3.2 Uterine Leiomyomas, Adenomyosis & Endometrial and Cervical Polyps
Key Takeaways
Leiomyomas are benign monoclonal smooth-muscle tumors present in up to 70%–80% of women by age 50; Black women develop them earlier and with more symptoms.
FIGO types 0–2 (submucosal) cause heavy bleeding and infertility and are treated by hysteroscopic myomectomy; types 3–8 cause bulk and pressure symptoms.
Oral GnRH antagonist combinations (elagolix/estradiol/norethindrone acetate and relugolix/estradiol/norethindrone acetate) treat fibroid-related heavy bleeding for up to 24 months but are contraindicated with high thrombotic risk, including smokers over 35.
Adenomyosis causes heavy, painful menses with a diffusely enlarged, globular, tender uterus; MRI shows a junctional zone of 12 mm or more, and the LNG-IUS is first-line medical therapy.
Endometrial polyps cause intermenstrual bleeding and are removed hysteroscopically when symptomatic or postmenopausal; every removed cervical or endometrial polyp is sent for pathology.
Uterine Leiomyomas (Fibroids)
Leiomyomas are benign, monoclonal smooth-muscle tumors of the myometrium and the most common pelvic tumor in women. Up to 70%–80% of women have them by age 50. They are estrogen- and progesterone-responsive, so they grow during the reproductive years and usually shrink after menopause.
Risk Factors
- Increased risk: Black race (earlier onset, larger and more numerous fibroids), increasing age until menopause, early menarche, nulliparity, obesity, family history, and vitamin D deficiency.
- Decreased risk: Parity and use of combined hormonal contraception or DMPA.
FIGO Classification
| FIGO Type | Location | Typical Symptom |
|---|---|---|
| 0 | Pedunculated, entirely intracavitary | Heavy bleeding, infertility |
| 1 | Submucosal, <50% intramural | Heavy bleeding, infertility |
| 2 | Submucosal, ≥50% intramural | Heavy bleeding, infertility |
| 3–4 | Intramural (3 touches the endometrium) | Bleeding, bulk |
| 5–7 | Subserosal to pedunculated subserosal | Pressure, urinary frequency, constipation |
| 8 | Other (cervical, parasitic) | Varies |
Clinical Presentation
Most fibroids are asymptomatic. Symptoms include heavy menstrual bleeding with iron deficiency anemia, pelvic pressure, urinary frequency, constipation, and an enlarged, irregular, firm, mobile uterus on bimanual exam. In pregnancy, fibroids can undergo red (carneous) degeneration, causing acute localized pain in the second trimester that is managed with rest and short-term analgesia; they also raise risks of malpresentation and postpartum hemorrhage.
Diagnosis
Transvaginal ultrasound is first-line. Saline infusion sonohysterography or hysteroscopy maps submucosal fibroids, and MRI maps multiple fibroids before myomectomy or embolization.
Warning
Rapid growth of a presumed fibroid after menopause, or a mass with irregular vascularity and necrosis on imaging, raises concern for leiomyosarcoma. The FDA warns against power morcellation of presumed fibroids in peri- and postmenopausal women and allows only contained morcellation in carefully selected patients.
Medical Management
| Option | Notes |
|---|---|
| NSAIDs and tranexamic acid | Reduce menstrual blood loss; tranexamic acid is avoided with active thromboembolic disease |
| LNG-IUS (52 mg) | Effective when the cavity is not distorted; higher expulsion with submucosal fibroids |
| Combined hormonal contraceptives | Reduce bleeding but do not shrink fibroids |
| Oral GnRH antagonist combinations | Elagolix/estradiol/norethindrone acetate (Oriahnn) and relugolix/estradiol/norethindrone acetate (Myfembree) treat heavy bleeding for up to 24 months; boxed warning for thromboembolic and vascular events; contraindicated with high VTE risk, smokers over 35, osteoporosis, and liver disease |
| GnRH agonist (leuprolide) | Short preoperative course (3–6 months) shrinks fibroids by 30%–50% and lets iron restore hemoglobin; add-back therapy for longer use |
| Iron | Oral or IV iron corrects anemia before surgery |
Procedural Management by Goal
- Desires future fertility: Hysteroscopic myomectomy for types 0–2; laparoscopic or abdominal myomectomy for intramural or subserosal fibroids.
- Uterine preservation without pregnancy plans: Uterine artery embolization (UAE), radiofrequency ablation, or MR-guided focused ultrasound. UAE is generally not first choice for patients planning pregnancy.
- Definitive: Hysterectomy, the only cure. ACOG recommends bilateral salpingectomy at the time of hysterectomy for ovarian cancer risk reduction.
Adenomyosis
Adenomyosis is the presence of endometrial glands and stroma within the myometrium, causing smooth-muscle hypertrophy.
- Risk factors: Multiparity, age 40–50, and prior uterine surgery such as cesarean or curettage.
- Presentation: Heavy menstrual bleeding, severe secondary dysmenorrhea, and dyspareunia, with a diffusely enlarged, globular, symmetric, boggy, tender uterus, typically no larger than a 12–14-week pregnancy.
- Imaging: TVUS shows asymmetric myometrial thickening, myometrial cysts, and a "venetian blind" pattern of shadowing; MRI shows a junctional zone of 12 mm or more.
- Treatment: The LNG-IUS is first-line medical therapy; NSAIDs, continuous hormonal contraceptives, progestins, and GnRH analogues also help. Hysterectomy is the definitive treatment, with histology confirming the diagnosis. Adenomyosis often coexists with endometriosis and fibroids.
Endometrial and Cervical Polyps
| Feature | Endometrial Polyp (AUB-P) | Cervical (Endocervical) Polyp |
|---|---|---|
| Description | Overgrowth of endometrial glands and stroma on a vascular stalk | Smooth, red, fragile growth protruding from the os |
| Symptoms | Intermenstrual or postmenopausal bleeding, heavy menses, infertility | Postcoital spotting or discharge; often incidental |
| Risk factors | Age, obesity, unopposed estrogen, tamoxifen | Multiparity, ages 40–60 |
| Diagnosis | TVUS (best in the proliferative phase) or saline infusion sonohysterography; hysteroscopy | Speculum exam |
| Malignancy risk | Low, but higher in postmenopausal women with bleeding | Very low |
| Treatment | Hysteroscopic polypectomy if symptomatic, postmenopausal, or affecting fertility | Office twisting removal with ring forceps; hemostasis with silver nitrate or Monsel's solution |
Send every removed polyp for pathology. A small, asymptomatic endometrial polyp in a premenopausal woman may be observed, because some regress.
Clinical Pearls and Exam Traps
- Fertility: Submucosal fibroids (types 0–2) lower implantation and raise miscarriage rates, so removing them improves fertility. Intramural fibroids that do not distort the cavity have uncertain effects, and subserosal fibroids do not affect fertility; removing them for fertility alone is not recommended.
- Acute presentations: A prolapsing submucosal fibroid can appear at the cervical os with heavy bleeding and cramping; it is removed vaginally. A pedunculated subserosal fibroid can twist and cause acute pain like adnexal torsion.
- Menopause: Fibroids usually shrink after menopause. Menopausal hormone therapy may cause slight growth, but a growing uterine mass in a postmenopausal woman who is not taking hormones needs evaluation for sarcoma.
- Anemia: Check a CBC and ferritin in every patient with heavy bleeding, and correct iron deficiency before any procedure.
- Tranexamic acid is taken only during menses (1.3 g three times daily for up to 5 days) and is avoided with active or prior thromboembolic disease; use extra caution when combined with estrogen-containing contraception.
A 34-year-old who wants to conceive has heavy menstrual bleeding and iron deficiency anemia. Saline infusion sonohysterography shows a 2.5-cm fibroid that lies entirely within the endometrial cavity on a stalk. Which classification and treatment are correct?
FIGO type 6 subserosal fibroid; uterine artery embolization
FIGO type 0 pedunculated submucosal fibroid; hysteroscopic myomectomy
FIGO type 4 intramural fibroid; observation with oral iron alone
FIGO type 8 cervical fibroid; total hysterectomy
A 38-year-old woman with symptomatic fibroids and heavy menstrual bleeding asks about relugolix/estradiol/norethindrone acetate. She smokes one pack of cigarettes daily. What is the most appropriate counseling?
It is preferred for smokers because the estradiol dose is lower than in combined pills.
It can be used indefinitely because the add-back hormones prevent bone loss.
It cures fibroids, so no further treatment will be needed after a 6-month course.
It is contraindicated because she is a smoker over 35, which carries high thromboembolic risk.
A 46-year-old multiparous woman with two prior cesarean births reports increasingly heavy, very painful menses. Bimanual examination reveals a diffusely enlarged, symmetric, globular, tender uterus about the size of a 10-week pregnancy. MRI shows a junctional zone of 15 mm. What is the most appropriate first-line medical therapy?
52 mg levonorgestrel intrauterine system
Clomiphene citrate on cycle days 3–7
Oral metronidazole for 14 days
Cabergoline twice weekly
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