Women's Health

Uterine fibroids

Benign uterine smooth-muscle tumours that may be asymptomatic or cause heavy menstrual bleeding, pain, pressure symptoms and fertility problems; management depends on symptoms, fibroid anatomy and reproductive wishes.

In a nutshell

Fibroids are benign smooth-muscle tumours whose symptoms depend on location and size. NICE uses an FBC for all heavy menstrual bleeding, targeted hysteroscopy or ultrasound for suspected structural disease, and an LNG-IUS first for fibroids under 3 cm that do not distort the cavity. Fibroids 3 cm or larger, submucosal disease, anaemia, severe symptoms or fertility goals need specialist planning. Current options include selected medical therapy, hysteroscopic removal, UAE, myomectomy and hysterectomy; ulipristal is restricted because of serious liver-injury risk.

Classic presentation

Heavy or painful menstrual bleeding with pelvic pressure, an enlarged irregular uterus or a mass-effect symptom such as urinary frequency; many fibroids are asymptomatic.

Key points

Submucosal fibroids most strongly affect bleeding and the uterine cavity; intramural and subserosal fibroids more often contribute to bulk symptoms, but location is not an absolute rule.
For heavy menstrual bleeding, perform an FBC for everyone; do not routinely request ferritin, female hormone or thyroid tests unless clinically indicated.
Use outpatient hysteroscopy when submucosal fibroid, polyp or endometrial pathology is suspected; do not use blind endometrial biopsy.
Use pelvic ultrasound when the uterus is palpable abdominally, a pelvic mass is suspected or examination is inconclusive; consider MRI before UAE or myomectomy if ultrasound is insufficient.
For fibroids under 3 cm without cavity distortion, offer an LNG-IUS first when suitable; consider tranexamic acid, NSAIDs, combined hormonal contraception or cyclical oral progestogens if it is unsuitable or declined.
For fibroids 3 cm or larger, refer for specialist assessment and discuss medical, hysteroscopic, radiological and surgical options according to anatomy and reproductive wishes.
Relugolix combination therapy is a NICE option for moderate to severe symptoms within its marketing authorisation; linzagolix is a NICE option for longer-term treatment, normally more than 6 months, under TA996 conditions.
Ulipristal acetate is not routine bridging treatment: it is restricted to intermittent use before menopause when surgery or UAE is unsuitable or has failed, with mandatory liver monitoring.
Rapid growth alone does not diagnose leiomyosarcoma; new or enlarging postmenopausal masses and unexplained bleeding need specialist assessment.

First-line investigation

History and examination with FBC for heavy menstrual bleeding, followed by pelvic ultrasound or outpatient hysteroscopy according to the suspected structural pathology.

Management

Assess severe bleeding, pain or obstruction

Stabilise haemodynamic compromise, assess pregnancy and anaemia, treat severe bleeding urgently and involve gynaecology for uncontrolled bleeding, acute severe pain, urinary obstruction or suspected acute pelvic pathology.^1,6

Confirm the anatomy and consequences

Perform FBC for all heavy menstrual bleeding; use outpatient hysteroscopy for suspected cavity pathology and pelvic ultrasound for a palpable uterus, pelvic mass or inconclusive examination.¹
Consider MRI before UAE or myomectomy when ultrasound does not adequately define fibroid size, number, position or vascularity; check for adenomyosis and alternative pelvic pathology.¹

Control bleeding and correct anaemia

For fibroids under 3 cm without cavity distortion, offer an LNG-IUS if suitable; if unsuitable or declined, consider tranexamic acid, NSAIDs, combined hormonal contraception or cyclical oral progestogens, with prescribing checked against BNF and comorbidity.^1,6
Treat iron deficiency or anaemia and review bleeding, fatigue, pain, pressure symptoms and quality of life rather than relying only on estimated menstrual volume.^1,6

Match specialist treatment to fibroid anatomy and fertility wishes

For fibroids 3 cm or larger or symptoms that persist, refer for specialist discussion of medical therapy, hysteroscopic removal, UAE, myomectomy or hysterectomy; use the person's priorities, anatomy, symptom severity and fertility plans to guide the choice.^1,8
Use relugolix combination therapy within its marketing authorisation, or linzagolix for longer-term treatment under TA996 conditions; ulipristal is restricted to exceptional intermittent treatment before menopause when surgery or UAE is unsuitable or has failed.^4,3,7,6
Discuss the fertility implications of UAE and myomectomy, and offer hysterectomy only after alternatives, fertility wishes, route, ovarian function and the person's preferences have been considered.^1,8

Safety-net recurrence and postmenopausal change

Review symptom response, FBC or anaemia treatment, medicine toxicity and reproductive plans; advise reassessment for new postmenopausal bleeding, a new or enlarging mass, worsening pain, urinary or bowel obstruction or treatment failure.^5,1,2

Exam traps

Do not use fibroid size alone: a small submucosal fibroid can cause major bleeding, while a large subserosal fibroid may mainly cause pressure.
Do not request routine ferritin, female hormone or thyroid tests for every person with heavy menstrual bleeding.
Do not perform blind endometrial biopsy for heavy menstrual bleeding; sample during hysteroscopy when indicated.
Do not describe ulipristal as routine pre-operative treatment: MHRA restrictions prohibit this use and require liver monitoring.
Do not equate rapid postmenopausal growth with a diagnosis of leiomyosarcoma; it is a reason for assessment, not a diagnostic test.
Preserve fertility discussions: UAE, myomectomy and hysterectomy have different implications for pregnancy and uterine preservation.

Illustrations

Fibroid classification by locationDiagram of submucosal, intramural and subserosal fibroids in relation to the uterine cavity and serosal surface, showing why each produces different symptom patterns.PassFinals · original

Fibroid symptoms across the reproductive lifespanDiagram showing the usual hormone-responsive pattern of fibroids during reproductive years and possible reduction after menopause, with a safety note that a new or enlarging postmenopausal mass needs assessment.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.