Diagnosis: Uterine Fibroids/Leiomyoma

Uterine fibroids (also known as uterine fibroma, leiomyoma, fibromyoma, and myoma) are the most common solid tumor of the female reproductive tract. (American College of Obstetricians and Gynecologists: ACOG Practice Bulletin, No. 16. Surgical Alternatives to Hysterectomy in the Management of Leiomyomas, 2000.) These benign smooth muscle tumors grow within the muscle layers of the uterus (subserosal, submucosal, or intramural), are intrauterine (intracavitary), or attach to the outside of the uterus by a thick pedunculated stalk. The etiology of these tumors is unknown, but leiomyomas contain estrogen-sensitive receptors. This explains why they often enlarge rapidly during pregnancy as estrogen levels surge, but tend to regress after menopause. Fibroid tumors vary in number and size. They can be microscopic or mimic a full-term uterus.

Although the true incidence of leiomyoma is unknown because many women are asymptomatic, it is estimated that from five percent to 80 percent of women are affected. (Am J Obstet Gynecol 2003;188:100.) In women of reproductive age, approximately 25 percent to 35 percent have fibroid tumors. (Fertil Steril 1981;36:433.) Women who are African-American, overweight, or older, however, appear to be at greater risk. (Br J Obstet Gynaecol 1990;97:285.)

The clinical presentation of uterine fibroids varies, and depends on the size, location, and number of tumors. Most fibroids are asymptomatic and inconsequential, but symptoms can range from abdominal fullness, menometrorrhagia, pain, urinary frequency or retention, dyspareuria, and constipation to infertility and gynecologic hemorrhage. Acute pain secondary to leiomyoma is uncommon, but can be caused by torsion of a pedunculated fibroid tumor or infarction of tissue within a tumor that has outgrown its blood supply. On physical examination, patients may have lower abdominal tenderness, a palpable suprapubic abdominal mass, bleeding from the cervical os, or a palpable uterine mass on pelvic examination.

The reported prevalence of fibroids in pregnancy ranges from 0.09 percent to 3.9 percent (Obstet Gynecol Clin NA 2006;33[1]:153), and can cause numerous potential antepartum and postpartum complications including miscarriage, preterm labor, placental abruption, preeclampsia, intrauterine growth restriction, disseminated intravascular coagulation, postpartum hemorrhage, and fetal malposition or anomalies.

Very few fibroid tumors are or become malignant, but rapidly growing lesions, particularly after menopause, should elicit concern. These lesions typically are diagnosed as leiomyosarcoma on histology.

ED evaluation and management depends on the severity of presentation. Uterine imaging including ultrasound, computerized tomography (CT) scan, and magnetic resonance imaging (MRI) may be helpful if the course of vaginal bleeding or intrabdominal mass is in question. Asymptomatic hemodynamically stable patients who are not critically anemic can be discharged with bleeding precautions, analgesics, and given a gynecological referral for outpatient management and possibly imaging. Obviously, standard resuscitation should be performed for those who are hemodynamically unstable.