History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include increasing age, black ethnicity, and being overweight.

asymptomatic

Most common presentation.[9][72]

heavy menstrual bleeding

Observational studies have found that uterine fibroids are associated with heavy menstrual bleeding and prolonged menses with rates of between 27% and 54%.[61] A 2002 study revealed an 80% rate of preoperative heavy menstrual bleeding among a series of patients undergoing uterine artery embolisation or myomectomy.[73]

irregular firm central pelvic mass

Easily palpable on pelvic examination in the absence of class III obesity (BMI 40 or above).

Other diagnostic factors

common

pelvic pain

Among patients undergoing myomectomy for symptomatic uterine fibroids, 34% report a history of pelvic pain with or without pressure and/or dysmenorrhoea.[23]

pelvic pressure

Among patients undergoing myomectomy for symptomatic uterine fibroids, 34% report a history of pelvic pain with or without pressure and/or dysmenorrhoea.[23]

dysmenorrhoea

Among patients undergoing myomectomy for symptomatic uterine fibroids, 34% report a history of pelvic pain with or without pressure and/or dysmenorrhoea.[23] Another more recent study showed a rate of 53% among patients prior to undergoing surgery for symptomatic fibroids.[73]

bloating

A series of 51 patients who underwent uterine artery embolisation and 30 who underwent myomectomy were contacted postoperatively in order to answer a mailed survey that reviewed presenting symptoms and clinical history. Among the 81 patients who agreed to participate, 57% complained of abdominal distention prior to surgery.[73]

fatigue and loss of productivity in working

Fatigue and loss of productivity are related to iron deficiency anaemia that is caused by heavy bleeding.

uncommon

infertility

In one literature review of patients prior to myomectomy, 27% reported infertility.[23]

Patients with uterine fibroids that are submucosal in location or those with an intrauterine cavity component are at increased risk for infertility.[74][75]

In a personal series of major operations for preservation or enhancement of fertility, only 2.4% involved performance of a myomectomy in whom no other cause for infertility was identified. One review of 18 studies involving patients in whom myomectomy was performed for infertility, 40% conceived following surgery.[23]

urinary complaints

In a mailed survey that reviewed presenting symptoms and clinical history prior to uterine artery embolisation and myomectomy, among the 81 patients who agreed to participate, 32% complained of urinary frequency prior to surgery.[73]

constipation

In a mailed survey that reviewed presenting symptoms and clinical history prior to uterine artery embolisation and myomectomy, among the 81 patients who agreed to participate, 37% complained of constipation prior to surgery.[73]

enlarged uterus (regular contour)

A symmetrically enlarged uterus is more commonly associated with a diagnosis of adenomyosis than uterine fibroids.

dyspareunia

Uterine fibroids can make sex, especially penetrative sex, painful.

Risk factors

strong

increased patient weight

The risk of uterine fibroids increases by about 21% for each 10 kg increase in weight over 50 kg. The matched relative risk for women weighing equal to or greater than 70 kg was 2.82. The mechanism of action appears to be related to weight-induced anovulation and accompanying unopposed oestrogen as well as increase in peripheral conversion of androgens to oestrone among obese individuals.[25] Oestrogen is a known initiator and promoter of uterine fibroids.[26]

age in the 40s

Studies have shown a progressive increase with a peak age interval of 40 to 44 years for hysterectomy rates and diagnosis of uterine fibroids followed by a decline.[7][27] Peak incidence for the diagnosis of fibroid uterus occurs during the 4th decade of life with a crude incidence of 22.5 per 1000 women-years.[7] The cause of this peak in the 4th decade of life may have several explanations including slow growth with delay in onset of symptomatology or possibly the effect of hormonal instability during the peri-menopausal years.[25]

black ethnicity

A case-control study finding revealed that black women had a 9.4-fold odds ratio of having fibroids compared with white women after adjusting for a number of variables known or suspected to have an impact on the development of uterine fibroids. There is speculation in the literature that black women have a tendency towards fibroid processes that include such entities as elephantiasis and keloids, involving proliferative conditions of both skin and myometrium.[28] It has also been found that the incidence of uterine fibroids among premenopausal black women is 2 to 3 times greater than for white women.[7][27]

hypovitaminosis of vitamin D

Serum vitamin D deficiency is now an established risk factor for developing uterine fibroids and may explain the severe profile of this disease in women of African descent who tend to suffer from severe vitamin D deficiency. Several studies from different regions of the world have shown that vitamin D deficiency is inversely related to the risk of uterine fibroids.[29][30]

weak

hypertension

There is evidence of a weak association between hypertensive disease and the development of uterine fibroids. A cohort prospective mail survey showed a dose-response relationship between increasing diastolic blood pressure and the incidence of self-reported uterine fibroids. For every 10 mmHg increase in diastolic pressure, there was an 8% increase in diagnosis of uterine fibroids among non-medicated women with hypertension and a 10% increase among patients on antihypertensive medications.

Incidence also increased with duration of hypertensive disease; hypertensive women were 24% more likely to have uterine fibroids than patients with normal blood pressure.[31]

A similar association between hypertension and the reported diagnosis of uterine fibroids was found in a case-control interview-based study. The proposed mechanism for this association is based on the similarities between the smooth muscle proliferation seen in fibroid production and that seen with atheromatous plaques induced by hypertension.[28] A common pathway of injury and induction of proliferation remains to be elucidated.

early menarche (under 10 years)

Risk of uterine fibroid increases with earlier age at menarche.[32] In one study, women with a reported age at menarche of 10 years or younger had a greater likelihood of surgery for fibroids than women with menarche at 13 years.[33]

use of oral contraceptives (if started before age 16 years)

Use of oral contraceptives before 16 years of age is associated with an increased risk of uterine fibroid.[34] However, uterine fibroid risk is lower in women who currently use oral contraceptives than in those who had never used them.[5]

nulliparity

Women with infertility are more likely to have uterine fibroids.[32]

Pregnancy seems to be protective. Increased parity is associated with decreasing risk of uterine fibroid, with a reduction in risk of between 20% and 50% for parous women compared with nulliparous women.[32]

younger age at first birth

Risk of fibroids is inversely related to age at first birth.[35]

Older age at first pregnancy appears to be associated with lower risk, but only in black women.[35]

poor vitamin A intake

Vitamin A and its active metabolite, all-trans retinoic acid (more commonly known as retinoic acid), have a role in uterine fibroid growth regulation.[36] Dietary vitamin A intake is associated with uterine fibroid risk and lower intakes of fruit and vegetables may be related to higher rates of uterine fibroids.[37] Of note, higher vitamin A intake, particularly if derived from animal sources (e.g., liver and dairy products), seems to be associated with decreasing uterine fibroid risk.[37]

dietary intake high in beef and other red meat

In a case-control study, a weak association (odds ratio 1.7) was identified between patients with high intake of beef and other red meat versus those with low intake in a case-control study.[38] A potential mechanism for this association may be related to altered bio-availability of oestrogens and progesterones by different food groups.[25]

sex hormone exposure

Most data stems from animal studies.

Sufficient but controversial evidence of an association exists in humans.[39]

menstrual history

Conflicting data in humans regarding contribution of menstrual cycle regularity, cycle length, age at menarche, and dysmenorrhoea and intermenstrual bleeding.[25]

smoking

The relationship between smoking and uterine fibroids is unclear. However, one meta-analysis found that non-smoking was associated with a small increased risk and current or former smoking was associated with a small risk reduction.[32][40]

alcohol consumption

Alcohol, and especially beer intake, could increase the risk of uterine fibroids.[41][42]

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