Often found incidentally, up to 70% of fibroids are asymptomatic—but they’re also the number one cause of heavy menstrual bleeding and occasionally become malignant. A woman’s age, fertility goals, symptoms and fibroid characteristics guide management decisions, explains Melbourne gynaecologist and fertility specialist Dr Priya Rajagopal.
Fibroids are benign tumours that arise from uterine smooth muscle and most are clinically insignificant.
“Only about 30% to somewhere around 50% of women with any fibroid that we see on a scan will have symptoms,” Dr Rajagopal says. “The rest of them, it’s just an incidental finding.”
Importantly, they are very rarely cancerous.
Fibroids are strongly linked to oestrogen levels and certain groups are at higher risk, with women who are aged 30 to 50, nulliparous, or from Southeast Asian or African backgrounds most likely to develop them, she says.
Heavy menstrual bleeding is the most common symptom, Dr Rajagopal says. “So the cycles remain normal. But patients often notice all of a sudden they start having flooding or passing clots, or their periods get longer.” This can lead to iron deficiency anaemia, which is sometimes the first indication.
Larger fibroids may cause pelvic pressure, urinary frequency or discomfort due to compression of adjacent structures.
Fertility concerns are another key presentation. “Fibroids are known to cause subfertility or sometimes recurrent miscarriage,” she notes, particularly when the uterine cavity is affected.
These symptoms can overlap with other conditions, and imaging is necessary to confirm the diagnosis.
Transvaginal ultrasound is the first-line investigation for suspected fibroids, but not all reports are equal, Dr Rajagopal stresses.
She recommends asking for the number of fibroids, their size, whether they distort the cavity, their Doppler vascularity, their location with respect to the endometrium (i.e. whether they are submucosal, intramural, or sub-serosal), and about the thickness and appearance of the endometrium itself.
These details influence treatment options, fertility counselling and the necessity and urgency of referral, she says. “All this can be derived if this information is present on the transvaginal scan.”
Management should be tailored to risk, she explains.
In women with single, small, asymptomatic fibroids, it’s important to provide reassurance and not over-medicate, Dr Rajagopal stresses. “They are benign growths and no intervention might be needed.”
For example, small, asymptomatic fibroids in postmenopausal women typically require no follow-up. “Whereas if we were to find a 4-to-5-centimetre intramural fibroid in an asymptomatic premenopausal patient, it would be reasonable to offer surveillance, such as repeat ultrasound in 6 to 12 months’ time.”
Family plans also impact management decisions, she says, noting women hoping to conceive who have a submucosal or intramural fibroid more than 3 cm in size should be referred to a fertility specialist or gynaecologist, Dr Rajagopal says. “This is the one category where evidence says that even though it’s asymptomatic, it will need resection.”
Women with fibroids found incidentally should be advised to report changes such as increased bleeding, abdominal enlargement or new symptoms, she adds.
Certain features warrant urgent referral, including severe anaemia from prolonged heavy bleeding, or acute pain arising from the fibroid—which can indicate degeneration or torsion, she says.
“The other most important sign to pick up is rapid growth in the size of the fibroid, because this might indicate it’s undergoing a sarcomatous change.”
“Treatment for fibroids should be individualised based on the patient’s preference, their treatment goals, symptom severity, and of course, the location and size of fibroids,” Dr Rajagopal says.
Medication is often first-line when fibroids cause symptoms, particularly heavy menstrual bleeding. Options depend on bleeding severity and contraceptive requirements.
Tranexamic acid or NSAIDs may be appropriate for patients with mild symptoms who’d prefer a non-hormonal option, but they only reduce bleeding by approximately 30%, she says. “Sometimes we use the tranexamic acid with the NSAIDs together as well.”
The combined oral contraceptive pill provides more effective control but can take up to three months to work. The levonorgestrel intrauterine device is highly effective, provided the uterine cavity is not distorted. “And the average length of time that takes to bring bleeding under control is said to be about 45 to 60 days.”
Approved in 2022 for treating fibroid symptoms in adult women of reproductive age, Ryeqo(relugolix, oestradiol and norethisterone acetate) is considered second-lime medical therapy, Dr Rajagopal says.
“For example, if a patient has moderate to severe fibroid-related menstrual bleeding and they fail to respond to initial medical management, and they are wanting to avoid surgery, Ryeqo can be used. It reduces bleeding volume up to about 70% and it starts acting within the first month of commencing treatment.”
It also has a place in preoperative management, she adds. “If they’re anaemic and their surgery is one or two months away, in those situations Ryeqo is very helpful.”
Treatment is recommended for a maximum of up to 24 months due to its impact on bone health, she notes. “Ryeqo can result in bone mineral density loss, especially when it’s used more than 12 months.”
“It should definitely be avoided in patients who have a history of osteoporosis or of thromboembolism. And we need to closely watch the patient’s blood pressure.”
Several uterus-preserving options are available depending on a woman’s fertility goals.
While both submucosal and intramural fibroids are known to reduce clinical pregnancy rates and increase miscarriage rates, there is only a clear indication for resection to improve these outcomes in submucosal fibroids that are distorting the cavity, Dr Rajagopal says.
“Current evidence doesn’t favour a myomectomy of an intramural fibroid. They are considered in very selective patients where there are repeated implantation failures following IVF.”
These patients can be referred to a specialist for counselling.
Uterine artery embolisation (UAE) is an option for women wishing to avoid hysterectomy, although current guidelines do not recommend it for those wanting to preserve their fertility, she explains. Potential short- and long-term complications include post-embolisation syndrome, reduced ovarian reserve and symptom recurrence—which occurs in about 20% to 30% of patients after five years, sometimes necessitating a myomectomy or hysterectomy.
MRI-guided focused ultrasound is less widely available and only suitable for selected patients. Long-term studies about fertility and pregnancy safety following treatment are lacking, so it is currently only recommended for women who’ve finished childbearing.
Key takeaways
Helpful resources
Australian Journal of General Practice | Contemporary management of uterine fibroids
RANZCOG | Fibroids in infertility
RANZCOG | Uterine artery embolisation for the treatment of uterine fibroids
Jean Hailes for Women’s Health | Fibroids
*This article was written independently and was not sponsored.
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