Uterine Leiomyomas (Fibroids) - Epidemiology, Clinical Features, Diagnosis, and Natural History - UpToDate

9/11/2019 Uterine leiomyomas (fibroids): Epidemiology, clinical features, diagnosis, and natural history - UpToDate
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Uterine leiomyomas (fibroids): Epidemiology, clinical

features, diagnosis, and natural history
Authors: Elizabeth A Stewart, MD, Shannon K Laughlin-Tommaso, MD
Section Editors: Robert L Barbieri, MD, Deborah Levine, MD
Deputy Editor: Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2019. | This topic last updated: Aug 06, 2019.
INTRODUCTION
Uterine leiomyomas (also referred to as fibroids or myomas) are the most common pelvic tumor in
women [1,2]. They are noncancerous monoclonal tumors arising from the smooth muscle cells and
fibroblasts of the myometrium. They arise in reproductive-age women and, when symptomatic,
typically present with symptoms of abnormal uterine bleeding and/or pelvic pain/pressure. Uterine
fibroids may also have reproductive effects (eg, infertility, adverse pregnancy outcomes).
The epidemiology, diagnosis, and natural history of uterine leiomyomas are reviewed here.
Leiomyoma histology and pathogenesis, management of uterine leiomyomas, differentiating
leiomyomas from uterine sarcomas, and leiomyoma variants are discussed separately. (See
"Overview of treatment of uterine leiomyomas (fibroids)" and "Histology and pathogenesis of uterine
leiomyomas (fibroids)" and "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas" and
"Variants of uterine leiomyomas (fibroids) and smooth muscle tumors of uncertain malignant
potential".)
TERMINOLOGY AND LOCATION
Uterine fibroids are described according to their location in the uterus although many fibroids have
more than one location designation (figure 1 and picture 1A-B). The International Federation of
Gynecology and Obstetrics (FIGO) classification system for fibroid location is as follows (figure 2) [3]:
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● Intramural myomas (FIGO type 3, 4, 5) – These leiomyomas are located within the uterine wall.
They may enlarge sufficiently to distort the uterine cavity or serosal surface. Some fibroids may
be transmural and extend from the serosal to the mucosal surface.
● Submucosal myomas (FIGO type 0, 1, 2) – These leiomyomas derive from myometrial cells just
below the endometrium (lining of the uterine cavity). These neoplasms protrude into the uterine
cavity. The extent of this protrusion is described by the FIGO/European Society of Hysteroscopy
classification system and is clinically relevant for predicting outcomes of hysteroscopic
myomectomy (figure 3) [4] (see "Hysteroscopic myomectomy", section on 'Leiomyoma
characteristics'):
• Type 0 – Completely within the endometrial cavity

• Type 1 – Extend less than 50 percent into the myometrium
• Type 2 – Extend 50 percent or more within the myometrium
● Subserosal myomas (FIGO type 6, 7) – These leiomyomas originate from the myometrium at the
serosal surface of the uterus. They may have a broad or pedunculated base (image 1) and may
be intraligamentary (ie, extending between the folds of the broad ligament).
● Cervical myomas (FIGO type 8) – These leiomyomas are located in the cervix rather than the
uterine corpus.
While conceptually straightforward, a study attempting to validate the FIGO classification system
found significant disagreement on classification among experts [5].
PREVALENCE
Uterine leiomyomas are the most common pelvic tumor in women [1,2,6]. Incidence is difficult to
determine since there are few longitudinal studies [7]. In addition, the actual prevalence in the female
population is unknown since studies have been conducted mainly in symptomatic women or following
hysterectomy. Representative studies include:
● In the Nurses' Health Study II, a large prospective study in the United States, over 95,000 women
ages 25 to 44 were followed from 1989 to 1993 [8]. The age-standardized incidence rates of
fibroids confirmed by ultrasound or hysterectomy were 9.2 per 1000 woman-years overall, 30.6
for black women, and 8.9 for white women. Overall incidences by age group were: 25 to 29 (3.3
per 1000 woman-years), 30 to 34 (6.8), 35 to 39 (10.3), and 40 to 44 (16.0).
● In a population-based study of an urban health plan in Washington, DC, 1364 women ages 35 to
49 years were randomly selected and assessed by survey and/or ultrasound [1]. Newly detected

fibroids were present in 59 percent of black women and 43 percent of white women; for women
in their late 40s, the estimated frequency of fibroids was >80 percent and near 70 percent for
black and white women, respectively.
● A cross-sectional study in Europe of 1756 women with fibroid-related symptoms found myomas
in 12 to 24 percent [9]. Myomas are clinically apparent in approximately 12 to 25 percent of
reproductive-age women and noted on pathologic examination in approximately 80 percent of
surgically excised uteri [9,10].
● A study of 100 hysterectomy specimens found myomas in 77 percent of uterine specimens [10].
Most women had multiple myomas, with an average of 7.6 fibroids.
● An ultrasound screening study of women aged 18 to 30 found a prevalence of 26 percent in

black women and 7 percent in white women [11].
The prevalence of leiomyomas increases with age during the reproductive years [1,8]. Leiomyomas
have not been described in prepubertal girls, but they are occasionally noted in adolescents. Most,
but not all, women have shrinkage of leiomyomas after menopause.
RISK FACTORS
Race — The incidence rates of fibroids are typically found to be two- to threefold greater in black
women than in white women [1,8,11,12]. Clinically relevant fibroids (uterine enlargement greater than
or equal to nine weeks size, fibroid greater than or equal to 4 cm, or submucosal fibroid) were
detectable by transvaginal sonography in approximately 50 percent of black women during the
menopausal transition and 35 percent of white women. Most data on the disparities by race and
ethnicity are from the United States, but a South African study indicated similar differences in fibroid
prevalence between black and nonblack women [13].
The etiology of the increased incidence of leiomyomas in black women is unknown. It cannot be
explained by known factors that vary by race [8,14]. Differences in genetic factors, diet, lifestyle,
psychosocial stress, and environmental exposures between black and white women are thought to
contribute this disparity [15-17]. The Study of Environment, Lifestyle, and Fibroids (SELF) trial is
specifically studying risk factors such as vitamin D deficiency and African ancestry among African
American women [18].
The natural history of leiomyomas also differs by race. Most white women with symptomatic fibroids
are in their 30s or 40s; however, black women develop symptoms on average four to six years
younger and may even present with disease in their 20s [19,20]. The prevalence of fibroids in women
less than or equal to 30 years of age is significantly higher in black women, with approximately 25
percent of black women having fibroids compared with 7 percent of white women [11]. In addition, it
appears that fibroids grow at a slower rate after age 45 years in white women but not in black women
[21].
The rate of hysterectomy for fibroids is greater among black women than among white women (38
versus 16 per 10,000 women) [22]. Several studies have confirmed that surgery for fibroids is more
common among black women than white women [12,23]. Also, among women undergoing
hysterectomy, black women have surgery at a younger age, larger uteri, and more severe anemia
[19,20]. There is also increased risk of myomectomy and hospitalization for fibroids for black women
[24]. The interplay of race, geographic residence, and access to health care makes it difficult to infer
patient choices for fibroid therapy. The Southern United States, which also has the highest racial
diversity, also has a higher prevalence of hysterectomy than the Northeast, but it is unknown if this is
due to patient or provider choice or familiarity [25]. In a large insurance database in the United States,
uterine-sparing procedures were more frequent in regions with higher proportion of African American
women.
Data are mixed regarding whether Latina women have an increased risk of uterine myomas
compared with non-Latina white women [8,22,26]. The risk was 1.3-fold in a prospective study of
133,000 women [22]. Some of this variation may be accounted for by whether black Latina women
are included in the analysis. Data are also limited for fibroid incidence in Asian women, but rates
appear to be similar to white women [8].
Reproductive and endocrine factors — The epidemiology of leiomyomas parallels the ontogeny
and life cycle changes of the reproductive hormones estrogen and progesterone. Although the growth
of fibroids is responsive to gonadal steroids, these hormones are not necessarily responsible for the
genesis of the tumors. (See "Histology and pathogenesis of uterine leiomyomas (fibroids)", section on
'Steroid hormones'.)
Parity — Parity (having one or more pregnancies extending beyond 20 weeks of gestation)
decreases the chance of fibroid formation [27-29]. There is a suggestion that additional pregnancies
further decrease the risk [7,29,30]. In some cohorts, older age at first birth was also associated with a
decreased risk compared with younger age at first birth and a longer interval since last birth with an
increased risk [7,30].
Early menarche — Early menarche (<10 years old) is associated with an increased risk of
developing fibroids. This may largely account for the early onset of disease in black women, in whom
menarche is generally earlier than in white women [19,30-33]. In white women, a specific
polymorphism in the transcription factor HMGA2 appears to be linked to both uterine leiomyomas and
shorter adult height, suggesting that early menarche may be a key influence [31]. Menarche is

associated with increase of estradiol to postpubertal levels which can plausibly lead both to increased
fibroid growth and early fusion of the long bone epiphyses leading to decreased height.
Hormonal contraception — Use of standard or lower dose oral contraceptives (OCs; ≤35 mcg
ethinyl estradiol/day) does not appear to cause fibroids to grow; therefore, administration of these
drugs is not contraindicated in women with fibroids [27,30,34-36]. One possible exception was
reported by the Nurses' Health Study, which suggested OC use was associated with an increased risk
of leiomyomas in women with early exposure to OCs (13 to 16 years old) [29].
Long-acting progestin-only contraceptives (eg, depot medroxyprogesterone) appear to protect against

development of leiomyomas [30,36,37]. However, studies of postpartum fibroid regression suggest
that these agents inhibit fibroid regression specifically when used in the postpartum period [38].
Studies investigating the symptomatic control of bleeding by progestin intrauterine devices have
shown small decreases in fibroid or uterine size [39,40].
Other endocrine factors — Prenatal exposure to diethylstilbestrol is associated with an increased

risk of fibroids, supporting the role of early hormonal exposure in pathogenesis [41]. (See "Outcome
and follow-up of diethylstilbestrol (DES) exposed individuals".)
There are no credible cases of uterine enlargement with ovulation induction [42,43]. A nationwide
cohort study of women undergoing in vitro fertilization reported a decrease in risk of fibroids for
women with a higher response to ovarian stimulation than those with a normal response [44].
Environmental exposures such as phthalates, polychlorinated biphenyl, and bisphenol A appear to be

linked to an increased risk of fibroids, possibly through endocrine disruption [45]. (See "Overview of
occupational and environmental risks to reproduction in females".)
Obesity — Most studies show a relationship between fibroids and increasing body mass index (BMI);
however, a relationship with increased BMI, weight gain as an adult, or body fat varies across studies
[34,46-50]. The relationship is complex and is likely modified by other factors, such as parity, and may
be more related to change in body habitus as an adult.
Diet, alcohol, and smoking
● Diet – Studies regarding dietary effects on fibroids include:
• Significant consumption of beef and other reds meats (1.7-fold) or ham (1.3-fold) is
associated with an increased relative risk of fibroids and consumption of green vegetables
(0.5-fold) and fruit (especially citrus fruit) with a decreased risk [51,52].
• One report suggested that consumption of dairy products, but not soy products, is inversely
related to fibroid risk in black women [53]. There was no confounding effect of soy
consumption, which is often a substitute for dairy products in lactose intolerant women.
• Increases in dietary glycemic index or load are associated with a small increase in fibroid
risk in some women [54].
• Dietary consumption of carotenoids is not associated with a change in risk for uterine
leiomyoma [55].
• Dietary vitamin A from animal sources may also be associated with decreased fibroid risk
[52].
• There is increasing evidence that vitamin D deficiency or insufficiency, which is more

prevalent among black women, is linked to fibroid risk [56,57]. The major source of vitamin D
is from synthesis from a prohormone when sunlight hits the skin, and this is inhibited by the
higher levels of melanin in darker skin. This relationship is especially interesting because it is
a biologically plausible explanation for the increased fibroid risk in black women that lends
itself to prevention trials.
• Caffeine consumption is generally not a risk factor for fibroids, except for weak associations
in women under age 35 with high consumption of coffee or caffeine intake [58].
● Alcohol – Consumption of alcohol, especially beer, appears to be associated with an increased

risk of developing fibroids [58].
● Smoking – Early studies showed that smoking decreased the risk of having fibroids, possibly
through the inhibition of aromatase [27,59,60]. Subsequent studies have not found an
association with fibroids [48,58].
Genetics — Studies imply a familial predisposition to leiomyomas in some women. There is also
evidence of specific susceptibility genes for fibroids [61-63].
The genetics of fibroids is discussed in detail separately. (See "Histology and pathogenesis of uterine
leiomyomas (fibroids)", section on 'Genetics'.)
Other factors — Hypertension is associated with an increased leiomyoma risk. The risk is related to
increased duration or severity of hypertension [64]. There are some studies showing a decreased
leiomyoma risk among women with type 2 diabetes, which appears to have a stronger association
among European Americans than African Americans [65-67].
Uterine infection was previously associated with an increased risk of leiomyomas, but a subsequent
study of self-reported reproductive tract infection did not find an association [64,68], and one study
found an inverse relationship with chlamydia exposure [69]. Factors associated with cervical

neoplasia are associated with a decreased risk [64,70]. Additional study is indicated regarding
infectious agents and fibroid risk.
There appears to be a link between a history of physical or sexual abuse and fibroids, especially in
black women [15,71,72].
PREVENTION
Given the high prevalence, high recurrence risk following conservative treatment, and substantial
impact on quality of life, preventive measures for uterine fibroids are needed. One study has
suggested low physical activity, even after adjustment for body mass index and other confounders,
was associated with a substantial decrease in risk of fibroid development [73]. Etiologic investigations
of vitamin D deficiency, inflammatory markers, hormonal receptors, and more are aimed at finding
preventive targets. Prevention of growth and symptoms by intermittent use of the progesterone
modulator ulipristal acetate is under investigation and shows promise as a medical therapy for fibroids
[74].
CLINICAL FEATURES
Uterine leiomyomas are typically brought to medical attention due to symptoms or are found
incidentally on pelvic imaging. Approximately 1 percent of women in a commercially insured
population have fibroids that receive medical attention in a year [75].
The majority of myomas are small and asymptomatic, but many women with fibroids have significant
problems that interfere with some aspect of their lives and warrant therapy [76]. These symptoms are
related to the number, size, and location of the tumors. Myomas can occur as single or multiple
tumors and range in size from microscopic to tens of centimeters. The size of the myomatous uterus
is described in menstrual weeks as with the gravid uterus. As an example, a 20-week size
myomatous uterus is not unusual and is often associated with heavy menses, increasing abdominal
girth, and a sense of abdominal fullness similar to pregnancy.
Symptoms are classified into three categories [77]:
● Heavy or prolonged menstrual bleeding

● Bulk-related symptoms, such as pelvic pressure and pain
● Reproductive dysfunction (ie, infertility or obstetric complications)
Among symptomatic women with uterine fibroids, abnormal uterine bleeding (AUB) and menstrual
cramps are the most common symptoms occurring in approximately 26 to 29 percent of all women.
African American women reported higher rates at 37 to 42 percent [78]. Abdominal pain or tightness
is reported in 19 percent of white women and 34 percent of African American women.
Heavy or prolonged menstrual bleeding — Heavy and/or prolonged menses is the typical bleeding
pattern with leiomyomas and the most common fibroid symptom [79,80]. Intermenstrual bleeding and
postmenopausal bleeding should prompt investigation to exclude endometrial pathology. For any
AUB pattern, endometrial sampling should be performed if endometrial hyperplasia or carcinoma is
suspected (table 1). It is important to keep in mind that a woman may have fibroids and may also
have endometrial neoplasia.
Heavy uterine bleeding may be responsible for associated problems, such as iron deficiency anemia,
social embarrassment, and lost productivity in the work force.
The presence and degree of uterine bleeding are determined, in large part, by the location of the
fibroid; size is of secondary importance (figure 1) (see 'Terminology and location' above):
● Submucosal myomas that protrude into the uterine cavity (eg, types 0 and 1) (figure 3) are most
frequently related to significant heavy menstrual bleeding [4,6,81]. As an example, a
retrospective study that included 912 women with leiomyomas found that those with submucosal
myomas were significantly more likely to be anemic than women with myomas in other locations
(34 versus 25 percent) [82].
● Intramural myomas are also commonly associated with heavy or prolonged menstrual bleeding,
but subserosal fibroids are not considered a major risk for heavy menstrual bleeding.
● Cervical fibroids that are close to the endocervical canal may be related to AUB.
The mechanism(s) of profuse menses in women with leiomyomas are unclear but may include both
microscopic and macroscopic abnormalities of the uterine vasculature, impaired endometrial
hemostasis, or molecular dysregulation of angiogenic factors [83]. A study of endometrial histology
showed distinct endometrial changes even remote from the location of fibroids, indicating that fibroids
located intramurally could also contribute to bleeding [84]. In addition, a study of uterine peristalsis
demonstrates altered uterine contractility near submucosal fibroids; one theory is that this inhibits the
usual ability of the uterus to contract during menses [85].
The evaluation of women with AUB is discussed in detail separately. (See "Approach to abnormal
uterine bleeding in nonpregnant reproductive-age women".)
Bulk-related symptoms — The myomatous uterus is enlarged and irregularly shaped and can cause
specific symptoms due to pressure from myomas at particular locations. These symptoms and
findings include pelvic pain or pressure, urinary tract or bowel obstruction, or venous compression.

Pelvic pressure or pain — In general, pelvic discomfort is common in women with fibroids but
less common than AUB. If discomfort is present, it is likely to be chronic, intermittent, dull pressure or
pain.
Back pain may, on occasion, be related to the presence of myomas, but other possible causes should
be considered.
Urinary tract or bowel issues — The urinary tract or bowel may be compressed by fibroids,
depending on their size and location. Symptoms and findings include:
● Urinary symptoms – A heterogeneous group of urinary symptoms including frequency, difficulty

emptying the bladder, or, rarely, complete urinary obstruction may all occur in up to 60 percent of
women with fibroids [76]. Bladder symptoms sometimes arise when an anterior fibroid presses
directly on the bladder or a posterior fibroid pushes the entire uterus forward. In a small cohort
study of women with fibroids on ultrasound, 14 percent demonstrated hydronephrosis, more
commonly on the right. Fibroids associated with hydronephrosis were larger with an average
largest fibroid of 6 cm and a uterine size of 18 weeks [86].
● Bowel symptoms – Fibroids that place pressure on the rectum can result in constipation.
Venous compression — Very large uteri may compress the vena cava and lead to an increase in
thromboembolic risk [87-89]. At least one study suggests the risk of venous thromboembolism is likely
to be the presenting complaint associated with an enlarged uterus rather than a postsurgical
complication [87].
Other pain or discomfort issues
Painful menses — Painful menses is reported by many women with fibroids. This pain in many
women appears to be correlated with heavy menstrual flow and/or passage of clots.
Painful intercourse — It is controversial whether women with fibroids are more likely to
experience painful intercourse than women without fibroids [90,91]. However, among women with
fibroids, anterior or fundal fibroids are the most likely to be associated with deep pain with
intercourse. Number and size of fibroids do not appear to influence the incidence or intensity of
painful intercourse.
Fibroid degeneration or torsion — Infrequently, fibroids cause acute pain from breaking down of
the fibroid tissue (eg, carneous or red degeneration) (picture 2) or torsion of a pedunculated tumor.
Fibroid degeneration typically results in pelvic pain and may be associated with a low-grade fever,
uterine tenderness on palpation, elevated white blood cell count, or peritoneal signs. The discomfort

resulting from degenerating fibroids is self-limited, lasting from days to a few weeks, and usually
responds to nonsteroidal anti-inflammatory drugs.
Diagnosis of fibroid degeneration is based upon the presence of a fibroid with a typical symptom
pattern. On ultrasound, a potential diagnosis of degeneration is suggested when pain is present when
scanning directly over the fibroid (image 2). In cases where the etiology of pain is unclear, pelvic
magnetic resonance imaging with gadolinium can be useful to make the diagnosis of degeneration
since regions of degeneration within fibroids do not have enhancement following contrast
administration [92]. If acute pain is the sole indication for surgery for uterine fibroids, other disease
processes, such as endometriosis, renal colic, or rare diagnoses such as pelvic tuberculosis, should
be carefully excluded [93,94]. (See "Endometriosis: Pathogenesis, clinical features, and diagnosis".)
Infertility or obstetric complications — Leiomyomas that distort the uterine cavity (submucosal or
intramural with an intracavitary component) have been thought to result in difficulty conceiving a
pregnancy and an increased risk of miscarriage [95]. However, a large prospective cohort study that
identified fibroids in the first trimester of pregnancy found that, while fibroids were associated with
miscarriage in univariate analysis, in multivariate analysis, increasing age appeared to be the primary
driver of this relationship [96]. Similar findings were obtained in a systematic review that addressed
confounders [97]. (See "Reproductive issues in women with uterine leiomyomas (fibroids)".)
In addition, leiomyomas have been associated with adverse pregnancy outcomes (eg, placental
abruption, fetal growth restriction, malpresentation, and preterm labor and birth). (See "Pregnancy in
women with uterine leiomyomas (fibroids)".)
Other issues
● Prolapsed fibroid – Infrequently, a submucosal leiomyoma will prolapse through the cervix and
present with a mass, bleeding, and possible ulceration or infection. (See "Prolapsed uterine
leiomyoma (fibroid)".)
● Endocrine effects – Rare symptoms of fibroid tumors where fibroids can secrete ectopic
hormones include:
• Polycythemia from autonomous production of erythropoietin [98]
• Hypercalcemia from autonomous production of parathyroid hormone-related protein [99]
• Hyperprolactinemia [100]
DIAGNOSTIC EVALUATION
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The clinical diagnosis of uterine leiomyomas is made based upon a pelvic examination and pelvic
ultrasound findings consistent with a uterine leiomyoma. Characteristic symptoms further support the
clinical diagnosis, although many women are asymptomatic. A definitive diagnosis by pathology
evaluation is not obtained in all cases but should be pursued if there is reason to be suspicious that
the uterine mass may not be a fibroid, but rather may be a uterine precancer or cancer. (See
"Differentiating uterine leiomyomas (fibroids) from uterine sarcomas".)
The pelvic examination findings are typically of an enlarged, mobile uterus with an irregular contour
on bimanual pelvic examination; however, small submucosal or intramural fibroids will not produce a
noticeably enlarged uterus or an irregular contour. The most common symptoms are heavy or
prolonged menstrual bleeding, and fibroids may be associated with pelvic pain, infertility, or other
symptoms. Typically, the clinical diagnosis is confirmed with a pelvic ultrasound.
History — A medical history is taken, including:
● Symptoms related to fibroids – The most common presenting symptoms of uterine fibroids are
heavy or prolonged menstrual bleeding, pelvic pain or pressure, and infertility. For all symptoms,
the duration, severity, and impact on quality of life should be assessed.
• It is important to assess the severity of heavy or prolonged menstrual bleeding. A menstrual

history is taken and the volume and duration of bleeding elicited. Questions to assess
uterine bleeding are shown in the table (table 2). If there is any possibility the patient is
pregnant, pregnancy testing should be performed. In addition, based on the bleeding pattern
and risk factors, the clinician should consider the risk of endometrial hyperplasia or cancer
and whether endometrial sampling should be performed (table 1). (See 'Clinical features'
above.)
• For women with pelvic pain or pressure, the location, severity, and characteristics of the pain
should be assessed. Pain related to fibroids is not likely to have an acute onset, except in
the infrequent cases of fibroid torsion and degeneration. In addition, while some women with
fibroids experience painful menses, the pain associated with fibroids can also be noncyclic.
Pain associated with menses may also indicate adenomyosis, endometriosis, or primary
painful menses.
Patients should be asked about other potential pain or bulk-related symptoms, including
dyspareunia, urinary retention, or constipation.
• The patient should be asked about infertility, recurrent miscarriage, or obstetric

complications that may be related to fibroids.

● Obstetric and gynecologic history, including prior history of uterine fibroids, history of pelvic pain,
obstetric or gynecologic surgeries, and risk factors for uterine malignancies other than
endometrial carcinoma (sarcoma, carcinosarcoma). Risk factors for sarcoma include
postmenopausal status, black race, tamoxifen, pelvic radiation, and hereditary leiomyomatosis
and renal cell carcinoma. (See "Clinical features, diagnosis, staging, and treatment of uterine
carcinosarcoma", section on 'Epidemiology and risk factors' and "Uterine sarcoma: Classification,
epidemiology, clinical manifestations, and diagnosis", section on 'Risk factors'.)
● Relevant medical and surgical history, including those that are part of the differential diagnosis or
may exacerbate the symptoms of a pelvic mass, pelvic pain, or abnormal uterine bleeding. This
includes coagulation disorders, anticoagulant medications, nongynecologic conditions that cause
pelvic or abdominal pain or mass, and prior pelvic or abdominal surgery.
Physical examination — The physical examination includes an abdominal and pelvic examination.
Vital signs are taken, as appropriate. Fibroids are rarely associated with fever, except in some women
with degenerating fibroids. Women with severe heavy menstrual bleeding may become anemic, but in
otherwise healthy reproductive-age women, a significant change in heart rate or blood pressure is
rare as part of the clinical presentation.
The abdominal examination should include palpation for a pelvic-abdominal mass. Large fibroid uteri
can be palpated abdominally. The level of the uterine fundus should be noted.
A thorough pelvic examination is performed. On bimanual pelvic examination, the size, contour, and
mobility should be noted. An enlarged, mobile uterus with an irregular contour is consistent with a
leiomyomatous uterus. These findings are helpful to follow changes in the uterus over time and to aid
surgical planning (eg, transverse or vertical incision, vaginal surgery or abdominal approach).
The size is described in terms of the fundal height in the superior-inferior axis in comparison to a
gravid uterus: Twelve weeks is palpable just above the pubic symphysis, 16 weeks is midway
between the symphysis and umbilicus, and 20 weeks is at the umbilicus. An increase in size or an
irregular contour may not be noted if the patient has small intramural or submucosal fibroids.
An enlarged uterus that is fixed raises suspicion of an inflammatory process (eg, endometriosis) or
malignancy.
Infrequently, on speculum examination, a prolapsed submucosal fibroid is visible at the external

cervical os. Prolapsed fibroids should be removed and are distinguished from a large endocervical or
endometrial polyp by the firm consistency of the tissue and by pathology evaluation. (See "Prolapsed
uterine leiomyoma (fibroid)".)

Cervical fibroids can present as an enlargement of the cervix seen during speculum examination or
felt on bimanual examination. A pedunculated cervical fibroid can also appear like a prolapsing
fibroid. Cervical fibroids generally have to be confirmed by an imaging study.
Laboratory testing — Laboratory testing does not have a role in the diagnosis of uterine
leiomyomas. If a patient has long-term heavy or prolonged menstrual bleeding, a hematocrit may be
ordered to evaluate for anemia and a thyroid-stimulating hormone to rule out concomitant
hypothyroidism as a source for heavy menstrual bleeding. A urine or serum human chorionic
gonadotropin is ordered if the patient may be pregnant.
Imaging and endoscopy — Pelvic ultrasound is the imaging study of choice for uterine leiomyomas,
based on the ability to visualize genital tract structures and cost-effectiveness. Ultrasound is typically
performed in all patients, and then other studies, such as saline-infused sonogram, hysteroscopy, or
magnetic resonance imaging (MRI), are ordered depending on the clinical indications.
Computed tomography has little clinical utility in delineating the position of fibroids relative to the
endometrium or myometrium [101]. Hysterosalpingograms can also sometimes show the distortion of
the endometrial cavity but are best reserved for the woman needing assessment of fallopian tube
patency for fertility.
Step one: Pelvic ultrasound — Pelvic ultrasound is the first-line study used to evaluate for
uterine fibroids. Transvaginal ultrasound has high sensitivity (95 to 100 percent) for detecting myomas
in uteri less than 10 gestational weeks' size [102]. Precise localization of fibroids is limited in larger
uteri or when there are many tumors. Fibroids are seen on ultrasound usually as hypoechoic, well-
circumscribed round masses, frequently with shadowing; cellular fibroids may appear to be more
isoechoic, making differentiation from the normal myometrium difficult, or hyperechoic. Adenomyomas
can mimic the appearance of cellular fibroids or multiple small fibroids. Sarcoma is also difficult to
differentiate on imaging.
On imaging, calcification in a fibroid generally implies that it has degenerated. These calcifications
can be seen on plain film as "popcorn" calcifications in the pelvis. On ultrasound, the calcifications
may appear as clumps or rim-like calcifications within a mass (image 3). At times, only the
calcification is seen and not the soft tissue component. In general, if compared with a sonogram
prenecrosis, the fibroid size will be smaller once it calcifies.
If fibroids are thought to be causing urinary tract obstruction, then a renal ultrasound can be obtained
to assess for hydronephrosis.
Step two: Evaluate the uterine cavity in women with suspected submucous fibroids or
those desiring fertility

Saline infusion sonography — Saline infusion sonography (sonohysterography) is an imaging

study in which pelvic ultrasound is performed while saline is infused into the uterine cavity. Use of this
technique allows identification of submucosal lesions (some of which may not be seen on routine
ultrasonography) and intramural myomas that protrude into the cavity and characterizes the extent of
protrusion into the endometrial cavity (image 4). (See "Saline infusion sonohysterography".)
Saline infusion sonography is helpful when planning a hysteroscopic resection of a fibroid or

evaluating the potential risks of fertility associated with a fibroid.
Hysteroscopy — Diagnostic hysteroscopy is useful for visualizing the endometrial cavity.

Similar to saline infusion sonography, this allows evaluation for submucosal or protruding myometrial
fibroids and can characterize the extent of protrusion. This can be performed in the office or operating
room.
When the entire fibroid is visualized arising from a pedicle, or has a broad base, the lesion is
hysteroscopically classified as intracavitary. However, when the fibroid abuts the endometrium or
protrudes into the myometrium, the depth of penetration cannot be ascertained hysteroscopically.
Additionally, hysteroscopy less accurately predicts the size of the myoma compared with ultrasound
and sonohysterography [103].
Hysteroscopy can help in the planning of a hysteroscopic resection of a submucosal fibroid if

ultrasound has already confirmed size and proximity to the endometrium and rule out small polyps not
seen on ultrasound.
Step three: Additional imaging as necessary when complex intervention is planned or

malignant disease is suspected
Magnetic resonance imaging — MRI is the most effective modality for visualizing the size and
location of all uterine myomas and can distinguish among leiomyomas, adenomyosis, and
adenomyomas. Due to the expense of this modality, its use is best reserved for procedural planning
for complicated procedures. For instance, for women with type 3 through 6 uterine fibroids, an MRI
can help the surgeon plan for laparoscopic myomectomy to know the expected depth into the
myometrium (figure 2). It may also be useful before uterine artery embolization since imaging patterns
predict uterine artery embolization outcome. MRI can also help identify features concerning for
leiomyosarcoma [104,105]. (See "Differentiating uterine leiomyomas (fibroids) from uterine
sarcomas", section on 'Imaging' and "Uterine leiomyomas (fibroids): Treatment with uterine artery
embolization".)
DIAGNOSIS

Uterine leiomyomas are a clinical diagnosis based upon pelvic imaging. The diagnosis is typically
made based upon a pelvic ultrasound finding of leiomyomas, although other imaging modalities may
be used. The indication for pelvic imaging typically includes symptoms of abnormal uterine bleeding
(AUB), pelvic pain or pressure, or infertility; some women have an enlarged uterus on pelvic
examination.
In general, pathology confirmation is not required to proceed with management, except in cases in
which another lesion is suspected, such as a uterine sarcoma or leiomyoma variant. Unfortunately, it
is difficult to differentiate benign leiomyomas from these conditions, and thus, some cases will be
wrongly diagnosed as leiomyomas. (See "Differentiating uterine leiomyomas (fibroids) from uterine
sarcomas".)
Additional characteristics — Information on volume and location of tumors within the uterus, based
on pelvic imaging, aids in determining the clinical impact and treatment planning. This includes:
● Are submucosal fibroids present? – These are the most likely to be associated with AUB or
infertility, although these issues can occur with fibroids in other locations.
● Are fibroids in one or more than one location? – Treatment planning must take into consideration
all fibroid locations. As an example, management of a single submucosal fibroid may be different
than if there is a submucosal fibroids and several intramural fibroids.
● Is the volume or location of fibroids consistent with bulk-related symptoms? – Pelvic pain or
pressure is likely to occur only if the uterus is sufficiently enlarged. In addition, urinary symptoms
may occur if there is an anterior fibroid that abuts the bladder, or bowel symptoms may occur if
there is a posterior or left fibroid that puts pressure on the rectum or sigmoid colon.
● Is there hydronephrosis? – Hydronephrosis due to ureteral obstruction by a fibroid uterus must

be alleviated to avoid renal failure.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of uterine leiomyomas includes other conditions that cause uterine
enlargement, abnormal uterine bleeding (AUB), pelvic pain, or infertility. It is important to note that
leiomyomas are a common condition, and other coexisting conditions may be the etiology of the
presenting symptoms.
The differential diagnosis of an enlarged uterus includes both benign and malignant conditions:
● Pregnancy

● Myometrial lesions:
• Benign leiomyoma
• Adenomyosis (diffuse infiltration of the myometrium) or adenomyoma
• Leiomyoma variant
• Leiomyosarcoma
• Metastatic disease – This is very rarely the cause of an enlarged uterus and typically from
another reproductive tract primary; these lesions are likely to be myometrial but may invade
the endometrium [106,107]
● Endometrial lesions:
• Endometrial polyp – These tend to be small and are unlikely to cause an enlarged uterus
• Endometrial carcinoma (may invade into the myometrium) or hyperplasia
• Carcinosarcoma – Considered an epithelial neoplasm
• Endometrial stromal sarcoma (mimics endometrium but invades the myometrium)
● Hematometra (blood within the uterine cavity, usually following an intrauterine procedure [eg,
dilation and curettage])
Pregnancy should be excluded in any woman of reproductive age who presents with an enlarged
uterus, AUB, and/or pelvic pain. (See "Clinical manifestations and diagnosis of early pregnancy",
section on 'Diagnosis'.)
Most commonly, when faced with an enlarged uterus, uterine leiomyomas must be differentiated from
uterine adenomyosis. Women with adenomyosis more often present with a diffusely enlarged uterus,
painful menses, and AUB. On examination in a woman with adenomyosis, the uterus is typically
smooth, globular, and boggy. The two conditions are usually differentiated by imaging since each has
a characteristic appearance on ultrasound. (See "Uterine adenomyosis".)
Women may develop adenomyomas, which are benign glandular tumors within the myometrium.
These can closely resemble leiomyomas on imaging. Adenomyosis and fibroids often occur in the
same woman, making differentiation more difficult [108,109]. Intraoperatively, adenomyomas are
generally more difficult to excise than leiomyomas. Leiomyomas are typically separated from the
adjacent myometrium by a pseudocapsule. With adenomyomas, there is typically no tissue plane
between the adenomyoma and the myometrium.
Benign or malignant uterine neoplasms must be differentiated from leiomyomas. The most common
neoplastic condition that is part of the differential diagnosis is endometrial carcinoma. This is the most
common site of gynecologic cancer in developed countries. Women present with uterine bleeding and
may have a uterine mass. However, the ultrasound findings in endometrial carcinoma are likely to be
a thickened endometrium or, in the case of more advanced disease, a lesion invading from the
endometrium to the myometrium. This is a distinctly different appearance than a fibroid, which may be
seen to distort the endometrial cavity, but not actually invade from the endometrium to the
myometrium. Endometrial sampling is the best method of diagnosis for endometrial carcinoma and
should be performed if this is a potential diagnosis (table 1). (See "Clinical features, diagnosis,
staging, and treatment of uterine carcinosarcoma".)
Leiomyomas are a common condition, and thus, it may be presumed that a patient has myomas
rather than a rare smooth muscle neoplasm. This includes leiomyoma variants that manifest some
facets of malignancy yet lack others. For example, they may metastasize but not be locally invasive
and be histologically benign. Some of these variants show no facets of malignancy. These lesions
appear to be exceedingly rare. (See "Variants of uterine leiomyomas (fibroids) and smooth muscle
tumors of uncertain malignant potential".)
Clinicians should also consider the possibility of a uterine sarcoma. Uterine sarcoma is rare (3 to 7
per 100,000 in the United States population) and has a poor prognosis [110]. Both leiomyomas and
uterine sarcoma present as focal masses in the uterine myometrium. There are several histologic
types of uterine sarcoma. The main type of sarcoma that may resemble a leiomyoma is
leiomyosarcoma, which presents as a myometrial mass, often with AUB. In contrast, endometrial
stromal sarcoma presents as an endometrial mass. However, this could potentially have a similar
appearance to a submucosal leiomyoma. Differentiating benign leiomyomas from uterine sarcomas is
a clinical challenge and most sarcomas are not detected preoperatively. If there is a suspicion of a
uterine sarcoma, operative techniques that disrupt the specimen (eg, myomectomy, morcellation)
should be avoided. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas".)
Adenomatoid tumors are an uncommon type of mass of the female reproductive tract that can be
seen in the myometrium or in the adnexa (the most common place is actually next to the fallopian
tube) [111]. They are mesothelial proliferations and are not histologically related to adenomyosis.
They may grossly mimic leiomyomas.
The differential diagnosis of AUB is aided by pelvic imaging and a clinical description of the bleeding.
Heavy or prolonged menstrual bleeding are typically the AUB patterns that are associated with
leiomyomas, although these symptoms are also consistent with many other etiologies. Other AUB
patterns, such as intermenstrual bleeding, irregular bleeding, or postmenopausal bleeding, are likely
due to other causes. In the absence of a mass on pelvic ultrasound, leiomyomas can be excluded
and other etiologies should be investigated (table 3 and figure 4). (See "Approach to abnormal uterine
bleeding in nonpregnant reproductive-age women" and "Postmenopausal uterine bleeding".)

Pelvic pain is a broad symptom category, and clarifying with the patient regarding the characteristics
of the pain (ie, location, acuity, duration, pattern, sensation, associated factors) is helpful in working
through the differential diagnosis (table 4). Gastrointestinal, urinary tract, or other sources of pelvic
pain should also be considered. In general, pain is not a major symptom in women with fibroids. If
discomfort is present, it is likely to be chronic, intermittent, dull pressure or pain. (See "Causes of
chronic pelvic pain in nonpregnant women".)
Female infertility has many etiologies. Fibroids are usually discovered, if present, on pelvic ultrasound
that is part of the routine evaluation.
NATURAL HISTORY
Premenopausal women — With modern pelvic imaging, we have achieved an increased

appreciation of the variability of growth and shrinkage of leiomyomas during the reproductive years
[21,112,113]. Prospective studies have found that between 7 to 40 percent of fibroids regress over six
months to three years [21,112]. There is also an increased appreciation of postpartum regression of
fibroids [38,114].
Representative studies include:
● In one prospective study of 64 women (mean age 44 years) with fibroids, the average growth
rate was 1.2 cm in diameter over 2.5 years (range 0.9 to 6.8 cm) [112].
● A second study followed 72 women with a total of 262 fibroids with magnetic resonance imaging
(MRI) and reported a median growth rate of 9 percent at six-month follow-up. [21]. There was
wide variation in the growth of individual fibroids across all study participants (range decrease in
size of 89 percent to increase in size of 138 percent) and for different fibroids within each
woman. Within this prospective study, 36 women with a total of 101 fibroids were evaluated with
MRI at all time points for one year [115]. Increase in volume of ≥30 percent in a three-month
period was found in 37 myomas; rapid growth was more likely in tumors that were ≤5 cm in
diameter.
Postpartum remodeling — It has been hypothesized that the postpartum remodeling of the
uterus may have the effect of clearing smaller fibroids [116]. One study supported this hypothesis with
the finding that over one-third of women with a single fibroid identified during pregnancy had none on
postpartum ultrasound, and almost 80 percent of fibroids were smaller following pregnancy [114].
Postmenopausal women — At menopause, menstrual cyclicity stops and steroid hormone levels
wane, and there is a cessation of the abnormal uterine bleeding symptoms associated with fibroids.
Most, but not all, women have shrinkage of leiomyomas at menopause.
Women on hormone therapy — Use of menopausal hormone therapy may cause some women
with leiomyomas to continue to have symptoms after menopause. The risk of symptoms may depend,
in part, on the location of the fibroid (higher if submucosal [117]) and type of estrogen preparation
(higher with transdermal estrogen in some studies [118,119] but not others [120]).
A systematic review including five randomized controlled trials found that postmenopausal hormone
therapy was associated with some myoma growth, but this typically occurred without clinical
symptoms [121]. These findings were confirmed in a subsequent prospective study [122]. Thus, the
presence of leiomyomas is not a contraindication to use of postmenopausal hormone therapy and
postmenopausal hormone therapy does not lead to development of new symptomatic fibroids in most
women. (See "Menopausal hormone therapy: Benefits and risks", section on 'Uterine leiomyomas'.)
IMPACT ON PATIENT AND SOCIETY
Quality of life — Women with symptomatic fibroids report multiple symptoms as well as concerns
about fibroids affecting relationships, employment, and overall health. In a survey study, 20 to 40
percent of women with symptomatic fibroids reported feeling worn out and sad or discouraged; 21
percent also reported that fibroids made them feel not in control of their life [78]. Twenty to 30 percent
reported interference with physical and social activities, and 24 percent reported that fibroids
prevented them from reaching full employment potential.
Compared with white women, black women experience more severe disease based on their
symptoms and have more extensive disease at the time of hysterectomy [19,20]. There is growing
evidence of increases in symptomatology for black women with fibroids apart from those seeking
surgical therapy, increased impairment of quality of life, different concerns regarding fibroids and the
consequences of fibroid therapies, and less satisfaction with the information they receive about
fibroids [76]. Importantly, black women were almost three times as likely to be concerned about
fertility and healthy pregnancy [78].
Economic impact — Uterine fibroids are costly to the health care system and the individual patient.
Because they are the cause of 40 percent of hysterectomies, surgical costs and missed work days
during recovery can add great expense to the treatment. Fibroids account for approximately $9.4
billion United States health care dollars annually [123]. Annual excess cost per woman with fibroids
was estimated at more than $4600, which included $771 in missed work days [124].
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Uterine leiomyomas (fibroids)".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Uterine fibroids (The Basics)")
● Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Uterine leiomyomas (fibroids or myomas) are the most common pelvic tumor in women
(cumulative incidence by age 50 of >80 percent for black women and almost 70 percent for white
women). The incidence of leiomyomas parallels the life cycle changes of the reproductive
hormones estrogen and progesterone. (See 'Prevalence' above and 'Race' above.)
● Leiomyomas are benign monoclonal tumors arising from the smooth muscle cells of the
myometrium. Fibroids are typically described according to their location in the uterus
(submucosal, intramural, subserosal, cervical). (See 'Prevalence' above.)
● Symptoms attributable to uterine myomas can generally be classified into three distinct
categories: abnormal uterine bleeding (AUB), pelvic pressure and pain, and reproductive
dysfunction. (See 'Clinical features' above.)
● Uterine leiomyomas are a clinical diagnosis based upon pelvic imaging. The diagnosis is typically
made based upon a pelvic ultrasound finding of leiomyomas, although other imaging modalities
may be used. The indication for pelvic imaging typically includes symptoms of AUB, pelvic pain

or pressure, or infertility; some women have an enlarged uterus on pelvic examination. In

general, pathology confirmation is not required to proceed with management, except in cases in
which another lesion is suspected, such as a uterine sarcoma or leiomyoma variant.
Unfortunately, it is difficult to differentiate benign leiomyomas from these conditions, and thus,
some cases will be wrongly diagnosed as leiomyomas. (See 'Diagnosis' above.)
● Transvaginal ultrasound is the most widely used imaging modality for evaluating fibroids due to
its availability and cost-effectiveness. Saline infusion sonography (sonohysterography) improves
characterization of the extent of protrusion into the endometrial cavity by submucous myomas
and allows identification of some intracavitary lesions not seen on routine ultrasonography. (See
'Imaging and endoscopy' above.)
● Relief of symptoms related to fibroids usually occurs at the time of menopause, when menstrual
cyclicity stops and steroid hormone levels wane. Most, but not all, women have shrinkage of
leiomyomas at menopause. Use of postmenopausal hormone therapy may cause some women
with leiomyomas to continue to have symptoms after menopause. Hormone therapy may be
associated with an increase in size of existing myomas but not with the development of new
myomas. (See 'Postmenopausal women' above and 'Women on hormone therapy' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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124. Hartmann KE, Birnbaum H, Ben-Hamadi R, et al. Annual costs associated with diagnosis of
uterine leiomyomata. Obstet Gynecol 2006; 108:930.
Topic 5486 Version 30.0

GRAPHICS
Fibroid locations in the uterus
These figures depict the various types and locations of fibroids. A woman may have one or more
types of fibroids.
Graphic 53241 Version 5.0

Hysterectomy specimen showing multiple leiomyomas
Reproduced with permission from: Aron Schuftan, MD. Copyright © Aron Schuftan,
MD.

Bivalved hysterectomy specimen showing intramural and

subserosal leiomyomas
Reproduced with permission from: Aron Schuftan, MD. Copyright © Aron Schuftan,
MD.

PALM-COEIN subclassification system for leiomyomas
From: Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press, 2010. Copyright © 2010 M. Munro.
Reprinted with the permission of Cambridge University Press.

Submucosal leiomyma position: European Society of Hysteroscopy

classification
The European hysteroscopic classification of submucous leiomyomas.
Reproduced with permission from: Baggish MS, Valle RF, Guedj H. Hysteroscopy: Visual Perspectives
of Uterine Anatomy, Physiology and Pathology. Philadelphia: Lippincott Williams & Wilkins, 2007.
Copyright © 2007 Lippincott Williams & Wilkins.

Pedunculated fibroid
Transvaginal ultrasound image of the right adnexa showing a pedunculated

fibroid. A solid-appearing mass is noted in the right adnexa (long arrow). No
cystic areas are identified. The mass is slightly heterogeneous and has no
appreciable posterior enhancement but has some areas of shadowing (short
arrow). The mass is separate from the right ovary. The arrowhead demonstrates
a thick stalk that connects the fibroid to the uterus.
Reproduced with permission from: Thomas D Shipp, MD. Copyright © Thomas D

Shipp, MD.

Women who should undergo evaluation for endometrial hyperplasia or endometrial

cancer
Abnormal uterine bleeding
Postmenopausal women – Any uterine bleeding, regardless of volume (including spotting or staining). Pelvic
ultrasound to evaluate endometrial thickness is an alternative to endometrial sampling in appropriately selected
women. A thickened endometrium should be further evaluated with endometrial sampling.
Age 45 years to menopause – In any woman, bleeding that is frequent (interval between the onset of bleeding
episodes is <21 days), heavy, or prolonged (>5 days). In women who are ovulatory, this includes intermenstrual
bleeding.
Younger than 45 years – Any abnormal uterine bleeding in obese women (BMI ≥30). In nonobese women,
abnormal uterine bleeding that is persistent and occurs in the setting of one of the following: chronic ovulatory
dysfunction, other exposure to estrogen unopposed by progesterone, failed medical management of the bleeding,
or women at high risk of endometrial cancer (eg, Lynch syndrome, Cowden syndrome).
In addition, endometrial neoplasia should be suspected in premenopausal women who are anovulatory and have
prolonged periods of amenorrhea (six or more months).
Cervical cytology results
Presence of AGC-endometrial.
Presence of AGC-all subcategories other than endometrial – If ≥35 years of age OR at risk for endometrial cancer
(risk factors or symptoms).
Presence of benign-appearing endometrial cells in women ≥40 years of age who also have abnormal uterine
bleeding or risk factors for endometrial cancer.
Other indications
Monitoring of women with endometrial pathology (eg, endometrial hyperplasia).
Screening in women at high risk of endometrial cancer (eg, Lynch syndrome).
These recommendations are based on an average age of menopause of 51 years. Evaluation of women who undergo
menopause earlier should be individualized based upon gynecologic history and risk of endometrial neoplasia.
BMI: body mass index; AGC: atypical glandular cells.

Uterine leiomyoma
Gross intraoperative photograph of a degenerated uterine leiomyoma. This

benign neoplasm can mimic an ovarian tumor.
Courtesy of Mitchel Hoffman, MD.

Cystic degeneration of uterine leiomyoma
Ultrasound of a degenerated uterine leiomyoma (arrow) that has the

appearance of a complex mass.
Courtesy of Jorge Londono, MD.

Questions to ask to help quantify blood loss during menses
How often do you change your sanitary pad/tampon during peak flow days?
How many pads/tampons do you use over a single menstrual period?
Do you need to change the pad/tampon during the night?
How large are any clots that are passed?
Has a medical provider told you that you are anemic?
Women with a normal volume of menstrual blood loss tend to:

Change pads/tampons at ≥3 hour intervals
Use fewer than 21 pads/tampons per cycle
Seldom need to change the pad/tampon during the night
Have clots less than 1 inch in diameter
Not be anemic
Adapted from: Warner PE, Critchley HD, Lumsden MA, et al. Menorrhagia I: Measured blood loss, clinical features, and
outcome in women with heavy periods: A survey with follow-up data. Am J Obstet Gynecol 2004; 190:1216.

Ultrasound of uterine leiomyoma with calcifications
Transvaginal image of a postmenopausal woman with calcified fibroids. The dense calcifications (arrows)
have shadowing behind them. The borders of the fibroids and uterus are not well seen due to the dense
calcifications.

Fibroid in 53-year-old woman who presented with

postmenopausal bleeding
(A) Sagittal transvaginal sonogram shows hypoechoic endometrial thickening

(arrowheads).
(B) Sagittal sonohysterogram shows submucosal fibroid with thin overlying endometrium
(cursors).
Reproduced with permission from: Joizzo JR, Chen MY, Riccio GJ. Endometrial polyps:
Sonohysterographic evaluation. AJR Am J Roentgenol 2001; 176:617. Copyright © 2001
American Journal of Roentgenology.

Evaluation and differential diagnosis of abnormal uterine bleeding (AUB) in

nonpregnant reproductive-age women
Other Differential diagnosis

Bleeding
associated Less common
Evaluation
pattern Common etiologies
clinical features etiologies
Regular menses that Enlarged uterus on Uterine leiomyoma - Pelvic ultrasound

are heavy or examination, discrete - Saline infusion
prolonged masses may be noted sonography or
hysteroscopy (if
intracavitary
pathology is
suspected)
- Dysmenorrhea Adenomyosis Pelvic ultrasound

- Enlarged, boggy
uterus on
examination
- Family history of Bleeding disorder Testing for bleeding

bleeding disorder disorder
- Symptoms of
bleeding diathesis
- Anticoagulant
therapy
Risk factors for Endometrial Endometrial sampling

uterine malignancy carcinoma or uterine
sarcoma
Regular menses with Endometrial polyp - Pelvic ultrasound

intermenstrual - Saline infusion
bleeding sonography or
hysteroscopy (if
available)
Risk factors for Endometrial Endometrial sampling

uterine malignancy carcinoma or uterine
sarcoma
Recent history of Chronic endometritis Endometrial sampling

uterine or cervical
procedure or
childbirth, particularly
if infection was
present
Irregular bleeding, Ovulatory

may be more or less dysfunction:
frequent than normal
Hirsutism, acne, PCOS Total testosterone
menses and volume
and/or obesity and/or other
and duration may
androgens (may not
vary
be increased in all
women with PCOS)
Galactorrhea Hyperprolactinemia Prolactin
- Recent weight gain Thyroid disease Thyroid function tests

or loss
- Heat or cold
intolerance

- Family history of
thyroid dysfunction
Risk factors for Endometrial Endometrial

uterine malignancy carcinoma or uterine sampling
sarcoma
Secondary History of irregular Ovulatory dysfunction Refer to ovulatory

amenorrhea bleeding dysfunction above
Poor nutrition or Hypothalamic - Follicle-stimulating

intense exercise amenorrhea hormone
- Luteinizing hormone
- Estradiol
Hot flushes Premature ovarian Follicle-stimulating

insufficiency hormone
Recent history of Cervical stenosis On pelvic

uterine or cervical examination,
procedure or instrument cannot be
childbirth, particularly passed through
if infection was internal cervical os
present (menses may
present, but Intrauterine Hysteroscopy
abnormally light or adhesions (Asherman
brief) syndrome)
Irregular or heavy Iatrogenic AUB

bleeding in a
patient using
hormonal
contraceptives or with
an intrauterine device
Other uncommon etiologies of AUB include a uterine arteriovenous malformation or endometriosis.
PCOS: polycystic ovarian syndrome.

PALM-COEIN classification system for abnormal uterine

bleeding in nongravid reproductive-age women
Basic classification system. The basic system comprises four categories that are defined
by visually objective structural criteria (PALM: polyp, adenomyosis, leiomyoma, and
malignancy and hyperplasia), four that are unrelated to structural anomalies (COEI:
coagulopathy, ovulatory dysfunction, endometrial, iatrogenic), and one reserved for
entities that are not yet classified (N). The leiomyoma category (L) is subdivided into
patients with at least one submucosal myoma (LSM) and those with myomas that do not
impact the endometrial cavity (LO).
Reproduced from: Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group on
Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine
bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.
Illustration used with the permission of Elsevier Inc. All rights reserved.

Common non-malignant conditions associated with chronic pelvic pain in women
Gynecologic
Endometriosis*
Leiomyoma*
Adenomyosis*
Recurrent ovarian cysts
Hydrosalpinx
Ovarian remnant syndrome*
Pelvic inflammatory disease*
Pelvic adhesive disease
Post-tubal ligation pain syndrome
Urologic
Interstitial cystitis/painful bladder syndrome*

Radiation cystitis*
Bladder cancer*
Urethral syndrome
Recurrent cystitis
Recurrent/chronic urolithiasis
Gastroenterologic
Irritable bowel syndrome*

Inflammatory bowel disease*
Colorectal carcinoma*
Celiac disease
Abdominal/pelvic hernias
Musculoskeletal
Abdominal wall myofascial pain (including trigger points)*

Pelvic floor tension myalgia*
Fibromyalgia*
Coccygodynia*
Piriformis syndrome
Neurologic
Abdominal wall cutaneous nerve entrapment (ilioinguinal and iliohypogastric)*

Pudendal neuralgia
Central sensitization of pain*
Vascular
Vulvar varicosities
Pelvic congestion syndrome
* Conditions with level A evidence of a causal relationship to chronic pelvic pain.
Data from: Howard F. Chronic pelvic pain. Obstetrics & Gynecology 2003; 101:594.

Contributor Disclosures
Elizabeth A Stewart, MD Grant/Research/Clinical Trial Support: NIH Grants [Uterine fibroids (P50 HS023418)].
Consultant/Advisory Boards: Bayer Health Care [Uterine fibroids (Levonorgestrel IUS)]; Myovant [Women's
health (Investigational drug)]. Other Financial Interest: Med Learning Group [CME course (Honorarium)]; Peer
View [CME course (Honorarium)]. Shannon K Laughlin-Tommaso, MD Consultant/Advisory Boards: Halt
Medical DSMB [Fibroids (Acessa)]; Allergan [Fibroids (Esmya)]. Robert L Barbieri, MD Nothing to
disclose Deborah Levine, MD Nothing to disclose Kristen Eckler, MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
Conflict of interest policy

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Uterine leiomyomas (fibroids): Epidemiology, clinical

TERMINOLOGY AND LOCATION

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• Type 0 – Completely within the endometrial cavity

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● An ultrasound screening study of women aged 18 to 30 found a prevalence of 26 percent in

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Long-acting progestin-only contraceptives (eg, depot medroxyprogesterone) appear to protect against

Other endocrine factors — Prenatal exposure to diethylstilbestrol is associated with an increased

Environmental exposures such as phthalates, polychlorinated biphenyl, and bisphenol A appear to be

Diet, alcohol, and smoking

● Diet – Studies regarding dietary effects on fibroids include:

• There is increasing evidence that vitamin D deficiency or insufficiency, which is more

● Alcohol – Consumption of alcohol, especially beer, appears to be associated with an increased

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Symptoms are classified into three categories [77]:

● Heavy or prolonged menstrual bleeding

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● Urinary symptoms – A heterogeneous group of urinary symptoms including frequency, difficulty

Other pain or discomfort issues

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• Polycythemia from autonomous production of erythropoietin [98]

• Hypercalcemia from autonomous production of parathyroid hormone-related protein [99]

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History — A medical history is taken, including:

• It is important to assess the severity of heavy or prolonged menstrual bleeding. A menstrual

• The patient should be asked about infertility, recurrent miscarriage, or obstetric

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Infrequently, on speculum examination, a prolapsed submucosal fibroid is visible at the external

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Saline infusion sonography — Saline infusion sonography (sonohysterography) is an imaging

Saline infusion sonography is helpful when planning a hysteroscopic resection of a fibroid or

Hysteroscopy — Diagnostic hysteroscopy is useful for visualizing the endometrial cavity.

Hysteroscopy can help in the planning of a hysteroscopic resection of a submucosal fibroid if

Step three: Additional imaging as necessary when complex intervention is planned or

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● Is there hydronephrosis? – Hydronephrosis due to ureteral obstruction by a fibroid uterus must

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Premenopausal women — With modern pelvic imaging, we have achieved an increased

Representative studies include:

IMPACT ON PATIENT AND SOCIETY

SOCIETY GUIDELINE LINKS

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INFORMATION FOR PATIENTS

● Basics topics (see "Patient education: Uterine fibroids (The Basics)")

SUMMARY AND RECOMMENDATIONS

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or pressure, or infertility; some women have an enlarged uterus on pelvic examination. In

Use of UpToDate is subject to the Subscription and License Agreement.

4. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous

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36. Lumbiganon P, Rugpao S, Phandhu-fung S, et al. Protective effect of depot-

40. Grigorieva V, Chen-Mok M, Tarasova M, Mikhailov A. Use of a levonorgestrel-releasing

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57. Halder SK, Sharan C, Al-Hendy A. 1,25-dihydroxyvitamin D3 treatment shrinks uterine

62. Mehine M, Kaasinen E, Mäkinen N, et al. Characterization of uterine leiomyomas by whole-

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