Uterine Fibroids (Myoma): Symptoms, Diagnosis and Treatment

Uterine fibroids — also called myomas or leiomyomas — are benign tumours arising from the smooth-muscle layer of the uterus. They affect approximately 70% of women of reproductive age and are even more prevalent by age 50. Fibroids range in size from a few millimetres to more than 20 centimetres, and may be solitary or multiple. A substantial proportion remain entirely asymptomatic and are discovered incidentally during routine examination.

What are uterine fibroids?

Fibroids are benign smooth-muscle tumours that develop from the myometrium, the muscular wall of the uterus. They are hormone- responsive, growing under the influence of oestrogen and progesterone. After menopause, when hormone levels decline, fibroids typically shrink. Malignant transformation (leiomyosarcoma) is exceedingly rare, occurring in fewer than 0.1% of cases.

Types of fibroids (by location)

Symptoms depend more on the location of a fibroid within the uterus than on its size:

• Submucosal fibroid: Projects into the uterine cavity. Even small submucosal fibroids can cause heavy bleeding and infertility.
• Intramural fibroid: Located within the muscular wall of the uterus. This is the most common type.
• Subserosal fibroid: Grows outward from the outer surface of the uterus and can exert pressure on neighbouring organs.
• Pedunculated fibroid: Attached to the uterus by a stalk. Torsion (twisting) around the stalk may cause sudden severe pain.
• Cervical fibroid: A rare variant located in the cervix.

Causes and risk factors

The precise cause of fibroids remains unknown. Hormonal, genetic, and growth-factor influences are thought to act together. Principal risk factors include:

• Age over 30 (risk increases until menopause)
• Family history of fibroids (mother or sister)
• Early menarche (first period before age 12)
• Nulliparity (never having given birth)
• Obesity and hypertension
• Alcohol consumption and vitamin D deficiency

Symptoms of uterine fibroids

Approximately half of all fibroids are asymptomatic. When symptoms occur, the most common presentations are as follows.

1. Heavy and prolonged menstrual bleeding

The most common reason for consultation. Menstrual periods lasting longer than seven days, passage of clots, the need to change sanitary protection hourly, and bleeding severe enough to cause iron-deficiency anaemia are typical. Submucosal fibroids are particularly associated with this pattern.

2. Pelvic pain and pressure

Large fibroids may cause a sensation of fullness, pressure, and dull pain in the lower abdomen. Torsion of a pedunculated fibroid can precipitate sudden severe pain requiring urgent evaluation.

3. Urinary frequency or constipation

Anteriorly located fibroids compressing the bladder can cause urinary frequency and a sense of incomplete emptying, while posterior fibroids pressing on the bowel may lead to constipation and rectal pressure.

4. Dyspareunia and lower back pain

Fibroids close to the cervix or in deep locations may cause pain during intercourse, while very large fibroids can produce lower back pain that radiates to the hips.

5. Infertility and recurrent pregnancy loss

Submucosal fibroids distorting the uterine cavity, and large intramural fibroids, may impair embryo implantation. Fibroids can also increase the risk of preterm birth, placental abnormalities, and caesarean delivery.

6. Abdominal enlargement and bloating

Very large fibroids may produce visible abdominal distension, a palpable mass, and bloating that can resemble pregnancy.

How is the diagnosis made?

• Pelvic examination: An enlarged, irregularly contoured uterus may be palpable.
• Transvaginal ultrasound: The first-line investigation for determining the number, size, and location of fibroids, with high diagnostic accuracy.
• Saline infusion sonohysterography (SIS): Ultrasound performed after instillation of saline into the uterine cavity; particularly valuable for characterising submucosal fibroids.
• Hysteroscopy: Direct visualisation of the uterine cavity with a thin camera, offering both diagnostic and therapeutic capability.
• MRI: Used for surgical mapping in cases with numerous or very large fibroids and to differentiate from adenomyosis.
• Full blood count: Detects iron-deficiency anaemia secondary to heavy bleeding.

Treatment options

Treatment is individualised according to age, pregnancy plans, severity of symptoms, and the number, size, and location of fibroids. Asymptomatic small fibroids are usually managed with regular surveillance.

1. Surveillance

Asymptomatic fibroids under 4–5 cm are monitored with ultrasound every 6–12 months. Treatment is initiated if rapid growth or new symptoms develop.

2. Medical therapy

• NSAIDs and tranexamic acid: Reduce menstrual blood loss and ease pain.
• Combined oral contraceptives: Can regulate bleeding patterns but do not shrink fibroids.
• Levonorgestrel-releasing IUD (LNG-IUS): Significantly reduces heavy bleeding in patients with a suitable uterine cavity.
• GnRH agonists/antagonists: Produce temporary fibroid shrinkage; used for pre-operative preparation or in women close to menopause. Long-term use requires add-back therapy.

3. Hysteroscopic myomectomy

The gold standard for removing submucosal fibroids. It is performed through the cervix, without any abdominal incision. Same-day discharge and rapid recovery are usual, and fertility outcomes are favourable.

4. Laparoscopic myomectomy

The preferred minimally invasive approach for intramural and subserosal fibroids. Three or four small incisions (0.5–1 cm) are made in the abdominal wall and fibroids are removed while the uterus is preserved. Advantages include:

• Less pain and reduced blood loss
• Short hospital stay (usually one night)
• Rapid recovery and minimal scarring
• Fertility preservation for women planning pregnancy

5. Open (abdominal) myomectomy

Open surgery may be required for numerous, very large, or deeply located fibroids. The uterus is preserved, making this option appropriate for women who wish to conceive.

6. Hysterectomy

The definitive solution for women who have completed childbearing and do not respond to medication or myomectomy, particularly those with multiple large fibroids. It can be performed laparoscopically or vaginally and eliminates the possibility of recurrence.

7. Uterine artery embolisation (UAE)

A minimally invasive interventional radiology procedure that blocks the blood supply to fibroids. It is an alternative for patients unsuitable for or wishing to avoid surgery; it is generally not recommended for women planning pregnancy.

Fibroids and pregnancy

Most women with fibroids conceive and deliver without complications. However, depending on fibroid location and size, the following risks may be increased: miscarriage, preterm birth, abnormal placentation, obstructed labour, and caesarean delivery. Pre-conception myomectomy may be considered for women with submucosal or large intramural fibroids who are planning pregnancy.

When to seek urgent care

• Sudden severe pelvic pain (which may indicate torsion of a pedunculated fibroid)
• Heavy bleeding accompanied by faintness or weakness
• Fever, foul-smelling discharge, and pain
• Rapidly enlarging abdomen or urinary retention

Fibroid care in Adana

The goal of fibroid treatment is not merely to remove the fibroid, but to select the approach that aligns with each patient's age, pregnancy plans, and quality-of-life goals. Op. Dr. Sadık Kükrer offers individualised, uterus-sparing care in Adana for uterine fibroids, drawing on extensive experience in hysteroscopic and laparoscopic surgery. If you are experiencing heavy menstrual bleeding, pelvic pain, or difficulty conceiving, you are welcome to arrange an assessment.