Gynecology & Family Medicine & Reproductive Medicine
Fibrome utérin - Medical Services at Omicron Clinic
Uterine fibroma - also known as uterine leiomyoma or myoma - is a benign tumor developed at the expense of the smooth muscle of the uterine wall (myometrium). It is the most common gynecological tumor in women of childbearing age: its cumulative prevalence reaches 70-80 % of white women and 80-90 % of black women at the age of 50, when asymptomatic fibroids discovered at autopsy or on imaging are included. Only 25-50 % of women with fibroids develop clinically significant symptoms warranting management. Histologically, fibroids are composed of monoclonal smooth muscle cells (derived from a single precursor cell) organized in concentric bundles surrounded by a pseudocapsule, in an abundant extracellular matrix of collagen, fibronectin and proteoglycans. Their growth is dependent on estrogen and progesterone - which explains their appearance during the reproductive years, their increase during pregnancy and their regression after the menopause. Recurrent somatic mutations in the MED12 (70 % fibroid), HMGA2 and COL4A5-COL4A6 genes have been identified. The FIGO-PALM-COEIN international classification lists fibroids according to their anatomical location in 8 subtypes (0 to 7): type 0 (submucosal pedicled intracavitary) + type 1 (submucosal sessile, <50 % intramural) + type 2 (submucosal, ≥50 % intramural) + types 3-5 (intramural according to their contact with the endometrium) + type 6-7 (subserous) + type 8 (parasitic or cervical). Location is the main determinant of symptoms: submucosal fibroids (types 0-2) cause the most severe menorrhagia and fertility problems, while bulky intramural and subserous fibroids cause more pelvic compression symptoms.
Clinical presentation, diagnosis, and workup
- Clinical manifestations according to location and size: menorrhagia (heavy menstrual bleeding): most frequent symptom (30-50 % of symptomatic women) - mainly caused by submucosal fibroids (types 0-2) which distort the endometrial cavity + increase endometrial surface area + alter myometrial contractility + promote local neovascularization and vascular fragility - objective definition : menstrual blood loss >80 mL/cycle or impact on quality of life - practical definition: change of protection >1/hour for several consecutive hours + passage of clots + duration of menses >7 days - complications of menorrhagia: iron-deficiency anemia (frequent - collapsed ferritin + low hemoglobin) + asthenia + socio-professional impact + social isolation during menses; pelvic pain and dysmenorrhea: secondary dysmenorrhea (painful menses) aggravated by submucosal fibroids + chronic pelvic pain in case of large fibroids + acute pain due to aseptic necrobiosis (hemorrhagic infarction of a fibroid - very painful + often febrile - frequent during pregnancy or under GnRH agonist treatment); symptoms of compression of adjacent organs: large fibroids (≥10 cm) or multiple fibroids - pollakiuria + urinary urgency + partial urinary retention (bladder compression) + constipation + tenesmus + ureteral compression with hydronephrosis (rare but possible) + venous compression with lower-limb edema; infertility and obstetric complications: submucosal fibroids (types 0-2) reduce implantation rate + increase risk of early miscarriage - intramural fibroids (types 3-4) may reduce fertility if >3-4 cm or multiple - subserous fibroids (types 6-7) generally do not affect fertility; obstetrical complications: dystocic presentation + prematurity + placental abruption + post-partum haemorrhage (fibroid-related uterine atony) + increased need for caesarean sections
- Diagnostic — Pelvic Ultrasound and Imaging: pelvic ultrasound (suprapubic + endovaginal route): 1st-line examination - identification + localization + measurement of fibroids - sensitivity 90-99 % for fibroids ≥1 cm - describe: number + FIGO localization + dimensions (3 measurements) + echostructure (usually homogeneous hypoechoic + calcifications possible in post-menopause) + vascularization with color Doppler; hysterosonography (saline instillation contrast ultrasound - SCSH): injection of saline into the uterine cavity under ultrasound control → better visualization of the intracavitary component of submucosal fibroids (types 0-2) - useful for planning operative hysteroscopy - sensitivity 95 % for submucosal fibroids; diagnostic hysteroscopy: direct visualization of uterine cavity - gold standard for submucosal fibroids - enables endometrial biopsy if associated anomaly - performed in consultation (mini-hysteroscopy) or in operating theatre; pelvic MRI: indicated if : multiple or large fibroids (preoperative mapping before myomectomy) + suspicion of associated adenomyosis (heterogeneous endometrium - thickened junctional zone >12 mm on MRI) + suspicion of leiomyosarcoma (rare - but warning signs: rapid growth + menopause + heterogeneous appearance on MRI + central necrotic zone) + before uterine artery embolization (UAE) + fertility work-up; Biological work-up: CBC (iron-deficiency anemia secondary to menorrhagia - Hb + ferritin + CST) + TSH (hypothyroidism as a differential cause of menorrhagia) + bHCG (pregnancy) + coagulation workup if severe menorrhagia since adolescence (von Willebrand disease type 1 - present in 13 % of adolescents with menorrhagia); endometrial biopsy: indicated in women aged ≥45 years with menorrhagia + in younger women with risk factors for endometrial cancer (obesity + PCOS + chronic anovulation + estrogen treatment without progestin) - endometrial cancer must be excluded before any conservative treatment of menorrhagia
- Differential Diagnosis and Severity Assessment: differential diagnoses of uterine fibroids: adenomyosis (ectopic endometrium in myometrium - globular uterus + pain + severe dysmenorrhea + menorrhagia - MRI diagnosis: junctional zone >12 mm + hyperechoic islands within myometrium on ultrasound - may coexist with fibroids in 30-50 % of cases) + endometrial polyps (intermenstrual bleeding + menorrhagia - diagnosis : hysterosonography + hysteroscopy - benign in 95 % of cases) + pregnancy (enlarged uterus - hCG) + endometrial cancer (postmenopausal or intermenstrual bleeding + endometrial biopsy mandatory) + uterine leiomyosarcoma (malignant smooth muscle tumour - rare: 0.5 % of uterine tumors - prevalence in presumed fibromatous uteri: 1/400 to 1/1,000 depending on series - warning signs: rapid growth after menopause + constitutional symptoms + heterogeneous MRI appearance + necrosis); assessment of impact of menorrhagia: PBAC (Pictorial Blood Assessment Chart) score - semi-objective quantification of menstrual blood loss - score >100 = clinically significant menorrhagia - useful for documenting impact + monitoring treatment efficacy; quality-of-life questionnaires: UFS-QoL (Uterine Fibroid Symptom and Quality-of-Life questionnaire) - validated tool for measuring the impact of fibroids on quality of life - useful for clinical research and follow-up.
Treatment
| Treatment | Mechanism, molecules, and modalities | Effectiveness, results, and indications |
|---|---|---|
| Medical management — control of menorrhagia 1st line — asymptomatic or mildly symptomatic fibroids |
Medical treatment aims to control bleeding and pain without directly treating the fibroids - it is proposed as 1st-line treatment for women with moderate symptoms, wishing to preserve their fertility or awaiting surgery; levonorgestrel intrauterine device (LNG-IUD - Mirena 52 mg): local release of levonorgestrel → endometrial atrophy + reduction of menorrhagia by 70-90 % - reduction of lost hemoglobin by 95 % - improvement of anemia in 3-6 months - effective if uterine cavity is not too deformed by fibroids (distorted cavity → difficult insertion + expulsion) - contraindicated if submucosal fibroids (distorted cavity → difficult insertion + expulsion) - contraindicated if submucosal fibroids (distorted cavity → difficult insertion + expulsion) - contraindicated if submucosal fibroids (distorted cavity → difficult insertion + expulsion).indicated if type 0-1 submucosal fibroids distort the cavity - very effective in intramural and subserous fibroids with menorrhagia - duration: 5 years (Mirena); tranexamic acid (Cyklokapron) 1 g × 3-4/d PO during menses (maximum 5 days/cycle): antifibrinolytic - reduces menorrhagia by 47-54 % - no hormonal effect - usable in women wishing immediate pregnancy - can be combined with NSAIDs; NSAIDs (ibuprofen 400-600 mg × 3/d + naproxen 500 mg × 2/d during menses): inhibition of prostaglandins → reduction of menorrhagia by 20-30 % + analgesic - less effective than tranexamic acid for menorrhagia - useful if associated dysmenorrhea; combined oral contraceptives (COCs): reduction of menorrhagia by 35-50 % + relief of dysmenorrhea - simple, well-tolerated option - no demonstrated effect on fibroid size (unlike GnRH agonists) - usual COC contraindications to be respected (age + smoking + thromboembolic history); oral progestins in luteal phase (norethisterone 5 mg × 3/d from D5 to D26): reduction in menorrhagia by 83 % - alternative to LNG-IUD - often less well tolerated in the long term (androgenic effects + weight gain) | Choice of 1st-line medical treatment according to patient profile: woman wishing immediate pregnancy → tranexamic acid + NSAIDs (no contraception); woman wishing effective contraception + menorrhagia control → LNG-IUD (Mirena) if cavity not deformed → COC if IUD contraindicated ; submucosal fibroid type 0-1 deforming the cavity → hysteroscopic resection (1st-line surgical treatment - no IUD possible); woman with severe preoperative anemia → preoperative treatment with GnRH agonist or linzagolix (see 2nd-line hormonal treatment) to correct anemia before surgery; ferrostimulation of concomitant iron-deficiency anemia: oral iron (ferrous fumarate + ferrous gluconate 150-200 mg elemental iron/d) - if digestive intolerance or poor absorption → IV iron (ferric carboxymaltose - Ferinject - 500-1000 mg IV in a single infusion) - superior efficacy to oral iron in severe fibroid-related anemia (Hb <100 g/L) - reimbursed by RAMQ in severe symptomatic iron-deficiency anemia; monitoring under medical treatment: CBC + ferritin at 3 months + clinical evaluation (PBAC score or standardized questionnaire) → if failure or worsening → switch to 2nd-line medical or surgical treatment |
| Second-line hormone therapy — GnRH agonists and selective modulators Volume reduction — preparation for surgery |
GnRH (gonadotropin-releasing hormone) agonists and GnRH receptor antagonists/modulators induce reversible profound hypoestrogenism, leading to fibroid volume reduction and amenorrhea; GnRH agonists (leuprorelin - Lupron Depot + nafarelin + triptrorelin - Decapeptyl): monthly IM or SC administration (leuprorelin 3.75 mg/month IM) or quarterly (11.25 mg) - initial flare-up effect (paradoxical increase in estrogens in the first 2 weeks → possible worsening of bleeding before improvement) - from the 2nd month: amenorrhea in 90 % of cases + volumetric reduction of fibroids by 35-65 % in 3-6 months - mainly used preoperatively (3 months) to reduce fibroids before myomectomy or hysterectomy + correct anemia; adverse effects of GnRH agonists: symptoms of artificial menopause (hot flushes + vaginal dryness + insomnia + depressed mood) + bone loss (reversible on discontinuation) - add-back therapy (low-dose estrogen + progesterone) if used >3 months to limit bone demineralization; linzagolix (Yselty 200 mg/d PO - oral GnRH antagonist): approved by Health Canada (2023) for treatment of moderate to severe menorrhagia associated with uterine fibroids in premenopausal women - advantages over injectable GnRH agonists: oral administration + no flare-up effect + rapid onset of action (reduction in bleeding from the 1st cycle) - reduction in menorrhagia by 75 % at 24 weeks (PRIMROSE 1 and 2 trials) + reduction in fibroid volume by 30-50 % - add-back therapy (estradiol 1 mg + norethisterone acetate 0.5 mg) recommended for prolonged use (>6 months); ulipristal acetate (Fibristal 5 mg/d PO - selective progesterone receptor modulator - SPRM) : withdrawn from the Canadian market in 2020 following reports of serious liver damage - no longer prescribed; retinapregline (2nd-generation SPRM modulator) + elagolix (Orilissa - oral GnRH antagonist): in development or under evaluation by Health Canada for fibroids. | Linzagolix (Yselty) - data from PRIMROSE trials in Canada (2022-2023): PRIMROSE 1 (without add-back): 75 % of women with response (losses 12 months without add-back; choice between linzagolix and GnRH agonists: oral linzagolix preferred if prolonged use desired + patient not wishing surgery + upcoming menopause (<5 years) - injectable GnRH agonists preferred if short-term preparation for surgery (3 months) + severe anemia to be corrected rapidly |
| Conservative surgery - myomectomy Uterine preservation — desired fertility |
Myomectomy is the selective surgical removal of fibroids with conservation of the uterus - treatment of choice for women wishing to preserve their fertility or their uterus, with symptoms refractory to medical treatment; hysteroscopic myomectomy : reference treatment for submucosal fibroids types 0, 1 and 2 (10 cm) + multiple fibroids (>4) + complex localization (intra-ligamentary + cervical fibroids) - longer recovery time - high risk of post-operative adhesions + uterine scar may require Caesarean section for subsequent pregnancies; pregnancy delay after myomectomy: 3 months after hysteroscopic myomectomy + 3-6 months after laparoscopic myomectomy + 6-12 months after laparotomy myomectomy (uterine scar to be consolidated) | Myomectomy results on fertility: meta-analyses and Cochrane reviews: hysteroscopic myomectomy of submucosal fibroids → improved clinical pregnancy rates (OR 2.4) + reduced miscarriages (OR 0.5) - myomectomy of intramural fibroids >3 cm → less conclusive data but favorable trend - no large-scale randomized trial available due to ethical difficulties in randomizing infertile women; preoperative preparation: correction of anemia (IV iron if Hb <100 g/L) + GnRH agonist or linzagolix × 3 months if large fibroid (volume reduction + amenorrhea = easier operative field + less blood loss) + autologous blood deposit possible (for laparotomy myomectomy); complications of myomectomy: intra-operative haemorrhage (transfusion in 1-5 % of laparotomies) + post-operative adhesions + infection + conversion to haemostatic salvage hysterectomy (<1 % of cases - risk to be discussed with the patient prior to any myomectomy) + fibroid recurrence (25-35 % at 5 years - uterine fibromyomatosis); uterine artery embolization (UAE) prior to myomectomy: not recommended prior to myomectomy (risk of adhesions + fibroma necrosis making removal more difficult) |
| Uterine Artery Embolization (UAE) Alternative mini-invasive — uterine preservation without surgery |
Uterine artery embolization (UAE) is a minimally invasive interventional radiological procedure performed under local anesthesia + sedation by the interventional radiologist - it involves selectively occluding the uterine arteries by injecting embolizing particles (polyvinyl alcohol - PVA - or trisacryl gelatin microspheres) via a catheter introduced through the femoral arterial route; mechanism of action: occlusion of uterine arteries → ischemia of myometrium + fibroids → coagulation necrosis of fibroids (more vascularized than normal myometrium → preferential infarction of fibroids) → volumetric reduction of fibroids by 40-70 % in 3-6 months → reduction in menorrhagia + pelvic pressure; technique: selective arteriography of right and left uterine arteries + injection of calibrated microspheres (500-900 µm) under fluoroscopic control - procedure duration: 60-90 min - hospitalization: 1-2 nights for post-procedural pain management (post-embolization syndrome: intense pelvic pain + fever + nausea in the 24-72h following the procedure - treatment: NSAIDs + IV analgesics + sometimes morphine); long-term results: menorrhagia reduction of 80-90 % + patient satisfaction >85 % at 5 years - uterine size reduction of 40-50 % - hysterectomy avoidance rate at 5 years: 75-80 %; preferred indications: multiple fibroids + large fibroid + patient refusing surgery + comorbidities contraindicating general anaesthesia + refusal of transfusion (Jehovah's Witnesses - non-surgical procedure with minimal blood loss); contraindications: desire for pregnancy (insufficient post-EAU fertility data - EAU may alter ovarian reserve through irradiation of the ovaries + ovarian ischemia) + pedunculated submucosal fibroma type 0 (risk of expulsion of necrotic fibroma into the uterine cavity and vagina) + suspicion of leiomyosarcoma + active pelvic infection + allergy to iodinated contrast media | REST trial (Randomised trial of Embolisation versus Surgical Treatment) - Radiology 2004 + 5-year follow-up - Hehenkamp et al. Fertil Steril 2008: EAU vs hysterectomy: equivalent reduction in symptoms at 5 years - comparable patient satisfaction - re-intervention rate at 5 years: EAU 32 % vs hysterectomy 0 % (expected difference as hysterectomy is definitive) - hospital stay and recovery: EAU advantage (1-2 nights vs 3-5 days); EMMY trial (EMbolization versus hysterectoMY) - similar results; availability of EAU in Quebec: procedure available in tertiary hospital centers with interventional radiology departments - CHUM + Hôpital Maisonneuve-Rosemont + CHU de Québec (CHUQ) + some CISSS-CIUSSS + private interventional radiology clinics; MRgFUS (magnetic resonance-guided focused ultrasound): non-invasive alternative - focused ultrasound waves heat and destroy fibroids without incision or catheter - 3-4h session + limited availability in Canada (few centers) + high costs + non-systematic reimbursement + strict eligibility criteria (anterior fibroids + non-calcified + not too numerous) |
| Hysterectomy Definitive treatment — refractory symptoms |
Hysterectomy - surgical removal of the uterus - is the only definitive and curative treatment for symptomatic uterine fibroids: it eliminates all possibility of recurrence and is the treatment of choice in women with no or no longer desire for pregnancy, with severe symptoms refractory to other treatments; approaches to fibroid hysterectomy: vaginal hysterectomy: route of choice if moderate uterus size (≤12-14 SA) + associated uterine prolapse + no subserous pedunculated fibroids - faster recovery + less post-operative pain + no abdominal scarring; total laparoscopic hysterectomy (TLH): current gold standard - moderate to large uterus (≤18 SA in expert hands) - rapid recovery (2-3 weeks) + less pain + minimal scarring - morcellation inside a containment bag (contained power morcellation) mandatory if ≥12 SA uterus for trocar extraction; laparotomy hysterectomy (open route): very large uterus (>20 SA) + multiple complex fibroids + suspicion of leiomyosarcoma (en bloc excision without morcellation) + major pelvic adhesions - longer recovery time (4-6 weeks) + scar complications; ovarian conservation: recommended in premenopausal women under 45 if healthy ovaries (elimination of risk of early surgical menopause) - after 45 or in case of genetic risk (BRCA): discuss bilateral salpingo-oophorectomy with the patient; subtotal hysterectomy (cervical conservation): laparoscopic option - recovery similar to HLT - annual cervical smears still required if cervical conservation + no indication in BRCA+ women or women with a history of cervical dysplasia | Results of hysterectomy for fibroids: patient satisfaction: 95-98 % - complete and definitive resolution of menorrhagia + pelvic pain + compression - significantly and durably improved quality of life - no possible recurrence; operative mortality: 0.1-0.2/1,000 (elective procedure); perioperative complications: hemorrhage (transfusion 1-3 %) + infections (endometritis + fundal cellulitis - 3-5 %) + bladder or ureteral lesions (<1 %) + deep vein thrombosis (systematic prophylaxis: LMWH + compression stockings + early lifting) + anesthetic complications; long-term effects: surgical menopause if bilateral oophorectomy (vasomotor symptoms + cardiovascular risk + osteoporosis → HRT recommended if <60 years and no contraindications) + post-hysterectomy syndrome (rare - early ovarian failure due to impaired ovarian vascularization even without oophorectomy - incidence 1-5 %); criteria for access to hysterectomy in Quebec: documented medical indication (refractory symptomatic fibroids + severe recurrent anemia + disabling symptoms) + mandatory gynecological consultation + documented informed consent + variable waiting time depending on the center (3-18 months in the public setting) → faster access in the private setting via Quebec private surgical clinics. |
ℹ️
Fibroids and Pregnancy — Key Points: The vast majority of women with fibroids have normal, uncomplicated pregnancies. Fibroids do not typically increase significantly in size during pregnancy, contrary to popular belief—about 70–80 % remain stable. However, submucosal fibroids and large intramural fibroids (>5 cm) increase the risks of early miscarriage, prematurity, malpresentation, and postpartum hemorrhage. Aseptic necrosis (hemorrhagic infarction of a fibroid) is a painful complication specific to pregnancy—it is treated with rest + acetaminophen + NSAIDs (before 32 weeks) + opioids if necessary—and it resolves spontaneously within a few days. Myomectomy during pregnancy is practically never performed except in exceptional cases.
Signs requiring urgent medical attention
Very heavy menstrual bleeding + dizziness + paleness + rapid heartbeat → Severe acute anemia due to menorrhagia → urgent medical consultation the same day or emergency room — CBC + ferritin + hemodynamic stabilization.
Severe and sudden acute pelvic pain in a woman with known fibroids Aseptic necrosis of a fibroid or torsion of a pedunculated fibroid -> urgent gynecological consultation + pelvic ultrasound.
Rapid growth of a known fibroid after menopause + constitutional symptoms → Suspicion of leiomyosarcoma → Urgent pelvic MRI + gynecologic oncology consultation.
Consult at Clinique Omicron
Clinique Omicron physicians evaluate women presenting with menorrhagia, pelvic pain, or uterine mass, prescribe initial pelvic ultrasound, initiate first-line medical treatment, and coordinate gynecological follow-up. Management of refractory symptomatic fibroids is directed to the gynecologist for planning myomectomy, UAE, or hysterectomy. Consultations are available at multiple service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not substitute the advice of a qualified gynecologist. The management of symptomatic uterine fibroids should be individualized according to symptoms, desire for pregnancy, and fibroid size and location.
Omicron Clinic
Need to consult a doctor?
Treatment within 24-48 hours. In-clinic or telemedicine, anywhere in Quebec.
Insurance receipts. 7j/7. No family doctor required.