The incidence of uterine fibroid tumors
increases as women grow older, and they may occur in more than 30
percent of women 40 to 60 years of age. Risk factors include
nulliparity, obesity, family history, black race, and
hypertension. Many tumors are asymptomatic and may be diagnosed
incidentally. Although a causal relationship has not been
established, fibroid tumors are associated with menorrhagia,
pelvic pain, pelvic or urinary obstructive symptoms, infertility,
and pregnancy loss. Transvaginal ultrasonography, magnetic
resonance imaging, sonohysterography, and hysteroscopy are
available to evaluate the size and position of tumors.
Ultrasonography should be used initially because it is the least
invasive and most cost-effective investigation. Treatment options
include hysterectomy, myomec- tomy, uterine artery embolization,
myolysis, and medical therapy. Treatment must be individualized
based on such considerations as the presence and severity of
symptoms, the patient"s desire for definitive treatment, the
desire to preserve childbearing capacity, the importance of
uterine preservation, infertility related to uterine cavity
distortions, and previous pregnancy complications related to
fibroid tumors. (Am Fam Physician 2007;75:1503-8. Copyright
© 2007 American Academy of Family Physicians.)
Many women develop uterine fibroid tumors
(i.e., leiomyomas) as they grow older. In one study, the
prevalence of ultrasound-identified tumors ranged from 4 percent
in women 20 to 30 years of age to 11 to 18 percent in women 30 to
40 years of age and 33 percent in women 40 to 60 years of age.1
Studies report that 5.4 to 77 per- cent of women have uterine
fibroid tumors, depending on the population studied and the
diagnostic method used.1,2 Women often consult family physicians
because of symptoms related to fibroid tumors or after the
lesions have been diagnosed incidentally during physical or
radiologic examinations. This article reviews the epidemiology
and etiology of uterine fibroid tumors, common clinical
presentations, diagnostic strategies, and treatment
options.
Epidemiology and
Etiology
Leiomyomas are the most common female
reproductive tract tumors. They are probably of unicellular
origin,3 and their growth rate is influenced by estrogen, growth
hormone, and progesterone. Although studies have not clarified
the exact process, uterine fibroid tumors arise during the
reproductive years and tend to enlarge during pregnancy and
regress after menopause. The use of estro- gen agonists is
associated with an increased incidence of fibroid tumors, 4 and
growth hormone appears to act synergistically with estradiol in
affecting the growth of fibroid tumors. Conversely, progesterone
appears to inhibit their growth.
Several studies have documented an
increased incidence of uterine fibroid tumors in black women.5
Some evidence also indicates that black women are more likely
than white women to have larger and more symptomatic tumors at
the time of treatment.6-10 Table 15-10 lists factors associated
with the development of fibroid tumors. Recent evidence suggests
that women with hypertension have a higher risk of fibroid
tumors, possibly through smooth muscle injury or cytokine
release.11
Clinical
Features
Because of the high prevalence of uterine
fibroid tumors and the fact that many are asymptomatic,
attributing symptoms specifically to the tumors is problematic.
Although evidence is largely drawn from uncontrolled studies,
uterine fibroid tumors are commonly identified in women who have
menorrhagia, pelvic pain, obstructive symptoms, infertility, or
pregnancy loss.
Menstrual abnormalities, including
menorrhagia, are the most common symptoms associated with uterine
fibroid tumors. Submucosal tumors are often cited as a cause of
menorrhagia, but there is no evidence that the endometrium over
submucosal tumors differs from that overlying other areas of the
uterus.12 Fibroid tumors may produce a dysregulation of local
growth factors, causing vascular abnormalities that contribute to
menorrhagia13 and are unrelated to their location in the uterus.
One study attributed 11 percent of cases of symptomatic
menorrhagia to uterine fibroid tumors.14 Conversely, a
population-based study did not find any evidence relating general
abnormalities in menstrual cycle length or heaviness to the
presence of fibroid tumors.15
Pelvic pain and pressure are less commonly
attributed to uterine fibroid tumors. Individual case reports
have described very large tumors that result in pelvic
discomfort, respiratory failure, urinary symptoms, and
constipation.16-18 During pregnancy, the combination of large
fibroid tumors and uterine enlargement can result in symptoms of
urinary tract obstruction,19 abdominal pain (attributed to the
degeneration of fibroid tumors), and, possibly, an increased risk
of placental abruption if the tumor is located
retroplacentally.20
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