884

Uterine fibroids

Uterine fibroids (also known as fibroids or leiomyoma) are extremely common gynecological lesions, affecting a significant percentage of women in a woman’s life, especially of childbearing age. It is estimated that they can occur in up to 70-80% of women under 50 years of age, although many of them may not be aware of their presence. The key information is that uterine fibroids are mostly benign (benign) tumors, originating from the muscle tissue of the smooth uterine wall. Despite their benign nature, they can cause a number of bothersome symptoms, significantly affecting the quality of life, and in some cases also fertility and pregnancy. Understanding the nature of fibroids, their potential symptoms, and the available methods of diagnosis and treatment is crucial for every woman who cares about her intimate health.

What are uterine fibroids?

Definition

Uterine fibroids are benign tumors that arise as a result of abnormal, monoclonal proliferation (multiplication) of smooth muscle cells that build the uterine wall, called myometrium. These are the most common tumors of the reproductive organs in women. In medical terminology, they are also referred to as leiomyoma or myoma, and colloquially they are sometimes called fibromas.

Gentle nature

The basic feature of uterine fibroids is their benign nature. This means that they are not cancer, they usually grow slowly, are separated from the surrounding tissues and do not metastasize to other organs. The risk of malignant transformation of myoma into leiomyosarcoma is very low, estimated at less than 0.1-0.8% of cases (i.e. less than 1 in 1000). Such a risk is slightly higher in postmenopausal women. Importantly, the presence of benign uterine fibroids does not increase the risk of developing other uterine malignant tumors. Despite the low risk of malignancy, rapid tumor growth, especially in postmenopausal women, always requires increased diagnostic vigilance, as it may (although rarely) suggest a malignant process. This small but existing transformative opportunity highlights the importance of regular gynecological check-ups, even for seemingly benign lesions.

Characteristics

Uterine fibroids usually take the form of hard, elastic, spherical tumors with a compact consistency and often occur within the uterus. Their size varies greatly – they can be microscopic, grain-sized, or reach considerable sizes, comparable to grapefruit, or even fill the entire pelvis minor. Fibroids can occur individually, but they are much more often multiple – one woman may develop several or more tumors of different sizes and locations. They develop within the uterine wall or on its surface, mainly in the body of the uterus (about 90% of cases). This high variability in the number and size of tumours has a direct impact on the potential symptoms and the complexity of possible treatment – a small, single fibroid often remains asymptomatic, while numerous, large tumours can lead to significant discomfort and uterine deformities.

Types of uterine fibroids

The classification of uterine fibroids is based primarily on their location in relation to the layers of the uterine wall: the mucous membrane (endometrium) lining the uterine cavity from the inside, the muscle membrane (myometrium) which is the main, middle layer, and the serous membrane (perimetrium) covering the uterus from the outside. The location of the tumour is crucial as it determines the type and severity of symptoms and influences the choice of treatment.

Main Classification (Location)

There are three main types of fibroids:

1. Submucosal fibroids (SM):
   • Location: They grow just below the mucous membrane (endometrium), entering the uterine cavity.
   • Characteristics: uterine fibroids are benign tumors that can occur in various forms. They make up about 5-10% of all fibroids. Even small fibroids of this type can cause significant symptoms due to their direct impact on the endometrium and the shape of the uterine cavity.
   • Typical symptoms: Most often they cause heavy, prolonged menstrual bleeding and intermenstrual bleeding. They can also cause pain.
   • Effects on Fertility: They are most strongly associated with fertility problems (difficulty implanting the embryo) and an increased risk of miscarriages.
2. Intramural:
   • Location: They develop in the thickness of the muscular wall of the uterus (myometrium).
   • Characteristics: They are the most common type of fibroids, accounting for about 40-50% of cases. They can reach different sizes.
   • Typical symptoms: They often cause heavy menstrual bleeding (especially if it is large or located close to the uterine cavity), pain, and a feeling of pressure in the pelvis.
   • Effects on Fertility: They can negatively affect fertility, especially if they are large (>6 cm) or distort the uterine cavity.
3. Subserous fibroids:
   • Location: Fibroids grow on the outer surface of the uterus, under the serous membrane, which affects the functioning of the uterine muscle.
   • Characteristics: They constitute a significant percentage of fibroids (about 55%), which proves that uterine fibroids are common. They can grow towards the abdominal cavity.
   • Typical symptoms: They are often asymptomatic. If they reach a large size, they can cause pressure symptoms on adjacent organs (bladder, intestines), leading to pollakiuria, constipation or a feeling of fullness. They usually do not cause heavy bleeding.
   • Effects on Fertility: They are thought to have the least effect on fertility unless they are very large or compress the fallopian tubes.

Other types of fibroids

In addition to the three main types, there are also:

• Pedunculated Fibroids: These are submucosal or subserous fibroids connected to the uterus by a thin “leg” (pedicle). They can be located inside the uterine cavity (submucosal pedunculated) or outside (subserous pedunculated). Subserous pedunculated fibroids can twist around their axis, leading to sudden, acute abdominal pain requiring urgent intervention.
• Cervical fibroids: They develop in the cervix; are rare.
• Intraligaments: They grow between the laminae of the broad ligament of the uterus; also rare.

FIGO Classification

In order to standardize the description of the location of fibroids, especially those in contact with the uterine cavity or growing in the wall, the International Federation of Gynecology and Obstetrics (FIGO) has developed a detailed classification. The FIGO system divides fibroids into 9 types (0-8):

• Type 0: Pedunculated submucosal fibroid entirely in the uterine cavity.
• Type 1: Submucosal myoma, <50% intramural component.
• Type 2: Submucosal myoma, ≥50% intramural component.
• Type 3: Intramural myoma, 100% in the wall, but affecting the endometrium.
• Type 4: Intramural myoma, entirely in the wall, without contact with the endometrium and serum.
• Type 5: Subserous myoma, ≥50% intramural component.
• Type 6: Subserous myoma, <50% intramural component.
• Type 7: Pedunculated subserous fibroid.
• Type 8: Other locations (e.g. cervical, parasitic).

There are also hybrid types (e.g., 2-5), describing fibroids that go through different layers. The FIGO classification is of great clinical importance because it helps in choosing the optimal method of treatment, especially surgery. For example, type 0, 1 and partially 2 fibroids can often be removed by hysteroscopic (transvaginal) method, while types 3-7 usually require transabdominal access (laparoscopy or laparotomy).

The following table summarizes the key characteristics of the main types of fibroids:

Types of uterine fibroids and their characteristics, including subserous uterine fibroids.

Type of fibroid (type)	Location	Common symptoms	Potential Effects on Fertility/Pregnancy
Submucosal	Under the mucous membrane (endometrium), it inserts into the uterine cavity	Heavy prolonged menstrual bleeding, intermenstrual bleeding, pain	High; difficulties with embryo implantation, increased risk of miscarriage, fertility problems
Intramural	In the thickness of the muscular wall of the uterus (myometrium)	Heavy bleeding (especially large tumors), pain, pressure in the pelvis, which may be caused by the presence of uterine fibroids.	Moderate (especially large 6 cm tumors >or those that distort the uterine cavity); may hinder implantation, increase the risk of miscarriage or preterm birth
Subserous	On the outer surface of the uterus, under the serous membrane	Often asymptomatic; in large sizes, pressure symptoms on the bladder/intestines (pollakiuria, constipation)	Low; They usually do not significantly affect fertility, unless they are very large or compress the fallopian tubes
Pedunculated	Connected to the uterus by pedicle; it can be submucosal or subserous	Location-dependent (as above); subserous may be torsion (acute pain)	Location-dependent (as above); pedunculated submucosal as submucosal, subserous usually low impact

Causes and Risk Factors of Fibroids

The exact cause of uterine fibroids has not been fully understood. Currently, their development is considered to be a complex process, resulting from the interaction of many factors, including genetic predisposition, the influence of sex hormones, as well as environmental and lifestyle factors. It seems that the underlying cause is the transformation of a single myometrial stem cell, which, under the influence of various stimuli, begins to divide uncontrollably, forming a tumor.

The key role of hormones

The best documented factor influencing the growth of fibroids is the dependence on female sex hormones – estrogen and progesterone. Fibroid cells have many more receptors for both of these hormones than normal myometrium cells. The growth of fibroids is stimulated during periods of high levels of these hormones, i.e. during childbearing age and during pregnancy. On the other hand, after menopause, when the production of estrogen and progesterone by the ovaries decreases rapidly, fibroids tend to decrease or even disappear, and the symptoms often subside. This also confirms the effectiveness of hormonal treatment that lowers the level of these hormones (e.g. GnRH analogues). Although historically a greater role has been attributed to estrogen, it is now believed that progesterone also plays a key and perhaps even initiating role in the development of fibroids. This strong hormonal dependence explains why fibroids are mainly a problem for women of reproductive age, and why wait-and-see is often a sensible option for women approaching menopause.

Genetic factors

There is evidence for a genetic basis for the tendency to develop fibroids. Their incidence is more common in families – the risk is about 3 times higher if the woman’s mother or sister had fibroids. Studies of twins also indicate a genetic component, with greater consistency in the occurrence of identical twins. Specific genetic changes (mutations or chromosomal aberrations) are often found in fibroid cells that distinguish them from normal uterine cells. They concern, m.in others, the HMG genes (HMGA1, HMGA2) and the MED12 gene (mutations in this gene occur in up to 70% of fibroids).

Risk Factors (non-modifiable)

• Age: The risk increases with age during the reproductive years, peaking between the ages of 30 and 50, especially in the perimenopausal period. Fibroids rarely occur before the first menstrual period and usually do not develop after menopause.
• Race/Ethnicity: Black women (African-American, women of African descent) have a significantly higher risk of developing fibroids (up to 2-3 times) compared to white women. In black women, fibroids often appear at a younger age, are more numerous, larger and cause more severe symptoms. The reasons for this imbalance are not fully explained, but can include genetic, environmental, dietary factors, differences in hormone metabolism or cellular response. This is a significant health problem and an area of inequality in women’s healthcare.
• Family history: As mentioned, the occurrence of fibroids in first-degree relatives (mother, sister) increases the risk.
• Early first menstruation (menarche): Starting menstruation at a young age (e.g. before the age of 10-11) is associated with an increased risk. A longer period of exposure to endogenous sex hormones may play a role. A late onset of the last menstrual period (menopause) can also be a risk factor.

Risk Factors (Potentially Modifiable)

• Obesity/Overweight: This is one of the strongest modifiable risk factors. Obese women have a 2-3 times higher risk of developing fibroids. Adipose tissue is the site of estrogen production (from androgen precursors), and obesity is often accompanied by hyperestrogenism and other metabolic disorders that can promote tumor growth. Weight loss can potentially lower the risk.
• Diet: Research suggests that a diet high in red meat (beef, pork, ham) may increase risk, while a diet high in green vegetables, fruits, and dairy products may have a protective effect. Vitamin D deficiency is also associated with an increased risk. High-sugar diets may also play a role.
• Alcohol: Alcohol consumption, including beer, appears to increase the risk of developing fibroids. Some sources also mention caffeine.
• Hypertension: There is a link between hypertension and an increased risk of fibroids.
• Nulliparity: Women who have never given birth have a higher risk. Each previous pregnancy, especially full-term pregnancy, seems to reduce this risk. Pregnancy before the age of 25 can be particularly protective. The mechanism of this phenomenon is not entirely clear, but it may be associated with hormonal and structural changes in the uterus during pregnancy and postpartum.

Other factors

Other factors may also be involved in the pathogenesis of fibroids, such as changes in the smooth cells of the uterine muscle.

• Growth factors: Substances such as insulin-like growth factor (IGF) can affect the growth of tumors.
• Extracellular Matrix (ECM): It is a substance that “binds” cells. An increased amount of ECM is observed in fibroids, which gives them a fibrous structure. The ECM can also store growth factors and influence cell behavior.
• Environmental factors: Exposure to endocrine disruptors (endocrine disruptors), present in some plastics or pesticides, for example, may play a role.
• Infections and inflammation: Chronic intimate infections or inflammation in the pelvis are cited as a potential risk factor.
• The microbiome of the genital tract: Changes in the composition of the vaginal and uterine microbiota can affect the local immune and hormonal environment.

Understanding these factors, especially modifiable ones such as diet or body weight, opens up potential (although not yet fully proven in terms of prevention) possibilities of influencing the risk of developing fibroids through a healthy lifestyle.

Symptoms of uterine fibroids: from no symptoms to bothersome ailments

One of the characteristic features of uterine fibroids is the fact that in many women, up to 50-80% estimated, they do not cause any symptoms. Such asymptomatic fibroids are often detected accidentally during a routine gynecological examination or ultrasound examination performed for other reasons. However, if symptoms do occur, their type and severity depend largely on the number, size and, most importantly, the location of fibroids in the uterus – the symptoms.

The most common symptoms

When fibroids make themselves felt, they most often manifest themselves through:

1. Abnormal uterine bleeding (AUB): This is the most common group of symptoms prompting women to visit a doctor. It includes:
   • Heavy menstrual bleeding (Menorrhagia): Menstruation is much heavier than usual, often with clots. A woman may need to change a sanitary pad or tampon every hour or more often, wake up at night due to bleeding, and the menstrual period itself may last longer than 7 days. The norm of blood loss during the period is about 30-80 ml, and with fibroids it can be much more. This symptom is especially typical for submucosal fibroids, which develop just below the uterine mucosa, and intramural ones.
   • Prolonged menstruation: The bleeding period lasts longer than normal (e.g. more than 7-10 days).
   • Irregular menstruation: The cycles become irregular.
   • Intermenstrual bleeding: Spotting or bleeding that occurs between periods.
2. Pain and Pressure in the Pelvis: Women may experience:
   • Chronic pain or discomfort in the lower abdomen: It can be a dull, continuous pain, a feeling of heaviness, expansion or fullness.
   • Painful menstruation (Dysmenorrhea): Menstrual cramps are stronger than usual.
   • Acute pelvic pain: Less commonly, sudden, severe pain may occur due to the torsion of the pedunculated myoma or the degeneration (necrosis) of a large fibroid that has “outgrown” its vascularization.
3. Bladder Pressure Symptoms: Large fibroids, especially those growing on the anterior wall of the uterus, can compress the bladder, leading to:
   • Urinary frequency: The need to urinate more often, often in small amounts.
   • Urinary urgency: Difficulty urinating in the world.
   • Difficulty emptying the bladder: Feeling of incomplete bowel movement.
   • Urinary incontinence: Involuntary urination.
   • Recurrent urinary tract infections: As a result of urine retention.
4. Symptoms of Pressure on the Intestines: Fibroids pressing on the rectum or large intestine can cause:
   • Constipation: Difficulty defecating.
   • Feeling of urgency to stool: Even with an empty rectum.
   • Pain during bowel movements.
   • Feeling of incomplete bowel movement.
   • In extreme cases, even intestinal obstruction.

Other possible symptoms

Less specific, but also possible to accompany fibroids, are:

• Lower back (lumbosacral region) or leg pain:.
• Pain during sexual intercourse (Dyspareunia):.
• Enlargement of abdominal circumference: The abdomen may look like a pregnant woman, sometimes the tumor is palpable through the abdominal wall.
• Bloating, feeling of fullness in the abdominal cavity:.
• Anaemia: It is a secondary complication resulting from chronic, heavy bleeding. It manifests itself in fatigue, weakness, pale skin, dizziness, increased heart rate, and sometimes unusual cravings (pica). Anaemia itself significantly reduces the quality of life and often becomes the main reason for seeking medical help.
• Fertility or pregnancy maintenance problems: Difficulties with getting pregnant, recurrent miscarriages. This aspect will be discussed in detail in the next section.
• Chronic vaginal discharge:.

The non-specific nature of many of these symptoms (e.g. pain) can make it difficult to diagnose uterine fibroids. back pain, constipation, fatigue) means that women may not initially associate them with a gynecological problem, which may delay the proper diagnosis. That is why it is so important to pay attention to any unusual or worsening ailments, especially if they are accompanied by changes in the menstrual cycle, and consult them with a gynecologist.

Diagnostics of uterine fibroids: how to detect changes?

The diagnosis of uterine fibroids is based on a combination of medical history, gynecological examination and imaging tests. The diagnostic process usually proceeds in stages, starting with the simplest and least invasive methods.

Clinical suspicion

The first step is to collect a thorough history of the symptoms reported by the patient (the nature of menstrual bleeding, pain, pressure symptoms, fertility problems) and medical history. Then the doctor performs a two-hand gynecological examination, during which he may find an enlarged uterus, its irregular shape or feel hard tumors in the pelvis.

Basic examination: ultrasound (ultrasound)

The key and basic test in the diagnosis of uterine fibroids is ultrasonography, especially transvaginal ultrasound (TVS). It is an easily available, relatively inexpensive, safe method (it does not use ionizing radiation) and very effective in imaging the reproductive organ. The TVS test allows for:

• Confirmation of the presence of fibroids.
• Determination of their number, size and exact location (submucosal, intramural, subserous, pedunculated).
• Assessment of the structure of fibroids.
• Assessment of the impact of tumors on the shape of the uterine cavity.
• Monitoring the growth of fibroids over time.
• Initial differentiation with other pelvic pathologies (e.g., ovarian tumors, endometrial polyps).

In the case of very large uteruses or tumors growing high in the abdominal cavity, it may be helpful to supplement the TVS examination with a transabdominal ultrasound.

Follow-up Testing (in selected cases)

In situations where the ultrasound image is ambiguous, surgical or minimally invasive treatment is planned, or there is a suspicion of other diseases, the doctor may order additional tests:

• Magnetic resonance imaging (MRI) of the pelvis: This is the most precise method of imaging fibroids and other pelvic structures. MRI is particularly useful for:
  • Accurate mapping of the number, size, and location of fibroids prior to planned myomectomy (enucleation of tumors) or uterine artery embolization (UAE).
  • Differentiation of fibroids from other lesions, e.g. adenomyosis (endometriosis of the inner uterus).
  • Evaluation of atypical or rapidly growing tumors for a possible (albeit rare) malignant process.
  • Planning focused ultrasound therapy (MRgFUS).
• Diagnostic hysteroscopy: It involves inserting a thin endoscope with a camera (hysteroscope) through the cervix in order to directly visualize the inside of the uterine cavity. This is the gold standard in the diagnosis of intrauterine lesions, such as uterine fibroids – symptoms.
  • Submucosal fibroids (FIGO type 0, 1, 2).
  • Endometrial polyps.
  • Intrauterine adhesions.
  • Congenital defects of the uterus. Hysteroscopy allows for an accurate assessment of these lesions, and often also for their simultaneous removal (surgical hysteroscopy). The test is usually performed in the first phase of the cycle, after the bleeding has stopped. May require anesthesia.
• Saline Infusion Sonohysterography (SIS/SHG): It is a modification of transvaginal ultrasound, during which a small amount of sterile saline solution is injected into the uterine cavity. The fluid dilates the uterine cavity, which significantly improves the visibility of its outlines and possible intrauterine changes, such as submucosal fibroids or polyps. It is a less invasive method than hysteroscopy, but it provides similar information about uterine pathologies.
• Diagnostic laparoscopy: Insertion of a camera through a small incision in the navel in order to view the pelvic organs from the abdominal side. It is rarely used only for the diagnosis of fibroids, more often as part of preoperative assessment or in the diagnosis of infertility or pelvic pain of unclear cause.
• Computed tomography (CT): It is usually of limited use in the diagnosis of fibroids due to poorer soft tissue imaging compared to ultrasound and MRI and the need to use X-rays. It can be helpful in the assessment of very large tumors or in the differential diagnosis of other abdominal and pelvic diseases, as well as in the presence of uterine fibroids.

Biopsy/Histopathological examination

Although imaging studies indicate fibroids with high certainty, definitive confirmation of their benign nature (or, in rare cases, detection of sarcoma) is only possible through histopathological examination of the tumor tissue collected during surgery (myomectomy or hysterectomy). In the case of abnormal bleeding, especially in postmenopausal women or with risk factors for endometrial cancer, your doctor may order a biopsy of the lining of the uterus (endometrium) to rule out other causes of bleeding, such as endometrial hyperplasia or cancer. A biopsy can be performed on an outpatient basis or during a hysteroscopy to assess changes in the smooth muscles of the uterus. This limited possibility of certain preoperative exclusion of a rare sarcoma is an important factor to consider when planning treatment, especially with minimally invasive methods that may require intra-abdominal morcellation (fragmentation) of the tumor.

Uterine Fibroids and Fertility, Pregnancy and Childbirth

The presence of uterine fibroids can have a significant impact on a woman’s ability to get pregnant, its course and the birth itself. However, the scale of this impact varies greatly and depends on many factors, primarily the location and size of the tumors.

Effects on Fertility

Most women with uterine fibroids get pregnant without problems. Nevertheless, fibroids are found in about 5-10% of women struggling with infertility , and in a small percentage (1-2.4%) they can be considered the only cause of it.

Fibroids can impair fertility through several mechanisms :

• Uterine cavity deformity: Submucosal fibroids and large intramural fibroids can change the shape of the uterine cavity, making it difficult or impossible for the embryo to implant properly.
• Blocking the fallopian tubes: Tumors located near the openings of the fallopian tubes to the uterus can cause their obstruction, preventing the sperm from meeting the egg or transporting the embryo to the uterus.
• Changes in uterine contractility: Fibroids can interfere with normal uterine contractions, which are important for sperm transport and implantation.
• Blood flow disorders: They can affect the blood supply to the endometrium at the site of potential implantation.
• Inducing inflammation: The presence of fibroid can lead to local inflammation in the lining of the uterus, which is unfavorable for the development of pregnancy.

The greatest negative impact on fertility is caused by submucosal fibroids (even small ones) and large intramural fibroids (>5-6 cm), which deform the uterine cavity. Women with such fibroids may have a lower pregnancy rate, both natural and after assisted reproduction procedures (e.g. in vitro – IVF). Subserous fibroids, which do not compress the fallopian tubes and do not distort the uterine cavity, usually do not have a significant effect on fertility. Therefore, any woman diagnosed with fibroids who is planning pregnancy or is having difficulty getting pregnant should consult an infertility treatment specialist to assess the potential impact of the tumors and a possible treatment plan.

Fibroids during pregnancy

Pregnancy in a woman with uterine fibroids is often treated as a high-risk pregnancy that requires careful monitoring.

• The behavior of fibroids in pregnancy can affect symptoms and treatment in the context of uterine health. Under the influence of high levels of pregnancy hormones (estrogen and progesterone), fibroids can increase in size, especially in the first trimester. However, this is not a rule – some fibroids remain stable, and some may even shrink later in pregnancy. After childbirth, many fibroids are significantly reduced.
• Potential complications: The presence of fibroids, especially large or numerous, increases the risk of various pregnancy complications:
  • Abortion: The risk of miscarriage, especially in the first trimester, is higher in women with fibroids (up to twice). The greatest risk is associated with submucosal fibroids.
  • Preterm birth: Fibroids can stimulate uterine contractions, leading to premature birth.
  • Placental abnormalities: Increased risk of placenta previa or placental abruption.
  • Intrauterine growth restriction (IUGR): Large fibroids can limit the space for a growing child.
  • Abnormal position of the fetus: Fibroids can make it difficult for the fetus to assume the correct (cephalic) position before birth, increasing the frequency of pelvic or transverse positions.
  • Pain: The growth or degeneration of a fibroid during pregnancy can cause severe pain.
  • Necessity of caesarean section: The risk of terminating a pregnancy by caesarean section is higher due to abnormal foetal position, birth obstruction (low-lying fibroids) or contraction disorders.

Fibroids and Childbirth and Postpartum

The presence of fibroids can also affect the course of labor and the postpartum period:

• Uterine contraction disorders: Fibroids can weaken or interfere with the coordination of uterine contractions during labor, leading to prolongation or no progression.
• Birth obstacle: Large fibroids located in the lower uterus or cervix can physically block the birth canal.
• Postpartum hemorrhage: Increased risk of excessive bleeding after childbirth due to uterine atony (impaired ability to contract after childbirth).

However, it is important to emphasize that many women with uterine fibroids go through pregnancy and childbirth without any complications. The risk is real, but it does not mean that problems are inevitable. An individual approach, risk assessment by the attending physician and careful monitoring of pregnancy are crucial. The relationship between fibroids and pregnancy is complex – fibroids can hinder pregnancy, but pregnancy and childbirth itself seem to have a protective effect on the development of fibroids in the future.

Methods of treating uterine fibroids (SEO subtitle)

The choice of treatment method for uterine fibroids depends on many factors and should always be individually tailored to the patient. The available options cover a wide spectrum of possibilities, from no intervention to pharmacological treatment, minimally invasive procedures and classic surgical operations.

Watchful Waiting

This approach is suitable for women who:

• They do not have any symptoms associated with fibroids.
• They have mild symptoms that do not significantly affect the quality of life.
• They are approaching menopause, when fibroids naturally tend to decrease.

The wait-and-see procedure consists of regular check-ups with a gynaecologist (usually every 6-12 months) along with an ultrasound examination to monitor the size of the fibroids and the possible appearance or worsening of symptoms. The advantage of this method is that it avoids the potential side effects and risks associated with treatment when it is not necessary.

Drug treatment (symptom control)

The aim of pharmacological treatment is primarily to alleviate or eliminate the symptoms of fibroids, such as heavy bleeding or pain. Medications usually do not remove fibroids permanently, although some may cause them to decrease temporarily.

• Hormonal drugs:
  • GnRH analogues (e.g. leuprolide acetate): These drugs put the body into a state of artificial, reversible menopause, inhibiting the production of estrogen and progesterone by the ovaries. This leads to a reduction in the volume of fibroids (by up to 50%) and the cessation of bleeding. They are mainly used short-term (3-6 months), e.g. before a planned surgery to shrink the tumor and improve blood parameters (treatment of anemia) or as a bridging therapy in women close to menopause. Their long-term use is limited by the bothersome side effects typical of menopause (hot flashes, vaginal dryness, decreased libido, risk of osteoporosis). Sometimes the so-called “add-back” therapy (adding small doses of estrogens and progestogens) is used to alleviate these symptoms.
  • Selective Progesterone Receptor Modulators (SPRM) (e.g. ulipristal acetate – UPA): They work by blocking progesterone receptors in fibroid cells. Effectively and quickly (often within a few days) they inhibit heavy bleeding and lead to a reduction in the volume of fibroids. They can be used in cycles (e.g. 3 months) as symptomatic or preoperative treatment. They are generally better tolerated than GnRH analogues. In the past, there have been reports of rare but serious cases of liver damage associated with UPA, which has led to restrictions on its use and the need to monitor liver function. The availability and indications for UPAs may vary depending on the country and current guidelines.
  • Hormonal Contraception (birth control pills, patches, rings): They can help regulate the cycle and reduce the amount of menstrual bleeding, but they do not affect the size of fibroids. They are an option for women who need contraception and have mild to moderate bleeding symptoms.
  • Levonorgestrel-releasing intrauterine device (LNG-IUS): It is very effective in reducing heavy menstrual bleeding in many women with fibroids by acting locally in the uterine cavity. However, it does not reduce the size of fibroids. Its use may be limited in the case of a significantly deformed uterine cavity.
• Non-hormonal drugs:
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (e.g. ibuprofen, naproxen): They can relieve menstrual pain (painful cramps), but have little effect on reducing the amount of blood lost.
  • Tranexamic acid: An anti-haemorrhagic (antifibrinolytic) medicine, taken only on the days of menstrual bleeding. It effectively reduces the amount of bleeding without affecting the fibroids themselves or hormones.
• Iron Supplements: Essential in the treatment of anemia caused by chronic blood loss.

Minimally invasive procedures (uterus conserving)

These are treatment methods that aim to remove or destroy fibroids with as little interference as possible, while preserving the uterus. They are an alternative to traditional surgery, especially for women who want to preserve fertility or avoid hysterectomy.

Uterine Artery Embolization (UAE/UFE): Procedure performed by an interventional radiologist. It involves inserting a thin catheter through the femoral artery in the groin into the uterine arteries supplying the fibroids with blood. Small molecules (embolization material) are then injected to block blood flow to the tumors. Cut off from the blood supply, fibroids die and gradually shrink (contract).

• Effectiveness: High effectiveness in relieving symptoms, especially heavy bleeding and pressure symptoms (improvement in 73-90% of patients).
• Advantages: Minimally invasive (no large surgical incisions), short hospital stay, faster return to activity compared to surgery, uterine preservation, which is particularly important in the case of uterine fibroids.
• Disadvantages/Risks: Pain after surgery (requires analgesic treatment), risk of infection (rare), post-embolization syndrome (pain, fever, nausea), low risk of damage to other organs, possibility (although rare) of premature menopause (especially in women >45 years of age). The impact on future fertility is uncertain and potentially negative, so this method is usually discouraged for women planning pregnancy in the future.

• Minimally invasive myomectomy: Surgical removal of fibroids with the preservation of the uterus, performed using minimally invasive techniques.
  • Hysteroscopic Myomectomy: Dedicated to submucosal fibroids (growing into the uterine cavity, type 0, 1, partially 2 according to FIGO). The procedure is performed through the vagina and cervix using an operative hysteroscope (resectoscope), without incisions on the abdomen. It is the method of choice for this type of fibroids in women planning pregnancy. Recovery is very fast. Sometimes it is necessary to perform the procedure in two stages if the fibroid is large.
  • Laparoscopic/robotic myomectomy: It is used to remove intramural and subserous fibroids. The surgeon makes several small (approx. 0.5-1 cm) incisions on the abdomen, through which a camera (laparoscope) and specialized instruments are inserted. In robotic surgery, the instruments are controlled by the surgeon via a console, which provides greater precision and better visualization. The removed fibroids are usually fragmented (morcelled) in a special bag inside the abdominal cavity so that they can be removed through small incisions.
    • Advantages: Less postoperative pain, shorter hospital stay (usually 1-3 days), faster return to normal activity (2-4 weeks), better cosmetic effect compared to open surgery. The method preferred for fertility preservation in the case of fibroids located in the wall or outside the uterus.
    • Disadvantages/Limitations: It can be technically more difficult with very large or numerous fibroids. Requires an experienced operator. Morcellation carries a minimal risk of spreading a previously undiagnosed sarcoma.
• Ablative methods (destruction of fibroid tissue): These techniques destroy the fibroid tissue in situ (at the site), without removing it, leading to gradual shrinkage of the tumor and relief of symptoms. These are methods that preserve the uterus.
  • Radio Frequency Ablation (RFA): It uses radiofrequency energy delivered by a special needle/electrode inserted into the fibroid (ultrasound-guided, laparoscopic or transvaginal). High temperature destroys tumor tissue.
  • Focused Ultrasound under Magnetic Resonance Guided Imaging (MRgFUS) or Ultrasound (HIFU): A completely non-invasive method. Concentrated high-energy ultrasound waves are precisely directed at the fibroid through the abdominal wall, heating it up and causing it to ablat (destroy). The entire process is monitored in real time using MRI or ultrasound. The procedure is performed on an outpatient basis, without general anesthesia and without incisions. Long-term efficacy and effects on fertility are still being studied. Not all fibroids qualify for this method (depends on location, size, vascularization).
  • Myolysis / Cryomyolysis: Older ablative methods that use heat (e.g. laser) or cold (freezing) to destroy fibroids, are now less commonly used.

Surgical treatment (classical surgery)

Traditional surgical methods that require a larger abdominal incision (laparotomy).

• Abdominal myomectomy (laparotomy): It involves the surgical removal (enucleation) of fibroids through an incision in the abdominal wall (usually transverse above the pubic symphysis). It is the method of choice in the case of very large, numerous or hard-to-reach fibroids that are not suitable for removal using minimally invasive techniques. It allows the uterus and potential fertility to be preserved. However, it is associated with a longer hospital stay (3-5 days), longer recovery (4-6 weeks), greater postoperative pain and a higher risk of adhesions compared to laparoscopy.
• • With very severe symptoms that do not respond to other treatments.
  • Who ended their reproductive plans.
  • With very large or numerous fibroids, where myomectomy would be too risky or technically impossible.
  • In whom there is a suspicion or confirmation of a malignant process.
  • In perimenopause or postmenopause. Hysterectomy can be performed using various techniques:
  • Transabdominal (abdominal): A classic surgery with opening the abdominal cavity.
  • Transvaginal (vaginal): Removal of the uterus through the vagina, without visible scars on the abdomen.
  • Laparoscopic (total – TLH or vaginal assisted – LAVH): A minimally invasive technique using small abdominal incisions.
  • Robotic: Laparoscopy using a surgical robot. Depending on the clinical situation, a hysterectomy may include:
  • Partial (supracervical): Removal of the uterine body while leaving the cervix.
  • Total: can be removed uterine fibroids are benign tumors. Removal of the body and cervix.
  • Total with appendages: Removal of the uterus, cervix, fallopian tubes and ovaries (salpingo-oophorectomy). The decision to remove the ovaries is made individually, in premenopausal women usually try to preserve them due to hormone production.
  • Radical: A very extensive procedure reserved for the treatment of malignant tumors. Hysterectomy (removal of the uterus): This is the most radical, but also the most effective method of treating fibroids, guaranteeing permanent resolution of symptoms and no recurrence. It involves surgical removal of the uterus. It is an irreversible method that ends a woman’s fertility. It is indicated for women:

Choosing a Treatment Method: Key Factors (SEO Subtitle)

The decision on the best treatment for uterine fibroids is complex and should be made by the patient in cooperation with a gynaecologist after careful consideration of many factors. There is no one-size-fits-all solution, and the optimal strategy is always individualized.

The main factors considered are:

1. Presence and Severity of Symptoms: This is a key factor. Women without symptoms usually only need observation. Treatment is indicated when the symptoms (heavy bleeding, pain, pressure, anaemia) are so bothersome that they significantly reduce the patient’s quality of life. The type of predominant symptoms can also influence the choice of therapy (e.g., hormonal drugs or tranexamic acid for bleeding, NSAIDs for pain, UAE for compression symptoms).
2. Patient’s age: Age matters, especially in the context of the approaching menopause. In women close to menopause, less invasive methods or wait-and-see may be considered, hoping for a natural reduction in fibroids after ovarian function has stopped. In younger women, especially those planning pregnancy, uterine conserving methods are preferred.
3. Procreation Plans (Desire to Have Children in the Future): This is one of the most important factors in deciding between uterine conservation methods and hysterectomy.
   • For women planning pregnancy, the methods of choice are myomectomy (laparoscopic, hysteroscopic or abdominal), which removes fibroids while preserving the uterus. Drug treatment (e.g., UPA, GnRH analogues) may be used prior to myomectomy to shrink tumors.
   • Uterine artery embolization (UAE) is usually discouraged for women wishing to become pregnant due to the uncertain and potentially negative impact on fertility and the course of future pregnancy.
   • Ablative methods (RFA, MRgFUS/HIFU) – their effect on future fertility is still being studied and is not routinely recommended for women planning pregnancy.
   • Hysterectomy definitely prevents pregnancy and is reserved for women who have completed their reproductive plans or for whom the preservation of the uterus is not a priority.
4. Size, Number and Location of Fibroids: These features, assessed mainly by ultrasound or MRI, determine both the severity of symptoms and the technical feasibility of individual treatment methods.
   • Small submucosal fibroids are best treated hysteroscopically.
   • Moderate intramural and subserous fibroids are often eligible for laparoscopic myomectomy or embolization.
   • Very large (>10-12 cm) or multiple fibroids may require abdominal myomectomy or hysterectomy.
   • Location close to important structures (e.g. bladder, ureters) may affect the surgical risk.
5. The patient’s general health: The presence of other diseases, past surgeries, and general physical condition can affect the choice of treatment method and anaesthesia and the risk of complications.
6. Patient preferences: After presenting all the available options, their advantages, disadvantages, risks, and expected results, the final decision should take into account the woman’s individual preferences, values, and expectations. Some patients may prefer to avoid surgery at all costs, others may strive to solve the problem as soon as possible and definitively.

It is important that the doctor has a detailed conversation with the patient, explaining all aspects related to each potential treatment method, so that an informed and best decision can be made for her.

Summary

Uterine fibroids are a common, benign gynecological condition that can significantly affect the health and well-being of women of childbearing age. Although many fibroids do not cause symptoms and only require regular observation, others can lead to bothersome ailments such as heavy menstrual bleeding, anemia, pelvic pain, pressure symptoms on adjacent organs, as well as fertility problems and pregnancy complications.

Diagnostics is mainly based on gynaecological examination and transvaginal ultrasonography, supplemented if necessary by more advanced imaging techniques, such as magnetic resonance imaging or hysteroscopy.

Modern medicine offers a wide range of treatment methods, from wait-and-see treatment, through pharmacological treatment to control symptoms, to a variety of minimally invasive uterus-sparing procedures (uterine artery embolization, laparoscopic and hysteroscopic myomectomy, ablative methods) and classic surgical treatment (abdominal myomectomy, hysterectomy).

The choice of the optimal treatment method is always individual and depends on many factors, including the severity of symptoms, the patient’s age, her plans for future pregnancy, the characteristics of the fibroids themselves and the woman’s preferences. Open communication between the patient and the doctor and access to reliable information are crucial, which allows you to make the best, informed therapeutic decision. Regular gynaecological check-ups are essential both in monitoring asymptomatic fibroids and in assessing the effectiveness of the treatment undertaken.