosarcoma. This complication is very rare and occurs in approximately 0.5% of women (one in 200) with fibroids.

 

What symptoms do fibroids cause?

Fibroids usually do not cause discomfort. Sometimes they are discovered during a gynecological examination, during pregnancy, or in a pelvic ultrasound. The most common symptoms associated with the presence of fibroids are:

  • Disturbance of the menstrual cycle: This symptom can manifest in four forms:
  • Menorrhagia: Excessive blood loss during menstruation.
  • Polymenorrhea: Frequent periods (every 15-20 days).
  • Metrorrhagia: Vaginal bleeding between normal menstrual periods.
  • Hypermenorrhea: Prolonged bleeding for 10-15 days with each menstrual flow.
  • Disturbance of menstrual flow: Usually caused by submucosal fibroids.
  • Pain: Pain may occur due to fibroids pressing on other organs, degeneration of the fibroid, or inflammation of the fibroid.
  • Pressure symptoms: Fibroids can cause a sensation of pressure or fullness in the lower abdomen or pelvis, frequent urination, or constipation.
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Infertility: Submucosal fibroids can hinder the implantation and growth of the embryo in the uterus and have been implicated in infertility and recurrent miscarriages (loss of 3 or more consecutive pregnancies).

How are fibroids diagnosed?

The diagnosis of fibroids is based on the following:

  • Symptoms reported by the patient
  • Findings from gynecological examination by a specialist physician
  • Pelvic ultrasound: Examination of the uterus and pelvic organs using transvaginal ultrasound is the best method for diagnosis, precise localization, and differential diagnosis of fibroids.
  • Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) and Hysterosalpingography can help when ultrasound does not provide sufficient information for a definitive diagnosis.

 

What is the treatment for fibroids?

Asymptomatic patients: If the patient does not have any symptoms, fibroids do not require specific treatment. However, periodic monitoring of the patient with transvaginal ultrasound every 6-12 months is necessary. Any changes in the size or composition of the fibroids should be evaluated by the gynecologist according to the patient’s age and clinical presentation.

Symptomatic patients: Fibroid removal. This method is suitable for young women who want to preserve their fertility or their uterus. Depending on the anatomical location, fibroids can be removed either laparoscopically or hysteroscopically (through the vaginal route with the help of a special instrument called a hysteroscope) or through the classical open method of laparotomy.

Hysterectomy: It is recommended for women who have completed their family, have multiple fibroids, and are over 45 years old.

The therapeutic options should be presented to the patient, who will ultimately choose the treatment.