Uterine Fibroids: Symptoms, Diagnosis and Treatment

Uterine Fibroids: Symptoms, Diagnosis and Treatment

Uterine fibroids — medically termed leiomyomas or myomas — are benign smooth muscle tumours of the uterus. They are the most common benign tumours in women and the most frequent indication for hysterectomy worldwide. Approximately 70% of white women and 80% of Black women will develop fibroids by age 50, though only 20–50% experience symptoms requiring medical attention.

Despite their prevalence, fibroids remain significantly underdiagnosed and undertreated — many women endure years of debilitating heavy menstrual bleeding, pelvic pain, and pressure symptoms, or experience infertility and recurrent pregnancy loss, before receiving a diagnosis. Confirmed uterine fibroids are benign (non-cancerous), but a suspected fibroid is not proof that a uterine growth is benign: other tumours, including uterine sarcoma, can resemble fibroids. Fibroids can still have a profound impact on quality of life, fertility, and reproductive outcomes.

What Are Fibroids and How Do They Form?

Fibroids arise from a single transformed smooth muscle cell (monoclonal origin) of the uterine myometrium. Each fibroid is a discrete, well-encapsulated nodule of smooth muscle and fibrous tissue, with a characteristic whorled appearance on cut section.

Why fibroids develop:

• Oestrogen and progesterone dependence — fibroids are hormonally driven; they grow during the reproductive years when oestrogen and progesterone are high, and regress after menopause when hormones decline. This is why GnRH agonists (which suppress ovarian hormones) shrink fibroids, and why fibroids are uncommon before puberty and often shrink after menopause. They do not invariably disappear: new growth, bleeding or other symptoms after menopause need medical assessment
• Genetic mutations — somatic mutations in MED12, HMGA2, and ARID1B genes are found in the majority of fibroids; these drive uncontrolled smooth muscle proliferation
• Local growth factors — EGF, IGF-1, and TGF-β amplify oestrogen signalling within fibroids; adipose tissue produces additional oestrogen via aromatase, partly explaining the association with obesity

Types of Fibroids by Location

Location determines symptoms. The FIGO classification defines fibroid types by relationship to the uterine wall:

Type	Location	Symptoms
Submucosal (Type 0–2)	Within or projecting into the uterine cavity	Heavy menstrual bleeding, infertility, pregnancy loss — most symptomatic type
Intramural (Type 3–4)	Within the myometrium; Type 3 contacts the endometrium, while Type 4 does not contact the endometrium or serosa	Heavy bleeding, pelvic pressure, bulk symptoms; may distort cavity
Subserosal (Type 5–7)	Type 5 has at least 50% of its diameter within the myometrium; Type 6 has less than 50%; Type 7 is pedunculated	Pelvic pressure, bladder/bowel symptoms; rarely affects bleeding
Pedunculated	Attached by a stalk (intracavitary or exophytic)	May prolapse through cervix; torsion risk (exophytic)
Cervical	Within cervical stroma	May cause obstruction, difficult delivery

Multiple fibroids of mixed types are common — the uterus may contain dozens of fibroids of varying sizes.

Risk Factors

• Age — prevalence rises with age; peak incidence in the perimenopausal 40s
• Black African/Caribbean ethnicity — 2–3× higher incidence; earlier onset; larger and more numerous fibroids; higher symptom burden; less response to conservative management
• Family history — first-degree relative with fibroids significantly increases risk
• Obesity — increased peripheral aromatisation of androgens to oestrogen
• Early menarche — longer lifetime oestrogen exposure
• Parity — a greater number of pregnancies is associated with lower fibroid risk; this association is not a guarantee of protection and should not be explained as reduced uterine distension or a simple progesterone effect
• Diet — red meat, processed foods, vitamin D deficiency associated with higher risk; green vegetables possibly protective

Oral contraceptives and the levonorgestrel IUS may help control heavy menstrual bleeding in selected patients; this does not establish that they shrink fibroids or reduce fibroid growth.

Symptoms

Heavy Menstrual Bleeding (HMB)

The most common and impactful symptom — particularly with submucosal fibroids. HMB is defined as blood loss interfering with quality of life. Features of fibroid-related HMB:

• Prolonged periods (>7 days)
• Passage of large clots
• Flooding (sudden loss of blood requiring urgent toilet access)
• Changing pads/tampons every 1–2 hours
• Iron deficiency anaemia — chronic blood loss; fatigue, breathlessness, pallor; frequently severe (haemoglobin <80 g/L in some women)

Pelvic Pressure and Bulk Symptoms

From large fibroids or subserosal fibroids:

• Urinary frequency and urgency — bladder compression; urinary retention in rare cases (large anterior fibroid compressing urethra)
• Constipation and rectal pressure — posterior fibroid compressing rectum
• Abdominal distension — uterus enlarged to the point of visible abdominal protrusion; a uterus enlarged to 20-week size by fibroids is not unusual
• Lower back and pelvic pain — pressure on pelvic nerves and vessels

Dysmenorrhoea

Painful periods — from uterine cramping to expel blood/clots, or from submucosal fibroids causing uterine contractions.

Subfertility and Reproductive Complications

Fibroids affect fertility in several ways:

• Submucosal fibroids — distort the uterine cavity; interfere with implantation; associated with recurrent miscarriage and reduced IVF success rates; removal improves outcomes
• Intramural fibroids — cavity distortion depends on the fibroid’s location and relationship to the endometrium, rather than size alone. The effect of non-cavity-distorting intramural fibroids on fertility remains uncertain and requires individual assessment
• Pregnancy complications: preterm labour, malpresentation, placental abruption, postpartum haemorrhage, caesarean section; fibroid growth during pregnancy (particularly first trimester) may cause acute red degeneration — sudden severe pain from infarction of a rapidly enlarging fibroid

Fibroid Degeneration

Fibroids outgrow their blood supply — necrosis and degeneration cause acute severe pelvic pain, fever, and tenderness (red degeneration — haemorrhagic infarction, common in pregnancy). Usually managed conservatively.

Diagnosis

Pelvic Ultrasound

The primary investigation — transvaginal ultrasound (TVUS) provides the best image quality. Accurately identifies fibroid number, location, size, and uterine volume. Essential for initial diagnosis, treatment planning, and monitoring response to medical therapy.

Saline-infusion sonography (SIS / sonohysterography) — saline injected into the uterine cavity enhances delineation of submucosal fibroid relationship to the cavity; important for pre-surgical planning.

MRI Pelvis

Ultrasound is used to assess the uterus and fibroids before myomectomy or uterine artery embolisation (UAE). MRI may be considered when more information about fibroid position, size, number or vascularity is needed for treatment planning; it is not required before every myomectomy or UAE. The clinician selects further imaging according to the initial findings and planned procedure. MRI can also help distinguish fibroids from adenomyosis; the conditions can coexist and may need different management.

Hysteroscopy

Direct visualisation of the uterine cavity — identifies and characterises submucosal fibroids; simultaneously allows resection (hysteroscopic myomectomy). Hysteroscopy may be used when direct cavity assessment or treatment is indicated, but is not required before every fertility treatment; ultrasound or saline-infusion sonography may also assess the cavity, with testing selected individually.

Investigations for HMB

• Full blood count: assesses haemoglobin and other blood-cell measures for anaemia. Ferritin is a separate test for iron stores and is ordered when clinically indicated; it is not included in a blood count
• Endometrial biopsy: in women over 45, or with abnormal bleeding pattern, to exclude endometrial hyperplasia or carcinoma as a concurrent cause

Treatment

Treatment choice depends on symptom severity, fibroid size and location, desire for future fertility, proximity to menopause, and patient preference.

Medical Management

Levonorgestrel Intrauterine System (LNG-IUS / Mirena)

First-line medical treatment for heavy menstrual bleeding with fibroids — reduces menstrual blood loss by 70–95%; controls dysmenorrhoea. An LNG-IUS is contraindicated when uterine-cavity distortion is incompatible with correct placement; the US Mirena label specifically lists cavity-distorting fibroids as a contraindication. Fibroids without cavity distortion are not automatically a contraindication, but the chosen product’s approved label and individual assessment must guide use. Does not shrink fibroids but very effective for symptom control in appropriate cases.

Tranexamic Acid / NSAIDs

Non-hormonal options for HMB: tranexamic acid (antifibrinolytic) taken during menstruation reduces blood loss by approximately 50%; NSAIDs reduce prostaglandin-driven blood loss and dysmenorrhoea. Suitable for women seeking to preserve fertility without hormonal methods.

Combined Oral Contraceptive Pill / Progestogens

Regulate cycle and reduce menstrual loss; do not shrink fibroids but manage bleeding symptoms; useful in perimenopausal women or those with cycle irregularity.

GnRH Agonists (Leuprorelin, Goserelin, Nafarelin)

Suppress pituitary gonadotropin release → profound oestrogen deficiency → fibroid shrinkage (typically 35–65% volume reduction) and amenorrhoea. Used primarily:

• Pre-operatively (2–3 months before myomectomy or hysterectomy): shrinks fibroids and uterus, reduces intraoperative blood loss, corrects anaemia
• Bridge to menopause: for perimenopausal women
• Side effects: menopausal symptoms (hot flushes, bone loss), cannot be used >3–6 months without add-back HRT

Ulipristal Acetate (Esmya)

Ulipristal acetate is a selective progesterone receptor modulator previously used for fibroid symptoms. Serious liver-injury concerns led to major restrictions; it should not be presented as a routine pre-operative option. The EU marketing authorisation for Esmya was withdrawn in July 2024 at the manufacturer’s request for commercial reasons. Any proposed use requires confirmation of the exact product’s current local authorisation, restrictions and monitoring; this does not establish availability in China.

Linzagolix / Relugolix (Oral GnRH Antagonists)

Oral GnRH antagonist options may be combined with hormonal add-back therapy to control fibroid symptoms in selected patients. Add-back can reduce hot flushes and bone loss but does not eliminate adverse effects. Product-specific eligibility, duration, contraindications and local approval must be checked.

Surgical Treatments

Hysteroscopic Myomectomy

Removal of submucosal fibroids via the uterine cavity — a resectoscope is passed through the cervix; the fibroid is resected in chips using electrocautery. No abdominal incisions required; day-case or overnight procedure.

• Curative for submucosal fibroids; resolves HMB in >90%
• The uterus is preserved, but future fertility is not guaranteed. Myomectomy may be considered for cavity-distorting fibroids to improve pregnancy rates; the decision before IVF is individualized rather than universally required
• Limited to fibroids that significantly protrude into the cavity (FIGO Type 0–1–2)

Laparoscopic Myomectomy

Minimally invasive surgical removal of fibroids through laparoscopic ports. Fibroids are excised from the myometrium; tissue extraction may use contained power morcellation, manual morcellation through an extended port site, or another method selected after risk assessment and discussion. Morcellation can spread an unsuspected malignancy and worsen prognosis; a containment bag does not eliminate this risk. US FDA recommendations restrict power morcellation to appropriately selected patients with compatible containment, and advise against it when malignancy is known or suspected, in postmenopausal patients or those over 50, or when en bloc removal through the vagina or a mini-laparotomy is feasible.

• Preferred for women wishing to preserve the uterus and fertility
• Recovery can be faster than after open surgery, but depends on the procedure and the individual; ask the surgical team about expected activity limits and follow-up
• Technical limits: very large fibroids (>8–10 cm), multiple (>3–5) fibroids — may require conversion to open
• Uterine scar integrity for future pregnancy is a consideration — myomectomy creates a uterine scar; caesarean section often recommended for subsequent delivery

Open (Laparotomy) Myomectomy

For large, multiple, or complex fibroids beyond laparoscopic limits; allows greatest surgical access; higher blood loss; longer recovery.

Hysterectomy

Definitive treatment — removes the uterus (and fibroids). Hysterectomy removes the uterus and is a definitive treatment for uterine fibroids. Indicated for:

• Severe symptoms not responding to conservative/surgical treatment
• Women who have completed childbearing and prefer definitive treatment
• Very large uteri

Total hysterectomy (removes uterine body and cervix) vs subtotal (preserves cervix) — no proven advantage to preserving cervix in most cases. Laparoscopic or robot-assisted hysterectomy standard at experienced centres; vaginal hysterectomy for appropriately sized mobile uteri.

Uterine Artery Embolisation (UAE)

Interventional radiology procedure — under local anaesthesia, a catheter is passed via the femoral artery into the uterine arteries bilaterally; tiny particles (polyvinyl alcohol microspheres) are injected to block blood flow to fibroids. Fibroids infarct and shrink (~50% volume reduction); HMB and bulk symptoms improve in 80–90% of women.

• Preserves the uterus and uses catheter access rather than an abdominal surgical incision. Hospital stay and recovery vary; confirm pain control, observation, follow-up and travel plans with the treating team
• Suitable for symptomatic multiple fibroids in women who do not wish surgery
• Fertility: UAE is generally not recommended in women desiring pregnancy — risk of ovarian failure (ovarian artery embolisation), uterine ischaemia, and placentation abnormalities; myomectomy preferred for fertility
• Further treatment may be needed after embolisation. The likelihood varies with the study population, fibroid characteristics and follow-up period; discuss this uncertainty when comparing treatment options

Focused Ultrasound Surgery (MRI-guided HIFU / ExAblate)

High-intensity focused ultrasound destroys fibroid tissue by thermal ablation without incisions — performed inside an MRI scanner; non-invasive; outpatient. Suitable for selected anterior fibroids with good MRI characteristics; growing evidence base; available at specialist centres.

Uterine Fibroid Care in China

China's gynaecology centres offer:

• Comprehensive fibroid assessment: transvaginal ultrasound, saline infusion sonography, and MRI pelvis; precise FIGO classification and treatment planning
• Hysteroscopic myomectomy: may be offered as a day procedure to suitable patients with submucosal fibroids; the treating team determines observation or admission needs and discharge readiness
• Laparoscopic myomectomy: minimally invasive fibroid removal; experienced laparoscopic gynaecological surgeons
• Uterine artery embolisation: interventional radiology teams performing UAE for symptomatic fibroids; 1–2 night inpatient
• MRI-guided HIFU: non-invasive focused ultrasound treatment available at specialist centres in China — one of the world leaders in HIFU deployment
• GnRH agonist and oral GnRH antagonist therapy: pre-operative fibroid shrinkage and anaemia correction
• Cost: care in China is generally less expensive than UK private treatment, but the hospital prices each case individually — ask us for the written quote before you commit.
• Full English care navigation from diagnosis through medical, surgical, or interventional treatment

Contact a PriumCare care navigator to arrange a fibroid assessment, hysteroscopy, or myomectomy consultation.

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Medical content based on MSD Manuals and international uterine fibroid guidelines (ESHRE, ACOG, NICE). Evidence reviewed 2025.

Additional targeted source clarification

Editorial source check: 25 October 2026. These corrections address the specific assessment and treatment-selection statements above; this is not a whole-article medical review.

• Source 1
• Source 2
• Source 3
• Source 4
• Source 5
• Source 6
• NICHD: uterine artery embolisation and further treatment

Targeted eligibility and imaging clarification

Editorial source check: 25 October 2026. This update checks only the specific eligibility, histology or imaging statements linked below; it is not a whole-article medical review and adds no named clinical reviewer. The original publication date is retained.

• NICE NG88: imaging before myomectomy or UAE
• ASRM: fibroid location, cavity distortion and fertility evidence

Targeted fibroid diagnosis clarification

Editorial source check: 26 October 2026. This update checks only the distinction between a confirmed benign fibroid and a suspected uterine growth; it is not a whole-article medical review and adds no named clinical reviewer. The original publication date is retained.

• NHS: fibroids are non-cancerous growths
• FDA: presumed fibroids and uterine sarcoma can be difficult to distinguish

Targeted LNG-IUS eligibility clarification

Editorial source check: 26 October 2026. This update checks only the distinction between fibroids themselves and uterine-cavity distortion that affects LNG-IUS eligibility described above. It is not a whole-article medical review, adds no named clinical reviewer, and retains the original publication date.

• CDC US MEC: fibroids and distorted-cavity IUD eligibility
• US Mirena prescribing label: contraindications

Targeted editorial source check — 26 October 2026: only hysteroscopy selection before fertility treatment and morcellation selection/remaining malignancy risk were reassessed using ASRM 2026 and the US FDA safety communication. FDA-specific recommendations are identified as US guidance. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.

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Targeted editorial source check — 26 October 2026: Only the passage distinguishing hormonal control of heavy bleeding from fibroid growth reduction was checked against US HHS patient information and NHS fibroids information. This is not a whole-article medical review, adds no named clinical reviewer and retains the original publication date.