Uterine Fibroids

Clinical Practice review. Case: A 33-year-old gravida 0 Black woman presents to her primary care clinician with From the Divisions of Reproductive heavy menstrual bleeding and abdominal bloating. She is noted to have iron- Endocrinology (E.A.S.) and Gynecology (S.K.L.-T.), Department of Obstetrics and deficiency anemia. Evaluation for thalassemia and sickle cell anemia is negative. She Gynecology, the Department of Physiolo- has no hematochezia and no family history of colon cancer or inflammatory bowel gy and Biomedical Engineering (E.A.S.), disease. She describes her menses as regular and monthly, lasting for 8 days, and the Division of Endocrinology, Depart- ment of Medicine (E.A.S.), the Depart- unchanged over time. She uses eight or nine tampons per day for the three heaviest ment of Surgery (E.A.S., S.K.L.-T.), and the days of her cycle and occasionally has menstrual accidents. She is in a Ph.D. program Women’s Health Research Center (E.A.S., and anticipates pursuing pregnancy in 2 years. Ultrasonography reveals an enlarged S.K.L.-T.), Mayo Clinic, and the Mayo Clinic College of Medicine and Science (E.A.S., uterus with multiple fibroids and normal ovaries. How would you treat this patient? Uterine fibroids (leiomyomas) are myometrial masses (Fig. 1) and Rochester, MN 55905. are the leading indication for hysterectomy. Fibroids affect 70 to 80% of N Engl J Med 2024;391:1721-33. persons with a uterus during their lifetime.1 Up to 50% of persons with DOI: 10.1056/NEJMcp2309623 fibroids have symptoms, including heavy and prolonged menstrual bleeding, Copyright © 2024 Massachusetts Medical Society. anemia-associated fatigue, pelvic pressure, and both menstrual and nonmenstrual CME pain. Fibroids can cause compression of surrounding structures with resultant bulk-related symptoms, including in the bowel (constipation), bladder (urinary frequency, urgency, or retention), and vagina (painful intercourse). Slow growth of uterine fibroids is typical, although both shrinkage and growth spurts do occur.2 Fibroid-related morbidity is compounded by underdetection and its symptoms being attributed to other conditions, such as gastrointestinal or hematologic dis- ease. Owing to the stigma associated with discussing menstruation, many persons with long or heavy menses are unaware that their experience is abnormal. Symp- tomatic persons often receive a delayed diagnosis. In one third of patients, diag- nosis can take 5 years, with some patients waiting more than 8 years.3 Delays in diagnosis adversely affect fertility, quality of life, and financial welfare,4,5 and in a qualitative study, 95% of persons with symptomatic fibroids reported psycho- logical sequelae, including depression, worry, anger, and body-image distress.6 Menstruation-related stigma and shame inhibit discussion, study, advocacy, and innovation in this field. A total of 50 to 72% of persons who receive a diagnosis of uterine fibroids on the basis of ultrasonography were not previously aware that they had fibroids, which suggests a potential role for wider ultrasonographic assess- ment for this common condition.